The Brief Pain Inventory (BPI) was designed to yield separate scores for pain intensity and interference. It has been proposed that the pain interference factor can be further broken down into unique factors of affective (e.g., mood) and activity (e.g., work) interference. The purpose of this analysis was to confirm this affective/activity interference dichotomy.
Patients and Methods
A retrospective confirmatory factor analysis was completed for a sample of 184 individuals diagnosed with castrate-resistant prostate cancer (Age 40–86, M = 65.46, 77% White Non-Hispanic) who had been administered the BPI as part of Cancer and Leukemia Group B (CALGB) trial 9480. A one-factor model was compared against two-factor and three-factor models that were developed based on the design of the instrument.
Root mean squared error of approximation (0.075), comparative fit index (0.971), and change in chi-square, given the corresponding change in degrees of freedom (13.33, p < .05) values for the three-factor model (i.e., pain intensity, activity interference, and affective interference) were statistically superior in comparison to the one- and two-factor models. This three-factor structure was found to be invariant across age, mean PSA and hemoglobin levels.
These results confirm that the BPI can be used to quantify the degree to which pain separately interferes with affective and activity aspects of a patient's everyday life. These findings will provide clinical trialists, pharmaceutical sponsors, and regulators with confidence in the flexibility of the BPI as they consider the use of this instrument to assist with understanding the patient experience as it relates to treatment.
Measurement; Cancer Pain; Quality of Life
To identify empirically-derived cutoffs for mild, moderate, and severe pain
Convenience sample of 236 individuals with MS and pain.
Main Outcome Measures
0-10 Numeric Rating Scale for pain severity (both average and worst pain) and Brief Pain Inventory for pain interference.
The optimal classification scheme for average pain was 0-2 = mild, 3-5 = moderate, and 6-10 = severe. Alternatively, the optimal classification scheme for worst pain was 0-4 = mild, 5-7 = moderate, 8-10 = severe.
The present study furthers our ability to use empirically-based cutoffs to inform the use of clinical guidelines for pain treatment as well as our understanding of the factors that might impact the cutoffs that are most appropriate for specific pain populations. The results of the present study also add to the existing literature by drawing similarities to studies of other populations but also by highlighting that clear, between-condition differences may exist that warrant using different cutoffs for patients with different medical conditions. Specifically, the present study highlights that cutoffs may be lower for persons with MS than other populations of persons with pain.
Pain; pain severity; pain interference; multiple sclerosis
To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems.
Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18–44, 45–64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2).
Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000).
Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35–50% increase). Per-patient daily doses did not increase.
No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.
Opioids; Prescriptions; Chronic Pain; Disparities—Gender; Aged; Mood; Anxiety
We examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings.
We recruited PCPs (n=61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes.
All PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use.
In order to improve PCPs confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.
chronic pain; opioid analgesics; substance use; primary care provider views
Pain medicine agreements are frequently recommended for use with high-risk patients on chronic opioid therapy. We assessed how consistently pain medicine agreements were used and whether patients were aware that they had signed a pain medicine agreement in a sample of HIV-infected adults prescribed chronic opioid treatment.
We recruited patients from a longitudinal cohort of community-based HIV-infected adults and recruited the patients’ Primary Care Providers (PCPs). Patients completed in-person interviews and PCPs completed mail-based questionnaires about the patients’ use of pain medicine agreements. Among patients prescribed chronic opioid therapy, we analyzed the prevalence of pain medicine agreement use, patient factors associated with their use, and agreement between patient and clinician reports of pain agreements.
We had 84 patient-clinician dyads, representing 38 PCPs. 72.8% of patients fit diagnostic criteria for a lifetime substance use disorder. PCPs reported using pain medicine agreements with 42.9% of patients. Patients with pain medicine agreements were more likely to be smokers (91.7% vs. 58.3%; p=.001) and had higher mean scores on the Screener and Opioid Assessment for Patients with Pain (μ=26.0 (SD=9.7) vs. μ=19.5 (SD=9.3); p=.003). Patients reported having a pain medicine agreement with a sensitivity of 61.1% and a specificity of 64.6%.
