Opioid Use and Depression in Chronic Pelvic Pain

Using Myofascial Therapy to Improve Psychological Outcomes, Quality of Life, and Sexual Function in Women with Chronic Pelvic Pain-A Case Series

(1) Background: Chronic pelvic pain represents a prevalent condition afflicting women. Research has highlighted the presence of psychological distress and sexual dysfunction in these individuals. Regrettably, myofascial pelvic pain often goes unnoticed and untreated despite its integral role in chronic pelvic pain. (2) Methods: By employing a longitudinal case series design, we studied eighteen women afflicted with chronic pelvic pain. Over a 12-week period, these participants underwent 15 sessions of myofascial therapy. Data encompassing sociodemographic particulars, the Hospital Anxiety and Depression Scale, the Medical Outcomes Study Short Form 12 questionnaire, and the Female Sexual Function Index were collected at baseline, 12 weeks post-intervention, and again at the 24-week mark. (3) Results: After a span of 12 weeks subsequent to the intervention, the participants demonstrated noteworthy enhancements (p < 0.001) in their depression and anxiety scores, their overall Mental Component scores in the Medical Outcomes Study Short Form 12, as well as sexual function. Importantly, these gains were sustained at the 24-week juncture post-therapy. (4) Conclusions: The findings stemming from our prospective case study underscore the potential utility of myofascial therapy for women grappling with chronic pelvic pain. This form of intervention yields significant advancements in alleviating anxiety, depression, health-related quality of life, and sexual function.

Nonhormonal therapy for endometriosis: a randomized, placebo-controlled, pilot study of cabergoline versus norethindrone acetate

Objective

To estimate the efficacy and safety of a novel nonhormonal therapeutic agent, cabergoline, compared with that of the standard clinical therapy, norethindrone acetate (NETA), for the treatment of endometriosis-associated pain in young women with endometriosis.

Design

Randomized, double-blind, placebo-controlled pilot study.

Setting

Tertiary care center.

Patient(s)

Women (n = 9) with surgically confirmed endometriosis.

Intervention(s)

A random, double-blind assignment to either NETA (5 mg/day) + placebo twice weekly or cabergoline (0.5 mg) twice weekly + placebo daily for 6 months.

Main Outcome Measure(s)

We collected the measures of pelvic pain and laboratory parameters every 3 months.

Result(s)

We observed a decrease in pain scores and increase in pain relief in women randomized to receive cabergoline, who appeared to show similar or more improvements than women treated with NETA. The serum measures of vascular endothelial growth factor receptor 1 declined over 6 months in those who received cabergoline. Cabergoline was well tolerated, and no serious adverse events occurred.

Conclusion(s)

Safe, effective adjunct treatments are lacking for patients with endometriosis who do not respond to standard care. Because the growth of endometriosis requires angiogenesis, blood vessel growth is an attractive therapeutic target. This pilot study suggests that cabergoline, a vascular endothelial growth factor pathway inhibitor, is an effective therapeutic option for women with chronic pain due to endometriosis. Building upon this investigation, we will conduct larger, randomized trials of cabergoline, advancing research on the best treatments for endometriosis—particularly disease resistant to hormonal therapies.

Clinical Trial Registration Number

clinicaltrials.gov; registration number NCT02542410.

Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

BACKGROUND

Females with persistent pelvic pain (PPP) report great variability in treatments they are recommended despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required.

OBJECTIVE

Identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

SEARCH STRATEGY

MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021.

SELECTION CRITERIA

Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society.

DATA COLLECTION AND ANALYSIS

We screened 1,379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

MAIN RESULTS

CPGs for seven conditions provided 281 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (Endometriosis, NICE, RANZCOG, ESHRE; PCOS, Teede et al. 2018) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy, and other conservative interventions.

CONCLUSIONS

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.

Pulsed electromagnetic field (PEMF) as an adjunct therapy for pain management in interstitial cystitis/bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) often experience chronic pelvic and even systemic pain that can be difficult to clinically manage. Pulsed electromagnetic field (PEMF) therapy, a non-invasive strategy that has shown significant efficacy for pain reduction in other chronic pain conditions, may provide benefit for pain management in patients with IC/BPS.

