Estimates of pain prevalence and severity in adults: United States, 2012

Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey

CONTEXT

Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists.

OBJECTIVES

To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness.

METHODS

A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs.

RESULTS

The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians.

CONCLUSION

This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.

Pains Revisited

OBJECTIVES

The management of pain patients has not evolved as rapidly as envisioned when IASP was founded almost 50 years ago. We sought to identify factors that could contribute to this situation, with a focus on concepts of pain and the education of pain physicians.

METHODS

Relevant literature describing new strategies for diagnosing and managing patients with high-impact chronic pain was reviewed.

RESULTS

It appears that the acute-chronic dichotomy has outlived its usefulness and pains should be identified as of peripheral origin or due to central processing errors. Pains of peripheral origin and those of central processing errors require different diagnostic and therapeutic strategies.

DISCUSSION

Peripheral treatments and opioids are not effective for central pains. When the cause of the pain lies in the central nervous system, a more centrally focused approach is needed to minimize wasteful pursuit of peripheral causes. The education and training of pain physicians should reflect the skills needed to address these 2 very different clinical problems.

TNFR1/p38αMAPK signaling in Nex + supraspinal neurons regulates estrogen-dependent chronic neuropathic pain

Upregulation of soluble tumor necrosis factor (sTNF) cytokine signaling through TNF receptor 1 (TNFR1) and subsequent neuronal hyperexcitability are observed in both animal models and human chronic neuropathic pain (CNP). Previously, we have shown that estrogen modulates sTNF/TNFR1 signaling in CNP, which may contribute to female prevalence of CNP. The estrogen-dependent role of TNFR1-mediated supraspinal neuronal circuitry in CNP remains unknown. In this study, we interrogated the intersect between supraspinal TNFR1 mediated neuronal signaling and sex specificity by selectively removing TNFR1 in Nex + neurons in adult mice (NexCreERT2::TNFR1f/f). We determined that mechanical hypersensitivity induced by chronic constriction injury (CCI) decreases over time in males, but not in females. Subsequently, we investigated two downstream pathways, p38MAPK and NF-κB, important in TNFR1 signaling and injury response. We detected p38MAPK and NF-κB activation in male cortical tissue; however, p38MAPK phosphorylation was reduced in NexCreERT2::TNFR1f/f males. We observed a similar recovery from acute pain in male mice following CCI when p38αMAPK was knocked out of supraspinal Nex + neurons (NexCreERT2::p38αMAPKf/f), while chronic pain developed in female mice. To explore the intersection between estrogen and inflammation in CNP we used a combination therapy of an estrogen receptor β (ER β) inhibitor with a sTNF/TNFR1 or general p38MAPK inhibitor. We determined both combination therapies lends therapeutic relief to females following CCI comparable to the response evaluated in male mice. These data suggest that TNFR1/p38αMAPK signaling in Nex + neurons in CNP is male-specific and lack of therapeutic efficacy following sTNF inhibition in females is due to ER β interference. These studies highlight sex-specific differences in pathways important to pain chronification and elucidate potential therapeutic strategies that would be effective in both sexes.

Pain Lowers Subjective Survival Probabilities Among Middle-Aged and Older Adults

OBJECTIVES

Pain is a leading cause of disability and a limiting factor in individuals' assessments of their own subjective health; however, its association with subjective longevity has yet to be explored. Subjective survival probabilities (SSPs), or one's own perceived chances of living to a given age, can influence individuals' behavior as they plan for their futures. This study assesses whether pain correlates to lower SSPs.

METHODS

We use a repeated cross-section of the 2000-2018 waves of the Health and Retirement Study, a longitudinal and nationally representative survey of Americans aged 51 and older (N = 31,773).

RESULTS

Fractional logit regressions indicate that, across all age groups, respondents with severe and/or interfering pain reported significantly lower SSPs than those with no pain (Marginal Effect [ME] = -0.03 to -0.06, p < .05). Controlling for all covariates, mild or moderate noninterfering pain was only associated with a significant reduction in SSPs among the youngest group reporting their chances of living to age 75 (ME = -0.02, p < .001). Descriptively and in the model results, respondents with mild or moderate noninterfering pain appeared to more closely resemble pain-free respondents than those with severe or interfering pain.

DISCUSSION

These findings highlight the importance of pain on SSPs, and contribute to the growing evidence that pain interference is uniquely important in predicting meaningful health outcomes.

Through the Lens of Movement-Evoked Pain: A Theoretical Framework of the "Pain-Movement Interface" to Guide Research and Clinical Care for Musculoskeletal Pain Conditions

Over 120 million Americans report experiencing pain in the past 3 months. Among these individuals, 50 million report chronic pain and 17 million report pain that limits daily life or work activities on most days (ie, high-impact chronic pain). Musculoskeletal pain conditions in particular are a major contributor to global disability, health care costs, and poor quality of life. Movement-evoked pain (MEP) is an important and distinct component of the musculoskeletal pain experience and represents an emerging area of study in pain and rehabilitation fields. This focus article proposes the "Pain-Movement Interface" as a theoretical framework of MEP that highlights the interface between MEP, pain interference, and activity engagement. The goal of the framework is to expand knowledge about MEP by guiding scientific inquiry into MEP-specific pathways to disability, high-risk clinical phenotypes, and underlying individual influences that may serve as treatment targets. This framework reinforces the dynamic nature of MEP within the context of activity engagement, participation in life and social roles, and the broader pain experience. Recommendations for MEP evaluation, encompassing the spectrum from high standardization to high patient specificity, and MEP-targeted treatments are provided. Overall, the proposed framework and recommendations reflect the current state of science in this emerging area of study and are intended to support future efforts to optimize musculoskeletal pain management and enhance patient outcomes. PERSPECTIVE: Movement-evoked pain (MEP) is a distinct component of the musculoskeletal pain experience and emerging research area. This article introduces the "Pain-Movement Interface" as a theoretical framework of MEP, highlighting the interface between MEP, pain interference, and activity engagement. Evaluating and treating MEP could improve rehabilitation approaches and enhance patient outcomes.

Cholesterol-dependent LXR transcription factor activity represses pronociceptive effects of estrogen in sensory neurons and pain induced by myelin basic protein fragments

Background

A bioactive myelin basic protein (MBP) fragment, comprising MBP84-104, is released in sciatic nerve after chronic constriction injury (CCI). Intraneural injection (IN) of MBP84-104 in an intact sciatic nerve is sufficient to induce persistent neuropathic pain-like behavior via robust transcriptional remodeling at the injection site and ipsilateral dorsal root ganglia (DRG) and spinal cord. The sex (female)-specific pronociceptive activity of MBP84-104 associates with sex-specific changes in cholesterol metabolism and activation of estrogen receptor (ESR)1 signaling.

Methods

In male and female normal and post-CCI rat sciatic nerves, we assessed: (i) cholesterol precursor and metabolite levels by lipidomics; (ii) MBP84-104 interactors by mass spectrometry of MBP84-104 pull-down; and (iii) liver X receptor (LXR)α protein expression by immunoblotting. To test the effect of LXRα stimulation on IN MBP84-104-induced mechanical hypersensitivity, the LXRα expression was confirmed along the segmental neuraxis, in DRG and spinal cord, followed by von Frey testing of the effect of intrathecally administered synthetic LXR agonist, GW3965. In cultured male and female rat DRGs exposed to MBP84-104 and/or estrogen treatments, transcriptional effect of LXR stimulation by GW3965 was assessed on downstream cholesterol transporter Abc, interleukin (IL)-6, and pronociceptive Cacna2d1 gene expression.

Results

CCI regulated LXRα ligand and receptor levels in nerves of both sexes, with cholesterol precursors, desmosterol and 7-DHC, and oxysterol elevated in females relative to males. MBP84-104 interacted with nuclear receptor coactivator (Ncoa)1, known to activate LXRα, injury-specific in nerves of both sexes. LXR stimulation suppressed ESR1-induced IL-6 and Cacna2d1 expression in cultured DRGs of both sexes and attenuated MBP84-104-induced pain in females.

Conclusion

The injury-released bioactive MBP fragments induce pronociceptive changes by selective inactivation of nuclear transcription factors, including LXRα. By Ncoa1 sequestration, bioactive MBP fragments render LXRα function to counteract pronociceptive activity of estrogen/ESR1 in sensory neurons. This effect of MBP fragments is prevalent in females due to high circulating estrogen levels in females relative to males. Restoring LXR activity presents a promising therapeutic strategy in management of neuropathic pain induced by bioactive MBP.

Assessment and management patterns for chronic musculoskeletal pain in the family practice setting

BACKGROUND

Chronic pain affects 11% of the US population. Most patients who experience pain, particularly chronic musculoskeletal pain, seek care in primary care settings. Assessment of the patient pain experience is the cornerstone to optimal pain management; however, pain assessment remains a challenge for medical professionals. It is unknown to what extent the assessment of pain intensity is considered in context of function and quality of life.