In a high risk sample, clinicians were using agreements at a low rate, but were more likely to use them with patients at highest risk of misuse. Patients exhibited low awareness of whether they signed a pain medicine agreement.
pain medicine agreements; opioid analgesics; chronic pain; patient-clinician agreement
Prior to testing the feasibility/potential efficacy of a newly developed self-management pain program for seniors with back pain, this study sought to: 1) determine prospective consumers’ prior exposure to self-management pain programs, 2) determine their willingness to participate in the new program; and 3) ascertain perceived barriers/facilitators to program participation.
Six senior centers located in New York City.
We enrolled a race/ethnicity stratified (African American, Hispanic, or non-Hispanic White) sample of 90 subjects who were ages 60 years or older and had chronic back pain.
While 60% of non-Hispanic Whites reported prior participation in a self-management pain program, fewer Hispanic (23%) and African Americans (20%) participants reported prior participation. Most participants (80%) were strongly willing to participate in the new program. Multivariate analyses revealed that only pain intensity had a trend toward significance (p=.07), with higher pain scores associated with greater willingness to participate. Few barriers to participation were identified, however, respondents felt that tailoring the course to best meet the needs of those with physical disabilities, providing flexibility in class timing, and informing individuals about program benefits prior to enrollment could help maximize program reach. No race/ethnicity differences were identified with respect to willingness to participate or program participation barriers.
These data support efforts to disseminate self-management pain programs in older populations, particularly minority communities. The recommendations made by participants can help to guide implementation efforts of the newly developed pain program and may help to enhance both their reach and success.
Pain is a major concern for individuals with cancer, particularly older adults who make up the largest segment of individuals with cancer and have some of the most unique pain challenges. One of the priorities of hospice is to provide a pain free death, and while outcomes are better in hospice, patients still die with poorly controlled pain.
This paper reports on the results of a Translating Research Into Practice intervention designed to promote the adoption of evidence-based pain practices for older adults with cancer in community-based hospice.
This IRB approved study was a cluster randomized trial implemented in sixteen Midwestern hospices.
Retrospective medical records from newly admitted patients were used to determine the intervention effect. Additionally, survey and focus group data gathered from hospice staff at the completion of the intervention phase were analyzed.
Improvement on the Cancer Pain Practice Index, an overall composite outcome measure of evidence-based practices for the experimental sites was not significantly greater than control sites. Decrease in patient pain severity from baseline to post intervention in the experimental group was greater, however, the result was not statistically significant (p=0.1032).
Findings indicate a number of factors may impact implementation of multi-component interventions, including unique characteristics and culture of the setting, the level of involvement with the change processes, competing priorities and confounding factors, and complexity of the innovation (practice change). Our results suggest future study is needed on specific factors to target when implementing a community-based hospice intervention, including determining and measuring intervention fidelity prospectively.
elderly; cancer pain; pain assessment; pain management; hospice
Hip fracture in geriatric patients has a substantial economic impact and represents a major cause of morbidity and mortality in this population. At our institution, a regional anesthesia program was instituted for patients undergoing surgery for hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly after July 2007) versus general anesthesia (mainly prior to July 2007) on morbidity, mortality and hospitalization costs.
This retrospective cohort study involved data collection from electronic and paper charts of 308 patients who underwent surgery for hip fracture from September 2006 to December 2008. Data on postoperative morbidity, in-patient mortality, and cost of hospitalization (as estimated from data on hospital charges) were collected and analyzed. Seventy-three patients received regional anesthesia and 235 patients received general anesthesia. During July 2007, approximately halfway through the study period, a regional anesthesia and analgesia program was introduced.
The average cost of hospitalization in patients who receive surgery for hip fracture was no different between patients who receive regional or general anesthesia ($16,789 + 631 v. $16,815 + 643, respectively, p = 0.9557). Delay in surgery and intensive care unit admission resulted in significantly higher hospitalization costs. Age, male gender, African-American race and intensive care unit admission were associated with increased in-hospital mortality. In-hospital mortality and rates of readmission are not statistically different between the two anesthesia groups.
There is no difference in postoperative morbidity, rates of re-hospitalization, in-patient mortality or hospitalization costs in geriatric patients undergoing regional or general anesthesia for repair of hip fracture. Delay in surgery beyond 3 days and intensive care unit admission both increase cost of hospitalization.
Little is known about the treatment Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receive for chronic non-cancer pain (CNCP). We sought to describe the prevalence of prescription opioid use, types and doses of opioids received, and identify correlates of receiving prescription opioids for CNCP among OEF/OIF veterans.
Retrospective review of VA administrative data.
