Ethnic differences in pain coping: factor structure of the coping strategies questionnaire and coping strategies questionnaire-revised

Health Care Discrimination Affects Patient Activation, Communication Self-Efficacy, and Pain for Black Americans

This study examines whether a key psychosocial factor-perceiving racial discrimination in health care-is associated with worse patient activation, communication self-efficacy, and physical health outcomes for Black veterans with chronic pain. Moreover, we explore the role of physician-patient working alliance as a moderator that may alleviate the potential consequences of perceiving racial discrimination. This work is a secondary analysis of baseline data from a clinical trial with 250 U.S. Black veterans with chronic musculoskeletal pain. Participants were recruited from primary care clinics at a Midwestern VA hospital between 2018 and 2021. Perceiving racial discrimination in health care was associated with lower patient activation, lower self-efficacy in communicating with one's physician, higher pain intensity, and lower pain management self-efficacy (ps < .049) but was unrelated to reports of pain interference or use of pain coping strategies (ps > .157). Although the relationship between perceived discrimination and patient activation was moderated by working alliance (P = .014), having a stronger working alliance improved patient activation to varying degrees across levels of perceived discrimination (rather than buffering against negative outcomes when perceiving higher levels of discrimination). Moderation was not significant on any other measures. This study deepens our understanding of the broad range of health outcomes that are (not) associated with perceiving racial discrimination in health care. Contrary to prior theorizing, this work also indicates that having a strong working alliance does not attenuate the consequences of perceiving discrimination among Black individuals living with pain. These results highlight the need for system-level interventions to address perceptions of racial mistreatment in health care. PERSPECTIVE: This work has important public health implications by identifying the broad range of outcomes associated with perceived discrimination in health care among Black Americans. Importantly, a strong physician-patient relationship did not buffer Black individuals from the consequences of perceiving discrimination. These findings inform intervention targets to mitigate racial health disparities.

Unraveling the Tapestry of Pain: A Comprehensive Review of Ethnic Variations, Cultural Influences, and Physiological Mechanisms in Pain Management and Perception

The medical management of pain is a nuanced challenge influenced by sociocultural, demographic, and ethical factors. This review explores the intricate interplay of these dimensions in shaping pain perception and treatment outcomes. Sociocultural elements, encompassing cultural beliefs, language, societal norms, and healing practices, significantly impact individuals' pain experiences across societies. Gender expectations further shape these experiences, influencing reporting and responses. Patient implications highlight age-related and socioeconomic disparities in pain experiences, particularly among the elderly, with challenges in managing chronic pain and socioeconomic factors affecting access to care. Healthcare provider attitudes and biases contribute to disparities in pain management across racial and ethnic groups. Ethical considerations, especially in opioid use, raise concerns about subjective judgments and potential misuse. The evolving landscape of placebo trials adds complexity, emphasizing the importance of understanding psychological and cultural factors. In conclusion, evidence-based guidelines, multidisciplinary approaches, and tailored interventions are crucial for effective pain management. By acknowledging diverse influences on pain experiences, clinicians can provide personalized care, dismantle systemic barriers, and contribute to closing knowledge gaps, impacting individual and public health, well-being, and overall quality of life.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

Opioid dose and pain effects of an online pain self-management program to augment usual care in adults with chronic pain: a multisite randomized clinical trial

ABSTRACT

Readily accessible nonpharmacological interventions that can assist in opioid dose reduction while managing pain is a priority for adults receiving long-term opioid therapy (LOT). Few large-scale evaluations of online pain self-management programs exist that capture effects on reducing morphine equivalent dose (MED) simultaneously with pain outcomes. An open-label, intent-to-treat, randomized clinical trial recruited adults (n = 402) with mixed chronic pain conditions from primary care and pain clinics of 2 U.S. academic healthcare systems. All participants received LOT-prescriber-provided treatment of MED ≥ 20 mg while receiving either E-health (a 4-month subscription to the online Goalistics Chronic Pain Management Program), or treatment as usual (TAU). Among 402 participants (279 women [69.4%]; mean [SD] age, 56.7 [11.0] years), 200 were randomized to E-health and 202 to TAU. Of 196 E-heath participants, 105 (53.6%) achieved a ≥15% reduction in daily MED compared with 85 (42.3%) of 201 TAU participants (odds ratio, 1.6 [95% CI, 1.1-2.3]; P = 0.02); number-needed-to-treat was 8.9 (95% CI, 4.8, 66.0). Of 166 E-health participants, 24 (14.5%) achieved a ≥2 point decrease in pain intensity vs 13 (6.8%) of 192 TAU participants (odds ratio, 2.4 [95% CI, 1.2-4.9]; P = 0.02). Benefits were also observed in pain knowledge, pain self-efficacy, and pain coping. The findings suggest that for adults on LOT for chronic pain, use of E-health, compared with TAU, significantly increased participants' likelihood of clinically meaningful decreases in MED and pain. This low-burden online intervention could assist adults on LOT in reducing daily opioid use while self-managing pain symptom burdens.

Psychosocial and Sensory Factors Contribute to Self-Reported Pain and Quality of Life in Young Adults with Irritable Bowel Syndrome

AIMS

Psychosocial and sensory factors, including anxiety, depression, and pressure pain threshold have been used to cluster chronic symptoms in irritable bowel syndrome (IBS). This study examined the contribution of psychosocial sensory factors on pain interference and quality of life (QOL) in this population.

DESIGN

We performed a cross-sectional analysis of baseline data from a randomized controlled trial.

SETTINGS

Two gastrointestinal clinics, general communities, and two large campuses of a public university in the Northeastern United States.

PARTICIPANTS/SUBJECTS

Eighty young adults with IBS aged 21 ± 2.57 years (76.25% female).

METHODS

Demographic and psychosocial factors including anxiety, depression, fatigue, cognition or general concerns, sleep disturbance, self-efficacy, coping, and food intake were measured as independent variables. Quantitative sensory testing was conducted to measure mechanical, thermal, and pressure pain thresholds. Self-reported pain measured by the brief pain inventory (BPI) and IBS-QOL were assessed as the outcome variables. Regression analysis and mediation analysis were conducted to determine the associated factors of IBS pain and QOL.

RESULTS

Age, sex, and psychosocial factors including coping, self-efficacy, alcohol intake, mechanical pain sensitivity, and cold pain threshold were significantly associated with pain interference (all p < 0.05). Coping, and self-efficacy were significantly associated with IBS-QOL (all p < 0.05). In the mediation analysis, coping catastrophizing and self-efficacy were indirectly associated with IBS-QOL mediated by fatigue.

CONCLUSIONS

Psychosocial factors including coping and self-efficacy, and quantitative sensory testing factors significantly correlate with self-reported pain and QOL among young adults with IBS. This preliminary research calls for further interventional studies that target personalized psychosocial and quantitative sensory factors to improve pain management and quality of life in IBS patients.