OBJECTIVE

To understand common practices related to assessment of pain and function in patients with chronic musculoskeletal disorders.

DESIGN

Cross-sectional survey.

METHODS

A 42-item electronic survey was developed with self-reported numeric ratings and responses related to knowledge, beliefs, and current practices. All physicians and non-physician clinicians affiliated with the AAFP NRN and 2000 AAFP physician members were invited to participate.

RESULTS/FINDINGS

Primary care clinicians report that chronic joint pain assessment should be comprehensive, citing assessment elements that align with the comprehensive pain assessment models. Pain intensity remains the primary focus of pain assessment in chronic joint pain and the most important factor in guiding treatment decisions, despite well-known limitations. Clinicians also report that patients with osteoarthritis should be treated by Family Medicine.

CONCLUSIONS

Pain assessment is primarily limited to pain intensity scales which may contribute to worse patient outcomes. Given that most respondents believe primary care/family medicine should be primary responsible for the care of patients with osteoarthritis, awareness of and comfort with existing guidelines, validated assessment instruments and the comprehensive pain assessment models could contribute to delivery of more comprehensive care.

Effects of Chronic Pain Diagnoses on the Antidepressant Efficacy of Transcranial Magnetic Stimulation

OBJECTIVE

Major depressive disorder (MDD) and chronic pain are highly comorbid and bidirectionally related. Repetitive transcranial magnetic stimulation (rTMS) over the dorsolateral prefrontal cortex is effective in treating MDD, but additional research is needed to determine if chronic pain interferes with rTMS for MDD.

METHODS

Participants were 124 veterans ( Mage = 49.14, SD = 13.83) scheduled for 30 sessions of rTMS across 6 weeks. Depression severity was monitored weekly using the Patient Health Questionnaire-9 (PHQ-9). Having any pain diagnosis, low back pain, or headache/migraine were assessed by chart review. We fit latent basis models to estimate total change by pain diagnosis in depression scores and quadratic latent growth models to examine differences in growth rates. Then, we computed χ2 tests of group differences in response (PHQ-9 reduction ≥50%) and remission rates (final PHQ-9 < 5).

RESULTS

A total of 92 participants (74%) had a documented pain diagnosis, 58 (47%) had low back pain, and 32 (26%) had headache/migraine. In growth models, depression scores initially decreased (linear slope estimate = -2.04, SE = 0.26, p < .0001), but the rate of decrease slowed over time (quadratic slope estimate = 0.18, SE = 0.04, p < .001). Overall change was not different as a function of any pain diagnosis ( p = .42), low back pain (p = .11 ), or headache/migraine ( p = .28). However, we found that low back pain was a negative predictor of response ( p = .032).

CONCLUSIONS

These data support rTMS as a viable treatment option for comorbid populations. Although patients with comorbid chronic pain conditions are likely to receive benefit from rTMS for depression, adjunctive pain treatment may be indicated.

Use of CYP2D6 Inhibitors with CYP2D6 Opioids: Association with Emergency Department Visits for Pain

Hydrocodone, tramadol, codeine, and oxycodone are commonly prescribed opioids that rely on activation by cytochrome P450 2D6 (CYP2D6). CYP2D6 inhibitors can significantly decrease CYP2D6 activity, leading to reduced generation of active metabolites, and impairing pain control. To understand this impact, we assessed emergency department (ED) visits in patients initiating these CYP2D6-dependent opioids while on CYP2D6-inhibitor antidepressants vs. antidepressants that do not inhibit CYP2D6. This retrospective cohort study included adult patients prescribed CYP2D6-dependent opioids utilizing electronic health records data from the University of Florida Health (2015-2021). The association between ED visits and inhibitor exposure was tested using multivariable logistic regression. The primary analysis had 12,118 patients (72% female; mean (SD) age, 55 (13.4)) in the hydrocodone/tramadol/codeine cohort and 5,547 patients (64% female; mean (SD) age, 53.6 (14.2)) in the oxycodone cohort. Hydrocodone/tramadol/codeine-treated patients exposed to CYP2D6-inhibitor antidepressants (n = 7,043) had a higher crude rate of pain-related ED visits than those taking other antidepressants (n = 5,075) (3.28% vs. 1.87%), with an adjusted odds ratio (aOR) of 1.75 (95% CI: 1.36 to 2.24). Similarly, in the oxycodone cohort, CYP2D6-inhibitor antidepressant-exposed individuals (n = 3,206) had a higher crude rate of ED visits than individuals exposed to other antidepressants (n = 2,341) (5.02% vs. 3.37%), with aOR of 1.70 (95% CI: 1.27-2.27). Similar findings were observed in secondary and sensitivity analyses. Our findings suggest patients with concomitant use of hydrocodone/tramadol/codeine or oxycodone and CYP2D6 inhibitors have more frequent ED visits for pain, which may be due to inadequate pain control.

Targeting Prefrontal Cortex Dysfunction in Pain

The prefrontal cortex (PFC) has justifiably become a significant focus of chronic pain research. Collectively, decades of rodent and human research have provided strong rationale for studying the dysfunction of the PFC as a contributing factor in the development and persistence of chronic pain and as a key supraspinal mechanism for pain-induced comorbidities such as anxiety, depression, and cognitive decline. Chronic pain alters the structure, chemistry, and connectivity of PFC in both humans and rodents. In this review, we broadly summarize the complexities of reported changes within both rodent and human PFC caused by pain and offer insight into potential pharmacological and nonpharmacological approaches for targeting PFC to treat chronic pain and pain-associated comorbidities. SIGNIFICANCE STATEMENT: Chronic pain is a significant unresolved medical problem causing detrimental changes to physiological, psychological, and behavioral aspects of life. Drawbacks of currently approved pain therapeutics include incomplete efficacy and potential for abuse producing a critical need for novel approaches to treat pain and comorbid disorders. This review provides insight into how manipulation of prefrontal cortex circuits could address this unmet need of more efficacious and safer pain therapeutics.

Pharmacogenetic landscape of pain management variants among Mediterranean populations

Background

Chronic pain is a major socioeconomic burden in the Mediterranean region. However, we noticed an under-representation of these populations in the pharmacogenetics of pain management studies. In this context, we aimed 1) to decipher the pharmacogenetic variant landscape among Mediterranean populations compared to worldwide populations in order to identify therapeutic biomarkers for personalized pain management and 2) to better understand the biological process of pain management through in silico investigation of pharmacogenes pathways.

Materials and Methods

We collected genes and variants implicated in pain response using the Prisma guidelines from literature and PharmGK database. Next, we extracted these genes from genotyping data of 829 individuals. Then, we determined the variant distribution among the studied populations using multivariate (MDS) and admixture analysis with R and STRUCTURE software. We conducted a Chi2 test to compare the interethnic frequencies of the identified variants. We used SNPinfo web server, miRdSNP database to identify miRNA-binding sites. In addition, we investigated the functions of the identified genes and variants using pathway enrichment analysis and annotation tools. Finally, we performed docking analysis to assess the impact of variations on drug interactions.

Results

We identified 63 variants implicated in pain management. MDS analysis revealed that Mediterranean populations are genetically similar to Mexican populations and divergent from other populations. STRUCTURE analysis showed that Mediterranean populations are mainly composed of European ancestry. We highlighted differences in the minor allele frequencies of three variants (rs633, rs4680, and rs165728) located in the COMT gene. Moreover, variant annotation revealed ten variants with potential miRNA-binding sites. Finally, protein structure and docking analysis revealed that two missense variants (rs4680 and rs6267) induced a decrease in COMT protein activity and affinity for dopamine.

Conclusion

Our findings revealed that Mediterranean populations diverge from other ethnic groups. Furthermore, we emphasize the importance of pain-related pathways and miRNAs to better implement these markers as predictors of analgesic responses in the Mediterranean region.

Evaluating the effectiveness of neurofeedback in chronic pain management: a narrative review

The prevalence and impact of chronic pain in individuals worldwide necessitate effective management strategies. This narrative review specifically aims to assess the effectiveness of neurofeedback, an emerging non-pharmacological intervention, on the management of chronic pain. The methodology adopted for this review involves a meticulous search across various scientific databases. The search was designed to capture a broad range of studies related to neurofeedback and chronic pain management. To ensure the quality and relevance of the included studies, strict inclusion and exclusion criteria were applied. These criteria focused on the study design, population, intervention type, and reported outcomes. The review synthesizes the findings from a diverse array of studies, including randomized controlled trials, observational studies, and case reports. Key aspects evaluated include the types of neurofeedback used (such as EEG biofeedback), the various chronic pain conditions addressed (like fibromyalgia, neuropathic pain, and migraines), and the methodologies employed in these studies. The review highlights the underlying mechanisms by which neurofeedback may influence pain perception and management, exploring theories related to neural plasticity, pain modulation, and psychological factors. The results of the review reveal a positive correlation between neurofeedback interventions and improved pain management. Several studies report significant reductions on pain intensity, improved quality of life, and decreased reliance on medication following neurofeedback therapy. The review also notes variations in the effectiveness of different neurofeedback protocols and individual responses to treatment. Despite the promising results, the conclusion of the review emphasizes the need for further research. It calls for larger, well-designed clinical trials to validate the findings, to understand the long-term implications of neurofeedback therapy, and to optimize treatment protocols for individual patients.