Ambulatory clinics within a VA regional healthcare network.
OEF/OIF veterans who had at least 3 elevated pain screening scores within a 12-month period in 2008. Within this group, those prescribed opioids (n=485) over the next 12 months were compared to those not prescribed opioids (n=277). In addition, patients receiving opioids short term (<90 days, n=284) were compared to patients receiving them long-term (≥90 consecutive days, n=201).
Of 762 OEF/OIF veterans with CNCP, 64% were prescribed at least one opioid medication over the 12 months following their index dates. Of those prescribed an opioid, 59% were prescribed opioids short-term and 41% were prescribed opioids long-term. The average morphine-equivalent opioid dose for short-term users was 23.7 mg (SD=20.5) compared with 40.8 mg (SD=36.1) for long-term users (p<0.001). Fifty-one percent of long-term opioid users were prescribed short-acting opioids only and one-third were also prescribed sedative-hypnotics. In adjusted analyses, diagnoses of low back pain, migraine headache, post-traumatic stress disorder, and nicotine use disorder were associated with an increased likelihood of receiving an opioid prescription.
Prescription opioid use is common among OEF/OIF veterans with CNCP and is associated with several pain diagnoses and medical conditions.
Chronic pain; Opioids; Veteran; Pain/drug therapy
Despite new guidelines and nationally mandated regular assessments, managing pain in cognitively impaired patients remains a complex and challenging task. Numerous studies have focused on assessing pain in this population, however studies of treatment are limited.
To characterize assessment and pain management strategies used by providers caring for hospitalized cognitively impaired patients with acute pain and to assess for associations between amount of opioid received and specific adverse outcomes in this patient population.
Medical records of patients admitted to the Geriatrics Service or Orthopedic Service or evaluated by the Geriatrics Consult Service at an urban tertiary care hospital between 9/1/06 and 9/30/07 with cognitive impairment and an acute pain problem on admission were reviewed.
Participants (N = 100) had a mean age of 86 years (range = 68–99), and were mostly female (83%) with fracture-related pain (62%). A numeric pain score was recorded in 67% of nursing assessments vs. <5% of physician assessments. Opioids were prescribed for 100% of the surgical patients vs. 43% of the medical patients. Only 15% of patients were placed on a standing analgesic regimen. Non-pharmacological management was employed for 75% of surgical patients vs. 43% of medical patients. Delirium occurred in 27% of patients, and 33% experienced an interruption of physical therapy. Neither, however, was associated with level of opioid use.
Current assessment and treatment practices in acute pain management for cognitively impaired patients vary widely (to include service and provider type). Implementation of evidence-based guidelines is needed to improve patient care.
Pain management; Cognitive Impairment; Aged; Hospitalization
To describe characteristics of older adults who received opioids for chronic noncancer pain (CP), ascertain types of opioid treatments received, and examine associations between patient characteristics and treatment outcomes.
Retrospective cohort study.
Primary care practice in New York City.
Eligible patients were ≥ 65 and newly started on an opioid for CP.
Patient characteristics and provider treatments, as well as duration of opioid therapy, proportion discontinuing therapy, and evidence of pain reduction and continued use of opioid for more than one year. Other outcomes included the presence and type(s) of side effects, abuse/misuse behaviors, and adverse events.
Participants (N=133) had a mean age of 82 (range=65–105), were mostly female (84%) and white (74%). Common indications for opioid treatment included back pain (37%) and osteoarthritis (35%). Mean duration of opioid use was 388 days (range=0–1880). Short-acting analgesics were most commonly prescribed. Physicians recorded side effects in 40% of cases. Opioids were discontinued in 48% of cases, mostly due to side effects/lack of efficacy. Pain reduction was documented in 66% of patient records, while 32% reported less pain and continued treatment for ≥ 1 year. Three percent displayed abuse/misuse behaviors, and 5% were hospitalized due to opioid-related adverse events.
Over 50% of older patients with CP tolerated treatment. Treatment was discontinued in 48% of cases, mostly due to side effects and lack of analgesic efficacy. Efforts are needed to establish the long-term safety and efficacy of opioid treatment for CP in diverse older patient populations.
