The impact of communication on adherence in pain management

The causal impact of shared decision making on pain outcomes: Gender matters

This national US study determined the causal impact of shared decision making (SDM) on pain outcomes, including any overall pain and the subcategories of any acute pain and any chronic pain. We additionally examined whether the causal impact of SDM on overall pain is moderated by gender, race-ethnicity, clinician-patient racial-ethnic concordance, and clinician-patient gender concordance. We used national US data from the 2003-2017 Medical Expenditure Panel Survey, which were externally valid to the US national non-institutionalized population, employed a standard measure of shared decision making, and applied an internally-valid two-stage least squares approach that used the peer SDM behavior of similar clinicians as an instrument. The instrument was sufficiently strong and statistically uncorrelated with patient characteristics. We found a large impact of SDM on both female and male chronic pain outcomes, where the effect for females was approximately 50% larger than for males, with a 10 percentage point increase in SDM quality resulted fewer females experiencing chronic pain that interfered with everyday activities (-24.8 percentage points; 95% confidence interval [CI]: 43.3, -6.4) than males (-16.5 percentage points; 95% CI: 32.9, -1.0). We estimated that a 10 percentage point national increase in the SDM index would thus result in 10.1 million fewer females and 5.7 million fewer males in the US experiencing chronic pain that interfered with their daily activities. Policy implications include both increasing the quality of SDM for all patients and educating male patients on the value of SDM.

Management of chronic non-cancer pain by primary care physicians: A qualitative study

Chronic non-cancer pain is a highly prevalent health issue with personal and societal consequences. Patients suffering from chronic non-cancer pain are mainly cared for by primary care physicians, but research shows that the latter perceive treating chronic pain as difficult. This qualitative descriptive study aimed to explore how primary care physicians in Switzerland manage patients with chronic non-cancer pain and what factors influence patient management. Data were collected through semi-structured interviews amongst primary care physicians in the German speaking part of Switzerland. A thematic analysis of the interviews allowed to identify four main themes: Investigation of chronic pain; patient-provider relationship; patient characteristics, and medical recommendations. These themes were closely interconnected and influenced each other. Physicians not only enquired about the origin of pain but also about the patients' beliefs and expectations towards it. They stressed the role of communication in fostering a good patient-physician relationship and to help patients cope with their pain. In addition to purely medical considerations, the psychological, social and economic situation of their patients and their possible impacts on the management of chronic non-cancer pain played a crucial role when recommending a treatment. This study highlighted the complexity of chronic pain management, which entails that primary care physicians need to figure out a unique strategy for each patient. By integrating patients' values and beliefs, as well as socioeconomic aspects, primary care physicians are in a position to take the lead in chronic non-cancer pain management. However, considering the burden of this disease, more continuous medical education on chronic pain is needed for primary care physicians, especially to better take into account the social determinants of pain.

Patient beliefs associated with medication hesitancy in palliative care: A systematic review using the theory of planned behavior

CONTEXT

The demand of palliative care is increasing due to the aging population and treatment hesitancy or intentional avoidance compromises symptom management.

OBJECTIVES

To identify patient beliefs associated with medication hesitancy by using the theory of planned behavior (TPB) namely, attitudes, subjective norms, behavioral intention, and perceived behavioral control associated with medication hesitancy or intentional noncompliance by avoidance.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline was followed to conduct a systematic literature search involving the CINAHL, Embase, MEDLINE, and PsycINFO databases from inception until March 2022. Hand-searched articles from reference lists and gray literature were included. Thematic analysis was conducted on qualitative data and triangulated with quantitative data.

RESULTS

About 554 articles were retrieved from the literature search and 17 articles were included based on the eligibility criteria. Three subthemes that were identified under TPB constructs were attitude: negative attitude toward medications, passive attitude toward illness and inaccurate information about disease or medication; one subtheme was identified under subjective norms: perceived negative opinions from others; and one subtheme was identified under perceived behavioral control: perception of manageable symptoms. Quantitative data provided triangulation of qualitative findings related to fear of addiction and side effects, feelings of hopelessness, unclear direction and information, social stigma, endurable symptoms, and illness as determinants for medication avoidance.

SIGNIFICANCE OF RESULTS

This systematic review highlighted some patient beliefs related to medication hesitancy or avoidance. Clinicians should take patient beliefs and concerns into consideration when creating treatment regimens for people receiving palliative care to optimize medication adherence and the quality of care.

[Pharmacological pain management in cancer patients]

Pharmacological pain therapy in cancer patients is based on guideline recommendations, which, however, do not fully coincide in all aspects due to varying weighting of evidence. The present article discusses current issues including the decreasing significance of the World Health Organization (WHO) analgesic ladder, with its distinction between step 2 and 3 being increasingly questioned. Risks of nonopioid analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in older populations, are discussed. Paracetamol may potentially reduce the effectiveness of immunotherapies. Aspects of administering analgesics via a feeding tube are considered. Recommendations for the treatment of episodic pain, transitioning between different opioids, and some relevant interactions are also discussed.

The experience of cancer pain in South African patients

BACKGROUND

Most people with cancer experience pain caused by the disease and treatment.

AIMS

To describe the experience of cancer pain of South African patients.

METHODS

A qualitative descriptive design was used; 20 (n=20) participants were purposively selected and in-depth interviews were conducted. Inductive content analysis was used to analyse the data.

FINDINGS

Two themes and five subthemes were identified. The themes were pain as a unique multi-dimensional experience, and that the unmet needs of the patient can influence their experience of pain.

CONCLUSION

The participants experienced total pain. Emotional pain, enhanced by loneliness and unmet information needs was experienced, and this was felt by participants as the worst kind of pain. Pain was mediated by means of medication that did not work well for all, support, compassionate care and hope that God would cure them and take the pain away.

RECOMMENDATION

A person-centred approach to pain management is needed, especially in diverse countries, such as South Africa, to better understand the complexity and influence of culture, language and education on the pain experience and to guide individual pain management.

What are Brazilian orthopaedists' views on the diagnosis and treatment of patients with chronic nonspecific low back pain? A qualitative investigation

BACKGROUND

Orthopaedists are often the first point of contact for patients who present with low back pain (LBP) and chronic LBP in Brazil.

AIM

To explore the views of orthopaedists on therapeutic approaches for chronic non-specific low back pain (CNLBP) with a view to gain insights into aspects of clinical practice considered important to them.

METHODS

A qualitative design underpinned by interpretivism was employed. Participants were (n = 13) orthopaedists with experience in treating patients with CNLBP. Following the pilot interviews, semi-structured interviews were conducted, audio-recorded, transcribed and de-identified. Interview data were thematically analysed.

RESULTS

Four themes were identified. (1) Biophysical aspects are important and predominate, but sometimes their relevance can be unclear; (2) Psychosocial aspects and lifestyle factors influence the therapeutic approach; (3) Treatment of CNLBP - including medication, physical activity, surgery and other invasive procedures and other therapeutic modalities; and (4) Nuances of clinical practice - "it goes beyond medicine".

CONCLUSION

Brazilian orthopaedists value identifying the biophysical cause(s) of chronic low back pain. Psychological factors were often discussed secondary to biophysical aspects, whereas social aspects were rarely mentioned. Orthopaedists highlighted their difficulties in navigating patients' emotions and reassuring patients without referrals to imaging tests. Orthopaedists may benefit from training that targets communication and other relational aspects of care in order to work with people who present with CNLBP.