A Critical Appraisal of the Evidence Supporting the Factor Structure of Extant Coping Instruments

This paper evaluated the evidence supporting the factor structure of extant coping instruments based on modern psychometric standards. Our literature search identified nine coping instruments that are routinely used to measure coping strategies in adult populations. While nearly 10 thousand papers have been published using these instruments, only 39 studies have investigated their psychometric validity. Our findings revealed that the majority of these studies did not follow current psychometric recommendations for establishing internal validity in part because they did not account for the ordinal nature of the data. Further, studies employing exploratory factor analysis used methods for identifying the number of factors to retain that have been found to have a low accuracy in a simulation study while those employing confirmatory factor analysis reported model fit statistics that did not meet widely accepted benchmarks. Hence, conflicting results were found within and across the nine coping instruments. Recommendations are made for improving future validation studies.

Associations between pain catastrophizing and resting-state functional brain connectivity: Ethnic/race group differences in persons with chronic knee pain

Chronic pain is a significant public health problem, and the prevalence and societal impact continues to worsen annually. Multiple cognitive and emotional factors are known to modulate pain, including pain catastrophizing, which contributes to pain facilitation and is associated with altered resting-state functional connectivity in pain-related cortical and subcortical circuitry. Pain and catastrophizing levels are reported to be higher in non-Hispanic black (NHB) compared with non-Hispanic White (NHW) individuals. The current study, a substudy of a larger ongoing observational cohort investigation, investigated the pathways by which ethnicity/race influences the relationship between pain catastrophizing, clinical pain, and resting-state functional connectivity between anterior cingulate cortex (ACC), dorsolateral prefrontal cortex (dlPFC), insula, and primary somatosensory cortex (S1). Participants included 136 (66 NHBs and 70 NHWs) community-dwelling adults with knee osteoarthritis. Participants completed the Coping Strategies Questionnaire-Revised Pain Catastrophizing subscale and Western Ontario and McMaster Universities Osteoarthritis Index. Magnetic resonance imaging data were obtained, and resting-state functional connectivity was analyzed. Relative to NHW, the NHB participants were younger, reported lower income, were less likely to be married, and self-reported greater clinical pain and pain catastrophizing (ps < 0.05). Ethnicity/race moderated the mediation effects of catastrophizing on the relationship between clinical pain and resting-state functional connectivity between the ACC, dlPFC, insula, and S1. These results indicate the NHB and NHW groups demonstrated different relationships between pain, catastrophizing, and functional connectivity. These results provide evidence for a potentially important role of ethnicity/race in the interrelationships among pain, catastrophizing, and resting-state functional connectivity.

Neurophysiological and transcriptomic predictors of chronic low back pain: Study protocol for a longitudinal inception cohort study

Chronic low back pain is one of the most common, costly, and debilitating pain conditions worldwide. Increased mechanistic understanding of the transition from acute to chronic low back and identification of predictive biomarkers could enhance the clinical assessment performed by healthcare providers and enable the development of targeted treatment to prevent and/or better manage chronic low back pain. This study protocol was designed to identify the neurological and transcriptomic biomarkers predictive of chronic low back pain at low back pain onset. This is a prospective descriptive longitudinal inception cohort study that will follow 340 individuals with acute low back pain and 40 healthy controls over 2 years. To analyze the neurophysiological and transcriptomic biomarkers of low back pain, the protocol includes psychological and pain-related survey data that will be collected beginning within 6 weeks of low back pain onset (baseline, 6, 12, 24, 52 weeks, and 2 years) and remotely at five additional time points (8, 10, 16, 20 weeks, and 18 months). Quantitative sensory testing and collection of blood samples for RNA sequencing will occur during the six in-person visits. The study results will describe variations in the neurophysiological and transcriptomic profiles of healthy pain-free controls and individuals with low back pain who either recover to pain-free status or develop chronic low back pain.

The Imperative for Racial Equality in Pain Science: A Way Forward

Racial equity is imperative to the future and integrity of scientific inquiry. In 2020, citizens of the United States (and globally) witnessed one of the most vile and egregious experiences of police brutality and systemic racism in recent history, the public execution of a Black American man. While some may isolate this and other similar events from influencing the scientific endeavors of pain researchers, events such as this can have a direct impact on the study, lived experience, and expression of pain in Black Americans. To truly understand the biopsychosocial effects of inequality and injustice on pain disparities, we must consider the unintended consequences that our current research approaches have in limiting the reliability and validity of scientific discovery. As we reflect on our current research practices in an effort to improve pain science, this perspective article discusses ways to initiate positive change in order to advance the science of pain in more equitable ways, not just for Black Americans, but for all individuals that identify as part of an underrepresented group. PERSPECTIVE: Elimination of inequities in pain care and research requires the identification, naming, and mitigation of systemic discriminatory and biased practices that limit our understanding of pain disparities. Now is the time to divest from traditional research methods and invest in equitable and innovative approaches to support pain researchers in advancing the science and improving the lives of people with pain.

Associations of pain catastrophizing with pain-related brain structure in individuals with or at risk for knee osteoarthritis: Sociodemographic considerations

Compelling evidence exists that non-Hispanic blacks (NHB) engage in pain catastrophizing (negatively evaluate one's ability to cope with pain) more often than non-Hispanic whites (NHW). Functional neuroimaging studies revealed that individuals with high levels of trait pain catastrophizing show increased cerebral responses to pain in several pain-related brain regions (e.g., insula, primary somatosensory cortex [S1]), but associations between brain structure and catastrophizing remain largely unexplored. The current investigation was conducted at the University of Florida and the University of Alabama at Birmingham. Participants were 129 community-dwelling adults with or at risk of knee osteoarthritis (OA). Participants completed the pain catastrophizing subscale of the Coping Strategies Questionnaire-Revised and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain intensity subscale. Magnetic Resonance Imaging data were obtained. MANOVA and Chi-Square analyses assessed sociodemographic/clinical differences stratified by ethnicity/race. Multivariate regression analyses with insula and somatosensory cortical thickness entered as dependent variables with catastrophizing and the interaction between catastrophizing and ethnicity/race as the independent variables. Covariates include education, body mass index, study site, and WOMAC pain (ethnicity/race was an additional covariate in non-stratified analyses). There were significant interactions between ethnicity/race, pain catastrophizing, and brain structure. Higher pain catastrophizing was associated with thinner S1 bilaterally (ps < .05) in NHW, but not NHB participants with or at risk for knee OA. These results suggest that pain catastrophizing might have differing effects on pain-related central pathways and may contribute to ethnic/race group differences in individuals with or at risk for knee OA.

Pilot study of an internet-based pain coping skills training program for patients with systemic Lupus Erythematosus

BACKGROUND

Patients with Systemic Lupus Erythematosus (SLE) often experience pain and other symptoms that negatively impact quality of life. Interventions that enhance the use of behavioral and cognitive coping strategies may lead to improved outcomes among patients with SLE. Pain coping skills training (PCST) programs have been shown to improve outcomes among patients with other rheumatic conditions, but there have been no trials of PCST among patients with SLE. This study was a preliminary assessment of the feasibility and efficacy of painTRAINER, an automated, internet-based PCST program, among patients with SLE.

METHODS

Participants (n = 60) with SLE from one health care system were randomly assigned with equal allocation to painTRAINER or a wait list control group. PainTRAINER involves 8 modules; participants were instructed to complete one module weekly, along with practice activities for each cognitive or behavioral coping skill. Outcome measures were assessed at baseline and 9-week follow-up, including the Pain Catastrophizing Scale, PROMIS Subscales (Pain Interference, Physical Function, Sleep Disturbance, Anxiety, Depression, Fatigue and Participation), and the LupusPRO questionnaire. Mean changes in outcomes from baseline to follow up and Cohen's d effect sizes were computed.