Opioid analgesics; chronic non-cancer pain; elderly; safety; efficacy; abuse/misuse
Previous Vagus Nerve Stimulation (VNS) studies have demonstrated anti-nociceptive effects, and recent non-invasive approaches; termed transcutaneous-VNS, or t-VNS, have utilized stimulation of the auricular branch of the vagus nerve in the ear. The dorsal medullary vagal system operates in tune with respiration, and we propose that supplying vagal afferent stimulation gated to the exhalation phase of respiration can optimize t-VNS.
counterbalanced, crossover study.
patients with chronic pelvic pain (CPP) due to endometriosis in a specialty pain clinic.
We evaluated evoked pain analgesia for Respiratory-gated Auricular Vagal Afferent Nerve Stimulation (RAVANS) compared with Non-Vagal Auricular Stimulation (NVAS). RAVANS and NVAS were evaluated in separate sessions spaced at least one week apart. Outcome measures included deep tissue pain intensity, temporal summation of pain, and anxiety ratings, which were assessed at baseline, during active stimulation, immediately following stimulation, and 15 minutes after stimulus cessation.
RAVANS demonstrated a trend for reduced evoked pain intensity and temporal summation of mechanical pain, and significantly reduced anxiety in N=15 CPP patients, compared to NVAS, with moderate to large effect sizes (eta2>0.2).
Chronic pain disorders such as CPP are in great need of effective, non-pharmacological options for treatment. RAVANS produced promising anti-nociceptive effects for QST outcomes reflective of the noted hyperalgesia and central sensitization in this patient population. Future studies should evaluate longer-term application of RAVANS to examine its effects on both QST outcomes and clinical pain.
Arthritis of the knee affects 46 million Americans. We aimed to determine the level of evidence of intraarticular knee injections in the management of arthritic knee pain.
We systematically searched PUBMED/MEDLINE and the Cochrane databases for articles published on knee injections and evaluated their level of evidence and recommendations according to established criteria.
The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis (1A+ level), osteoarthritis (1A+ level), and juvenile idiopathic arthritis (2C+ level). Pain relief and functional improvement are significant for months up to one year after the injection. Triamcinolone hexacetonide offers an advantage over triamcinolone acetonide and should be the intraarticular steroid of choice (2B+ level). Intraarticular injection of hyaluronate may provide longer pain relief than steroid injection in osteoarthritis (2B+ level). It can also be effective for rheumatoid arthritis knee pain (1A+ level). However, it is only recommended for patients with significant surgical risk factors and for patients with mild radiographic disease in whom conservative treatment has failed (2B± level). Botulinum toxin Type A injection is effective in reducing arthritic knee pain (2B+ level) and so is tropisetron (2B+ level) and tanezumab (2B+ level). The new agents, such as rAAV2-TNFR:Fc, SB-210396/CE 9.1, and various radioisotopes have provided various degrees of success, but their long-term safety and efficacy remains to be determined.
We conclude that strong evidence supports the use of intraarticular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries.
Knee injection; Rheumatoid arthritis (RA); Osteoarthritic (OA); Juvenile rheumatoid arthritis (JRA); Intraarticular corticosteroid injection (IACI); Hyaluronic acid (HA); Radiation synovectomy (RSO)
Prior to performing a cervical interlaminar epidural steroid injection (CIESI), knowledge of the depth from lamina to epidural space may assist in preventing cord injury.
This is a prospective analysis of data including gender, age, weight, height, previous surgery, neck circumference, distances from tip of chin to sternal notch, occiput to C7 vertebral prominence, and ear lobe to tip of shoulder, pain score, angle from C7 vertebral prominence to the back, depth at which the Tuohy needle contacted T1 vertebral lamina and depth at which the epidural space was entered was conducted with 92 subjects, average age (± SD) 41.3 ± 13.2 years underwent fluoroscopically-guided C7-T1 intralaminar epidural steroid injections.
Depth to lamina was the best individual predictor with an r-value of 0.86. Weight, neck circumference, and BMI correlated positively with depth to epidural space with r-values of 0.66, 0.62, and 0.61 respectively. A linear regression model of depth to lamina for predicting depth to epidural space was accurate to within ± 0.5 cm of the actual depth in 69% of subjects. However, when comparing predicted to actual depth to epidural space for individual subjects, the prediction was inaccurate by as much as 1.6 cm deep or 1.7 cm shallow.
While statistically significant correlations do exist between both quantitative external body characteristics and depth to cervical epidural space and T1vertebral lamina to depth of cervical epidural space for fluoroscopically guided interlaminar epidural steroid injections at C7-T1, even the most optimal regression models do not permit clinical confidence in predicted depth to epidural space.