METHODS

PEMF delivery to patients occurs via a bio-electromagnetic-energy device which consists of a flexible mat (180 × 50 cm) that the patient lies on for systemic, full-body delivery and/or a flexible pad (50 × 15 cm) for targeted delivery to a specific body region (e.g., pelvic area). The duration of individual sessions, number of sessions per day, total number of sessions, and follow-up observation period vary between previously published studies. Positive outcomes are typically reported as a significant reduction in visual analog scale (VAS) pain score and functional improvement assessed using validated questionnaires specific to the condition under study.

RESULTS AND CONCLUSIONS

The use of PEMF has been evaluated as a therapeutic strategy for pain management in several clinical scenarios. Randomized, double-blinded, placebo-controlled trials have reported positive efficacy and safety profiles when PEMF was used to treat non-specific low back pain, patellofemoral pain syndrome, chronic post-operative pain, osteoarthritis-related pain, rheumatoid arthritis-related pain, and fibromyalgia-related pain. Based on these positive outcomes in a variety of pain conditions, clinical trials to evaluate whether PEMF can provide a safe, non-invasive therapeutic approach to improve symptoms of chronic pain and fatigue in patients with IC/BPS are warranted.

Impact of pain and nonpain co-morbidities on opioid use in women with endometriosis

Aim: To evaluate impact of co-morbidities on opioid use in endometriosis. Patients & m ethods: This was a retrospective analysis of data obtained from the Symphony Health database (July 2015-June 2018), which contains medical and pharmacy claims information on 79,947 women with endometriosis. Relative risk (RR) of postdiagnosis opioid use and supply duration associated with baseline co-morbidities were determined. Results: Women with endometriosis using opioids at baseline were 61% more likely to receive opioids postdiagnosis (RR: 1.61; 95% CI: 1.59-1.63). Risk of prolonged opioid supply postdiagnosis was highest for those with prolonged supply at baseline (RR: 21.14; 20.14-22.19), and was 1.32 (1.26-1.38) for patients with ≥1 co-morbidity, 1.37 (1.31-1.43) for pain co-morbidities and 1.07 (1.04-1.11) for psychiatric co-morbidities. Conclusion: Risk of opioid use after endometriosis diagnosis was greater in patients who used opioids before diagnosis. Risk of prolonged opioid use was greater if co-morbidities existed before diagnosis.

Impact of hysterectomy on analgesic, psychoactive and neuroactive drug use in women with endometriosis: nationwide cohort study

Objective

To evaluate how hysterectomy affects the prescription of analgesic, psychotropic and neuroactive drugs in women with endometriosis using population‐based nationwide registers.

Design

Nationwide cohort study.

Setting

Swedish national registers, from 1 January 2009 to 31 December 2018.

Population

Women with benign disease undergoing a total hysterectomy during the 4‐year period of 2012–2015. Women with endometriosis (n = 1074) were identified and compared with women who did not have endometriosis (n = 10 890).

Methods

Prospectively collected data from two population‐based registers were linked: the Swedish National Quality Register of Gynaecological Surgery and the Swedish National Drug Register. Multivariate logistic regression was used as the main statistical method.

Main outcome measures

Changes in drug prescription over time for 3 years prior to and 3 years after hysterectomy.

Results

The frequency of prescription of analgesics was higher in women with endometriosis compared with women without endometriosis (OR 2.2, 95% CI 1.7–2.9). Among women with endometriosis, the prescription of analgesics (OR 1.0, 95% CI 0.8–1.2) did not decrease 3 years after hysterectomy compared with the 3 years prior to surgery. There was also a significantly higher rate of prescription of psychoactive (OR 1.6, 95% CI 1.4–2.0) and neuroactive drugs (OR 1.9, 95% CI 1.3–2.7) in the long term postoperatively.

Conclusions

In women undergoing hysterectomy, endometriosis was associated with a higher prescription rate of analgesics. In the endometriosis group the prescription of analgesic, psychoactive and neuroactive drugs did not decrease when comparing prescription rates for the 3 years prior to and the 3 years after surgery.

Tweetable abstract

In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy.

In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy.

Cognitive behavioral therapy for the treatment of chronic pelvic pain

Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.