Patient-Provider Shared Decision-Making, Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid Therapy for Chronic Pain

BACKGROUND

Patient-provider shared decision-making is associated with better treatment adherence and pain outcomes in opioid-specific pain management. One possible mechanism through which shared decision-making may impact pain management outcomes is trust in one's prescribing provider. Elucidating relationships between factors that enhance the patient-provider relationship, such as shared decision-making and trust, may reduce risks associated with opioid treatment, such as opioid misuse.

OBJECTIVE

The purpose of this study was to investigate the mediating effect of trust in one's prescribing provider on the relationship between shared decision-making and current opioid misuse.

DESIGN

A secondary analysis of data from a prospective cohort study of US Veterans (N = 1273) prescribed long-term opioid therapy (LTOT) for chronic non-cancer pain.

PARTICIPANTS

Eligibility criteria included being prescribed LTOT, ability to speak and read English, and access to a telephone. Veterans were excluded if they had a cancer diagnosis, received opioid agonist therapy for opioid use disorder, or evidence of pending discontinuation of LTOT. Stratified random sampling was employed to oversample racial and ethnic minorities and women veterans.

MAIN MEASURES

Physician Participatory Decision-Making assessed level of patient involvement in medical decision-making, the Trust in Provider Scale assessed interpersonal trust in patient-provider relationships, and the Current Opioid Misuse Measure assessed opioid misuse.

KEY RESULTS

Patient-provider shared decision-making had a total significant effect on opioid misuse, in the absence of the mediator (c =  - 0.243, p < 0.001), such that higher levels of shared decision-making were associated with lower levels of reported opioid misuse. When trust in provider was added to the mediation model, the indirect effect of shared decision-making on opioid misuse through trust in provider remained significant (c' =  - 0.147, p = 0.007).

CONCLUSIONS

Shared decision-making is associated with less prescription opioid misuse through the trust that is fostered between patients and providers.

Proof of concept of prehabilitation: a combination of education and behavioural change, to promote physical activity in people with fibromyalgia

OBJECTIVES

To establish proof of concept of a prehabilitation intervention, a combination of education and behavioural change, preceding a physical activity programme in people with fibromyalgia (FM).

SETTINGS

Open-label, feasibility clinical trial.

PARTICIPANTS

Eleven people with FM (10 women).

INTERVENTIONS

The prehabilitation intervention consisted of 4 weeks, 1 weekly session (~1 to 1.5 hours), aimed to increase self-efficacy and understand why and how to engage in a gentle and self-paced physical activity programme (6 weeks of walking with telephone support).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was the acceptability and credibility of the intervention by means of the Credibility/Expectancy Questionnaire. Secondary outcomes comprised scales to measure FM severity, specific symptoms and sedentary behaviour. An exit interview was conducted to identify the strengths and weaknesses and barriers to the intervention.

RESULTS

One participant dropped out due to finding the walking programme excessively stressful. Participants expected the intervention would improve their symptoms by 22%-38% but resulted in 5%-26% improvements. Participants would be confident in recommending this intervention to a friend who experiences similar problems. The interviews suggested that the fluctuation of symptoms should be considered as an outcome and that the prehabilitation intervention should accomodate these fluctuation. Additional suggestions were to incorporate initial interviews (patient-centred approach), to tailor the programmes to individuals' priorities and to offer a variety of physical activity programmes to improve motivation.

CONCLUSIONS

This feasibility study demonstrated that our novel approach is acceptable to people with FM. Future interventions should pay attention to flexibility, symptoms fluctuation and patients support.

TRIAL REGISTRATION NUMBER

NCT03764397.

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

Communication and access to healthcare: Experiences of Aboriginal and Torres Strait Islander people managing pain in Queensland, Australia

Background

Pain management requires a multidisciplinary approach and a collaborative relationship between patient-provider in which communication is crucial. This study examines the communication experiences of Aboriginal and Torres Strait Islander patients and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs), to improve understanding of how pain is managed in and through patient-health professional communication.

Methods

This qualitative study involved a purposive sample of patients attending three persistent pain clinics and ATSIHLOs working in two hospitals in Queensland, Australia. Focus groups and in-depth interviews explored the communication experiences of patients managing pain and ATSIHLOs supporting patients with pain. This study adopted a descriptive phenomenological methodology, as described by Colaizzi (1978). Relevant statements (patient and ATSIHLOs quotes) about the phenomenon were extracted from the transcripts to formulate meanings. The formulated meanings were subsequently sorted into thematic clusters and then integrated into themes. The themes were then incorporated into a concise description of the phenomenon of communication within pain management. Findings were validated by participants.

Results

A total of 21 Aboriginal and Torres Strait Islander participants were involved in this study. Exploration of the communication experiences of patients and ATSIHLOs revealed overlapping themes of important barriers to and enablers of communication that affected access to care while managing pain. Acknowledging historical and cultural factors were particularly important to build trust between patients and health professionals. Some patients reported feeling stigmatized for identifying as Aboriginal and Torres Strait Islander, while others were reluctant to disclose their background for fear of not having the same opportunity for treatment. Differences in the expression of pain and the difficulty to use standard pain measurement scales were identified. Communication was described as more than the content delivered, it is visual and emotional expressed through body language, voice intonation, language and the speed of the conversation.

Conclusion

Communication can significantly affect access to pain management services. Aboriginal and Torres Strait Islander patients highlighted the burden of emotional pain caused by historical factors, negative stereotypes and the fear of discrimination. Pain management services and their health professionals need to acknowledge how these factors impact patients trust and care.

Preferred Communication Strategies Used by Physical Therapists in Chronic Pain Rehabilitation: A Qualitative Systematic Review and Meta-Synthesis

OBJECTIVE

Lack of clarity regarding effective communication behaviors in chronic pain management is a barrier for implementing psychologically informed physical therapy approaches that rely on competent communication by physical therapist providers. This study aimed to conduct a systematic review and meta-synthesis to inform the development of a conceptual framework for preferred communication behaviors in pain rehabilitation.

METHODS

Ten databases in the health and communication sciences were systematically searched for qualitative and mixed-method studies of interpersonal communication between physical therapists and adults with chronic pain. Two independent investigators extracted quotations with implicit and explicit references to communication and study characteristics following Standards for Reporting Qualitative Research and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Methodological quality for individual studies was assessed with Critical Appraisal Skills Programme, and quality of evidence was evaluated with GRADE-CERQual. An inductive thematic synthesis was conducted by coding each quotation, developing descriptive themes, and then generating behaviorally distinct analytical themes.

RESULTS

Eleven studies involving 346 participants were included. The specificity of operationalizing communication terms varied widely. Meta-synthesis identified 8 communication themes: (1) disclosure-facilitating, (2) rapport-building, (3) empathic, (4) collaborative, (5) professional accountability, (6) informative, (7) agenda-setting, and (8) meta-communication. Based on the quality of available evidence, confidence was moderate for 4 themes and low for 4 themes.

CONCLUSION

This study revealed limited operationalization of communication behaviors preferred by physical therapists in chronic pain rehabilitation. A conceptual framework based on 8 communication themes identified from the literature is proposed as a preliminary paradigm to guide future research.

IMPACT

This proposed evidence-based conceptual framework for preferred communication behaviors in pain rehabilitation provides a framework for clinicians to reflect on their own communication practices and will allow researchers to identify if and how specific communication behaviors impact clinical outcomes.

Stigma perceived by patients with functional somatic syndromes and its effect on health outcomes - A systematic review

BACKGROUND

Patients with functional somatic syndromes (FSS) experience stigma which arguably affects their health.

AIM

To determine the presence of perceived stigma and its effects on physical and mental health in patients with FSS compared to patients with comparable explained conditions.