How Chronic Pain Patients' and Physicians' Communication Influences Patients' Uncertainty: A Pre- and Post-Consultation Study

Chronic pain is a health problem that is difficult to diagnose, treat, and manage, partly owing to uncertainty surrounding ambiguous causes, few treatment options, and frequent misunderstandings in clinical encounters. Pairing uncertainty management theory with medical communication competence, we predicted that both physicians and patients are influential to patients' uncertainty appraisals and uncertainty management. We collected pre- and post-consultation data from 200 patients with chronic neck and spine/back pain and their physicians. Patients' reports of their physician's communication were a consistent predictor of their post-consultation uncertainty outcomes. Physicians' reports of both their own and patients' communication competence were associated with patients' positive uncertainty appraisals. Physicians' reports of patients' communication competence were also associated with reductions in patients' uncertainty. Findings illustrate how both interactants' perceptions of communication competence-how they view their own (for physicians) and the other's-are associated with patients' post-consultation outcomes.

High contrast cartilaginous endplate imaging in spine using three dimensional dual-inversion recovery prepared ultrashort echo time (3D DIR-UTE) sequence

PURPOSE

To investigate the feasibility and application of a novel imaging technique, a three-dimensional dual adiabatic inversion recovery prepared ultrashort echo time (3D DIR-UTE) sequence, for high contrast assessment of cartilaginous endplate (CEP) imaging with head-to-head comparisons between other UTE imaging techniques.

METHOD

The DIR-UTE sequence employs two narrow-band adiabatic full passage (AFP) pulses to suppress signals from long T2 water (e.g., nucleus pulposus (NP)) and bone marrow fat (BMF) independently, followed by multispoke UTE acquisition to detect signals from the CEP with short T2 relaxation times. The DIR-UTE sequence, in addition to three other UTE sequences namely, an IR-prepared and fat-saturated UTE (IR-FS-UTE), a T1-weighted and fat-saturated UTE sequence (T1w-FS-UTE), and a fat-saturated UTE (FS-UTE) was used for MR imaging on a 3 T scanner to image six asymptomatic volunteers, six patients with low back pain, as well as a human cadaveric specimen. The contrast-to-noise ratio of the CEP relative to the adjacent structures-specifically the NP and BMF-was then compared from the acquired images across the different UTE sequences.

RESULTS

For asymptomatic volunteers, the DIR-UTE sequence showed significantly higher contrast-to-noise ratio values between the CEP and BMF (CNRCEP-BMF) (19.9 ± 3.0) and between the CEP and NP (CNRCEP-NP) (23.1 ± 1.7) compared to IR-FS-UTE (CNRCEP-BMF: 17.3 ± 1.2 and CNRCEP-NP: 19.1 ± 1.8), T1w-FS-UTE (CNRCEP-BMF: 9.0 ± 2.7 and CNRCEP-NP: 10.4 ± 3.5), and FS-UTE (CNRCEP-BMF: 7.7 ± 2.2 and CNRCEP-NP: 5.8 ± 2.4) for asymptomatic volunteers (all P-values < 0.001). For the spine sample and patients with low back pain, the DIR-UTE technique detected abnormalities such as irregularities and focal defects in the CEP regions.

CONCLUSION

The 3D DIR-UTE sequence is able to provide high-contrast volumetric CEP imaging for human spines on a clinical 3 T scanner.

Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies.

RECENT FINDINGS

There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.

Intravenous recombinant cerebellin 1 treatment restores signalling by spinal glutamate delta 1 receptors and mitigates chronic pain

BACKGROUND AND PURPOSE

Chronic pain remains a major clinical problem that needs effective therapeutic agents. Glutamate delta 1 (GluD1) receptors and the protein cerebellin 1 (Cbln1) are down-regulated in the central amygdala (CeA) in models of inflammatory and neuropathic pain. One treatment with Cbln1, intracerebroventricularly (ICV) or in CeA, normalized GluD1 and reduced AMPA receptor expression, resulting in lasting (7-10 days) pain relief. Unlike many CNS-targeting biological agents, the structure of Cbln1 suggests potential blood-brain barrier penetration. Here, we have tested whether systemic administration of Cbln1 provides analgesic effects via action in the CNS.

EXPERIMENTAL APPROACH

Analgesic effects of intravenous recombinant Cbln1 was assessed in complete Freund's adjuvant inflammatory pain model in mice. GluD1 knockout and a mutant form of Cbln1 were used.

KEY RESULTS

A single intravenous injection of Cbln1 mitigated nocifensive and averse behaviour in both inflammatory and neuropathic pain models. This effect of Cbln1 was dependent on GluD1 receptors and required binding to the amino terminal domain of GluD1. Time course of analgesic effect was similar to previously reported ICV and intra-CeA injection. GluD1 in both spinal cord and CeA was down -regulated in the inflammatory pain model, whereas GluD1 expression in spinal cord but not in CeA, was partly normalized by intravenous Cbln1. Importantly, recombinant Cbln1 was detected in the synaptoneurosomes in spinal cord but not in the CeA.

CONCLUSIONS AND IMPLICATIONS

Our results describe a novel mechanism by which systemic Cbln1 induces analgesia potentially by central actions involving normalization of signalling by spinal cord GluD1 receptors.

Longitudinal associations between subjective cognitive impairment, pain and depressive symptoms in home-dwelling older adults: Modelling within-person effects

OBJECTIVES

Cognitive impairment, pain and depressive symptoms are common and interrelated factors in older adults. However, the directionality and specificity of their association remains unclarified. This study explored whether these factors prospectively increase reciprocal risk and examined the longitudinal association between these factors and quality of life (QoL).

METHODS

This study used longitudinal data from The Older Persons and Informal Caregivers Survey Minimal Data Set (TOPICS-MDS; the Netherlands). Older adults self-reported cognitive impairment, pain, depressive symptoms and QoL at baseline and after 6 and 12 months of follow-up. The Random Intercept Cross-Lagged Panel Model was used to assess the prospective association between the three factors, while a multilevel linear regression analysis in a two-level random intercept model was used to examine the longitudinal associations between the three factors and QoL at the within-person level.

RESULTS

The data of 11,582 home-dwelling older adults with or without subjective cognitive impairment were analysed. At the within-person level, pain at 6 months was associated with subsequent depressive symptoms (β = 0.04, p = 0.024). The reverse association from depression to pain, and longitudinal associations between pain and subjective cognitive impairment and between depressive symptoms and subjective cognitive impairment were non-significant. Pain, depressive symptoms and subjective cognitive impairment showed a significant association with poor QoL 6 months later.

CONCLUSIONS

A directional relationship was observed from pain to depressive symptoms. Pain reduction holds a potential benefit in the prevention of depressive symptoms, ultimately optimising the QoL of older adults.

Enhancing Chronic Non-Cancer Pain Management: A Systematic Review of Mindfulness Therapies and Guided Imagery Interventions

Background and Objectives: There has been an increasing interest in the use of non-pharmacological approaches for the multidimensional treatment of chronic pain. The aim of this systematic review was to assess the effectiveness of mindfulness-based therapies and Guided Imagery (GI) interventions in managing chronic non-cancer pain and related outcomes. Materials and Methods: Searching three electronic databases (Web of Science, PubMed, and Scopus) and following the PRISMA guidelines, a systematic review was performed on Randomized Controlled Trials (RCTs) and pilot RCTs investigating mindfulness or GI interventions in adult patients with chronic non-cancer pain. The Cochrane Risk of Bias Tool was utilized to assess the quality of the evidence, with outcomes encompassing pain intensity, opioid consumption, and non-sensorial dimensions of pain. Results: Twenty-six trials met the inclusion criteria, with most of them exhibiting a moderate to high risk of bias. A wide diversity of chronic pain types were under analysis. Amongst the mindfulness interventions, and besides the classical programs, Mindfulness-Oriented Recovery Enhancement (MORE) emerges as an approach that improves interoception. Six trials demonstrated that mindfulness techniques resulted in a significant reduction in pain intensity, and three trials also reported significant outcomes with GI. Evidence supports a significant improvement in non-sensory dimensions of pain in ten trials using mindfulness and in two trials involving GI. Significant effects on opioid consumption were reported in four mindfulness-based trials, whereas one study involving GI found a small effect with that variable. Conclusions: This study supports the evidence of benefits of both mindfulness techniques and GI interventions in the management of chronic non-cancer pain. Regarding the various mindfulness interventions, a specific emphasis on the positive results of MORE should be highlighted. Future studies should focus on specific pain types, explore different durations of the mindfulness and GI interventions, and evaluate emotion-related outcomes.

