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Nunes JC, Costa GPA, Weleff J, Rogan M, Compton P, De Aquino JP. Assessing pain in persons with opioid use disorder: Approaches, techniques and special considerations. Br J Clin Pharmacol 2024. [PMID: 38556851 DOI: 10.1111/bcp.16055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/30/2024] [Accepted: 02/29/2024] [Indexed: 04/02/2024] Open
Abstract
Pain and opioid use disorder (OUD) are inextricably linked, as the former can be a risk factor for the development of the latter, and over a third of persons with OUD suffer concomitant chronic pain. Assessing pain among people with OUD is challenging, because ongoing opioid use brings changes in pain responses and most pain assessment tools have not been validated for this population. In this narrative review, we discuss the fundamentals of pain assessment for populations with OUD. First, we describe the biological, psychological and social aspects of the pain experience among people with OUD, as well as how opioid-related phenomena may contribute to the pain experience in this population. We then review methods to assess pain, including (1) traditional self-reported methods, such visual analogue scales and structured questionnaires; (2) behavioural observations and physiological indicators; (3) and laboratory-based approaches, such as quantitative sensory testing. These methods are considered from a perspective that encompasses both pain and OUD. Finally, we discuss strategies for improving pain assessment in persons with OUD and implications for future research, including educational strategies for multidisciplinary teams. We highlight the substantial gaps that persist in this literature, particularly regarding the applicability of current pain assessment methods to persons with OUD, as well as the generalizability of the existing results from adjacent populations on chronic opioid therapy but without OUD. As research linking pain and OUD evolves, considering the needs of diverse populations with complex psychosocial backgrounds, clinicians will be better equipped to reduce these gaps.
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Affiliation(s)
- Julio C Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gabriel P A Costa
- Faculty of Medicine, University of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Jeremy Weleff
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Rogan
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peggy Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joao P De Aquino
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Connecticut, USA
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Schudlo LC, Anagnostou E, Chau T, Doyle-Thomas K. Investigating sensory response to physical discomfort in children with autism spectrum disorder using near-infrared spectroscopy. PLoS One 2021; 16:e0257029. [PMID: 34478466 PMCID: PMC8415580 DOI: 10.1371/journal.pone.0257029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
Self-reporting of pain can be difficult in populations with communication challenges or atypical sensory processing, such as children with autism spectrum disorder (ASD). Consequently, pain can go untreated. An objective method to identify discomfort would be valuable to individuals unable to express or recognize their own bodily distress. Near-infrared spectroscopy (NIRS) is a brain-imaging modality that is suited for this application. We evaluated the potential of detecting a cortical response to discomfort in the ASD population using NIRS. Using a continuous-wave spectrometer, prefrontal and parietal measures were collected from 15 males with ASD and 7 typically developing (TD) males 10-15 years of age. Participants were exposed to a noxious cold stimulus by immersing their hands in cold water and tepid water as a baseline task. Across all participants, the magnitude and timing of the cold and tepid water-induced brain responses were significantly different (p < 0.001). The effect of the task on the brain response depended on the study group (group x task: p < 0.001), with the ASD group exhibiting a blunted response to the cold stimulus. Findings suggest that NIRS may serve as a tool for objective pain assessment and atypical sensory processing.
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Affiliation(s)
- Larissa C. Schudlo
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Computer and Biomedical Engineering Department, Ryerson University, Toronto, Canada
| | - Evdokia Anagnostou
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Tom Chau
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Krissy Doyle-Thomas
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- School of Health and Community Services, Mohawk College, Hamilton, Canada
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Hachem GE, Rocha FO, Pepersack T, Jounblat Y, Drowart A, Lago LD. Advances in pain management for older patients with cancer. Ecancermedicalscience 2019; 13:980. [PMID: 32010204 PMCID: PMC6974363 DOI: 10.3332/ecancer.2019.980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Indexed: 12/19/2022] Open
Abstract
The population of older patients is growing with a rising prevalence of cancer diagnoses and cancer-related pain syndromes. Older patients are also vulnerable to misleading pain evaluations and under treatment with opioids. Barriers to the effective and safe management of analgesics include pain assessments and the complex management of the best analgesic choice and dose-titration while achieving the fewest side effects. In this review, we will provide an overview of the challenges present in assessment and treatment choices, along with practical tips for routine clinical practice.