RESULTS

Effect sizes for the painTRAINER group (relative to the wait list group) were small, with changes being greatest for the PROMIS Depression score (d = - 0.32). Among those randomized to the painTRAINER group, 50% accessed the program ("painTRAINER users"). Most of those who did not access the program stated that they did not receive instructions via email. Effect sizes for "painTRAINER users" (relative to wait list) were larger than for the whole painTRAINER group: Pain Catastrophizing d = - 0.60, PROMIS Pain Interference d = - 0.3., PROMIS Depression d = - 0.44, LupusPRO Health-Related Quality of Life d = 0.30.

CONCLUSIONS

PainTRAINER users reported meaningful improvements in multiple physical and psychological outcomes, supporting the potential of PCST programs to benefit individuals with SLE. However, strategies are needed to improve engagement with the program and tailor content to comprehensively address key SLE symptoms and challenges.

TRIAL REGISTRATION

NCT03933839 , May 1, 2019.

Pain coping skills training for African Americans with osteoarthritis: results of a randomized controlled trial

African Americans bear a disproportionate burden of osteoarthritis (OA), but they have been underrepresented in trials of behavioral interventions for pain. This trial examined a culturally tailored pain coping skills training (CST) program, compared to a wait list control group, among 248 African Americans with knee or hip OA. The pain CST program involved 11 telephone-based sessions over 3 months. Outcomes were assessed at baseline, 3 months (primary), and 9 months, and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (primary outcome), WOMAC total score and function subscale, PROMIS Pain Interference, Short-Form 12 Mental and Physical Composite Subscales, Coping Strategies Questionnaire-Total Coping Attempts, Pain Catastrophizing Scale, Patient Health Questionnaire-8, Arthritis Self-Efficacy Scale, and Patient Global Impression of Arthritis Symptom Change. Linear mixed models were fit for all outcomes. There were no significant between-group differences in WOMAC pain score at 3 months (-0.63 [95% confidence interval -1.45, 0.18]; P = 0.128) or 9 months (-0.84 [95% confidence interval -1.73, 0.06]; P = 0.068). Among secondary outcomes, at 3 months, there were significant differences, in favor of the CST group, for Coping Strategies Questionnaire Total Coping Attempts, Pain Catastrophizing Scale, Arthritis Self-Efficacy, and Patient Global Impression of Arthritis Symptom Change (P < 0.01). Coping Strategies Questionnaire Total Coping Attempts, Arthritis Self-Efficacy, and Patient Global Assessment Change were also significantly improved at 9 months in the CST group, compared with wait list (P < 0.01). The culturally tailored pain CST program did not significantly reduce pain severity but did improve key measures of pain coping and perceived ability to manage pain among African Americans with OA.

Assessing peripheral fibers, pain sensitivity, central sensitization, and descending inhibition in Native Americans: main findings from the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) have a higher prevalence of chronic pain than other U.S. racial/ethnic groups, but there have been few attempts to understand the mechanisms of this pain disparity. This study used a comprehensive battery of laboratory tasks to assess peripheral fiber function (cool/warm detection thresholds), pain sensitivity (eg, thresholds/tolerances), central sensitization (eg, temporal summation), and pain inhibition (conditioned pain modulation) in healthy, pain-free adults (N = 155 NAs, N = 150 non-Hispanic Whites [NHWs]). Multiple pain stimulus modalities were used (eg, cold, heat, pressure, ischemic, and electric), and subjective (eg, pain ratings and pain tolerance) and physiological (eg, nociceptive flexion reflex) outcomes were measured. There were no group differences on any measure, except that NAs had lower cold-pressor pain thresholds and tolerances, indicating greater pain sensitivity than NHWs. These findings suggest that there are no group differences between healthy NAs and NHWs on peripheral fiber function, central sensitization, or central pain inhibition, but NAs may have greater sensitivity to cold pain. Future studies are needed to examine potential within-group factors that might contribute to NA pain risk.

Pain-related anxiety promotes pronociceptive processes in Native Americans: bootstrapped mediation analyses from the Oklahoma Study of Native American Pain Risk

INTRODUCTION

Evidence suggests Native Americans (NAs) experience higher rates of chronic pain than the general US population, but the mechanisms contributing to this disparity are poorly understood. Recently, we conducted a study of healthy, pain-free NAs (n = 155), and non-Hispanic whites (NHWs, n = 150) to address this issue and found little evidence that NAs and NHWs differ in pain processing (assessed from multiple quantitative sensory tests). However, NAs reported higher levels of pain-related anxiety during many of the tasks.

OBJECTIVE

The current study is a secondary analysis of those data to examine whether pain-related anxiety could promote pronociceptive processes in NAs to put them at chronic pain risk.

METHODS

Bootstrapped indirect effect tests were conducted to examine whether pain-related anxiety mediated the relationships between race (NHW vs NA) and measures of pain tolerance (electric, heat, ischemia, and cold pressor), temporal summation of pain and the nociceptive flexion reflex (NFR), and conditioned pain modulation of pain/NFR.

RESULTS

Pain-related anxiety mediated the relationships between NA race and pain tolerance and conditioned pain modulation of NFR. Exploratory analyses failed to show that race moderated relationships between pain-related anxiety and pain outcomes.

CONCLUSION

These findings imply that pain-related anxiety is not a unique mechanism of pain risk for NAs, but that the greater tendency to experience pain-related anxiety by NAs impairs their ability to engage descending inhibition of spinal nociception and decreases their pain tolerance (more so than NHWs). Thus, pain-related anxiety may promote pronociceptive processes in NAs to place them at risk for future chronic pain.