A Single-Session, 2-Hour Version of Mindfulness-Oriented Recovery Enhancement (One MORE) Improves Chronic Pain Patients' Pain-Related Outcomes Through 3-Month Follow-Up in a Randomized Controlled Trial

Introduction: Traditional, 8-week, mindfulness-based interventions can effectively treat chronic pain, but require a time and resource investment too burdensome for many patients and providers. The solution to this logistical challenge may be to distill the core, therapeutic elements of an efficacious 8-week, mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), into a 2-h, single-session intervention. Methods: In this study, the authors conducted a waitlist-controlled, randomized clinical trial to assess the impact of a 2-h, single-session adaptation of MORE (i.e., One MORE) on chronic pain patients' (N = 40) pain-related outcomes through 3-month follow-up. Results: Results indicated that One MORE significantly improved chronic pain patients' pain catastrophizing (i.e., primary outcome; F = 9.97, p = 0.002), pain intensity (F = 26.58, p < 0.001), pain interference (F = 39.43, p < 0.001), physical function (F = 16.29, p < 0.001), sleep (F = 16.66, p < 0.001), anxiety (F = 12.54, p < 0.001), and depression (F = 17.48, p < 0.001). One MORE also significantly increased theoretically indicated therapeutic mechanisms through the 3-month follow-up: mindfulness, positive reappraisal, savoring, self-transcendence. Discussion: Study results are promising, and if replicated, would suggest that One MORE is a highly scalable, low-cost (e.g., sustainable), nonpharmacologic treatment for chronic pain. Clinical Trial Registration: NCT05194241.

Acute pain impairs retention of locomotor learning

Despite abundant evidence that pain alters movement performance, considerably less is known about the potential effects of pain on motor learning. Some of the brain regions involved in pain processing are also responsible for specific aspects of motor learning, indicating that the two functions have the potential to interact, yet it is unclear if they do. In experiment 1, we compared the acquisition and retention of a novel locomotor pattern in young, healthy individuals randomized to either experience pain via capsaicin and heat applied to the lower leg during learning or no stimulus. On day 1, participants learned a new asymmetric walking pattern using distorted visual feedback, a paradigm known to involve mostly explicit re-aiming processes. Retention was tested 24 h later. Although there were no differences in day 1 acquisition between groups, individuals who experienced pain on day 1 demonstrated reduced retention on day 2. Furthermore, the degree of forgetting between days correlated with pain ratings during learning. In experiment 2, we examined the effects of a heat stimulus alone, which served as a control for (nonpainful) cutaneous stimulation, and found no effects on either acquisition or retention of learning. Thus, pain experienced during explicit, strategic locomotor learning interferes with motor memory consolidation processes and does so most likely through a pain mechanism and not an effect of distraction. These findings have important implications for understanding basic motor learning processes and for clinical rehabilitation, in which painful conditions are often treated through motor learning-based interventions.NEW & NOTEWORTHY Pain is a highly prevalent and burdensome experience that rehabilitation practitioners often treat using motor learning-based interventions. Here, we showed that experimental acute pain, but not a heat stimulus, during locomotor learning impaired 24-h retention of the newly learned walking pattern. The degree of retention loss was related to the perceived pain level during learning. These findings suggest important links between pain and motor learning that have significant implications for clinical rehabilitation.

Problems with opioids beyond misuse

The U.S. is grappling with an opioid epidemic, with millions of adults on long-term opioid therapy (LTOT). Although patients often report pain relief and improved daily function with opioids, research shows no significant differences in short-term outcomes between opioid and non-opioid users, as well as no long-term opioid benefits. This scoping review aims to identify lesser-known side effects of long-term opioid use and increase awareness of them, allowing healthcare providers and patients to better assess the risks and benefits of opioid use. Our data search from PubMed and Google Scholar used keywords related to opioids, chronic pain, hypogonadism, endocrinopathies, cancer progression, cardiovascular events, renovascular events, sleep disturbances, mood disorders and others, narrowing down to English-language full articles published from January 2018 to April 2023. This review emphasizes the probable serious adverse consequences of long-term opioid use on various body systems in patients with chronic pain. Given the lack of long-term benefits and significant adverse effects, our review underscores the critical need for healthcare providers to include these risks in discussions with patients when considering the long-term use of opioid therapy.

Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities

ABSTRACT

Co-occurrence of chronic pain and clinically significant symptoms of anxiety and/or depression is regularly noted in the literature. Yet, little is known empirically about population prevalence of co-occurring symptoms, nor whether people with co-occurring symptoms constitute a distinct subpopulation within US adults living with chronic pain or US adults living with anxiety and/or depression symptoms (A/D). To address this gap, this study analyzes data from the 2019 National Health Interview Survey, a representative annual survey of self-reported health status and treatment use in the United States (n = 31,997). Approximately 12 million US adults, or 4.9% of the adult population, have co-occurring chronic pain and A/D symptoms. Unremitted A/D symptoms co-occurred in 23.9% of US adults with chronic pain, compared with an A/D prevalence of 4.9% among those without chronic pain. Conversely, chronic pain co-occurred in the majority (55.6%) of US adults with unremitted A/D symptoms, compared with a chronic pain prevalence of 17.1% among those without A/D symptoms. The likelihood of experiencing functional limitations in daily life was highest among those experiencing co-occurring symptoms, compared with those experiencing chronic pain alone or A/D symptoms alone. Among those with co-occurring symptoms, 69.4% reported that work was limited due to a health problem, 43.7% reported difficulty doing errands alone, and 55.7% reported difficulty participating in social activities. These data point to the need for targeted investment in improving functional outcomes for the nearly 1 in 20 US adults living with co-occurring chronic pain and clinically significant A/D symptoms.

Claims data analysis of provider-to-provider tele-mentoring program impact on opioid prescribing in Missouri

OBJECTIVE

The objective of this study was to assess opioid prescribing patterns of primary care providers (PCPs) participating in a virtual tele-mentoring program for patients with chronic pain as compared to nonparticipants.

DESIGN

We utilized Missouri Medicaid claims from 2013 to 2021 to compare opioid prescription dosages and daily supply of opioids prescribed by PCPs. Participants and nonparticipants were matched using propensity score matching.

SETTING

Missouri Medicaid data were received through partnership with the Center for Health Policy's MO HealthNet Data Project, the state's leading provider of Medicaid data.

PARTICIPANTS

Missouri-based prescribers.

INTERVENTION

Show-Me Project Extension for Community Healthcare Outcomes (ECHO), an evidence-based provider-to-provider telehealth intervention that connects PCPs with a team of specialists.

MAIN OUTCOME MEASURES

We compared the rate of prescription opioid >50 morphine milligram equivalents (MMEs), mean MMEs/day, and mean number of daily supply to understand the impact of the ECHO model on providers' opioid prescribing.

RESULTS

Patients treated by ECHO providers have 33 percent lower odds of being prescribed opioid dose >50 MME/day (p < 0.001) compared to non-ECHO providers. There is also a 14 percent reduction in the average opioid dose prescribed to patients of ECHO providers (p < 0.001). We observed a 3 percent (p < 0.001) reduction in average daily supply of opioids among patients of ECHO providers compared to the comparison group.

CONCLUSIONS

Pain Management ECHO supports PCPs with needed education and skills to provide specialty care in the management of pain conditions and safe prescribing of opioid medications.

The effect of vitamin D and omega-3 fatty acid supplementation on pain prevalence and severity in older adults: a large-scale ancillary study of the VITamin D and OmegA-3 triaL (VITAL)

ABSTRACT

A diet supplemented with vitamin D and marine omega-3 fatty acids may prevent and treat painful disorders by promoting the resolution of inflammation. However, large, randomized placebo-controlled trials evaluating the effects of supplementation with omega-3 fatty acids and vitamin D on the presence and severity of pain are lacking. VITamin D and OmegA-3 triaL-Pain (VITAL-Pain) is an ancillary study to the VITAL trial, a large randomized, double-blind, placebo-controlled trial of vitamin D (2000 IU/day) and omega-3 supplementation (1 g/day) over 5.3 years of median follow-up, among 25,871 older men and women. We assessed pain among those reaching the end of the VITAL intervention phase using questions from the 2012 National Health Interview Survey. We used ordinal logistic regression to test the effect of vitamin D and omega-3 fatty acids on the odds ratio (OR) and 95% confidence interval [CI] of reporting higher pain prevalence or severity. Overall, 19,611 participants provided complete pain information at the end of the VITAL trial. The ORs for higher pain prevalence or severity for vitamin D and omega-3 supplementation vs placebo were 0.99 ([CI] 0.94-1.05) and 0.99 ([CI] 0.94-1.04), respectively. There was no interaction between the 2 active treatments. Dietary supplementation with commonly used moderate doses of vitamin D or omega-3 fatty acids over a median of 5.3 years did not result in a lower prevalence or severity of pain in middle-aged and older U.S. adults.