Pain is a subjectively complex and universal experience. We examine research investigating ethnic group differences in experimental pain response, and factors contributing to group differences.
We conducted a systematic literature review and analysis of studies using experimental pain stimuli to assess pain sensitivity across multiple ethnic groups. Our search covered the period from 1944-2011, and utilized the PUBMED bibliographic database; a reference source containing over 17 million citations. We calculated effect sizes, identified ethnic/racial group categories, pain stimuli and measures, and examined findings regarding biopsychosociocultural factors contributing to ethnic/racial group differences.
We found 472 studies investigating ethnic group differences and pain. Twenty-six of these met our review inclusion criteria of investigating ethnic group differences in experimental pain. The majority of studies included comparisons between African Americans (AA) and non-Hispanic Whites (NHW). There were consistently moderate to large effect sizes for pain tolerance across multiple stimulus modalities; African Americans demonstrated lower pain tolerance. For pain threshold, findings were generally in the same direction, but effect sizes were small to moderate across ethnic groups. Limited data were available for suprathreshold pain ratings. A subset of studies comparing NHW and other ethnic groups showed a variable range of effect sizes for pain threshold and tolerance.
There are potentially important ethnic/racial group differences in experimental pain perception. Elucidating ethnic group differences, has translational merit for culturally-competent clinical care and for addressing and reducing pain treatment disparities among ethnically/racially diverse groups.
ethnicity/race differences; experimental pain; pain disparities; pain threshold/tolerance; pain treatment
The pre-clinical study of pain and aging represents an area of research where considerations of age, strain of animal, gender, and method of behavioral assessment are but some of the challenges that must be addressed. The results of studies related to the impact of age on pain sensitivity have ranged from increased sensitivity to decreased sensitivity to no change. Examining the design of these studies one discovers that cross-sectional designs using animals of different ages have been used to evaluate age-related effects in normal animals as well as animals with inflammatory and neuropathic pain conditions. The dominant method of behavioral assessment in these studies has been reflex-based strategies that unfortunately do not reveal the same effects of experimental manipulations known to affect pain sensitivity in humans. Explanations for the increases in pain sensitivity under different experimental conditions have been suggested to include age-related anatomical, physiological, and biochemical changes as well as compensatory changes in homeostatic mechanisms and intrinsic plasticity of somatosensory pathways involved in the processing and perception of pain. Other potential contributing factors related to the impact of age on pain sensitivity include dysregulation of the hypothalamic-pituitary-axis and changes in autonomic function along with an increased prevalence of auto-immune disorders that occur with advancing age. In the future translational research in the field of pain and aging will need to focus on a number of objectives, including the establishment of clinically relevant animals models and assessment strategies to evaluate the causal relationships between age-related biological changes and behavioral changes in pain sensitivity.
inflammation; neuropathic; reflex behavior; operant behavior; microglia; central sensitization; plasticity
Although effective alone, opioids are often used in combination with other drugs for relief of moderate to severe pain. Guidelines for acute perioperative pain recommend the use of multimodal therapy for pain management although combinations of opioids are not specifically recommended. Mu opioid drugs include morphine, heroin, fentanyl, methadone, and morphine 6β-glucuronide (M6G). Their mechanism of action is complex, resulting in subtle pharmacological differences among them and with unpredictable differences in their potency, effectiveness, and tolerability among patients. Highly selective mu opioids do not bind to a single receptor. Rather, they interact with a large number of mu receptor subtypes with different activation profiles for the various drugs. Thus, mu-receptor-based drugs are not all the same and it may be possible utilize these differences for enhanced pain control in a clinical setting. These differences among the drugs raise the question of whether combinations might result in better pain relief with fewer side effects. This concept already has been demonstrated between two mu opioids in preclinical studies and clinical trials other combinations are ongoing. This article reviews the current state of knowledge about mu opioid receptor pharmacology, summarizes preclinical evidence for synergy from opioid combinations, and highlights the complex nature of the mu opioid receptor pharmacology.
analgesia; combinations; mu receptor; opioid; synergy; MOR-1; morphine
To describe the methodology of the first NIH-funded clinical trial for seniors with comorbid depression and chronic low back pain.