METHODS

A comprehensive search of PubMed, Embase, PsycINFO, CINAHL and Cochrane Library was performed to select studies focusing on stigma perceived by patients with irritable bowel syndrome (IBS), fibromyalgia (FM) or chronic fatigue syndrome (CFS), comparing these patients to patients with comparable but explained conditions.

RESULTS

We identified 1931 studies after duplicate removal. After screening we included eight studies: one study about all three FSS, one about IBS, five about FM and one about CFS. We found that patients with IBS did not consistently experience higher levels of stigma than those with a comparable explained condition. Patients with CFS and FM experienced higher levels of stigma compared to patients with comparable explained conditions. All studies showed a correlation between stigma and negative health outcomes.

DISCUSSION

Patients with FSS experience stigma and negative health outcomes. However, experiencing stigma is not restricted to patients with FSS, as many patients with explained health conditions also experience stigma. Whether stigma has more negative health consequences in patients with FSS compared to patients with explained health conditions remains unclear and should be assessed in future research.

Patient-clinician brain concordance underlies causal dynamics in nonverbal communication and negative affective expressivity

Patient-clinician concordance in behavior and brain activity has been proposed as a potential key mediator of mutual empathy and clinical rapport in the therapeutic encounter. However, the specific elements of patient-clinician communication that may support brain-to-brain concordance and therapeutic alliance are unknown. Here, we investigated how pain-related, directional facial communication between patients and clinicians is associated with brain-to-brain concordance. Patient-clinician dyads interacted in a pain-treatment context, during synchronous assessment of brain activity (fMRI hyperscanning) and online video transfer, enabling face-to-face social interaction. In-scanner videos were used for automated individual facial action unit (AU) time-series extraction. First, an interpretable machine-learning classifier of patients' facial expressions, from an independent fMRI experiment, significantly distinguished moderately painful leg pressure from innocuous pressure stimuli. Next, we estimated neural-network causality of patient-to-clinician directional information flow of facial expressions during clinician-initiated treatment of patients' evoked pain. We identified a leader-follower relationship in which patients predominantly led the facial communication while clinicians responded to patients' expressions. Finally, analyses of dynamic brain-to-brain concordance showed that patients' mid/posterior insular concordance with the clinicians' anterior insula cortex, a region identified in previously published data from this study¹, was associated with therapeutic alliance, and self-reported and objective (patient-to-clinician-directed causal influence) markers of negative-affect expressivity. These results suggest a role of patient-clinician concordance of the insula, a social-mirroring and salience-processing brain node, in mediating directional dynamics of pain-directed facial communication during therapeutic encounters.

A Novel Method for Digital Pain Assessment Using Abstract Animations: Human-Centered Design Approach

Background

Patients with chronic pain face several challenges in using clinical tools to help them monitor, understand, and make meaningful decisions about their pain conditions. Our group previously presented data on Painimation, a novel electronic tool for communicating and assessing pain.

Objective

This paper describes the human-centered design and development approach (inspiration, ideation, and implementation) that led to the creation of Painimation.

Methods

We planned an iterative and cyclical development process that included stakeholder engagement and feedback from users. Stakeholders included patients with acute and chronic pain, health care providers, and design students. Target users were adults with acute or chronic pain who needed clinical assessment and tracking of the course of their pain over time. Phase I (inspiration) consisted of empathizing with users, understanding how patients experience pain, and identifying the barriers to accurately expressing and assessing pain. This phase involved understanding how patients communicate pain symptoms to providers, as well as defining limitations of current models of clinical pain assessment tools. In Phase II (ideate) we conceptualized and evaluated different approaches to expressing and assessing pain. The most promising concept was developed through an iterative process that involved end users and stakeholders. In Phase III (implementation), based on stakeholder feedback from initial designs and prototypes of abstract pain animations (painimations), we incorporated all concepts to test a minimally viable product, a fully functioning pain assessment app. We then gathered feedback through an agile development process and applied this feedback to finalizing a testable version of the app that could ultimately be used in a pain clinic.

Results

Engaging intended users and stakeholders in an iterative, human-centered design process identified 5 criteria that a pain assessment tool would need to meet to be effective in the medical setting. These criteria were used as guiding design principles to generate a series of pain assessment concept ideas. This human-centered approach generated 8 highly visual painimations that were found to be acceptable and useable for communicating pain with medical providers, by both patients with general pain and patients with sickle cell disease (SCD). While these initial steps continued refinement of the tool, further data are needed. Agile development will allow us to continue to incorporate precision medicine tools that are validated in the clinical research arena.

Conclusions

A multiphase, human-centered design approach successfully resulted in the development of an innovation that has potential to improve the quality of medical care, particularly for underserved populations. The use of Painimation may especially benefit the medical care of minority populations with chronic and difficult-to-treat pain, such as adults with SCD. The insights generated from this study can be applied to the development of patient-reported outcomes tools that are more patient-centered, engaging, and effective.

Experiences with an addiction consultation service on care provided to hospitalized patients with opioid use disorder: a qualitative study of hospitalists, nurses, pharmacists, and social workers

Background: In response to the opioid epidemic, addiction consultation services (ACS) increasingly provide dedicated hospital-based addiction treatment to patients with substance use disorder. We assessed hospitalist and medical staff perceptions of how the presence of 2 hospitals' ACS impacted care for hospitalized patients with opioid use disorder (OUD). We inquired about ongoing challenges in caring for this patient population.Methods: We conducted a qualitative study of hospital-based providers utilizing focus groups and key informant interviews for data collection. Transcripts were analyzed using a mixed inductive-deductive approach. Emergent themes were identified through an iterative, multidisciplinary team-based process using a directed content analysis approach.Results: Hospitalists (n = 20), nurses (n = 13), social workers (n = 11), and pharmacists (n = 18) from a university hospital and a safety-net hospital in Colorado participated in focus groups or key informant interviews. In response to the availability of an ACS, hospitalists described increased confidence using methadone and buprenorphine to treat opioid withdrawal, which they perceived as contributing to improved patient outcomes and greater job satisfaction. Participants expressed concern about inconsistent care provided to patients with OUD that varied by the admitting team's specialty and the physician's background and training. Nurses and hospitalists reported frustrations with achieving adequate pain control among patients with OUD. Last, pharmacists reported practice variations when physicians dosed buprenorphine for acute pain among patients with OUD. A lack of standardized dosing led to concerns of inadequate analgesia or return to opioid use following hospital discharge.Conclusions: An ACS reportedly supports hospitalists and medical staff to best care for hospitalized patients with OUD. Notably, care provided to patients with OUD may not be uniform depending on various physician-level factors. Future work to address the concerns reported by study participants may include education for OUD treatment, early involvement of the ACS, and incorporation of buprenorphine prescribing algorithms to standardize care.

Impact of Personal, Cultural and Religious Beliefs on Medication Adherence among Patients with Chronic Diseases at University Hospital in Northwest Ethiopia

BACKGROUND

Subjective beliefs about chronic disease conditions and their drug management are among factors determining adherence to medications that are amenable to interventions. Patient-level factors such as personal, cultural, and religious beliefs about diseases, and medication use may have a significant impact on medication adherence. The purpose of this study was to assess the impact of personal, cultural and religious beliefs on medication adherence behavior among patients with chronic follow-up.

PATIENTS AND METHODS

An institutional-based cross-sectional study design was conducted among chronic ambulatory patients from July to August 2021. The data was collected through an interviewer administered questionnaire. Initially stratified sampling technique was used to include proportional participants from different disease conditions, and systematic random sampling was employed to enroll eligible patients from each subgroup. Descriptive statistics such as frequencies and percentages were computed for categorical variables and mean with (standard deviation ±SD) used for continuous variables. Logistic regression model was employed to determine variable with poor adherence. A 95% confidence interval with P-value ≤0.05 was used to declare statically significance.