Pharmacologic Characterization of LTGO-33, a Selective Small Molecule Inhibitor of the Voltage-Gated Sodium Channel NaV1.8 with a Unique Mechanism of Action

Discovery and development of new molecules directed against validated pain targets is required to advance the treatment of pain disorders. Voltage-gated sodium channels (NaVs) are responsible for action potential initiation and transmission of pain signals. NaV1.8 is specifically expressed in peripheral nociceptors and has been genetically and pharmacologically validated as a human pain target. Selective inhibition of NaV1.8 can ameliorate pain while minimizing effects on other NaV isoforms essential for cardiac, respiratory, and central nervous system physiology. Here we present the pharmacology, interaction site, and mechanism of action of LTGO-33, a novel NaV1.8 small molecule inhibitor. LTGO-33 inhibited NaV1.8 in the nM potency range and exhibited over 600-fold selectivity against human NaV1.1-NaV1.7 and NaV1.9. Unlike prior reported NaV1.8 inhibitors that preferentially interacted with an inactivated state via the pore region, LTGO-33 was state-independent with similar potencies against closed and inactivated channels. LTGO-33 displayed species specificity for primate NaV1.8 over dog and rodent NaV1.8 and inhibited action potential firing in human dorsal root ganglia neurons. Using chimeras combined with mutagenesis, the extracellular cleft of the second voltage-sensing domain was identified as the key site required for channel inhibition. Biophysical mechanism of action studies demonstrated that LTGO-33 inhibition was relieved by membrane depolarization, suggesting the molecule stabilized the deactivated state to prevent channel opening. LTGO-33 equally inhibited wild-type and multiple NaV1.8 variants associated with human pain disorders. These collective results illustrate LTGO-33 inhibition via both a novel interaction site and mechanism of action previously undescribed in NaV1.8 small molecule pharmacologic space. SIGNIFICANCE STATEMENT: NaV1.8 sodium channels primarily expressed in peripheral pain-sensing neurons represent a validated target for the development of novel analgesics. Here we present the selective small molecule NaV1.8 inhibitor LTGO-33 that interdicts a distinct site in a voltage-sensor domain to inhibit channel opening. These results inform the development of new analgesics for pain disorders.

Chronic Pain and Pain Management in Older Adults: Protocol and Pilot Results

BACKGROUND

Chronic pain occurs in 30% of older adults. This prevalence rate is expected to increase, given the growth in the older adult population and the associated growth of chronic conditions contributing to pain. No population-based studies have provided detailed, longitudinal information on the experience of chronic pain in older adults; the pharmacological and nonpharmacological strategies that older adults use to manage their chronic pain; and the effect of chronic pain on patient-reported outcomes.

OBJECTIVES

This article aims to describe the protocol for a population-based, longitudinal study focused on understanding the experience of chronic pain in older adults. The objectives are to determine the prevalence and characteristics of chronic pain; identify the pharmacological and nonpharmacological pain treatments used; evaluate for longitudinal differences in biopsychosocial factors; and examine how pain types and pain trajectories affect important patient-reported outcomes. Also included are the results of a pilot study.

METHODS

A population-based sample of approximately 1,888 older adults will be recruited from the National Opinion Research Center at the University of Chicago's AmeriSpeak Panel to complete surveys at three waves: enrollment (Wave 1), 6 months (Wave 2), and 12 months (Wave 3). To determine the feasibility, a pilot test of the enrollment survey was conducted among 123 older adults.

RESULTS

In the pilot study, older adults with chronic pain reported a range of pain conditions, with osteoarthritis being the most common. Participants reported an array of pharmacological and nonpharmacological pain strategies. Compared to participants without chronic pain, those with chronic pain reported lower physical and cognitive function and poorer quality of life. Data collection for the primary, longitudinal study is ongoing.

DISCUSSION

This project will be the first longitudinal population-based study to examine the experience and overall effect of chronic pain in older adults. Pilot study results provide evidence of the feasibility of study methods. Ultimately, this work will inform the development of tailored interventions for older patients targeted to decrease pain and improve function and quality of life.

Lifetimes of Vulnerability: Childhood Adversity, Poor Adult Health, and the Criminal Legal System

On average, incarcerated people have higher rates of poor health, mental illness, and histories of adverse childhood experiences (ACEs) than the general population. This mixed-methods analysis examines the relationship between ACEs and poor adult health among a sample of formerly incarcerated people. The quantitative analysis (N = 122) shows childhood adversity is associated with various health conditions in adulthood, although the strength of this relationship varies by the kinds of ACEs respondents encountered. The qualitative analysis of life history timelines (N = 42) reveals two pathways relating ACEs to poor health and legal system involvement: (1) violence and victimization and (2) drug use as a coping mechanism. Unaddressed mental health challenges in the aftermath of adversity emerged as an important precursor to both pathways. Prisons lack a meaningful consideration of these early life events and the social structures that result in the high rates of vulnerable people in its care.

Transformer encoder with multiscale deep learning for pain classification using physiological signals

Pain, a pervasive global health concern, affects a large segment of population worldwide. Accurate pain assessment remains a challenge due to the limitations of conventional self-report scales, which often yield inconsistent results and are susceptible to bias. Recognizing this gap, our study introduces PainAttnNet, a novel deep-learning model designed for precise pain intensity classification using physiological signals. We investigate whether PainAttnNet would outperform existing models in capturing temporal dependencies. The model integrates multiscale convolutional networks, squeeze-and-excitation residual networks, and a transformer encoder block. This integration is pivotal for extracting robust features across multiple time windows, emphasizing feature interdependencies, and enhancing temporal dependency analysis. Evaluation of PainAttnNet on the BioVid heat pain dataset confirm the model's superior performance over the existing models. The results establish PainAttnNet as a promising tool for automating and refining pain assessments. Our research not only introduces a novel computational approach but also sets the stage for more individualized and accurate pain assessment and management in the future.

The United States opioid crisis: Big pharma alone is not to blame."

OBJECTIVE

The opioid crisis in the United States continues essentially unabated, fueled by fentanyl contamination of the heroin supply and resulting in 79,770 reported opioid-involved overdose deaths in the calendar year 2022. To prevent another such crisis emerging, it is necessary to fully identify its root causes.

METHODS

Despite the well-recognized role the pharmaceutical industry played in facilitating the crisis via the aggressive marketing of prescription opioids, several other less appreciated but perhaps more influential factors were also contributors, and the overall goal of this review is to ensure that these are not be lost to history in a concerted effort to blame opioid manufacturers and distributors. Presented is a historical review of research and regulatory documents beginning with the loosening of opioid prescription for chronic pain through current thought and practice today. Beginning with a necessary decoupling of the current opioid crisis from the increased use of opioids to treat chronic pain, this review will examine these contributing factors.

RESULTS

Clinical concerns about under- or untreated pain, practice guidelines from standard-setting organizations and government entities, and a health system-wide move away from specialty interdisciplinary pain programs together set the stage for an over-reliance on opioids in chronic pain care.

CONCLUSIONS

This review reminds the health care community that despite the deep pockets of the pharmaceutical industry and highly the organized efforts of the drug cartels, additional self-reflection is warranted to fully understand the true root causes of the current epidemic and ways to prevent similar epidemics in the future.

Health-related quality of life and recovery capital among recovery residents taking medication for opioid use disorder in Texas

Background

Recovery from opioid use disorder (OUD) includes improvements in health-related quality of life (HRQOL) and is supported by recovery capital (RC). Little is known about RC and HRQOL among recovery residents taking medication for OUD. We described HRQOL and RC and identified predictors of HRQOL.

Methods

Project HOMES is an ongoing longitudinal study implemented in 14 recovery homes in Texas. This is a cross-sectional analysis of data from 358 participants' on HRQOL (five EQ-5D-5L dimensions-mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and RC (Assessment of Recovery Capital scores) collected from April 2021 to June 2023. Statistical analyses were conducted using T-, Chi-squared, and Fisher's exact tests.

Results

Most participants were 35 years/older (50.7%), male (58.9%), non-Hispanic White (68.4%), heterosexual (82.8%), and reported HRQOL problems, mainly anxiety/depression (78.4%) and pain/discomfort (55.7%). Participants who were 35 years/older [mean (SD) = 42.6 (7.3)] were more likely to report mobility and pain/discomfort problems than younger participants. Female participants were more likely to report pain/discomfort problems than male participants. Sexual minorities were more likely to report anxiety/depression problems than heterosexual participants. Married participants and those in committed relationships were more likely to report problems conducting self-care than single/never-married participants. Comorbid conditions were associated with mobility, pain/discomfort, and usual activities problems. Most participants reported high social (65.4%), personal (69.0%), and total (65.6%) RC. Low personal RC was associated with mobility (aOR = 0.43, CI = 0.24-0.76), self-care (aOR = 0.13, CI = 0.04-0.41), usual activities (aOR = 0.25, CI = 0.11-0.57), pain/discomfort (aOR = 0.37, CI = 0.20-0.68), and anxiety/depression (aOR = 0.33, CI = 0.15-0.73) problems. Low total RC was associated with problems conducting self-care (aOR = 0.20, CI = 0.07-0.60), usual activities (aOR = 0.43, CI = 0.22-0.83), pain/discomfort problems (aOR = 0.55, CI = 0.34-0.90), and anxiety/depression (aOR = 0.20, CI = 0.10-0.41) problems. Social RC was not associated with HRQOL.

