Community Violence, PTSD, Hopelessness, Substance Use, and Perpetuation of Violence in an Urban Environment

Demographic, Environmental, and Psychosocial Influences on Resilience Toward Chronic Stress

As studied previously, chronic stress environments lead to the formation of distinctive resilience groupings when related to individual outcomes among participants. The majority of the population has decreased mental and physical strength during prolonged periods of mental distress but returns to baseline status when those stressors are removed. Others have increased and decreased mental fortitude despite the removal of stressors. Our hypothesis is that certain demographic, environmental, and/or transgenerational aspects are associated with resilience or lack thereof in populations with a history of chronic stress. The end goal is the early identification of at-risk populations to decrease adverse outcomes and improve quality of life. In this review, we looked at 17 studies to gain a greater understanding of which factors influence individual resilience. The factors found to have a positive relationship with resilience were religion, cognitive function, socioeconomic status, marriage, psychological functioning, positive coping mechanisms, and relationships; the negative were medical diagnoses, violence exposure, female sex, stressors/trauma, disaster exposure, and negative coping mechanisms. During our research, we found that transgenerational aspects such as race/ethnicity, occupation, education, age, substance use, and physical location had mixed results across multiple studies. These findings suggest the need for future original research to allow for a definitive understanding of populations resilient to chronic stress.

Gunshot Trauma Patients Have Higher Risk of PTSD Compared With Blunt Trauma and Elective Populations: A Retrospective Comparative Study of Outpatient Orthopaedic Care

BACKGROUND

Posttraumatic stress disorder (PTSD) has been extensively studied in patients who have experienced natural disasters or military conflict, but there remains a substantial gap in knowledge about the prevalence of PTSD after civilian orthopaedic trauma, especially as related to firearms. Gun violence is endemic in the United States, especially in urban centers, and the mental impact is often minimized during the treatment of physical injuries.

QUESTIONS/PURPOSES

(1) Do patients who experience gunshot wound (GSW) trauma have higher PTSD screening scores compared with patients with blunt or other trauma (for example, motor vehicle and motorcycle accidents or stab wounds) and those with elective conditions (for example, arthritis, tendinitis, or nerve compression)? (2) Are PTSD scores correlated with pain scores in patients with GSW trauma, those with non-GSW trauma, and patients with elective orthopaedic symptoms?

METHODS

We performed a retrospective study of adults older than 18 years of age presenting to an orthopaedic clinic over an 8-month period between August 2021 and May 2022. All patients presenting to the clinic were approached for inclusion (2034 patients), and 630 new or postoperative patients answered study surveys as part of routine care. Patients were divided into three cohorts based on the orthopaedic condition with which they presented, whether gunshot trauma, blunt trauma, or elective orthopaedic symptoms. Overall, the results from 415 patients were analyzed, including 212 patients with elective orthopaedic symptoms, 157 patients with non-GSW trauma, and 46 patients with GSW trauma. Clinical data including demographic information were collected at the time of appointment and abstracted along with results from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, short screening questionnaire, which uses a 7-item scale scored from 0 to 7 (with higher scores representing worse symptoms), and from the numeric rating scale for pain (range 0 to 10). Both questionnaires were routinely administered by medical assistants at patient intake. The proportions of patients completing PTSD scoring were 45% (95) in the elective group, 74% (116) in the group with non-GSW trauma, and 85% (39) in the group with GSW trauma (p = 0.01). We compared the PTSD scores across the three groups and then dichotomized the scores as a negative versus positive screening result at a value of ≥ 4 with further comparative analysis. The correlation between pain and PTSD scores was also evaluated.