Randomized controlled effectiveness trial using stepped care methodology. Participants are ≥ 60 years old. Phase 1 (6 weeks) is open treatment with venlafaxine xr 150 mg/day and supportive management (SM). Response is two weeks of PHQ-9 ≤ 5 and at least 30% improvement in the average numeric rating scale for pain. Non-responders progress to phase 2 (14 weeks) in which they are randomized to high-dose venlafaxine xr (up to 300 mg/day) with Problem Solving Therapy for Depression and Pain (PST-DP) or high-dose venlafaxine xr and continued SM. Primary outcomes are the univariate pain and depression response and both observed and self-report disability. Survival analytic techniques will be used, and the clinical effect size will be estimated with NNT. We hypothesize that self-efficacy for pain management will mediate response for subjects randomized to venlafaxine xr and PST-DP.
The results of this trial will inform the care of these complex patients and further understanding of comorbid pain and depression in late-life.
clinical trial; geriatrics; depression; back pain; survival analysis
The purpose of this study, in a sample of preschool children (ages 3 to 5 years; N=47), was to evaluate the feasibility of scheduled analgesic dosing following outpatient tonsillectomy in order to optimize pain management.
Parents were instructed to give their child acetaminophen with hydrocodone (167mg/5ml) every 4 hours around-the-clock for the first 3 days following surgery. Parents recorded ratings of their child’s pain with/without swallowing using the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale, pain relief ratings, and severity of analgesic side effects in a home diary. Audiotaped interviews were conducted with parents to document descriptions of their experiences in managing their child’s pain at home.
Mean FLACC scores with/without swallowing were less than 2 at each measurement time and pain relief scores increased over time. Total analgesic dose decreased and the number of missed doses increased over the first 3 days after surgery. Moderate-to-severe daytime sedation, nausea, vomiting, and constipation were reported by parents.
Study results suggest that acetaminophen with hydrocodone is effective in relieving preschool children’s pain following tonsillectomy, and that parental adherence to a scheduled analgesic regimen decreases over time. Time-contingent dosing was associated with moderate to severe side effects, and should be addressed in discharge teaching with parents. Findings provide insight into parents’ perspective of pain management at home following tonsillectomy and methods for relieving their child’s pain.
tonsillectomy pain; pediatric pain; postoperative pain management; acetaminophen with hydrocodone
It is generally well established that catastrophizing exerts a potent influence on individuals' experience of pain and accompanying emotional distress. Further, preliminary evidence has shown that meaningful differences among various pain relevant outcomes (e.g., pain ratings, endogenous pain inhibitory processes) can be attributed to individuals' ethnic background. The mechanisms that might explain ethnic differences in pain outcomes are unclear, and it remains to be fully established whether the relation between ethnicity and pain response may be indirectly affected by pain catastrophizing.
In the current study, we examined differences in pain responses by ethnicity among healthy, young adults (N = 62), and attempted to determine whether such an ethnicity-pain relation was mediated by catastrophizing using the standard Pain Catastrophizing Scale (PCS) and a modified version of the PCS reflecting situational catastrophizing during a cold pressor task.
Results showed that pain responses varied by ethnicity, as did reported catastrophizing. Catastrophizing mediated the relation between ethnicity and affective and sensory pain responses.
To better explicate our findings, we described the context in which these findings occurred following a ‘who, what, where, when, and why’ approach. This approach provides an efficient description of how our findings align with previous research, while identifying future research that should clarify the theoretical underpinnings of catastrophizing and pain and also inform clinical intervention.
Pain; Pain Quality; Catastrophizing; Sex; Ethnicity
Sleep quality and ethnicity are related to a host of general health outcomes including the experience of pain, yet it remains unclear whether poor sleep quality and ethnicity might interactively affect pain catastrophizing and laboratory-evoked acute pain reports. The current study examined the cross-sectional associations of subjective sleep quality, ethnicity, and their interaction with pain catastrophizing and pain reports.
Healthy (N = 149), ethnically diverse (58% Caucasian American, 23% Asian American, 19% African American) young adults were subjected to a cold pressor task (CPT). Prior to CPT, participants completed the Pittsburgh Sleep Quality Index (PSQI) and a standard version of the Pain Catastrophizing Scale (PCS). Following CPT, participants completed a situation-specific version of the PCS.