RESULTS

Among the 404 participants, more than half (51%) were males. The mean (±SD) age of the patients was 47.8 ± 14.8 years. Patients with strong belief in the harm of medications were found 4 times more likely to have poor medication adherence than those with weak belief in the harm of medications (AOR = 4.027, 95% CI:1.232-13.161, P = 0.021). In contrast, having strong personal belief regarding the necessity of medications were found to be less likely to have poor medication adherence (AOR = 0.368, 95% CI: 0.220-0.615, P < 0.001).

CONCLUSION

This study generalized that most of the patients were poor adherent to their medications. Personal beliefs were found to influence medication adherence of the patients. Future studies could be needed to explore and identify how these factors affect patients' medication adherence.

Barriers and facilitators to older adults' use of nonpharmacologic approaches for chronic pain: a person-focused model

ABSTRACT

In the context of the opioid epidemic and the growing population of older adults living with chronic pain, clinicians are increasingly recommending nonpharmacologic approaches to patients as complements to or substitutes for pharmacologic treatments for pain. Currently, little is known about the factors that influence older adults' use of these approaches. We aimed to characterize the factors that hinder or support the use of nonpharmacologic approaches for pain management among older adults with multiple morbidities. We collected semistructured qualitative interview data from 25 older adults with multiple morbidities living with chronic pain for 6 months or more. Transcripts were coded to identify factors that hindered or supported participants' use of various nonpharmacologic approaches. We used the constant comparative method to develop a person-focused model of barriers and facilitators to participants' use of these approaches for chronic pain management. Participants described a wide range of factors that influenced their use of nonpharmacologic approaches. We grouped these factors into 3 person-focused domains: awareness of the nonpharmacologic approach as relevant to their chronic pain, appeal of the approach, and access to the approach. We propose and illustrate a conceptual model of barriers and facilitators to guide research and clinical care. This study identifies numerous factors that influence patients' use of nonpharmacologic approaches, some of which are not captured in existing research or routinely addressed in clinical practice. The person-centered model proposed may help to structure and support patient-clinician communication about nonpharmacologic approaches to chronic pain management.

Portuguese Version of the Intentional Non-Adherence Scale: Validation in a Population of Chronic Pain Patients

Objective: Despite the effectiveness of pain medicines, nonadherence to prescribed medication remains a major problem faced by healthcare systems. The aim of present study was to perform the translation, cultural adaptation, and validation of the Intentional Non-Adherence Scale (INAS) for the European Portuguese language in a sample of chronic pain patients.

Methods: A Portuguese version of the INAS scale was constructed through a process of translation, back translation, and expert’s panel evaluation. A total of 133 chronic pain patients were selected from two chronic pain clinics from tertiary hospitals in Porto, Portugal. The protocol interview included the assessment of pain beliefs (PBPI), beliefs about medicine (BMQ), medication adherence (MARS-P9), and two direct questions about adherence previously validated.

Results: The internal consistency in all subscales was α = 0.902 for testing treatment; α = 0.930 for mistrust treatment; α = 0.917 for resisting treatment; and α = 0.889 for resisting illness. Exploratory and confirmatory factor analysis revealed a four-factor structure that explained 74% of the variance. The construct validity of the INAS was shown to be adequate, with the majority of the previously defined hypotheses regarding intercorrelations with other measures confirmed.

Conclusion: The Portuguese version of INAS could be a valuable and available instrument for Portuguese researchers and clinicians to assess the intentional nonadherence determinants during the management of chronic pain.

The comfort ability program for adolescents with sickle cell pain: Evaluating feasibility and acceptability of an inpatient group-based clinical implementation

BACKGROUND

Integration of nonpharmacological therapies, such as cognitive and behavioral pain management strategies, is recommended to support comprehensive disease and pain management among children and adolescents with sickle cell disease (SCD). The Comfort Ability Program for Sickle Cell Pain (CAP for SCP) introduces psychological and biobehavioral pain management strategies to children and adolescents with SCD. This study aimed to pilot the implementation of the CAP for SCP in a group setting to children and adolescents hospitalized for SCD pain examining feasibility, acceptability, and preliminary effectiveness on improving pain knowledge and coping efficacy.

METHOD

Adaptation of CAP for SCP into a three-session group format was guided by four phases of the Dynamic Adaptation Process model: Exploration, Preparation, Implementation, and Sustainment. Youth with SCD (n = 57) hospitalized for pain participated in at least one session and completed self-report of knowledge of pain management skills, pain coping efficacy, and treatment acceptance. Completion rates of sessions and qualitative feedback were gathered to evaluate feasibility and acceptability.

RESULTS

Feasibility of conducting inpatient group sessions was suboptimal; however, patients and medical providers reported moderate to high levels of treatment acceptance. Patients also reported significant improvements in knowledge of pain management skills following session 1.

CONCLUSIONS

CAP for SCP is a patient-centered first-line psychoeducational intervention that can be integrated into clinical practice settings to introduce youth to cognitive and behavioral pain management strategies to support SCD pain management.

'Drawing a line in the sand': Physician diagnostic uncertainty in paediatric chronic pain

BACKGROUND

Diagnostic uncertainty is the subjective perception of an inability to provide an accurate explanation of the patient's health problem or that a label is missing or incorrect. While recently explored in youth with chronic pain and families, this is the first study to investigate diagnostic uncertainty from the perspectives of physicians.

METHODS

Individual, semi-structured interviews were conducted with 16 paediatricians who assess and/or treat youth who experience complex chronic pain. Interviews explored paediatricians' perceptions, beliefs and confidence regarding the assessment and management of chronic pain in youth and how they manage uncertainty regarding the diagnosis. Interviews were analysed using inductive reflexive thematic analysis.

RESULTS

Analyses generated one prominent theme: 'drawing a line in the sand'. Within this theme, physicians discussed uncertainty as inherent to their role treating youth with chronic pain. The metaphor of 'drawing a line in the sand' was used to describe a process of identifying a point at which physicians no longer sought a new diagnosis for the child's pain or continued diagnostic investigations. This line was influenced by numerous factors, which are highlighted through four subthemes: physician training, experience and mentorship; individual patient and family factors; perceived reassurance of diagnostic investigations; and the broader social context and implications.

CONCLUSIONS

How physicians manage diagnostic uncertainty must be understood, as it is likely to critically impact how a diagnosis of chronic pain is communicated, the diagnostic investigations undertaken, the wait time to receiving a diagnosis, and ultimately youths' pain experiences.

Patient-Initiated Pain Expressions: Interactional Asymmetries and Consequences for Cancer Care

Only minimal attention has been given to analyzing interactional moments when patients and providers talk about "pain" in general consultations and primary care, and no attention has focused on how pain gets managed during oncology interviews. Conversation analysis (CA) is used to examine a sampling of instances drawn from a collection of 146 pain instances across 65 video recorded and transcribed clinical encounters in a comprehensive cancer clinic. Specific attention is drawn to how pain descriptions are not static but malleable as cancer patients upgrade, downgrade, and produce combined orientations when making their experiences available to oncologists. In response, it is shown that doctors acknowledge patients' descriptions, but do not elaborate nor affiliate with, important pain disclosures. Three interactional environments are closely examined: 1) Reporting and responding to past pain/hurt incidents; 2) Doctor's missing assessments in response to good news announcements about patients' minimal pain; and 3) Patient-initiated pain responses to doctors' questions. These empirical findings confirm identified patterns of interactional asymmetries comprising pain events in UK consultations and USA primary care. Close examination of these social actions provides basic knowledge about how pain communication reframes historical understandings of individuals' pain experiences. Implications for future research are identified, and a protocol is described for how clinical practice and medical education can be improved by refining understandings of pain communication to promote increased sensitivities and more personalized responses to pain expressions.