Enhanced recovery after surgery outcomes in minimally invasive nonhysterectomy gynecologic procedures

BACKGROUND

Improved patient outcomes and satisfaction associated with enhanced recovery after surgery protocols have increasingly replaced traditional perioperative anesthesia care. Fast-track surgery pathways have been extensively validated in patients undergoing hysterectomies, yet the impact on fertility-sparing laparoscopic gynecologic operations, particularly those addressing chronic pain conditions, has not been examined.

OBJECTIVE

The objective of the study was to determine the effects of enhanced recovery after surgery pathway implementation compared with conventional perioperative care in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.

STUDY DESIGN

We conducted a retrospective cohort study of women undergoing uterine-sparing laparoscopic gynecologic procedures for benign conditions (tubal/adnexal pathology, endometriosis, or leiomyomas) during a 24 month period before and after enhanced recovery after surgery implementation at a tertiary care center. We compared immediate perioperative outcomes and 30 day complications. The primary outcome was same-day discharge rates. Factors influencing unplanned admissions, postoperative pain, sedation, nausea, and vomiting represented secondary analyses.

RESULTS

A total of 410 women (enhanced recovery after surgery, n = 196; conventional perioperative care, n = 214) met inclusion criteria. Following enhanced recovery after surgery implementation, same-day discharge rates increased by 9.4% (P = .001). Reductions in postoperative pain and nausea/vomiting represented the primary driving factor behind lower unplanned admissions. Higher preoperative antiemetic medication administration in the enhanced recovery after surgery group resulted in a 57% reduction in postanesthesia care unit antiemetics (P < .001). Total perioperative narcotic medication use was also significantly reduced by 64% (P < .001), and the enhanced recovery after surgery cohort still demonstrated significantly lower postanesthesia unit care pain scores at hours 2 and 3 (P < .001). A 19 minute shorter postanesthesia care unit stay was noted in the enhanced recovery after surgery cohort (P = .036). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery.

CONCLUSION

Enhanced recovery after surgery implementation resulted in increased same-day discharge rates and improved perioperative outcomes without affecting 30 day morbidity in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.

Effect of Acupuncture on Chronic Pain with Depression: A Systematic Review

Background

Numerous studies suggested that chronic pain and depression were closely related and widespread in the population. When patients have symptoms of chronic pain and depression, the corresponding treatment will become difficult. Acupuncture, a unique therapeutic method of traditional Chinese medicine, has been reported to potentially serve as an alternative treatment for patients with comorbid chronic pain and depression by many research studies.

Methods

A comprehensive search was conducted through the online database, including the Cochrane Library, PubMed, EMBASE, SinoMed, CNKI, and Wanfang database. Trials were RCTs published in the English or Chinese language, recruiting participants with chronic pain and depression comorbidity. The primary outcomes were the Visual Analogue Scale (VAS) and Hamilton Depression Scale (HAMD). Statistical analyses were conducted using Review Manager 5.3. Each trail was quality appraised with the five-point Jadad Score.

Results

7 eligible RCTs involving 535 patients were included. Better therapeutic effect and safety could be observed in the experimental group compared with the control group. There was a significant decrease in the VAS (mean difference (MD) = −0.68 (−1.24, −0.12), P=0.02) and HAMD (MD = −2.18 (−3.09, −1.26), P < 0.00001) scores and the incidence of adverse events between two groups.

Conclusion

In the treatment of chronic pain with depression, acupuncture could not only get better clinical efficacy, but also have higher security compared with medicine therapy, which can be used in patients with poorer response to the conventional medication or suffering from serious side effects.

Healthcare utilization and cost burden among women with endometriosis by opioid prescription status in the first year after diagnosis: a retrospective claims database analysis