An experimental investigation of the relationships among race, prayer, and pain

Background and aims Compared to White individuals, Black individuals demonstrate a lower pain tolerance. Research suggests that differences in pain coping strategies, such as prayer, may mediate this race difference. However, previous research has been cross-sectional and has not determined whether prayer in and of itself or rather the passive nature of prayer is driving the effects on pain tolerance. The aim of this study was to clarify the relationships among race, prayer (both active and passive), and pain tolerance. Methods We randomly assigned 208 pain-free participants (47% Black, 53% White) to one of three groups: active prayer ("God, help me endure the pain"), passive prayer ("God, take the pain away"), or no prayer ("The sky is blue"). Participants first completed a series of questionnaires including the Duke University Religion Index, the Coping Strategies Questionnaire-Revised (CSQ-R), and the Pain Catastrophizing Scale. Participants were then instructed to repeat a specified prayer or distractor coping statement while undergoing a cold pressor task. Cold pain tolerance was measured by the number of seconds that had elapsed while the participant's hand remained in the cold water bath (maximum 180 s). Results Results of independent samples t-tests indicated that Black participants scored higher on the CSQ-R prayer/hoping subscale. However, there were no race differences among other coping strategies, religiosity, or catastrophizing. Results of a 2 (Race: White vs. Black)×3 (Prayer: active vs. passive vs. no prayer) ANCOVA controlling for a general tendency to pray and catastrophizing in response to prayer indicated a main effect of prayer that approached significance (p=0.06). Pairwise comparisons indicated that those in the active prayer condition demonstrated greater pain tolerance than those in the passive (p=0.06) and no prayer (p=0.03) conditions. Those in the passive and no prayer distractor conditions did not significantly differ (p=0.70). There was also a trending main effect of race [p=0.08], with White participants demonstrating greater pain tolerance than Black participants. Conclusions Taken together, these results indicate that Black participants demonstrated a lower pain tolerance than White participants, and those in the active prayer condition demonstrated greater tolerance than those in the passive and no prayer conditions. Furthermore, Black participants in the passive prayer group demonstrated the lowest pain tolerance, while White participants in the active prayer group exhibited the greatest tolerance. Results of this study suggest that passive prayer, like other passive coping strategies, may be related to lower pain tolerance and thus poorer pain outcomes, perhaps especially for Black individuals. On the other hand, results suggest active prayer is associated with greater pain tolerance, especially for White individuals. Implications These results suggest that understanding the influence of prayer on pain may require differentiation between active versus passive prayer strategies. Like other active coping strategies for pain, active prayer may facilitate self-management of pain and thus enhance pain outcomes independent of race. Psychosocial interventions may help religiously-oriented individuals, regardless of race, cultivate a more active style of prayer to improve their quality of life.

Racial/ethnic differences in experimental pain sensitivity and associated factors - Cardiovascular responsiveness and psychological status

This study evaluated the contributions of psychological status and cardiovascular responsiveness to racial/ethnic differences in experimental pain sensitivity. The baseline measures of 3,159 healthy individuals-non-Hispanic white (NHW): 1,637, African-American (AA): 1,012, Asian: 299, and Hispanic: 211-from the OPPERA prospective cohort study were used. Cardiovascular responsiveness measures and psychological status were included in structural equation modeling based mediation analyses. Pain catastrophizing was a significant mediator for the associations between race/ethnicity and heat pain tolerance, heat pain ratings, heat pain aftersensations, mechanical cutaneous pain ratings and aftersensations, and mechanical cutaneous pain temporal summation for both Asians and AAs compared to NHWs. HR/MAP index showed a significant inconsistent (mitigating) mediating effect on the association between race/ethnicity (AAs vs. NHWs) and heat pain tolerance. Similarly, coping inconsistently mediated the association between race/ethnicity and mechanical cutaneous pain temporal summation in both AAs and Asians, compared to NHWs. The factor encompassing depression, anxiety, and stress was a significant mediator for the associations between race/ethnicity (Asians vs. NHWs) and heat pain aftersensations. Thus, while pain catastrophizing mediated racial/ethnic differences in many of the QST measures, the psychological and cardiovascular mediators were distinctly restrictive, signifying multiple independent mechanisms in racial/ethnic differences in pain.

Pain coping skills training for African Americans with osteoarthritis study: baseline participant characteristics and comparison to prior studies

Background

The Pain Coping Skills Training for African Americans with OsteoaRTthritis (STAART) trial is examining the effectiveness of a culturally enhanced pain coping skills training (CST) program for African Americans with osteoarthritis (OA). This disparities-focused trial aimed to reach a population with greater symptom severity and risk factors for poor pain-related outcomes than previous studies. This paper compares characteristics of STAART participants with prior studies of CST or cognitive behavioral therapy (CBT)-informed training in pain coping strategies for OA.

Methods

A literature search identified 10 prior trials of pain CST or CBT-informed pain coping training among individuals with OA. We descriptively compared characteristics of STAART participants with other studies, in 3 domains of the National Institutes of Minority Health and Health Disparities’ Research Framework: Sociocultural Environment (e.g., age, education, marital status), Biological Vulnerability and Mechanisms (e.g, pain and function, body mass index), and Health Behaviors and Coping (e.g., pain catastrophizing). Means and standard deviations (SDs) or proportions were calculated for STAART participants and extracted from published manuscripts for comparator studies.

Results

The mean age of STAART participants, 59 years (SD = 10.3), was lower than 9 of 10 comparator studies; the proportion of individuals with some education beyond high school, 75%, was comparable to comparator studies (61–86%); and the proportion of individuals who are married or living with a partner, 42%, was lower than comparator studies (62–66%). Comparator studies had less than about 1/3 African American participants. Mean scores on the Western Ontario and McMaster Universities Osteoarthritis Index pain and function scales were higher (worse) for STAART participants than for other studies, and mean body mass index of STAART participants, 35.2 kg/m² (SD = 8.2), was higher than all other studies (30–34 kg/m²). STAART participants’ mean score on the Pain Catastrophizing scale, 19.8 (SD = 12.3), was higher (worse) than other studies reporting this measure (7–17).

Conclusions

Compared with prior studies with predominantly white samples, STAART participants have worse pain and function and more risk factors for negative pain-related outcomes across several domains. Given STAART participants’ high mean pain catastrophizing scores, this sample may particularly benefit from the CST intervention approach.

Trial registration

NCT02560922

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2249-6) contains supplementary material, which is available to authorized users.

Coping with Pain in the Face of Healthcare Injustice in Patients with Sickle Cell Disease

To evaluate the pain coping strategies of patients with sickle cell disease (SCD) who experience healthcare injustice from either physicians or nurses during medical visits for pain management. It is unknown how patients' coping with pain relates to their experiences of healthcare injustice from physicians or nurses. This descriptive comparative study included adult outpatients with SCD who completed the PAINReportIt^®, Healthcare Justice Questionnaire^©, and Coping Strategies Questionnaire-SCD. Data were analyzed using independent t tests. Frequent coping strategies of patients who experienced healthcare justice from physicians were praying-hoping and from nurses were praying-hoping, calming self-statements, diverting attention, and increasing behavioral activity. In contrast, frequent coping strategies of patients who experienced healthcare injustice from physicians were catastrophizing and isolation and from nurses were isolation. Patients who experienced healthcare justice used different sets of pain coping strategies than those who experienced healthcare injustice during medical visits for pain management.

Effects of a Home-Based Telephone-Supported Physical Activity Program for Older Adult Veterans With Chronic Low Back Pain

BACKGROUND

Chronic low back pain (CLBP) is highly prevalent in older adults, leading to functional decline.

OBJECTIVE

The objective of this study was to evaluate physical activity (PA) only and PA plus cognitive-behavioral therapy for pain (CBT-P) among older adult veterans with CLBP.

DESIGN

This study was a pilot randomized trial comparing a 12-week telephone-supported PA-only intervention group (PA group) or PA plus CBT-P intervention group (PA + CBT-P group) and a wait-list control group (WL group).

SETTING

The study setting was the Durham Veterans Affairs Health Care System.

PARTICIPANTS

The study participants were 60 older adults with CLBP.

INTERVENTIONS

The PA intervention included stretching, strengthening, and aerobic activities; CBT-P covered activity pacing, relaxation techniques, and cognitive restructuring.

MEASUREMENTS

Feasibility measures included enrollment and completion metrics; acceptability was measured by completed phone calls. Primary outcomes included the Timed "Up & Go" Test and the PROMIS Health Assessment Questionnaire. Generalized linear mixed models were used to estimate changes within and between groups. Effect sizes were calculated with the Cohen d. Adverse effects were measured by self-report.