Conclusion

Personal and total RC and comorbid conditions predict HRQOL. Although the opioid crisis and the increasing prevalence of comorbidities have been described as epidemics, they are currently being addressed as separate public health issues. Our findings underscore the importance of ensuring residents are provided with interprofessional care to reduce the burden of comorbidities, which can negatively impact their OUD recovery. Their RC should be routinely assessed and enhanced to support their recovery and improve HRQOL.

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

Regional vs global physical therapy interventions to treat chronic pain in survivors of trauma: a randomized controlled trial

BACKGROUND

A history of traumatic life events is associated with chronic pain in later life. Physical therapists utilize a variety of methods to treat pain, however, they have struggled to find effective interventions to improve patient outcomes.

OBJECTIVE

To compare impairment-based, regional (REGION-PT) physical therapy (PT) to a global (GLOBAL-PT) model consisting of pain neuroscience education, graded motor imagery, and exercise for adults with chronic pain and history of trauma.

DESIGN

Randomized Controlled Trial.

METHODS

Adults ≥ 18 years of age with chronic pain and a history of ≥1 trauma identified through the Life Events Checklist received the allocated intervention once a week for six weeks. Treatment effects were assessed using linear mixed models.

RESULTS

Ninety-eight participants completed the trial. There were no difference in outcomes between groups. There were significant interactions between race and intervention. Both interventions were associated with improvements in pain interference for white participants, but non-white participants experienced improvement only with GLOBAL-PT. Regardless of allocation, participants improved in physical function, six of the PROMIS-29 domains, and in pain interference measures.

CONCLUSION

Both interventions are reasonable strategies for individuals with chronic pain and a history of trauma.

Cebranopadol for the Treatment of Chronic Pain

PURPOSE OF REVIEW

Regardless of the etiology, if pain persists chronically, it can detrimentally impact multiple aspects of a patient's well-being. Both physical and psychological effects are significant in many chronic pain patients. In this regard, psychological consequences can alter a patient's quality of life, functionality, and social functioning. Opioids have been the long-established gold standard for acute pain treatment in settings such as the postoperative period. An alternative to opioids in pain management has been highly sought after. Through a non-selective mechanism, cebranopadol is a first-in-class oral drug which combines agonism of the mu and nociceptin opioid peptide (NOP) receptors to provide improved analgesia, while reducing the occurrence of many typically opioid side effects. This manuscript is a narrative review of the possible use of cebranopadol in pain management.

RECENT FINDINGS

In pre-clinical studies, cebranopadol was similar to morphine in its pain control efficacy. In a phase IIa trial, cebranopadol was superior to placebo in reducing pain. In a randomized clinical trial, cebranopadol was superior to morphine. Another study concluded that cebranopadol had a lower misuse potential when compared to hydromorphone. In summary, cebranopadol offers new opportunities in treating chronic moderate to severe pain, while also countering risks of addiction. Additional studies are warranted to further evaluate the safety and efficacy of cebranopadol. In this regard, cebranopadol could prove to be a promising alternative to current pain treatment options.

International Society for the Advancement of Spine Surgery Statement: Restorative Neurostimulation for Chronic Mechanical Low Back Pain Resulting From Neuromuscular Instability

This International Society for the Advancement of Spine Surgery statement has been generated to respond to growing requests for background, supporting literature and evidence, and proper coding for restorative neurostimulation for chronic low back pain. Chronic low back pain describes the diverse experience of a significant proportion of the population. Conservative management of these patients remains the predominant care pathway, but for many patients, symptom relief is poor. The application of new techniques in patients who have exhausted traditional care paradigms should be undertaken with a detailed understanding of the pathology being treated, the mechanisms involved, and the data supporting efficacy. This statement on restorative neurostimulation places this technology in the context of the current understanding of the etiology of mechanical low back pain and the currently available evidence for this technique. In an appropriately selected cohort with a specific subset of chronic low back pain symptoms, this technique may provide benefit to payers and patients.

Sex differences in acute delta-9-tetrahydrocannabinol (Δ9-THC) response and tolerance as a function of mouse strain

Cannabinoids are increasingly used to alleviate pain; however, tolerance to their antinociceptive effects, including those of delta-9-tetrahydrocannabinol (Δ9-THC), may limit their therapeutic utility. With more women than men using medical cannabis for pain relief, it is crucial to understand how sex influences cannabinoid-mediated antinociception and tolerance. Though studies in rats consistently find females are more sensitive to the acute antinociceptive effects of cannabinoids, our work with mice consistently finds the converse. The present study examined whether our observed sex differences in Δ9-THC-induced antinociception and tolerance are consistent across multiple mouse strains or are strain-dependent. Male and female C57BL/6J (B6), DBA/2, AKR, and CBA/J mice were assessed for differences in acute Δ9-THC-induced antinociception and hypothermia prior to and following seven days of once-daily Δ9-THC administration. Consistent with our previous findings, male B6 mice were more sensitive to the acute antinociceptive effects of Δ9-THC than female littermates, an effect which dissipated with age. B6 males had decreased cannabinoid expression in the PAG compared to females. While DBA and CBA female mice showed increased Δ9-THC-antinociception compared to male littermates at 30 and 10 mg/kg Δ9-THC, respectively, these differences were less pronounced at higher doses, revealing that dose of Δ9-THC may also be important. Overall, CBA mice were more sensitive to Δ9-THC-induced antinociception while AKR mice were less responsive. These studies highlight the therapeutic potential of Δ9-THC in pain management and underscore the importance of considering not only Δ9-THC dose as a function of sex, but potentially genetic differences when evaluating their clinical utility.

A Pilot Mixed-Methods Study to Establish the Clinical Usefulness of a Chronic Pain Profile (CPP) for Pain Management

The Chronic Pain Profile (CPP) was developed as a tool for patients to document types and levels of use for all pain management strategies used. This pilot mixed-methods (quantitative and qualitative methods) study aimed to assess the perceived clinical usefulness of the CPP and identify potential areas of difficulty using the CPP among a sample of pharmacists. Data were obtained from an online survey of pharmacists licensed to practice in Arizona. Quantitative analysis included assessing the clinical usefulness of the CPP using 10 numerical items (scores ≥50% = useful), 5 ordinal items (scores ≥ 4 out of 5 = useful), and 11 open-response items. Qualitative analysis was conducted by two independent researchers who coded the comments and identified key themes through consensus. Data were collected for 33 individuals. Mean usefulness scores ranged from 66.6 ± 22.4 to 80.9 ± 23.5, and three of the five ordinal items had a median score ≥ 4. Three key themes (and subthemes) were identified: favorable features of the CPP, which included promoting patient advocacy and saving time when accessing pain information; using the CPP, which included evaluating of the effectiveness and appropriateness of the pain management approach and identifying gaps in patient knowledge; and limitations of the CPP, which included absence of customization, interpretation issues, complexity and wording issues, and concerns of internal consistency and reliability. This pilot study provides initial evidence of the CPP's clinical usefulness that could ultimately be used to help manage pain and improve health outcomes. Further analyses are needed to assess the CPP's validity and explore its use in wider populations of patients with pain.

Outpatient opioid prescribing by Alzheimer's diagnosis among older adults with pain in United States

OBJECTIVE

To examine opioid prescribing practices for pain in older adults with and without Alzheimer's Disease and Related Dementias (ADRD).

METHODS

This cross-sectional study used National Ambulatory Medical Care Survey data (2014-2016, and 2018). Adults aged ≥ 50 years with pain were analyzed. Prescribing of opioid and concomitant sedative prescriptions (including benzodiazepines, Z-drugs, and barbiturates) were identified by the Multum lexicon code. Multivariable logistic regression evaluated the risk of opioid prescribing or co-prescribing of opioid and sedative associated with ADRD in older adults with pain.

RESULTS

There were 13,299 office visits in older adults with pain, representing 451.75 million visits. Opioid prescribing occurred in 27.19%; 30% involved co-prescribing of opioids and sedatives. ADRD was not associated with opioid prescribing or co-prescribing of opioid and sedative therapy.

CONCLUSIONS

Opioid and sedatives are commonly prescribed in older adults with pain. Longitudinal studies need to understand the etiology and chronicity of opioid use in older patients, specifically with ADRD.