Four-Week Pain Profile and Patient Non-Adherence to Pharmacological Pain Therapy After Day Surgery

Background

Nowadays, complicated and painful surgical procedures are encouraged to be carried out in an ambulatory setting.

Objectives

The current study aimed to assess 4-week postoperative pain profiles of 4 painful ambulatory surgical procedures. We analyzed the prevalence of and reasons for non-adherence and partial adherence of patients to a predefined treatment schedule after the ambulant surgery.

Methods

The current study analyzed data from a large randomized trial by evaluating the effect of postoperative pain medication on acute postoperative pain at home during the first 4 postoperative days (POD) in patients scheduled for ambulatory hemorrhoid surgery, shoulder or knee arthroscopy, and inguinal hernia repair. Postoperative pain intensity was assessed at POD 0, 1, 2, 3, 4, 7, 14, and 28 via the Numeric Rating Scale (NRS). Adherence was assessed on POD 1, 2, 3, and 4.

Results

Median average pain scores were above an NRS of 3 during the first postoperative week after shoulder arthroscopy and even above 4 during the first postoperative week after hemorrhoid surgery. 26% of patients undergoing shoulder arthroscopy and hemorrhoid surgery still had moderate pain 1 week after surgery. Median average pain scores were below an NRS of 3 during the whole study period after inguinal hernia repair and knee arthroscopy. 24.61% of patients did not use the study medication as prescribed, 5.76% of whom were non-adherent, and 18.85% were partially adherent.

Conclusions

Each type of ambulant surgery has its unique postoperative pain profile. New strategies should be developed for pain therapy at home, particularly after the ambulatory arthroscopic shoulder surgery and hemorrhoid surgery. Non-adherence is uncommon if they are provided with a multimodal analgesic home kit together with clear verbal, written instructions, and intensive follow-up.

Mobile Health App (AGRIPPA) to Prevent Relapse After Successful Interdisciplinary Treatment for Patients With Chronic Pain: Protocol for a Randomized Controlled Trial

BACKGROUND

To facilitate adherence to adaptive pain management behaviors after interdisciplinary multimodal pain treatment, we developed a mobile health app (AGRIPPA app) that contains two behavior regulation strategies.

OBJECTIVE

The aims of this project are (1) to test the effectiveness of the AGRIPPA app on pain disability; (2) to determine the cost-effectiveness; and (3) to explore the levels of engagement and usability of app users.

METHODS

We will perform a multicenter randomized controlled trial with two parallel groups. Within the 12-month inclusion period, we plan to recruit 158 adult patients with chronic pain during the initial stage of their interdisciplinary treatment program in one of the 6 participating centers. Participants will be randomly assigned to the standard treatment condition or to the enhanced treatment condition in which they will receive the AGRIPPA app. Patients will be monitored from the start of the treatment program until 12 months posttreatment. In our primary analysis, we will evaluate the difference over time of pain-related disability between the two conditions. Other outcome measures will include health-related quality of life, illness perceptions, pain self-efficacy, app system usage data, productivity loss, and health care expenses.

RESULTS

The study was approved by the local Medical Research Ethics Committee in October 2019. As of March 20, 2020, we have recruited 88 patients.

CONCLUSIONS

This study will be the first step in systematically evaluating the effectiveness and efficiency of the AGRIPPA app. After 3 years of development and feasibility testing, this formal evaluation will help determine to what extent the app will influence the maintenance of treatment gains over time. The outcomes of this trial will guide future decisions regarding uptake in clinical practice.

TRIAL REGISTRATION

Netherlands Trial Register NL8076; https://www.trialregister.nl/trial/8076.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18632.

Pain in low-income older women with disabilities: a qualitative descriptive study

The purpose of this qualitative study was to identify how low-income older women with disabilities perceive pain, pain management, and communication with healthcare providers. We interviewed 26 low-income women (average age 75 years; SD 7.0), eliciting the following overarching themes: "Invisibility of Pain: Unnoticed or Undetected," "Escalating Pain Leads to Help Seeking," "Communication with Healthcare Providers and Outcomes," "Pain Management Facilitates Function and Accomplishment," and "The Intersection of Pain, Disability, and Depressive Symptoms." Study findings support the ways in which behavior changes from pain can impede pain management.

The safety of medications used to treat peripheral neuropathic pain, part 1 (antidepressants and antiepileptics): review of double-blind, placebo-controlled, randomized clinical trials

INTRODUCTION

Peripheral neuropathic pain is a highly disabling condition for patients and a challenge for neurologists and pain physicians. Although many drugs have been assessed in scientific studies, few have demonstrated a clear clinical efficacy against neuropathic pain. Moreover, the paucity of data regarding their safety raised the question on the benefit-risk ratio when used in patients experiencing peripheral neuropathies.

AREAS COVERED

The authors conducted a review of double-blind, placebo-controlled, randomized clinical trials to assess the safety of medications used to treat neuropathic pain. This first review was focused on antidepressant and antiepileptic medications. The aim was to provide an overview of the treatment-emergent adverse events (≥10%) and the serious adverse effects described in clinical trials.

EXPERT OPINION

Among antiepileptics and antidepressants, duloxetine appeared to have the most detailed safety for the treatment of peripheral neuropathic pain. Over all studies, the most commonly reported adverse effects were dizziness, drowsiness, nausea, and constipation. Only 20.0% of the included studies (N = 90) presented a good description of adverse effects that included a statistical comparison vers usa placebo group. Important methodological improvements must be made to improve the assessment of medication safety in future clinical trials.

Observed discordance between outcomes reported by acromegaly patients and their treating endocrinology medical provider

BACKGROUND

Acromegaly patients, even those with IGF-1 values within the normal range receiving somatostatin receptor ligands (SRLs), often suffer from significant symptoms. It is not known to what extent patients' medical providers are aware of the frequency and severity of acromegaly symptoms or level of treatment satisfaction with SRLs. This study sought to examine the concordance between outcomes reported by acromegaly patients treated with long-acting SRLs and those perceived by their medical provider.

METHODS

US acromegaly patients on a stable dose of SRL and seen by their medical provider in the past year completed an online survey which included the Acro-TSQ. Their medical providers were interviewed about the perception of their patient's symptoms, level of control, and general health, and completed relevant portions of the Acro-TSQ. Concordance between patient and medical provider reported data was examined.

RESULTS

Medical providers reported that their patients experienced acromegaly symptoms on a regular basis, however, there was poor agreement between patients and medical providers on the frequency, severity, and pattern of symptoms, as well as on the severity of injection site reactions and multiple domains of the Acro-TSQ, with patients generally reporting symptoms and injection site reactions more often and with higher severity than medical providers.

CONCLUSIONS

Medical providers were aware that their patients who were receiving a stable dose of SRL regularly experienced acromegaly symptoms. Addressing discordance in patient- and medical provider-reported frequency and severity of acromegaly symptoms and injection site reactions by facilitating better communication may improve care of acromegaly patients.

Nurses' experiences of providing nonpharmacological pain management in palliative care: A qualitative study

AIM AND OBJECTIVES

To explore the experiences and views of nurses who provide nonpharmacological therapies for chronic pain management in palliative care.

BACKGROUND

Nursing expertise in palliative care is essential in providing pain relief to patients with chronic diseases. Examinations of the use of nonpharmacological therapies for chronic pain management in palliative care have revealed what nonpharmacological therapies have been used, but there is insufficient knowledge regarding nurses' attitudes, views and experiences regarding pain therapies in this context.