RESULTS

The mean participant age was 70.3 years; 53% were not white, and 93% were men. Eighty-three percent of participants completed the study, and the mean number of completed phone calls was 10 (of 13). Compared with the results for the WL group, small to medium treatment effects were found for the intervention groups in the Timed "Up & Go" Test (PA group: -2.94 [95% CI = -6.24 to 0.35], effect size = -0.28; PA + CBT-P group: -3.26 [95% CI = -6.69 to 0.18], effect size = -0.31) and the PROMIS Health Assessment Questionnaire (PA group: -6.11 [95% CI = -12.85 to 0.64], effect size = -0.64; PA + CBT-P group: -4.10 [95% CI = -11.69 to 3.48], effect size = -0.43). Small treatment effects favored PA over PA + CBT-P. No adverse effects were noted.

LIMITATIONS

This was a pilot study, and a larger study is needed to verify the results.

CONCLUSIONS

This pilot trial demonstrated that home-based telephone-supported PA interventions were feasible, acceptable, and safe for older adult veterans. The results provide support for a larger trial investigating these interventions.

Active pain coping is associated with the response in real-time fMRI neurofeedback during pain

Real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback is used as a tool to gain voluntary control of activity in various brain regions. Little emphasis has been put on the influence of cognitive and personality traits on neurofeedback efficacy and baseline activity. Here, we assessed the effect of individual pain coping on rt-fMRI neurofeedback during heat-induced pain. Twenty-eight healthy subjects completed the Coping Strategies Questionnaire (CSQ) prior to scanning. The first part of the fMRI experiment identified target regions using painful heat stimulation. Then, subjects were asked to down-regulate the pain target brain region during four neurofeedback runs with painful heat stimulation. Functional MRI analysis included correlation analysis between fMRI activation and pain ratings as well as CSQ ratings. At the behavioral level, the active pain coping (first principal component of CSQ) was correlated with pain ratings during neurofeedback. Concerning neuroimaging, pain sensitive regions were negatively correlated with pain coping. During neurofeedback, the pain coping was positively correlated with activation in the anterior cingulate cortex, prefrontal cortex, hippocampus and visual cortex. Thermode temperature was negatively correlated with anterior insula and dorsolateral prefrontal cortex activation. In conclusion, self-reported pain coping mechanisms and pain sensitivity are a source of variance during rt-fMRI neurofeedback possibly explaining variations in regulation success. In particular, active coping seems to be associated with successful pain regulation.

Examining Biopsychosocial Factors in Relation to Multiple Pain Features in Pediatric Sickle Cell Disease

OBJECTIVE

To examine biopsychosocial variables in relation to multiple pain features in pediatric sickle cell disease (SCD).

METHODS

76 children with SCD (M = 14.05, SD = 3.26), ages 8-19 years, and 70 caregivers completed measures of coping, mood, and family functioning and reported on multiple pain features via retrospective interviews during routine hematological visits. Sickle cell genotype and health care utilization were collected via medical record review. Using hierarchical regression, biological (genotype), child psychological (coping and mood), and social factors (caregiver coping and family functioning) were evaluated in relation to multiple pain features.

RESULTS

Genotype was associated with pain intensity, and child psychological factors were associated with pain frequency. Multiple biopsychosocial factors were related to health care utilization.

CONCLUSIONS

Biopsychosocial factors may have distinct relationships with pain features in pediatric SCD. Understanding these relationships may refine the biopsychosocial model and inform integrated medical and psychosocial approaches in SCD.

A comparison of coping strategies in patients with fibromyalgia, chronic neuropathic pain, and pain-free controls

Patients suffering from chronic pain may benefit from learning adaptive coping strategies. Consensus on efficient strategies for this group of patients is, however, lacking, and previous studies have shown inconsistent results. The present study has examined coping strategies in two distinctly different groups of chronic pain patients and a group of healthy controls. Thirty neuropathic pain (NP) patients, 28 fibromyalgia (FM) patients, and 26 pain-free healthy controls completed the Coping Strategy Questionnaire (CSQ-48/27) and rated their daily pain. The results showed that FM and NP patients did not cope differently with pain. The only difference between the groups was that FM patients felt more in control of their pain than NP patients. Both patient groups used more maladaptive/passive coping strategies, but surprisingly also more adaptive/active coping strategies than healthy controls. However, FM patients with high levels of passive strategies felt less in control than FM patients with low levels of passive strategies. This was not seen in NP patients. An important implication for clinical practice is therefore that passive coping strategies should be restructured into active ones, especially for FM patients. Otherwise, the same psychological treatment model can be applied to both groups since they use similar coping styles.

Pain coping skills training for African Americans with osteoarthritis (STAART): study protocol of a randomized controlled trial

BACKGROUND

African Americans bear a disproportionate burden of osteoarthritis (OA), with higher prevalence rates, more severe pain, and more functional limitations. One key barrier to addressing these disparities has been limited engagement of African Americans in the development and evaluation of behavioral interventions for management of OA. Pain Coping Skills Training (CST) is a cognitive-behavioral intervention with shown efficacy to improve OA-related pain and other outcomes. Emerging data indicate pain CST may be a promising intervention for reducing racial disparities in OA symptom severity. However, there are important gaps in this research, including incorporation of stakeholder perspectives (e.g. cultural appropriateness, strategies for implementation into clinical practice) and testing pain CST specifically among African Americans with OA. This study will evaluate the effectiveness of a culturally enhanced pain CST program among African Americans with OA.

METHODS/DESIGN

This is a randomized controlled trial among 248 participants with symptomatic hip or knee OA, with equal allocation to a pain CST group and a wait list (WL) control group. The pain CST program incorporated feedback from patients and other stakeholders and involves 11 weekly telephone-based sessions. Outcomes are assessed at baseline, 12 weeks (primary time point), and 36 weeks (to assess maintenance of treatment effects). The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index, and secondary outcomes include self-efficacy, pain coping, pain interference, quality of life, depressive symptoms, and global assessment of change. Linear mixed models will be used to compare the pain CST group to the WL control group and explore whether participant characteristics are associated with differential improvement in the pain CST program. This research is in compliance with the Helsinki Declaration and was approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, Durham Veterans Affairs Medical Center, East Carolina University, and Duke University Health System.

DISCUSSION

This culturally enhanced pain CST program could have a substantial impact on outcomes for African Americans with OA and may be a key strategy in the reduction of racial health disparities.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02560922 , registered 9/22/2015.

Differences in Pain Coping Between Black and White Americans: A Meta-Analysis

Compared with white individuals, black individuals experience greater pain across clinical and experimental modalities. These race differences may be due to differences in pain-related coping. Several studies examined the relationship between race and pain coping; however, no meta-analytic review has summarized this relationship or attempted to account for differences across studies. The goal of this meta-analytic review was to quantify race differences in the overall use of pain coping strategies as well as specific coping strategies. Relevant studies were identified using electronic databases, an ancestry search, and by contacting authors for unpublished data. Of 150 studies identified, 19 met inclusion criteria, resulting in 6,489 participants and 123 effect sizes. All of the included studies were conducted in the United States. Mean effect sizes were calculated using a random effects model. Compared with white individuals, black individuals used pain coping strategies more frequently overall (standardized mean difference [d] = .25, P < .01), with the largest differences observed for praying (d = .70) and catastrophizing (d = .40). White individuals engaged in task persistence more than black individuals (d = -.28). These results suggest that black individuals use coping strategies more frequently, specifically strategies associated with poorer pain outcomes. Future research should examine the extent to which the use of these strategies mediates race differences in the pain experience.