Mechanisms of cannabinoid tolerance

Cannabis has been used recreationally and medically for centuries, yet research into understanding the mechanisms of its therapeutic effects has only recently garnered more attention. There is evidence to support the use of cannabinoids for the treatment of chronic pain, muscle spasticity, nausea and vomiting due to chemotherapy, improving weight gain in HIV-related cachexia, emesis, sleep disorders, managing symptoms in Tourette syndrome, and patient-reported muscle spasticity from multiple sclerosis. However, tolerance and the risk for cannabis use disorder are two significant disadvantages for cannabinoid-based therapies in humans. Recent work has revealed prominent sex differences in the acute response and tolerance to cannabinoids in both humans and animal models. This review will discuss evidence demonstrating cannabinoid tolerance in rodents, non-human primates, and humans and our current understanding of the neuroadaptations occurring at the cannabinoid type 1 receptor (CB1R) that are responsible tolerance. CB1R expression is downregulated in tolerant animals and humans while there is strong evidence of CB1R desensitization in cannabinoid tolerant rodent models. Throughout the review, critical knowledge gaps are indicated and discussed, such as the lack of a neuroimaging probe to assess CB1R desensitization in humans. The review discusses the intracellular signaling pathways that are responsible for mediating CB1R desensitization and downregulation including the action of G protein-coupled receptor kinases, β-arrestin2 recruitment, c-Jun N-terminal kinases, protein kinase A, and the intracellular trafficking of CB1R. Finally, the review discusses approaches to reduce cannabinoid tolerance in humans based on our current understanding of the neuroadaptations and mechanisms responsible for this process.

Depression as a Mediator and Social Participation as a Moderator in the Bidirectional Relationship Between Sleep Disorders and Pain: Dynamic Cohort Study

BACKGROUND

Chronic pain, sleep disorders, and depression are major global health concerns. Recent studies have revealed a strong link between sleep disorders and pain, and each of them is bidirectionally correlated with depressive symptoms, suggesting a complex relationship between these conditions. Social participation has been identified as a potential moderator in this complex relationship, with implications for treatment. However, the complex interplay among sleep disorders, pain, depressive symptoms, and social participation in middle- and old-aged Asians remains unclear.

OBJECTIVE

This study aimed to examine the bidirectional relationship between sleep disorders and pain in middle- and old-aged Chinese and measure the role of depression as a mediator and social participation as a moderator in this bidirectional relationship through a dynamic cohort study.

METHODS

We used data from the China Health and Retirement Longitudinal Study across 5 years and included a total of 7998 middle- and old-aged people (≥45 years old) with complete data in 2011 (T1), 2015 (T2), and 2018 (T3). The cross-lag model was used to assess the interplay among sleep disorders, pain, depressive symptoms, and social participation. Depressive symptoms were assessed by the 10-item Centre for Epidemiological Studies Depression scale. Sleep disorders were assessed by a single-item sleep quality scale and nighttime sleep duration. The pain score was the sum of all pain locations reported. Social participation was measured using self-reported activity.

RESULTS

Our results showed significant cross-lagged effects of previous sleep disorders on subsequent pain at T2 (β=.141; P<.001) and T3 (β=.117; P<.001) and previous pain on subsequent poor sleep at T2 (β=.080; P<.001) and T3 (β=.093; P<.001). The indirect effects of previous sleep disorders on pain through depressive symptoms (β=.020; SE 0.004; P<.001; effect size 21.98%), as well as previous pain on sleep disorders through depressive symptoms (β=.012; SE 0.002; P<.001; effect size 20.69%), were significant across the 3 time intervals. Among participants with high levels of social participation, there were no statistically significant effects of previous sleep disorders on subsequent pain at T2 (β=.048; P=.15) and T3 (β=.085; P=.02), nor were there statistically significant effects of previous pain on subsequent sleep disorders at T2 (β=.037; P=.15) and T3 (β=.039; P=.24). Additionally, the mediating effects of depressive symptoms on the sleep disorders-to-pain pathway (P=.14) and the pain-to-sleep disorders pathway (P=.02) were no longer statistically significant.

CONCLUSIONS

There is a bidirectional relationship between sleep disorders and pain in middle- and old-aged Asians; depression plays a longitudinal mediating role in the bidirectional relationship between them; and social participation moderates the bidirectional relationship between them directly and indirectly by affecting depression. Future interventions may consider the complex relationship between these conditions and adopt a comprehensive treatment regime.

#ChronicPain: Automated Building of a Chronic Pain Cohort from Twitter Using Machine Learning

Background

Due to the high burden of chronic pain, and the detrimental public health consequences of its treatment with opioids, there is a high-priority need to identify effective alternative therapies. Social media is a potentially valuable resource for knowledge about self-reported therapies by chronic pain sufferers.

Methods

We attempted to (a) verify the presence of large-scale chronic pain-related chatter on Twitter, (b) develop natural language processing and machine learning methods for automatically detecting self-disclosures, (c) collect longitudinal data posted by them, and (d) semiautomatically analyze the types of chronic pain-related information reported by them. We collected data using chronic pain-related hashtags and keywords and manually annotated 4,998 posts to indicate if they were self-reports of chronic pain experiences. We trained and evaluated several state-of-the-art supervised text classification models and deployed the best-performing classifier. We collected all publicly available posts from detected cohort members and conducted manual and natural language processing-driven descriptive analyses.

Results

Interannotator agreement for the binary annotation was 0.82 (Cohen's kappa). The RoBERTa model performed best (F1 score: 0.84; 95% confidence interval: 0.80 to 0.89), and we used this model to classify all collected unlabeled posts. We discovered 22,795 self-reported chronic pain sufferers and collected over 3 million of their past posts. Further analyses revealed information about, but not limited to, alternative treatments, patient sentiments about treatments, side effects, and self-management strategies.

Conclusion

Our social media based approach will result in an automatically growing large cohort over time, and the data can be leveraged to identify effective opioid-alternative therapies for diverse chronic pain types.

Posttraumatic stress and pain-related anxiety among trauma-exposed adults with chronic pain in terms of opioid misuse and dependence

Trauma-exposure and posttraumatic stress symptoms increase risk for opioid-related problems in the context of chronic pain. Yet, there has been little exploration of moderators of the posttraumatic stress-opioid misuse association. Pain-related anxiety, defined as worry about pain and the negative consequences of pain, has shown relations to both posttraumatic stress symptoms and opioid misuse, and it may moderate the association between posttraumatic stress symptoms and opioid misuse, as well as dependence. The current study examined the moderating role of pain-related anxiety on the relationship between posttraumatic stress symptoms and opioid misuse and dependence among 292 (71.6 % female, M_age = 38.03 years, SD = 10.93) trauma exposed adults with chronic pain. Results indicated that pain-related anxiety significantly moderated the observed relations, such that compared to those with low pain-related anxiety, the relationship between posttraumatic stress symptoms and opioid misuse and dependence was stronger for those with elevated pain-related anxiety. These results highlight the importance of assessing and targeting pain-related anxiety among this trauma-exposed segment of the chronic pain population with elevated posttraumatic stress symptoms.

Associations Between Opioid Prescriptions and Use of Hospital-Based Services Among US Adults with Longstanding Physical Disability or Inflammatory Conditions Compared to Other Adults in the Medical Expenditure Panel Survey, 2010-2015

Purpose

To investigate the association of filling opioid prescriptions with healthcare service utilization among a nationally representative sample of adults with disability.

Materials and Methods

The Medical Expenditure Panel Survey (MEPS) for 2010-2015, Panels 15-19, was used to identify adults who were prescribed opioids during each two-year period. We examined the data for associations between opioid prescription filling and the number of emergency department (ED) visits and hospitalizations. The participants were grouped as those with inflammatory conditions or with longstanding physical disability, and a comparison group of those without these conditions.

Results and conclusions

Opioid prescription filling differed among adults with inflammatory conditions and longstanding physical disability compared to the comparison group (44.93% and 40.70% vs 18.10%, respectively). For both groups of people with disability, the relative rates for an ED visit or hospitalization were significantly higher for those who filled an opioid prescription, compared to adults with the same conditions who did not fill an opioid prescription. People with a longstanding physical disability who filled an opioid prescription had the highest rate ratio of ED use and hospitalization. Results from this investigation demonstrate that opioid prescription filling among persons with inflammatory conditions and longstanding physical disabilities is associated with higher rates of ED visits and hospitalizations.

Psychosocial problems and high amount of opioid administration are associated with opioid dependence and abuse after first exposure for chronic pain patients

Controversy surrounding the use of opioids for the treatment and the unique characteristics of chronic pain heighten the risks for abuse and dependence; however, it's unclear if higher doses of opioids and first exposure are associated with dependence and abuse. This study aimed to identify patients who developed dependence or opioid abuse after exposed to opioids for the first time and what were the risks factors associated with the outcome. A retrospective observational cohort study analyzed 2,411 patients between 2011 and 2017 who had a diagnosis of chronic pain and received opioids for the first time. A logistic regression model was used to estimate the likelihood of opioid dependence/abuse after the first exposure based on their mental health conditions, prior substance abuse disorders, demographics, and the amount of MME per day patients received. From 2,411 patients, 5.5 % of the patients had a diagnosis of dependence or abuse after the first exposure. Patients who were depressed (OR = 2.09), previous non-opioid substance dependence or abuse (OR = 1.59) or received greater than 50 MME per day (OR = 1.03) showed statistically significant relationship with developing opioid dependence or abuse, while age (OR = -1.03) showed to be a protective factor. Further studies should stratify chronic pain patients into groups who is in higher risk in developing opioid dependence or abuse and develop alternative strategies for pain management and treatments beyond opioids. This study reinforces the psychosocial problems as determinants of opioid dependence or abuse and risk factors, and the need for safer opioid prescribing practices.