Adjusted analyses revealed a significant sleep quality by ethnicity interaction for standard catastrophizing reports. Particularly, African Americans with poor overall sleep quality reported the greatest level of catastrophizing on the standard PCS relative to their Caucasian and Asian American counterparts. Furthermore, African Americans with poorer sleep efficiency reported greater catastrophizing on the situation-specific PCS compared to Caucasian and Asian Americans. Catastrophizing was significantly correlated with pain reports.
These results suggest that African Americans with poorer sleep quality may be at greater risk for catastrophizing, a known contributor to more intense pain and increased pain-related emotional distress. Whether interventions that improve the sleep quality of ethnic minorities affect pain catastrophizing is in need of investigation.
Ethnicity; sleep quality; pain catastrophizing; cold pressor; disparities
To identify correlates of perceived pain-related restrictions in a community sample of women with fibromyalgia.
The fibromyalgia group was composed of white women with a self-reported, physician-given fibromyalgia diagnosis (N = 238) from the Biopsychosocial Religion and Health Study (BRHS). BRHS respondents had participated in the larger Adventist Health Study-2. To identify associations with pain-related restrictions, we used hierarchical linear regression. The outcome measure was subjects' pain-related restrictions (one SF-12 version 2 item). Predictors included age, education, body mass index (BMI), sleep apnea, and fibromyalgia treatment in the last year, as well as standardized measures for trauma, major life stress, depression, and hostility. To better interpret the findings, pain-related restrictions also were predicted in women with osteoarthritis and no fibromyalgia.
Women with fibromyalgia reporting the more severe pain-related restrictions were those who had experienced trauma accompanied by physical pain, were older, less educated, more depressed, more hostile, had high BMI scores, and had been treated for fibromyalgia in the last 12 months (adjusted R2 = 0.308). Predictors in women with osteoarthritis were age, BMI, treatment in the last 12 months, experience of a major life stressor, and greater depression symptom severity (adjusted R2 = 0.192).
In both groups, age, BMI, treatment in the last 12 months, and depression predicted pain-related restrictions. Experience of a traumatic event with physical pain was the strongest predictor in the fibromyalgia group. These findings may be useful in constructing novel treatments and prevention strategies for pain-related morbidity in fibromyalgia patients.
Fibromyalgia; Osteoarthritis; Pain; Central Nervous System; Trauma; Stress
Current evidence supports the efficacy of hypnosis for reducing the pain associated with experimental stimulation and various acute and chronic conditions; however, the mechanisms explaining how hypnosis exerts its effects remain less clear. The hypothalamic-pituitary-adrenal (HPA) axis and pro-inflammatory cytokines represent potential targets for investigation given their purported roles in the perpetuation of painful conditions; yet, no clinical trials have thus far examined the influence of hypnosis on these mechanisms.
Healthy participants, highly susceptible to the effects of hypnosis, were randomized to either a hypnosis intervention or a no-intervention control. Using a cold pressor task, assessments of pain intensity and pain unpleasantness were collected prior to the intervention (Pre) and following the intervention (Post) along with pain-provoked changes in salivary cortisol and the soluble receptor of tumor necrosis factor-α (sTNFαRII).
Compared to the no-intervention control, data analyses revealed that hypnosis significantly reduced pain intensity and pain unpleasantness. Hypnosis was not significantly associated with suppression of cortisol or sTNFαRII reactivity to acute pain from Pre to Post; however, the effect sizes for these associations were medium-sized.
Overall, the findings from this randomized controlled pilot study support the importance of a future large-scale study on the effects of hypnosis for modulating pain-related changes of the HPA axis and pro-inflammatory cytokines.
Hypnosis; Hypnotic analgesia; Pain; Cortisol; Tumor necrosis factor-α; HPA axis; Inflammation
To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA).
Health, Aging and Body Composition Study
652 participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA.
Analgesic use was defined as taking ≥ 1 non-opioid and/or ≥ 1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% were taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using < 1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR]=2.44; 95% confidence interval [95% CI]=1.49-3.99) and opioid (AOR=2.64; 95% CI, 1.26-5.53) use.
Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion take less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use.
Aged; Analgesic; Osteoarthritis
There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an “Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults” conference in September, 2010, to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and non-steroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits.
Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists’ slide presentations were reviewed to identify the gaps, and the types of studies and research methods panelists suggested could best address them.
Fifteen gaps were identified in the areas of treatment(e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation(e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life.
Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well being of older adults with chronic pain.
Analgesic use; chronic non-cancer pain; older adults