PERSPECTIVE

Results of this meta-analysis examining race differences in pain-related coping indicate that, compared with white individuals, black individuals use coping strategies more frequently, specifically those involving praying and catastrophizing. These differences in coping may help to explain race differences in the pain experience.

Comparison of Low Back Pain Recovery and Persistence: A Descriptive Study of Characteristics at Pain Onset

BACKGROUND

Persistent low back pain is a significant problem worldwide. Early identification and treatment of individuals at high risk for persistent low back pain have been suggested as strategies to decrease the rate of disability associated with this condition.

PURPOSE

To examine and compare demographic, pain-related, psychological, and somatosensory characteristics in a cohort of participants with acute low back pain who later went on to experience persistent low back pain or whose pain resolved within the first 6 weeks after initial onset.

METHODS

A descriptive study was conducted among men and women 18-50 years of age who had an acute episode of low back pain. Study questionnaires were administered to collect demographic information and measures of pain, coping, reactivity, mood, work history and satisfaction, and disability. A standardized protocol of quantitative sensory testing was performed on each participant at the painful area of their low back and at a remote site on their arm.

RESULTS

The sample consisted of 48 participants, of whom 19 went on to develop persistent low back pain and 29 resolved. Compared to the resolved group, the persistent low back pain group was significantly older and had a lower level of educational attainment, a higher body mass index, and higher mean "least" pain score on the Brief Pain Inventory-Short Form. Significantly higher thermal detection thresholds at the painful and remote sites as well as signs of central sensitivity differentiated the persistent pain group from the resolved group during the acute stage of low back pain.

Associations between psychological variables and pain in experimental pain models. A systematic review

BACKGROUND

The association between pain and psychological characteristics has been widely debated. Thus, it remains unclear whether an individual's psychological profile influences a particular pain experience, or if previous pain experience contributes to a certain psychological profile. Translational studies performed in healthy volunteers may provide knowledge concerning psychological factors in healthy individuals as well as basic pain physiology. The aim of this review was to investigate whether psychological vulnerability or specific psychological variables in healthy volunteers are predictive of the level of pain following experimental pain models.

METHODS

A systematic search on the databases, PubMed, Embase, Cochcrane library, and Clinicaltrials.gov was performed during September 2014. All trials investigating the association between psychological variables and experimental pain in healthy volunteers were considered for inclusion.

RESULTS

Twenty-nine trials met the inclusion criteria, with a total of 2637 healthy volunteers. The included trials investigated a total of 45 different psychological tests and 27 different types of pain models. The retrieved trials did not present a sufficiently homogenous group to perform meta-analysis. The collected results were diverse. A total of 16 trials suggested that psychological factors may predict the level of pain, seven studies found divergent results, and six studies found no significant association between psychological variables and experimental pain.

CONCLUSION

Psychological factors may have predictive value when investigating experimental pain. However, due to substantial heterogeneity and methodological shortcomings of the published literature, firm conclusions are not possible.

Mental health outcomes during colorectal cancer survivorship: a review of the literature

OBJECTIVE

This article reviews literature on adults' mental health outcomes during acute and long-term colorectal cancer (CRC) survivorship.

METHODS

We identified articles that included at least one measure of psychological symptoms or mental quality of life or well-being through a search of databases (CINAHL, MEDLINE, PsycINFO, and PsycARTICLES). Articles were published between January 2004 and April 2015.

RESULTS

A significant proportion of CRC survivors experience clinically meaningful levels of anxiety and depressive symptoms or reduced mental well-being across the trajectory of the illness. Demographic, medical, and psychosocial predictors of mental health outcomes were identified. However, few studies were theory-driven, and gaps remain in our understanding of risk and protective factors with respect to mental health outcomes, especially during long-term CRC survivorship.

CONCLUSIONS

Theory-driven longitudinal research with larger samples is required to identify subgroups of CRC survivors with different trajectories of psychological adjustment. Such research would assess adjustment as a function of internal resources (e.g., personality and coping) and external resources (e.g., finances and social support) to inform future interventions for CRC survivors. Copyright © 2015 John Wiley & Sons, Ltd.

Dental pain and self-care: a cross-sectional study of people with low socio-economic status residing in rural India

CONTEXT

Self-care is one of the ways in which people without access to professional care can actively engage in managing their oral health problems.

AIM

To find out the prevalence of dental pain and the type of self-care remedies utilised for pain relief by people with low socio-economic status residing in Kollipara mandal, Guntur district, Andhra Pradesh.

SETTINGS AND DESIGN

This was a cross-sectional population-based study.

METHODS AND MATERIAL

A multistage simple random-sampling technique was adopted to obtain an appropriate sample. A questionnaire, which consisted of sections on socio-economic and demographic variables, dental pain, pain characteristics and self-care remedies utilised to combat dental pain, was used to collect data. Statistical analysis used the chi-square test and descriptive statistics.

RESULTS

The survey covered a total population of 630 individuals. The mean age of the population was 32.8±16.7 years. Among the total study subjects, 44.1% were male and 55.9% were female. The prevalence of dental pain reported during the preceding 6 months was 28.3%. Subjects who experienced dental pain reported the home remedies and self-care methods that they utilised to get relief from the pain. They more frequently reported using over-the-counter medication (49.6%) for pain relief.

CONCLUSIONS

This study provides an insight into the type and usage of self-care in relief of dental pain. Pain sufferers used a variety of self-care methods to deal with their problems.

Religious leaders' opinions and guidance towards oral health maintenance and promotion: a qualitative study

Religions emphasize the supreme value of life. However, potential or concrete conflicts of perception between dictates of faith and science often present an inescapable dilemma. The aim of this qualitative research was to examine the views of spiritual and religious leaders towards general and oral health issues. A total of 11 eminent Jewish spiritual and religious community leaders were purposively chosen. They were interviewed using a semi-structured questionnaire. The verbatim transcriptions of the interviews were analysed in the spirit of grounded theory, using qualitative data analysis software. Open, axial, and thematic coding served to build categories and themes. Analysis of participants' perspectives reflected that they, based upon Jewish theology, attributed high importance to primary prevention at both personal and community levels. Religious and orthodox people were depicted as being motivated towards maintaining oral health behaviours due to a sense of obligation to follow religious edicts, strong social support, and elevated perceived spiritual levels. We offer a theoretical model that can explain the potential high motivation among these communities towards implementing positive general and oral health behaviours. Religiosity may be regarded as an example of a psycho-social health determinant, encompassing spiritual belief ("psycho") and social support ("social") components.