Evaluation of Sex Differences in Preclinical Pharmacology Research: How Far Is Left to Go?

Until the last quarter of the 20th century, sex was not recognized as a variable in health research, nor was it believed to be a factor that could affect health and illness. Researchers preferred studying male models for a variety of reasons, such as simplicity, lower costs, hormone confounding effects, and fear of liability from perinatal exposure in case of pregnancy. Equitable representation is imperative for determining the safety, effectiveness, and tolerance of therapeutic agents for all consumers. Decades of female models' underrepresentation in preclinical studies has resulted in inequality in the understanding, diagnosis, and treatment of disease between the sexes. Sex bias has been highlighted as one of the contributing factors to the poor translation and replicability of preclinical research. There have been multiple calls for action, and the inclusion of sex as a biological variable is increasingly supported. However, although there has been substantial progress in the efforts to include more female models in preclinical studies, disparities today remain. In the present review, we consider the current standard practice of the preclinical research setting, why the sex bias exists, why there is the need to include female models, and what risks may arise from continuing this exclusion from experimental design.

Pain Neuroscience Education in Elementary and Middle Schools

PURPOSE

The purpose of this study was to deliver pain neuroscience education (PNE) to participants in grades 3 to 8 to determine whether participants in these grades had positive shifts in pain knowledge and beliefs.

METHODS

Three hundred twenty participants, grades 3 to 8, received a 1-time, 30-minute PNE lecture. The Neurophysiology of Pain Questionnaire and the Health Care Provider's Pain and Impairment Relationship Scale were administered before and after the PNE lecture.

RESULTS

All grades improved in pain knowledge and beliefs. Higher-grade school participants (sixth to eighth grades) experienced larger shifts in pain knowledge and attitudes and beliefs than lower-grade (third to fifth grades) participants.

CONCLUSION

PNE results in changes in pain knowledge and beliefs in school participants in grades 3 to 8.

Respiratory Function Analysis in Patients with Chronic Pain: An Umbrella Review and Meta-Analysis of Pooled Findings

BACKGROUND

The main aim of this umbrella review was to assess the respiratory function in patients with chronic pain (CP), including patients with chronic neck pain (CNP), chronic low back pain (CLBP), and fibromyalgia syndrome (FMS).

METHODS

We searched in PubMed, PEDro, EMBASE, CINAHL, and Google Scholar (4 February 2023). The outcome measures were respiratory muscle strength (MIP/MEP) and pulmonary function (VC, MVV, FVC, FEV₁, FEV₁/FVC ratio, FEV_25-75, and PEF). This review was previously registered in the international prospective register of systematic reviews, PROSPERO (CRD42023396722). The methodological quality was analyzed using AMSTAR and ROBIS scales, and the strength of the evidence was established according to the guidelines advisory committee grading criteria. To compare the outcomes reported by the studies, we calculated the standardized mean differences and the corresponding 95% confidence interval for the continuous variables.

RESULTS

Four systematic reviews with and without meta-analysis were included, from which a total of 15 primary studies were extracted. Five meta-analyses were carried out, using analyses by subgroup according to the type of CP. The meta-analyzing variables were MIP, MEP, MVV, FEV₁, and FVC.

CONCLUSIONS

Overall, patients with CP have decreased respiratory muscle strength with a moderate quality of evidence. Regarding the pulmonary function, patients with CNP showed a diminished VC, PEF, MVV, FEV₁, and FVC, while FEV_25-75 and the FEV₁/FVC ratio were conserved with a limited to moderate quality of evidence. Finally, patients with FMS and CLBP only showed a decrease in MVV with a limited quality of evidence.

Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020

Importance

Chronic pain risk and prognosis estimates are needed to inform effective interventions.

Objective

To estimate rates of chronic pain and high-impact chronic pain (HICP) incidence and persistence in US adults across demographic groups.

Design, Setting, and Participants

This cohort study examined a nationally representative cohort with 1 year of follow-up (mean [SD], 1.3 [0.3] years). Data from the 2019-2020 National Health Interview Survey (NHIS) Longitudinal Cohort were used to assess the incidence rates of chronic pain across demographic groups. The cohort was created using random cluster probability sampling of noninstitutionalized civilian US adults 18 years or older in 2019. Of 21 161 baseline participants in the 2019 NHIS who were randomly chosen for follow-up, 1746 were excluded due to proxy response(s) or lack of contact information, and 334 were deceased or institutionalized. Of the 19 081 remaining, the final analytic sample of 10 415 adults also participated in the 2020 NHIS. Data were analyzed from January 2022 to March 2023.

Exposures

Self-reported baseline sex, race, ethnicity, age, and college attainment.

Main Outcomes and Measures

Primary outcomes were the incidence rates of chronic pain and HICP, and secondary outcomes were the demographic characteristics and rates across demographic groups. A validated measure of pain status ("In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?") yielded 3 discrete categories each year: pain free, nonchronic pain, or chronic pain (pain "most days" or "every day"). Chronic pain present in both survey years was considered persistent; HICP was defined as chronic pain that limited life or work activities on most days or every day. Rates were reported per 1000 person-years (PY) of follow-up, and age standardized based on the 2010 US adult population.

Results

Among 10 415 participants included in the analytic sample, 51.7% (95% CI, 50.3%-53.1%) were female, 54.0% (95% CI, 52.4%-55.5%) were aged 18 to 49 years, 72.6% (95% CI, 70.7%-74.6%) were White, 84.5% (95% CI, 81.6%-85.3%) were non-Hispanic or non-Latino, and 70.5% (95% CI, 69.1%-71.9%) were not college graduates. Among pain-free adults in 2019, incidence rates of chronic pain and HICP in 2020 were 52.4 (95% CI, 44.9-59.9) and 12.0 (95% CI, 8.2-15.8) cases per 1000 PY, respectively. The rates of persistent chronic pain and persistent HICP in 2020 were 462.0 (95% CI, 439.7-484.3) and 361.2 (95% CI, 265.6-456.8) cases per 1000 PY, respectively.

Conclusions and Relevance

In this cohort study, the incidence of chronic pain was high compared with other chronic diseases. These results emphasize the high disease burden of chronic pain in the US adult population and the need for early management of pain before it becomes chronic.

A historical review of pain disparities research: Advancing toward health equity and empowerment

BACKGROUND AND PURPOSE

This theory-guided review draws on 30 years of published data to examine and interrogate the current and future state of pain disparities research.

METHODS

Using the Hierarchy of Health Disparity Research framework, we synthesize and present an overview of "three generations" of pain disparities scholarship, while proposing directions for adopting a "fourth generation" that redefines, explains, and theorizes future pain disparities research in a diverse society.

DISCUSSION

Prior research has focused on describing the scope of disparities, and throughout the historical context of human existence, racialized groups have been subjected to inadequate pain care. It is imperative that research not only illuminates existing problems but also provides solutions that can be implemented and sustained across varying social milieus.

CONCLUSION

We must invest in new theoretical models that expand on current perspectives and ideals that position all individuals at the forefront of justice and equity in their health.

Precision Medicine in Oral Health and Diseases: A Systematic Review

Precision medicine (PM) is personalized medicine that can develop targeted medical therapies for the individual patient, in which "omics" sciences lead to an integration of data that leads to highly predictive models of the functioning of the individual biological system. They enable rapid diagnosis, assessment of disease dynamics, identification of targeted treatment protocols, and reduction of costs and psychological stress. "Precision dentistry" (DP) is one promising application that need further investigation; the purpose of this paper is therefore to give physicians an overview of the knowledge they need to enhance treatment planning and patient response to therapy. A systematic literature review was conducted on the PubMed, Scopus, and Web of Science databases by analyzing the articles examining the role of precision medicine in dentistry. PM aims to shed light on cancer prevention strategies, by identifying risk factors, and on malformations such as orofacial cleft. Another application is pain management by repurposing drugs created for other diseases to target biochemical mechanisms. The significant heritability of traits regulating bacterial colonization and local inflammatory responses is another result of genomic research, and is useful for DP in the field of caries and periodontitis. This approach may also be useful in the field of orthodontics and regenerative dentistry. The possibility of creating an international network of databases will lead to the diagnosis, prediction, and prevention of disease outbreaks, providing significant economic savings for the world's health care systems.