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Affiliation(s)
- Georges El Hachem
- Department of Hematology and Medical Oncology, Saint George Hospital University Medical Center, University of Balamand, PO Box 166378, Ashrafieh, Beirut 1100 2807, Lebanon
- Georges El Hachem and Francisco Oliveira Rocha contributed equally to writing this article
| | - Francisco Oliveira Rocha
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
- Georges El Hachem and Francisco Oliveira Rocha contributed equally to writing this article
| | - Thierry Pepersack
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Youssef Jounblat
- Department of Hematology and Medical Oncology, Lebanese University, PO Box 6573/14, Badaro, Museum, Beirut, Lebanon
| | - Annie Drowart
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Lissandra Dal Lago
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
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Cegla TH, Horlemann J. [Pain in old age]. Z Gerontol Geriatr 2018; 51:865-870. [PMID: 30456471 DOI: 10.1007/s00391-018-01477-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 11/27/2022]
Abstract
The prevalence of chronic pain increases with increasing age. Multimorbidity increases the risk of disease-related pain. Addressing the problem of pain in higher age is concerned with an increasing problem of care. The multimorbidity and the resulting multimedication are important for the medical care of pain. The therefore necessary physician-patient verbal communication can hardly be remunerated and carried out in the current care landscape. Existing resources must be bundled. The quality of life of older people and not the absence of pain, must be emphasized. Particularly problematic is the recognition and treatment of pain in patients with dementia. Pain in dementia patients is more rarely detected. In addition to questioning relatives and caregivers, a structured pain interview is necessary. The pharmacology of chronic pain is concerned above all with the prevention of iatrogenic risks through interactions and pharmacological complications. The patient-related treatment priorities must be checked and adjusted during the course of treatment. To be considered are age-related altered metabolic pathways. A sensible therapy option is the training of physical activity with a positive effect on the entire pain experience. Behavioral medical treatment procedures are other important building blocks in pain therapy. In addition to the multimodal therapeutic approaches, a stronger interdisciplinary collaboration of special pain medicine and geriatrics is necessary.
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Affiliation(s)
- Thomas Hubert Cegla
- Helios Universitätsklinikum Wuppertal - Schmerzklinik, Im Saalscheid 5, 42369, Wuppertal, Deutschland.
| | - Johannes Horlemann
- Helios Universitätsklinikum Wuppertal - Schmerzklinik, Im Saalscheid 5, 42369, Wuppertal, Deutschland
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Do nurses in acute care settings administer PRN analgesics equally to patients with dementia compared to patients without dementia? Collegian 2016. [DOI: 10.1016/j.colegn.2015.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Bradford A, Shrestha S, Snow AL, Stanley MA, Wilson N, Hersch G, Kunik ME. Managing pain to prevent aggression in people with dementia: a nonpharmacologic intervention. Am J Alzheimers Dis Other Demen 2012; 27:41-7. [PMID: 22467413 PMCID: PMC10697350 DOI: 10.1177/1533317512439795] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
Aggression is a common form of behavioral disturbance in dementia. Strategies to prevent and treat aggressive behavior are underdeveloped. However, recent work points to several modifiable risk factors that may be targets for intervention. Pain management is an evidence-based, feasible, but potentially underused, strategy that may be incorporated with other behavioral interventions to prevent aggression. In this article, we review areas of overlap in interventions for pain and for behavioral disturbances and describe an intervention concept that may hold promise for older adults with dementia who are at risk of developing aggressive behavior.