DESIGN

A qualitative descriptive design was chosen.

METHODS

Data were collected through individual interviews in a purposive sample with 15 nurses to ensure maximum variation. The data were analysed using qualitative content analysis. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) checklist.

RESULTS

The analysis yielded four categories, as follows: "building and sustaining favourable therapeutic relationships" involved the creation of trust and a solid relationship; in "recognising the diversity of patients' needs," person-centred care is expressed as being vital for individualised nonpharmacological pain management; "incorporating significant others" describes how nurses can help to ease the patient's pain by identifying positive encounters with family members or friends; and in "recognising the existence of barriers," nurses highlight vulnerable groups such as children, for whom nurses require special education to enable optimal nonpharmacological pain management.

CONCLUSION

The unique knowledge that nurses gain about the patient through the nurse-patient relationship is central and crucial for successful nonpharmacological pain management.

RELEVANCE TO CLINICAL PRACTICE

This study emphasises the need for nurses to get to know their patient and to be open and sensitive to patients' descriptions of their unique life situations, as this provides the necessary knowledge for optimal care and pain management. Nurses should be encouraged and given the opportunity to attend specialised training in palliative care and pain management.

Tell me your dreams and goals: Structuring communication exchanges to improve patient-centered care with chronic pain patients

BACKGROUND

Communicating pain is a difficult endeavor due to the lack of observable pathology, the immeasurable nature of pain, and the presence of comorbid symptoms. While research has shown the value of cure-centered and care-centered communication, it is unclear how chronic pain patients would like to structure pain communication with their providers so that it produces pain disclosure and emotional support. Aim This study examines communication preferences of chronic pain patients including types of questions asked and information received to allow a holistic portrayal of the experience of living with chronic pain.

DESIGN

The research used a quantitative survey that was disseminated via online chronic pain devoted support groups.

PARTICIPANTS

192 respondents took the survey, with women respondents outnumbering men at a 4:1 ratio. Respondents came from 38 states and represented eight countries.

RESULTS

For providers to better understand patients' chronic pain, results indicate they would like providers to inquire about how pain impacts their daily activities, relationships, work responsibilities, and goals and dreams using open-ended questions. These low-stake questions can facilitate emotional disclosure, increase feelings of support, and allow for co-morbid linkages.

CONCLUSION

These inquiries prioritize patients' own subjective knowledge, can deepen the communication exchange between provider and patient, and facilitate pain disclosure. The findings help to deliver patient-centered care, promote rapport, and foster trust between providers and their patients.

Non-Adherence to Pharmacotherapy: A Prospective Multicentre Study About Its Incidence and Its Causes Perceived by Chronic Pain Patients

OBJECTIVE

Pharmacological interventions remain the cornerstone of chronic pain treatment; however, nearly 40% of the prescription medicines are not taken as prescribed. The present study aims at understanding and describing non-adherence from the perspective of chronic pain patients during a 1-year follow-up study.

METHODS

A cohort of 950 consecutive patients referred to a first consultation in Multidisciplinary Chronic Pain Clinics was followed with a standardized protocol for 1 year. This included assessment of pain characteristics; prescribed medication; therapeutic adherence; effectiveness of treatment, non-adherence and its perceived reasons; clinical outcomes and quality of life. We used a mixed methods approach, including qualitative and quantitative analyses.

RESULTS

Forty-nine percent of the 562 patients who responded to all assessments during follow-up were adherent after 1 year of chronic pain treatment. The core associations between each "non-adherence reason" and Anatomical Therapeutic Chemical Code (ATC) group were perceived side effects (p=0.019) and delayed start (p=0.022) for narcotic analgesics (opioids); perceived non-efficacy (p=0.017) and delayed start (p=0.004) for antiepileptics and anticonvulsants; perceived low necessity (p=0.041) and delayed start (p=0.036) for analgesics antipyretics; change in prescriptions because of a new clinical condition for antidepressants (p=0.024); high concerns (p=0.045) and change in prescriptions because of a new clinical condition (p<0.001) for non-steroidal anti-inflammatory drugs; delayed start (p=0.016) and financial constraints (p=0.018) for other medications.

DISCUSSION

This study emphasizes the patient's perspective regarding non-adherence to pharmacological treatment of chronic pain, providing valuable and novel information to be used in future interventions to help patients make an informed choice about their adherence behavior.

Pain situations among working adults and the educational needs identified: an exploratory survey via WeChat

OBJECTIVES

The aim of this study is to 1) investigate the pain situation among working adults in China; 2) explore the self-initiate pain reliving strategies applied by working adults; and 3) collect people's interests and suggestions to the topics of the online pain education program.

METHODS

This is an exploratory survey through WeChat. The study was conducted from May 2018 to December 2018. Participants were recruited following the snowball sampling. In total of 664 people were recruited and 502 satisfied the criteria. SPSS was used for data analysis. Descriptive statistical analysis were used to present the utilization of pain treatments and suggested topics. Chi-square test, independent multiple logistic regression and Spearman's correlation were used to analysis the data.

RESULTS

The overall incidence of pain among the participants is 45% and higher among female (63%) than male (37%). Neck (68.72%, 4.10 ± 2.31), shoulder (62.56%, 3.78 ± 2.41) and head (49.34%, 4.23 ± 2.52) are reported as the most common and severe pain sites. Working is affected by pain and the results show that there is a negative correlation between pain intensity and work (rs = - 0.194) among the working population. Non-pharmacological treatments (55.77%) were chosen more by pain suffers. Totally 63.39% of participants show interests in the online pain education program and physical and psychological impact of pain is the most suggested topic (22.51%).

CONCLUSION

The pain prevalence is high among working adults in China. Impact of pain on work is a significant problem for the working adults. It is important to identify people at risk and deliver timely intervention to reduce pain. People showed their willingness in joining the online program. Therefore, future online pain education program can be developed.

Patients' perceptions of recovery following a 6-week exercise intervention for the treatment of patellofemoral pain: A mixed methods study

Background

Patellofemoral pain (PFP) is a common and complex condition. The diagnosis and causal mechanisms are not well understood and therefore the long-term prognosis tends to be poor. Exercise is currently the only evidence-based treatment strategy suggested to improve pain and function in the long term. However, no qualitative studies have been conducted to establish patients’ perceptions of recovery in the long term following an exercise intervention.

Objectives

To measure self-reported recovery on a 7-point Likert scale in 31 participants with PFP 6 months after a 6-week physiotherapy intervention. To explore the subjective accounts of patients who received a physiotherapy intervention for PFP, regarding their expectations and perceptions of recovery.

Method

Semi-structured exit interviews were conducted electronically 6 months after intervention to ascertain the patients’ perspectives on whether expectations of treatment were met, and factors that influenced their recovery experience.

Results

Quantitative analysis of self-reported recovery on a 7-point Likert scale showed that 48.4% of participants felt that they were ‘recovered’. Qualitative analysis showed three main categories: expectations of treatment, perceptions of recovery and changes in functional abilities.

Conclusion

Clinicians should address patients’ expectations of treatment and include the patients in decision-making regarding their treatment. Long-term follow-up is essential to ensure that treatment effects have been maintained, and this should include information about patients’ self-reported recovery.

Clinical implications

This study suggests that patients’ expectations of treatment and perceptions of recovery from PFP may influence prognosis. Clinicians need to collaborate with patients and involve them in decision-making to achieve their goals. An individualised treatment approach is essential to adequately address patients’ experiences, priorities and beliefs.