RESULTS

Patients with GSW trauma had higher mean ± SD PTSD scores compared with those who had non-GSW trauma (4.87 ± 4.05 versus 1.75 ± 2.72, mean difference 3.21 [95% CI 1.99 to 4.26]; p < 0.001) and those who presented with elective conditions (4.87 ± 4.05 versus 0.49 ± 1.04, mean difference 4.38 [95% CI 3.50 to 5.26]; p < 0.001). When dichotomized for positive or negative PTSD screening results, patients with GSW trauma had a higher risk of having PTSD (64% [25 of 39]) compared with patients with non-GSW trauma (27% [31 of 116], relative risk 2.40 [95% CI 1.64 to 3.51]; p < 0.001) and compared with patients with elective conditions (4% [4 of 95], relative risk 15.22 [95% CI 5.67 to 40.87]; p < 0.001). Pain scores were correlated with PTSD scores only for patients with non-GSW trauma (ρ = 0.37; p < 0.0001). No correlation with pain scores was present for patients with GSW (ρ = 0.24; p = 0.16) or patients with elective conditions (ρ = -0.04; p = 0.75).

CONCLUSION

In an orthopaedic clinic population, the prevalence of positive screening for PTSD was highest in the population sustaining gunshot trauma as compared with blunt or other trauma and elective orthopaedic conditions. Interestingly, pain scores correlated with PTSD screening only in the patients with non-GSW trauma. These differences suggest a substantial difference in the populations at risk of PTSD after trauma. Overall, the psychological impacts of gun trauma are poorly understood. The next step would be to prospectively study the differences and timelines of PTSD screening in patients with GSW trauma in comparison with patients with blunt or other trauma to better define the treatment needs in this population.

LEVEL OF EVIDENCE

Level III, prognostic study.

The role of physical activity in the relationship between exposure to community violence and mental health: A systematic review

Community violence is a global public health problem that is associated with mental health disorders. Physical activity can enhance mental health and may play an important role in the relationship between exposure to community violence and mental health. We systematically reviewed the literature to better understand the potential role of physical activity in this relationship. In this review, we searched the databases PubMed, Embase, Web of Science, Cochrane Central, PsycInfo, and SPORTdiscus, and conducted a grey literature search of one clinical trials registry and four organizations' websites. The review included quantitative observational studies, intervention studies, and qualitative studies published by November 30, 2022 and that involved generally healthy individuals across the lifespan. Eligible studies included measures of community violence, mental health, and physical activity. Five studies met the inclusion criteria for the review. Four studies were conducted in high-income countries, only two minority populations were represented in the studies, and none of the studies included older adults or children. Studies defined and measured community violence, mental health, and physical activity in different ways. In most studies, physical activity was not a primary focus but assessed as one item within a larger construct. The role of physical activity was examined differently across the studies and only one study found a significant role (mediator) of physical activity. This review revealed that few studies have specifically examined physical activity's role in the relationship between exposure to community violence and mental health. Further research is needed involving low-income countries, diverse minority populations, and children.

Physicians' perception about predictors of opioid abuse in patients with chronic non-cancer pain: a Delphi study

Background

Opioids are being prescribed widely, and increasingly, for the treatment of chronic non-cancer pain (CNCP). However, several side effects are associated with mid- and long-term opioid use and, for certain patients, with the risk of problematic opioid use. The aim of this study is to know the perception of the physicians about which variables could be associated with increased risk of patients with CNCP developing a problem of abuse or misuse of the prescribed opioid medication.

Methods

Twenty-nine physicians with experience in CNCP pain management and opioids prescription participated in a two-round Delphi study focused on the risk factors for opioid misuse and abuse.

Results

The variables that reached consensus regarding their relationship with the increased risk of suffering a problem of opioid abuse or misuse were: (1) Experiencing pain on a daily basis, (2) previous use of high-dose opioids, (3) generalized anxiety, (4) hopelessness, (5) benzodiazepine intake, (6) use of opioids for reasons other than pain, (7) family problems, family instability or family breakdown, and (8) having access to several opioid prescribers. The only variable that reached consensus regarding it not being associated to a possible risk of abuse or misuse was having mild pain intensity (0-4 on a NRS-11).

Conclusions

This study provides useful information that could help make decisions about the use of opioids for CNCP treatment and prevent future difficulties. Prospective studies testing the relationship of the variables that reached consensus with the risk of opioid misuse and abuse are warranted.

Significance

This study shows the variables of CNCP that the professional must take into account in order to avoid possible problems when prescribing opioids.