In Vivo praying and catastrophizing mediate the race differences in experimental pain sensitivity

Black individuals have a lower tolerance for experimental pain than white individuals. Black and white individuals also differ in their use of pain coping strategies, which may explain the race differences in pain sensitivity. We examined the extent to which situation-specific pain coping mediated black-white differences in pain sensitivity. We hypothesized that 1) black participants would demonstrate lower pain tolerance than white participants, 2) black participants would use different pain coping strategies than white participants, and 3) the differential use of these strategies would mediate the relationship between race and pain tolerance. Healthy college undergraduates (N = 190) participated in a cold pressor task and then completed the Coping Strategies Questionnaire-Revised to assess their situation-specific pain coping. Compared with white participants, black participants demonstrated lower pain tolerance, engaged in more situation-specific catastrophizing and praying, and ignored pain less frequently. Catastrophizing and praying were inversely related to pain tolerance and were significant mediators of the relationship between race and pain tolerance. The indirect effect of praying was stronger than that of catastrophizing. Race differences in pain sensitivity may be due, in part, to differences in the use of catastrophizing and praying as coping strategies. These results may help guide treatments addressing maladaptive pain coping.

PERSPECTIVE

This study suggests that race differences in pain sensitivity may be due, in part, to the differential use of catastrophizing and praying strategies. Psychosocial treatments for pain should encourage patients to take an active role in their pain management.

The significance of pain catastrophizing in clinical manifestations of patients with lumbar spinal stenosis: mediation analysis with bootstrapping

BACKGROUND CONTEXT

Pain intensity in various chronic pain disorders has been associated with catastrophizing. Considering the pathomechanism and clinical symptoms of lumbar spinal stenosis (LSS), pain catastrophizing could be associated with pain intensity and disability in patients with LSS.

PURPOSE

Firstly, to determine whether catastrophizing is associated with an increased intensity of pain and disability, and secondly, to determine whether it is linked to the relationship of gender to pain and disability in patients with degenerative LSS by using mediation analyses with bootstrapping.

STUDY DESIGN

Medical records review.

PATIENT SAMPLE

Patients with degenerative LSS were included.

OUTCOME MEASURES

They included visual analog scale (VAS) for back pain, VAS for leg pain, Oswestry Disability Index (ODI), and pain catastrophizing scale (PCS).

METHODS

Ninety-five patients who were diagnosed with degenerative LSS were included in this study. Detailed demographic data including age, sex, and body mass index and series of questionnaires were collected, including PCS, ODI, and VAS for back and leg pain. Radiologic analysis including the grade of canal stenosis and disc/facet joint degeneration was performed using magnetic resonance imaging and computed tomography findings. After adjustment of covariates, multivariate regression analysis was used to assess each component of the proposed mediation models among VAS for back/leg pain, ODI, gender, and PCS. Mediation was also assessed by the bootstrapping technique.

RESULTS

Pain catastrophizing demonstrated a significant positive association with pain intensity and disability represented by VAS for back and leg pain and ODI scores. The mediation analysis confirmed the mediating role of VAS for back pain in the relationship between PCS and ODI. Furthermore, multivariate regression analysis with bootstrapping demonstrated that the PCS significantly mediated the gender differences in VAS for back pain and ODI.

CONCLUSIONS

Pain catastrophizing was a mediator of gender differences for back pain and disability in patients with LSS. In addition, pain catastrophizing was associated with disability in LSS, which was partially mediated by increased back pain intensity.

Psychological factors associated with development of TMD: the OPPERA prospective cohort study

Case-control studies have consistently associated psychological factors with chronic pain in general and with temporomandibular disorder (TMD) specifically. However, only a handful of prospective studies have explored whether preexisting psychological characteristics represent risk factors for first-onset TMD. The current findings derive from the prospective cohort study of the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) cooperative agreement. For this study, 3,263 TMD-free participants completed a battery of psychological instruments assessing general psychological adjustment and personality, affective distress, psychosocial stress, somatic symptoms, and pain coping and catastrophizing. Study participants were then followed prospectively for an average of 2.8 years to ascertain cases of first-onset of TMD, and 2,737 provided follow-up data and were considered in the analyses of TMD onset. In bivariate and demographically adjusted analyses, several psychological variables predicted increased risk of first-onset TMD, including reported somatic symptoms, psychosocial stress, and affective distress. Principal component analysis of 26 psychological scores was used to identify latent constructs, revealing 4 components: stress and negative affectivity, global psychological and somatic symptoms, passive pain coping, and active pain coping. In multivariable analyses, global psychological and somatic symptoms emerged as the most robust risk factor for incident TMD. These findings provide evidence that measures of psychological functioning can predict first onset of TMD. Future analyses in the OPPERA cohort will determine whether these psychological factors interact with other variables to increase risk for TMD onset and persistence.

PERSPECTIVE

This article reports that several premorbid psychological variables predict first-onset TMD in the OPPERA study, a large prospective cohort study designed to discover causal determinants of TMD pain. Measures of somatic symptoms were most strongly associated with TMD onset, but perceived stress, previous life events, and negative affect also predicted TMD incidence.

Experimental pain phenotype profiles in a racially and ethnically diverse sample of healthy adults

OBJECTIVE

To examine patterns of interindividual variability in experimental pain responses emerging from multiple experimental pain measures in a racially/ethnically diverse sample of healthy adults and to examine the association between the derived phenotype profiles with demographic, psychological, and health-related measures.

METHODS

Two hundred and ninety-one participants underwent heat, cold, pressure, and ischemic pain assessments, and completed several psychological and health-related assessments. The experimental pain measures were subjected to a principal component analysis and factor scores were used to compute Pain Sensitivity Index scores. The scores were subsequently submitted to a cluster analysis to identify patterns of pain sensitivity across experimental pain modalities.

RESULTS

The sample was equally composed of non-Hispanic whites, African Americans, and Hispanic whites. Sensitivity scores were computed for heat pain, pressure pain, cold pain, ischemic pain, and temporal summation of heat pain. Five distinct clusters were characterized by high heat pain sensitivity, low ischemic pain sensitivity, low cold pain sensitivity, low pressure pain sensitivity, and high temporal summation. Cluster membership was significantly different by sex as well as somatic reactivity and catastrophizing, although cluster differences were most pronounced between the heat pain-sensitive individuals vs the cold pain-insensitive individuals.

CONCLUSIONS

Our findings highlight the importance of phenotyping individuals to account for interindividual differences in pain responses. Our findings also replicate previously reported pain phenotypes, which are not solely related to demographic, psychosocial, or health-related factors in our healthy participants. Future studies designed to elucidate the biological underpinnings of pain sensitivity profiles would be of substantial value.

Stress mitigation to promote development of prosocial values and school engagement of inner-city urban African American and Latino youth

Studies of predictors of development of young men of color have been primarily focused on factors that impede positive development rather than factors that promote it. There are also few examples of longitudinal studies of positive development of this population and few that consider multiple protective factors simultaneously. Little is also known about how such positive outcomes might relate to prediction of problematic functioning. This study tests a developmental-ecological framework of positive and risky development among a sample of young men of color growing up in high-risk urban environments. African American and Latino adolescent males (148 African American, 193 Latino) were followed from early to late adolescence. Stress in early adolescence was related to school engagement and prosocial values as well as depressive symptoms and problems assessed 2 years later. The role of family and individual protective factors as direct effects and as mitigating the stress-outcome relation were also tested. Stress predicted problem outcomes but not positive functioning. Early engagement in prosocial activities and coping skills did predict positive outcomes. In contrast, problem outcomes were predicted directly by stress, with some indication of interaction with some protective factors for both such outcomes. Overall results suggest value in focusing on positive outcomes along with negative outcomes, as they are not the antithesis and have some shared but some different predictors. Implications for supporting positive development are presented.