Aims: Opioids do not represent standard therapy for endometriosis; however, women with endometriosis are frequently prescribed an opioid to manage related abdominal or pelvic pain. The aim of this study was to evaluate the impact of opioid use on endometriosis-related economic and healthcare burden in the United States.Materials and methods: We performed a retrospective, propensity-matched cohort analysis of the Truven MarketScan Commercial database from 1 January 2011 to 31 December 2016. Eligible women had at least 1 inpatient or 2 outpatient codes for endometriosis and 12 months of continuous enrollment before and after the index date (i.e. first recorded endometriosis diagnosis). The primary analysis examined healthcare costs and utilization for 12 months after the index date in women who filled at least 1 opioid prescription versus those who did not. The secondary analysis examined healthcare costs and utilization by the pattern of opioid use.Results: The primary analysis matched 43,516 women across 2 groups and the secondary analysis matched 13,230 women across 5 groups. In the primary analysis, total 12-month healthcare costs were significantly higher in the opioid group compared to the non-opioid group ($29,236.00 vs. $18,466.00, respectively; p < .001); the same pattern was observed for all healthcare utilization parameters. In the secondary analysis, higher morphine equivalent daily dose and proportion of days covered were associated with the highest healthcare costs and utilization compared to the non-opioid group.Limitations: Retrospective design and inability to confirm whether filled opioid prescriptions were actually taken.Conclusions: Filling an opioid prescription within 1 year after an endometriosis diagnosis was associated with significant excess healthcare burden. Patients prescribed an opioid may experience inadequate symptom management and benefit from the use of disease-specific, non-opioid therapies.

Neurobehavioral Consequences Associated with Long Term Tramadol Utilization and Pathological Mechanisms

:

Tramadol is a synthetic analog of codeine used to treat pain of moderate to severe intensity and is reported to have neurotoxic potential. At therapeutic dose, tramadol does not cause major side effects in comparison to other opioid analgesics, and is useful for the management of neurological problems like anxiety and depression. Long term utilization of tramadol is associated with various neurological disorders like seizures, serotonin syndrome, Alzheimer’s disease and Parkinson’s disease. Tramadol produces seizures through inhibition of nitric oxide, serotonin reuptake and inhibitory effects on GABA receptors. Extensive tramadol intake alters redox balance through elevating lipid peroxidation and free radical leading to neurotoxicity and produces neurobehavioral deficits. During Alzheimer’s disease progression, low level of intracellular signalling molecules like cGMP, cAMP, PKC and PKA affect both learning and memory. Pharmacologically tramadol produces actions similar to Selective Serotonin Reuptake Inhibitors (SSRIs), increasing the concentration of serotonin, which causes serotonin syndrome. In addition, tramadol also inhibits GABAA receptors in the CNS has been evidenced to interfere with dopamine synthesis and release, responsible for motor symptoms. The reduced level of dopamine may produce bradykinesia and tremors which are chief motor abnormalities in Parkinson’s Disease (PD).

A 10-yr Analysis of Chronic Pelvic Pain and Chronic Opioid Therapy in the Women Veteran Population

Introduction

Chronic pelvic pain (CPP) affects an estimated 30% of women Veterans. Previous research shows high rates of narcotic abuse in the women Veteran population. Narcotics are not recommended for the treatment of CPP. Understanding how CPP impacts narcotic prescribing in the women Veteran population is critical to addressing the public health crisis of opioid abuse. Our objective was to compare chronic opioid therapy (COT) prescribed 5 yr prior to and following CPP diagnosis and to identify predictors of COT as well as adverse events associated with COT. We choose to look at 10 yr of data because we thought this time period would provide unique insight into the longitudinal associations of CPP and COT and was available in the database.

Materials and Methods

Women with non-cancer CPP were included for analyses from the Veteran's Affairs Corporate Database Warehouse. COT was defined as 90 d of opiates/calendar year for each of the 5 yr proceeding and following the diagnosis of CPP. Patient characteristics and potential variables influencing COT were collected. We compared baseline demographics between the women who received COT to the women who did not receive COT to find additional demographic predictors of COT in association with CPP. Multivariable analysis identified predictors of COT in this population of women with CPP. We utilized an interrupted time series analysis to understand the impact of the diagnosis of CPP on COT.

Results

A total of 49,601 women met inclusion criteria with an average age of 40.1 ± 11.5 yr; 37.3% self-characterized as being a racial minority and 24% had a history of military sexual trauma. Chronic use increased significantly (p < 0.001) in the 5 yr preceding the diagnosis of CPP from 6.3% (n = 3124) of women at time -5 to 13.6% (n = 6746) at time 0. In the first year following the diagnosis of CPP, 16.8% (n = 8,333) of women with CPP met the criteria for COT (p < 0.001) and 15% (n = 7440) of women with CPP remained in the COT group for the remaining 5 yr following the diagnosis. On average women in the COT group had 250-292 d of opioids/year. When comparing women who received chronic narcotics following the diagnosis of CPP versus those who did not receive chronic narcotics, women who received COT were older, more likely to smoke and more frequently diagnosed with other pain conditions such as back pain, headaches, and fibromyalgia. (All p < 0.001). In the multivariable model, predictors of COT following CPP diagnosis included prior COT (OR = 10.0 (95% CI 9.4, 10.6), a positive history of military sexual trauma, smoking, and other chronic pain conditions.