Pinning to Cope: Using Pinterest for Chronic Pain Management

Chronic pain is an increasing public health concern, with an associated poor quality of life. Social media platforms play an increasing role in health communication issues, but visual platforms such as Pinterest are understudied. This study analyzed 502 Pinterest posts for chronic pain–related variables, including health belief model constructs, as well as measures of social support and coping mechanisms. Most pins mentioned the high severity of chronic pain, and a third mentioned self-efficacy related to self-care, while almost 50% referred to cues to action related to self-care. This study positions Pinterest as a social media platform with the potential to both transfer knowledge and provide social support for patients with chronic pain. Health care and public health practitioners should consider participating in these conversations as well as providing quality information to ensure that reputably sourced information is available.

Factors Influencing Patients' Experiences of Pain Management in the Emergency Department

Background

Despite management of acute pain, concerns regarding pain are still prevalent in the emergency department (ED).

Purpose

This study aimed to explore the factors influencing patients’ pain management in a Jordanian ED.

Method

Fifteen semistructured interviews (N = 15) with purposively selected patients in the ED.

Results

The thematic analysis uncovered two related themes. The first theme described the stage of “being on ED bed” which encapsulates two subthemes: “bad pain means, bad diagnosis” and “smiley faces versus grumpy faces.” The second theme referred to as “being discharged” including two subthemes, namely, “praying for not paying” and “being grateful to God.” The lack of money to pay for pain management was equally as stressful as pain itself. Patients’ narratives suggest that nursing pain management is a critical time, extending beyond medical management to encompass communication and spirituality.

Conclusions

The factors influencing the patients’ experience of pain management extend beyond addressing the source of the pain. Consequently, effective communication coupled with respecting patients’ spirituality and socioeconomic concerns is essential to pain management. To enhance patients’ experience of pain management, the ED system should shift toward a patient-centric model.

Exploring the potential role of mesocorticolimbic circuitry in motivation for and adherence to chronic pain self-management interventions

Adherence to pain self-management strategies is associated with favorable psychobehavioral outcomes among individuals with chronic pain. Substantive adherence to treatments teaching these adaptive skills often proves challenging, resulting in poor individual and societal outcomes. Evidence demonstrates motivation for behavior change as a key predictor of treatment adherence. Despite behavioral techniques that target motivation, however, nonadherence persists as a barrier to positive clinical outcomes in chronic pain. Understanding the neurobiological mechanisms underlying treatment motivation might highlight novel avenues for augmentative therapies. The purpose of this review is to present theory and evidence that the mesocorticolimbic system (i.e., brain circuitry associated with reward processing and motivation) contributes to treatment motivation among chronic pain patients, ultimately influencing adherence. We review evidence for motivation as a key adherence determinant, detail neuroimaging findings relating mesocorticolimbic circuitry and motivation, and discuss data supporting mesocorticolimbic dysfunction among chronic pain patients. We propose a neurobehavioral model for adherence to pain self-management interventions, listing testable hypotheses. Finally, we discuss potential research and intervention implications from the proposed model.

The Role of Primary Care Experiences in Obtaining Treatment for Depression

BACKGROUND

Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.

OBJECTIVE

In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.

DESIGN AND PARTICIPANTS

We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients.

MAIN MEASURES

We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1.

KEY RESULTS

Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2.

CONCLUSIONS

In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.

Integrating culturally informed approaches into physiotherapy assessment and treatment of chronic pain: a pilot randomised controlled trial

OBJECTIVE

To evaluate patient engagement with, and the feasibility of, a novel, culturally adapted physiotherapy pain management approach.

DESIGN

A participant-blinded and assessor-blinded pilot randomised controlled trial.

SETTING

Outpatient physiotherapy departments at two public hospitals and one district pain clinic.

PARTICIPANTS

Adults (n=48) with chronic musculoskeletal pain (daily pain >3 months), who self-identified as Mandaean, Assyrian or Vietnamese, were randomised to one of two physiotherapy treatment conditions.

INTERVENTIONS

24 participants underwent combined group and individualised treatment described as 'culturally adapted physiotherapy', while 24 underwent evidence-informed 'usual physiotherapy care'. Both treatment arms consisted of up to 10 sessions over a 3-month period.

OUTCOME MEASURES

Patient engagement was measured via participant attendance, adherence and satisfaction data. Secondary outcomes included clinical measures of pain severity, interference and suffering, physical function and negative emotional state.

RESULTS

96% of participants undergoing culturally adapted physiotherapy completed treatment, compared with 58% of the usual physiotherapy group. For the culturally adapted group attendance (87%±18%) and adherence (68%±32%) were higher relative to usual care (68%±32% and 55%±43%). Satisfaction was similar for the culturally adapted (82.7%±13.4%) and usual care (79.3±17.3) groups. For secondary outcomes, a significant between-group effect for pain-related suffering in favour of the culturally adapted group was observed with a medium effect size (partial η2 0.086, mean 3.56, 95% CI 0.11 to 7), while results for pain severity, interference, physical function and negative emotional state were similar.

CONCLUSIONS

Aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances patient engagement with physiotherapy. These results support the feasibility of a larger, multisite trial to determine if improved engagement with culturally adapted physiotherapy translates to improved clinical outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616000857404; Pre-results.

What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis

BACKGROUND

Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain.

PURPOSE

The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention.

DATA SOURCES

Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016.

STUDY SELECTION

Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention.

DATA EXTRACTION

A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence.

DATA SYNTHESIS

Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends.

LIMITATIONS

This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located.

CONCLUSIONS

The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.

Spanish transcultural adaptation and validation of the English version of the compliance questionnaire in rheumatology

To perform a transcultural adaptation and validation of a Spanish version of the compliance questionnaire in rheumatology (sCQR). In this transversal study of transcultural adaptation of the sCQR, validity was evaluated in patients with rheumatoid arthritis (RA) and a minimum 6-month follow-up by determining compliance with the electronic prescription system in consuming steroids or nonbiologic disease-modifying antirheumatic drugs. A two-week retest was proposed to all patients. All patients completed the health assessment questionnaire (HAQ), and the Morisky-Green test was also performed. Reliability was analyzed using Cronbach's alpha and the intraclass correlation coefficient (ICC). Convergent construct validity was tested in the electronic prescription system using discriminative analysis, and divergent construct validity was tested by comparing it to the HAQ. Sensitivity, specificity and ROC curves were evaluated for the sCQR and the Morisky-Green test. Of 123 recruited patients, 101 fulfilled the inclusion criteria, and 61 were on biologic therapy. 23 performed the retest. Test-retest reliability (ICC) was 0.76 (Cronbach's alpha 0.86). Multiple regression analysis showed correlation with each item of the sCQR as independent variables (r² = 0.60). No correlation was seen between total score punctuation of the sCQR and the HAQ (r² = 0.22). Discriminative analysis weighting each sCQR item showed a cutoff point of - 0.9991 (sensibility and 58.8%, specificity 98.3%). The likelihood ratio of the sCQR to detect ≤ 80% adherence with electronic prescriptions was 35.3. The Morisky-Green test revealed sensibility and specificity were 29.4 and 83.3%, respectively. This study validates the transcultural adaptation of sCQR in RA patients. A high reliability of sCQR for measuring adherence was found. Its predictive value suggests that it could be used as a screening instrument.

Effects of validating communication on recall during a pain-task in healthy participants

Background

Increasing recall of instructions and advice in a pain consultation is important, since it is a prerequisite for adherence to treatment recommendations. However, interference due to pain-related distress may result in poor recall. Whereas there are some indications that recall can be increased by empathic communication that reduces interference, this interesting possibility remains largely untested experimentally.

The current experiment aimed at studying effects of empathic communication, and more specifically validation, on recall during a pain test and possible mediators and moderators of this effect.