Adaptive coping strategies among adults with dental fear. Further development of a new version of the Dental Coping Strategy Questionnaire

OBJECTIVE

The aim of this study was to further develop and investigate a newly constructed 15-item questionnaire on strategies for coping with dental treatment, used by fearful adult patients undergoing regular dental care and those with phobic avoidance.

MATERIALS AND METHODS

The dental coping strategy questionnaire (DCSQ-15) was distributed to 77 individuals with dental phobic avoidance and 94 fearful patients undergoing regular dental care. Previous analyses of a 20-item coping questionnaire (DCSQ-20) revealed that 2 of 4 identified factors predicted regularity or phobic avoidance of dental care. However, one of these factors was considered related to catastrophizing thoughts and not to coping strategies and it was therefore removed in the present study.

RESULTS

The reduced 15-item questionnaire was analyzed to identify its factor structure and a 5-factor solution was found. The five factors were labeled (i) 'self-efficacy', (ii) 'self-distraction', (iii) 'distancing', (iv) 'praying' and (v) 'optimism'. The factors of 'praying' and 'optimism' correlated significantly with dental anxiety and were assessed significantly higher and lower respectively, among individuals with phobic avoidance. A logistic regression analysis revealed that 'optimism', together with gender and dental anxiety, was predictive of the regularity or phobic avoidance of dental care.

Potential psychosocial risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study

Case-control studies have consistently associated psychosocial factors with chronic pain in general, and with temporomandibular disorders (TMD) specifically. Moreover, a handful of prospective studies suggest that preexisting psychosocial characteristics represent risk factors for new onset TMD. The current study presents psychosocial findings from the baseline case-control study of the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) cooperative agreement. For this study, 1,633 TMD-free controls and 185 TMD cases completed a battery of psychosocial instruments assessing general psychosocial adjustment and personality, affective distress, psychosocial stress, somatic awareness, and pain coping and catastrophizing. In bivariate and demographically adjusted analyses, odds of TMD were associated with higher levels of psychosocial symptoms, affective distress, somatic awareness, and pain catastrophizing. Among controls, significant gender and ethnic group differences in psychosocial measures were observed, consistent with previous findings. Principal component analysis was undertaken to identify latent constructs revealing 4 components: stress and negative affectivity, global psychosocial symptoms, passive pain coping, and active pain coping. These findings provide further evidence of associations between psychosocial factors and TMD. Future prospective analyses in the OPPERA cohort will determine if the premorbid presence of these psychosocial factors predicts increased risk for developing new onset TMD.

PERSPECTIVE

This article reports baseline psychosocial findings from the OPPERA Study, a large prospective cohort study designed to discover causal determinants of TMD pain. Findings indicate significant differences between TMD cases and TMD-free controls across multiple psychosocial constructs, and future analyses will determine whether these psychosocial factors increase risk for new onset TMD.

Challenges and opportunities in pain management disparities research: implications for clinical practice, advocacy, and policy

Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward.

PERSPECTIVE

Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

Ethnicity interacts with the OPRM1 gene in experimental pain sensitivity

Robust interindividual variation in pain sensitivity has been observed, and recent evidence suggests that some of the variability may be genetically mediated. Our previous data revealed significantly higher pressure pain thresholds among individuals possessing the minor G allele of the A118G SNP of the mu-opioid receptor gene (OPRM1) compared with those with 2 consensus alleles. Moreover, ethnic differences in pain sensitivity have been widely reported. Yet, little is known about the potential interactive associations of ethnicity and genotype with pain perception. This study aimed to identify ethnic differences in OPRM1 allelic associations with experimental pain responses. A total of 247 healthy young adults from three ethnic groups (81 African Americans; 79 non-white Hispanics; and 87 non-Hispanic whites) underwent multiple experimental pain modalities (thermal, pressure, ischemic, cold pressor). Few African Americans (7.4%) expressed the rare allele of OPRM1 compared to non-Hispanic whites and Hispanics (28.7% vs. 27.8%, respectively). Across the entire sample, OPRM1 genotype did not significantly affect pain sensitivity. However, analysis in each ethnic group separately revealed significant genotype effects for most pain modalities among non-Hispanic-whites (P<.05) but not Hispanics or African Americans. The G allele was associated with decreased pain sensitivity among whites only; a trend in the opposite direction emerged in Hispanics. The reasons for this dichotomy are unclear; they may involve ethnic differences in haplotypic structure, or A118G may be a tag-SNP linked to other functional polymorphisms. These findings demonstrate an ethnicity-dependent association of OPRM1 genotype with pain sensitivity. Additional research is warranted to uncover the mechanisms influencing these relationships.

A quantitative review of ethnic group differences in experimental pain response: do biology, psychology, and culture matter?

OBJECTIVE

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.

METHOD

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 to 2011, and used 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.

RESULTS

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; AA 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.

CONCLUSION

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.

Defining racial and ethnic disparities in pain management

BACKGROUND

Substantial pain prevalence is as high as 40% in community populations. There is consistent evidence that racial/ethnic minority individuals are overrepresented among those who experience such pain and whose pain management is inadequate.

QUESTIONS/PURPOSES

The objectives of this paper are to (1) define parameters of and summarize evidence pertinent to racial/ethnic minority disparities in pain management, (2) identify factors contributing to observed disparities, and (3) identify strategies to minimize the disparities.

METHODS

Scientific literature was selectively reviewed addressing pain epidemiology, differences in pain management of non-Hispanic whites versus racial/ethnic minority groups, and patient and physician factors contributing to such differences.

RESULTS

Racial/ethnic minorities consistently receive less adequate treatment for acute and chronic pain than non-Hispanic whites, even after controlling for age, gender, and pain intensity. Pain intensity underreporting appears to be a major contribution of minority individuals to pain management disparities. The major contribution by physicians to such disparities appears to reflect limited awareness of their own cultural beliefs and stereotypes regarding pain, minority individuals, and use of narcotic analgesics.

CONCLUSIONS

Racial/ethnic minority patients with pain need to be empowered to accurately report pain intensity levels, and physicians who treat such patients need to acknowledge their own belief systems regarding pain and develop strategies to overcome unconscious, but potentially harmful, negative stereotyping of minority patients.

Subjective sleep quality and ethnicity are interactively related to standard and situation-specific measures of pain catastrophizing

OBJECTIVE

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.

DESIGN

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 and a standard version of the Pain Catastrophizing Scale (PCS). Following CPT, participants completed a situation-specific version of the PCS.

RESULTS

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 American and Asian American counterparts. Furthermore, African Americans with poorer sleep efficiency reported greater catastrophizing on the situation-specific PCS compared with Caucasian American and Asian Americans. Catastrophizing was significantly correlated with pain reports.

CONCLUSIONS

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.