Conclusions

The distinct pattern of prescribing shown in this cohort may mean COT is prescribed for CPP and this prescribing pattern contributes to the adverse events associated with COT. As COT is not recommended for CPP, physicians need more education on the therapies available to help CPP patients.

Depressive symptoms among women with endometriosis: a systematic review and meta-analysis

OBJECTIVE

To evaluate whether endometriosis is associated with depressive symptoms, and whether the association is modulated by pelvic pain.

DATA SOURCES

PubMed, Embase, PsychINFO, and the Cochrane Library, were systematically searched through September 2017.

STUDY ELIGIBILITY CRITERIA

The following eligibility criteria applied: full-text original article; quantitative data about depressive symptoms or depression; comparison of women with and without endometriosis, or women with endometriosis with and without pelvic pain. Articles reporting duplicated data were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers selected and reviewed the studies. Disagreements were resolved through discussion or a third opinion. Qualitative synthesis was performed through tabulation and assessment using a modified version of the Newcastle-Ottawa Scale. Effect sizes were pooled through meta-analysis, and moderator analyses were performed to identify potential confounders with several variables: region of the sample, method of ascertainment of endometriosis, method of measurement of depression, year of publication, and quality score.

RESULTS

A meta-analysis of 24 studies (99,614 women) showed higher levels of depression among women with endometriosis compared to controls (standardized mean difference [SMD], 0.22, 95% confidence interval [CI], 0.13-0.32). The heterogeneity in this analysis (I² = 68%) was not explained by any of the moderating variables. When only healthy controls were considered, a larger endometriosis-depression effect was found (11 studies, SMD, 0.49; 95% CI, 0.24-0.73; I² = 69%). Endometriosis patients reporting pelvic pain had significantly higher levels of depression compared to those without pain (4 studies; SMD, 1.01; 95% CI, 0.71-1.31; I² = 0%). No significant difference was found between women with pelvic pain and endometriosis and those with pelvic pain but without endometriosis (11 studies, SMD, -0.11; 95% CI, -0.25 to 0.04; I² = 0%).

CONCLUSION

The association between endometriosis and depressive symptoms is largely determined by chronic pain but may also be modulated by individual and context vulnerabilities. Awareness of the complex relationship between endometriosis and depressive symptoms informs tailored care and patient-centered research outcomes.

Opioid Pain Medication Use in New Urogynecology Patients

OBJECTIVES

The aim of this study was to determine the prevalence of opioid pain medication use among patients presenting for a new visit to the urogynecology clinic compared with those presenting to general gynecology.

METHODS

We identified all patients who presented for new patient visits to the urogynecology and gynecology clinics between January 1, 2016, and December 31, 2016. Any previous or current opioid use was extracted from the electronic medical record medication list. Statistical analysis was performed using χ and Fisher exact tests for comparisons of categorical variables. Modified Poisson regression models were used to estimate prevalence proportion ratios (PPRs).

RESULTS

There were 1835 (955 gynecology, 880 urogynecology) patients included. Median age was 47 years (interquartile range, 29 years), and median body mass index was 28.15 kg/m (interquartile range, 9.96 kg/m). Prevalence of opioid use was lowest among women who identified as Asian or other race and highest among black and Native American women; however, when compared by ethnicity, use was lowest among Hispanic women (P = 0.01). Among new urogynecology patients, 14% had self-reported opioid pain medication usage. Opioid use was almost twice as likely in the urogynecology group (PPR, 1.86; 95% confidence interval, 1.4-2.4). When adjusted for confounders, the urogynecology group was 1.3 times as likely to report opioid use (PPR 1.29; 95% confidence interval, 1.0-1.8), with this result approaching statistical significance.

CONCLUSIONS

Opioid use is greater in patients presenting to the urogynecology clinic compared with general gynecology. Urogynecologists need to know this information for planning and optimizing pain management in this population.