Method

Participants received either validating (N = 25) or invalidating responses (N = 25) from the experimenter during a pain provoking task, followed by self-report measures of interference (affect, situational pain catastrophizing) and recall (accurate and false memories of words).

Results

As expected, the validated group exhibited higher accurate recall and less false memories following the pain test as compared to the invalidated group. This was partly due to the effect of interference being counteracted by moderating the relationship between pain catastrophizing and recall.

Conclusion

These novel results suggest that validating communication can counteract interference due to pain catastrophizing on recall, at least in a controlled experimental setting.

Implications

Good communication by health professionals is of utmost importance for adherence to pain management. The current results expand our knowledge on the effects of pain communication by establishing and explaining a clear link between empathic communication and recall, highlighting the role of pain catastrophizing.

Impact of patient information leaflets on pain medication intake behavior: a pilot study

Negative wording in package information leaflets of pain medication is associated with a tendency to evoke negative emotions and lower willing to take medication.

Introduction:

Patient information leaflets on pain medication primarily list side effects while positive effects and action mechanisms remain underrepresented. Nocebo research has shown that negative instructions can lower analgesic effects.

Objectives:

Research on information leaflets and their influence on mood, memory of side effects, and intake behavior of healthy participants is needed.

Methods:

To determine the ratio of positive to negative phrases, 18 information leaflets of common, over-the-market analgesics were examined of which 1 was selected. In a randomized, controlled study design, 18 healthy participants read this leaflet while 18 control group participants read a matched, neutral leaflet of an electrical device. Collected data concerned the recall of positive and negative contents, mood, anxiety, and the willingness to buy and take the drug.

Results:

All examined leaflets listed significantly more side effects than positive effects (t₁₇ = 5.82, P < 0.01). After reading the analgesic leaflet, participants showed a trend towards more negative mood (F_1,34 = 3.78, P = 0.06, η_p² = 0.1), a lower intention to buy [χ² (1, n = 36) = 12.5, P < 0.01], a higher unwillingness to take the medication [χ² (1, n = 36) = 7.2, P < 0.01], and even a greater recall for side effects than positive effects (t₁₇ = 7.47, P < 0.01).

Conclusion:

Reading the patient information leaflets can increase fear and lower the intention to buy and the willingness to take a pain medication.

A pragmatic trial to improve adherence with scheduled appointments in an inner-city pain clinic by human phone calls in the patient's preferred language

STUDY OBJECTIVE

We investigated if human reminder phone calls in the patient's preferred language increase adherence with scheduled appointments in an inner-city chronic pain clinic. We hypothesized that language and cultural incongruence is the underlying mechanism to explain poor attendance at clinic appointments in underserved Hispanic populations.

DESIGN

Pragmatic randomized controlled clinical trial SETTING: Innercity academic chronic pain clinic with a diverse, predominantly African-American and Hispanic population PATIENTS: All (n=963) adult patients with a scheduled first appointment between October 2014 and October 2015 at the Montefiore Pain Center in the Bronx, New York were enrolled.

INTERVENTIONS

Patients were randomized to receive a human reminder call in their preferred language before their appointment, or no contact.

MEASUREMENTS

We recorded patients' demographic characteristics and as primary outcome attendance as scheduled, failure to attend and/or cancellation calls. We fit Bayesian and classical multinomial logistic regression models to test if the intervention improved adherence with scheduled appointments.

MAIN RESULTS

Among the 953 predominantly African American and Hispanic/Latino patients, 475 patients were randomly selected to receive a language-congruent, human reminder call, while 478 were assigned to receive no prior contact, (after we excluded 10 patients, scheduled for repeat appointments). In the experimental group, 275 patients adhered to their scheduled appointment, while 84 cancelled and 116 failed to attend. In the control group, 249 patients adhered to their scheduled appointment, 31 cancelled and 198 failed to attend. Human phone reminders in the preferred language increased adherence (RR 1.89, CI95% [1.42, 1.42], (p<0.01). The intervention seemed particularly effective in Hispanic patients, supporting our hypothesis of cultural congruence as possible underlying mechanism.

CONCLUSIONS

Human reminder phone calls prior in the patient's preferred language increased adherence with scheduled appointments. The intervention facilitated access to much needed care in an ethnically diverse, resource poor population, presumably by overcoming language barriers.

Adherence and Persistence with Drug Therapy among Fibromyalgia Patients: Data from a Large Health Maintenance Organization

Objective.

To assess 1-year persistence and adherence rates with drug therapy among patients with fibromyalgia (FM) and to identify factors associated with therapy discontinuation.

Methods.

This retrospective, cohort study included members ≥ 21 years old from the Maccabi Healthcare Services, a large health maintenance organization in Israel, who were diagnosed with FM from 2008 through 2011. Medications of interest included the anticonvulsant pregabalin, antidepressants [selective serotonin reuptake inhibitor (SSRI), serotonin/norepinephrine reuptake inhibitor (SNRI)], and tricyclic antidepressants (TCA). Time to treatment discontinuation and proportion of days covered (PDC) with FM-specific therapies during the year from first dispensed were analyzed. PDC < 20% was considered low adherence and PDC ≥ 80% was considered high adherence. Logistic regression models were constructed for multivariable analyses.

Results.

Overall, 3932 patients with FM were included; 88.7% were female. Pre-diagnosis use of medication of interest was documented in 41% of the study population. Of the remaining 2312 patients, 56.1% were issued a prescription, 45.0% were dispensed at least 1 medication in the year following diagnosis, and only 28.8% had prescriptions filled twice within the first year from diagnosis. Among newly prescribed patients, 1-year discontinuation was highest for TCA (91.0%) and lowest for SSRI/SNRI antidepressants (73.7%). Over half of the patients (60.5%) had fewer than 20% of the days covered by any medication during the year and only 9.3% were very adherent (PDC ≥ 80%).

Conclusion.

This study clearly shows that in an Israeli “real-life” population of patients with FM, persistence and adherence with FM therapy in the year following diagnosis is remarkably low.

Prevalence and Predictors of Patient Nonadherence to Pharmacological Acute Pain Therapy at Home After Day Surgery: A Prospective Cohort Study

BACKGROUND

Good adherence to prescribed analgesics can be crucial to suppress or even prevent acute postoperative pain after day surgery. The aim of this study was to analyze prevalence and predictors of analgesic nonadherence after day surgery.

METHODS

Elective patients scheduled for day surgery were prospectively enrolled from November 2008 to April 2010. Outcome parameters were measured by using questionnaire packages at 2 time points: 1 week preoperatively and 4 days postoperatively. The primary outcome parameter was analgesic nonadherence. Adherence was defined according to the patient's response to the questionnaire item "analgesia use as prescribed": full adherence, "yes"; partial adherence, "yes, sometimes"; nonadherence, "no." Bivariate and multivariate logistic regression analyses were performed to identify predictors of analgesic nonadherence.

RESULTS

A total of 1,248 patients were included. The prevalence rates of analgesic nonadherence and partial adherence were 21.6% and 20.0%, respectively, in the total study population but dropped to 9.4% and 19.8%, respectively, in patients with moderate to severe pain. Low postoperative pain intensity and short duration of surgery were the most important predictors of analgesic nonadherence. The most important preoperative predictors for analgesic nonadherence were low preoperative pain intensity, low preoperative expectations of pain, and low fear of short-term effects of surgery.

CONCLUSION

Analgesic nonadherence and partial adherence are common after day surgery but decrease as average pain intensity increases. Patients at risk for analgesic nonadherence can be identified during the preoperative period based on preoperative pain intensity, preoperative expectations of pain, and fear of surgery.