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Affiliation(s)
- Andrea Bradford
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srijana Shrestha
- VA HSR&D Houston Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - A. Lynn Snow
- Center for Mental Health and Aging, University of Alabama, Tuscaloosa, AL, USA
- Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, AL, USA
| | - Melinda A. Stanley
- VA HSR&D Houston Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
| | - Nancy Wilson
- VA HSR&D Houston Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Gayle Hersch
- School of Occupational Therapy, Texas Woman’s University, Houston, TX, USA
| | - Mark E. Kunik
- VA HSR&D Houston Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
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Tosato M, Lukas A, van der Roest HG, Danese P, Antocicco M, Finne-Soveri H, Nikolaus T, Landi F, Bernabei R, Onder G. Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: Results from the SHELTER study. Pain 2012; 153:305-310. [DOI: 10.1016/j.pain.2011.10.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 09/01/2011] [Accepted: 10/04/2011] [Indexed: 11/29/2022]
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Jordan A, Hughes J, Pakresi M, Hepburn S, O'Brien JT. The utility of PAINAD in assessing pain in a UK population with severe dementia. Int J Geriatr Psychiatry 2011; 26:118-26. [PMID: 20652872 DOI: 10.1002/gps.2489] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Studies suggest that pain is under-recognized and under-treated in those with severe dementia. Identifying pain is the first step in its effective management. Few studies have investigated the utility of behavioural pain tools in those with advanced dementia. METHODS Participants were nursing home residents with advanced dementia who were observed on three occasions using a pain assessment tool (PAINAD). Following further assessment, an appropriate management plan was formulated for those thought to be in pain. Participants who scored above the cutoff (two) on the PAINAD scale, but were felt not to be in pain, formed the false positive group. The pain and false positive groups were reassessed at 1 and 3 months. RESULTS Seventy-nine participants completed the study, with 39 participants scoring above two on the PAINAD. Of these, only 13 were assessed as being in pain. The other 26 participants who scored above the cutoff on PAINAD were not felt to be in pain. Instead, their behaviour had a psychosocial explanation, often to do with a lack of understanding as to what was happening to them. The sensitivity of PAINAD was 92%. In those with pain, a significant decrease was demonstrated in the PAINAD scores on intervention following treatment for pain (p=0.008). CONCLUSIONS PAINAD is a sensitive tool for detecting pain in people with advanced dementia, but has a high false positive rate, frequently detecting psychosocial distress rather than pain. PAINAD can be used to assess whether pain management strategies have been successful.
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Affiliation(s)
- Alice Jordan
- Northumbria Healthcare NHS Foundation Trust, UK.
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Shega JW, Rudy T, Keefe FJ, Perri LC, Mengin OT, Weiner DK. Validity of pain behaviors in persons with mild to moderate cognitive impairment. J Am Geriatr Soc 2008; 56:1631-7. [PMID: 18662203 DOI: 10.1111/j.1532-5415.2008.01831.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the validity of traditional pain behaviors (guarding, bracing, rubbing, grimacing, and sighing) in persons with and without cognitive impairment and chronic low back pain (CLBP). DESIGN Prospective observational study. SETTING Outpatient clinics. PARTICIPANTS Thirty-seven cognitively intact and 40 cognitively impaired participants with and without CLBP. MEASUREMENTS Frequency of traditional pain behaviors. RESULTS Forty-six of the participants were pain free, and 31 had CLBP. The internal consistency reliability coefficient of the five pain behaviors was 0.32, suggesting that a unidimensional scale did not exist. Multivariate analysis of variance analysis according to the independent variables pain status (pain free vs CLBP) and cognitive status (intact vs impaired) with the dependent variable frequency of pain behaviors found significant differences according to pain status (F[5,61]=3.06, P=.02) and cognitive status (F[5,61]=5.41, P<.001) but without evidence of an interaction (F[5,61]=1.14, P=.35). Participants with CLBP exhibited significantly higher levels of grimacing (P<.001) and guarding (P=.02) than pain-free participants. Intact subjects exhibited fewer guarding (P=.02) and rubbing behaviors (P<.001) but a higher number of bracing behaviors (P=.03) than cognitively impaired participants. CONCLUSION These results support the utility of facial grimacing in assessing pain in patients with mild to moderate cognitive impairment and call into question the validity of guarding and rubbing in assessing pain in persons with mild to moderate cognitive impairment.
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Affiliation(s)
- Joseph W Shega
- Department of Medicine, Division of Hematology and Oncology, Northwestern University, Chicago, Illinois 60611, USA.
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