Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient

Loss of Sigma-2 Receptor/TMEM97 Is Associated with Neuropathic Injury-Induced Depression-Like Behaviors in Female Mice

Previous studies have shown that ligands that bind to sigma-2 receptor/TMEM97 (s2R/TMEM97), a transmembrane protein, have anxiolytic/antidepressant-like properties and relieve neuropathic pain-like effects in rodents. Despite medical interest in s2R/TMEM97, little affective and pain behavioral characterization has been done using transgenic mice, which limits the development of s2R/TMEM97 as a viable therapeutic target. Using wild-type (WT) and global Tmem97 knock-out (KO) mice, we sought to identify the contribution of Tmem97 in modulating affective and pain-like behaviors using a battery of affective and pain assays, including open field, light/dark preference, elevated plus maze, forced swim test, tail suspension test, and the mechanical sensitivity tests. Our results demonstrate that female Tmem97 KO mice show less anxiety-like and depressive-like behaviors in light/dark preference and tail suspension tests but not in an open field, elevated plus maze, and forced swim tests at baseline. We next performed spared nerve injury in WT and Tmem97 KO mice to assess the role of Tmem97 in neuropathic pain-induced anxiety and depression. WT mice, but not Tmem97 KO mice, developed a prolonged neuropathic pain-induced depressive-like phenotype when tested 10 weeks after nerve injury in females. Our results show that Tmem97 plays a role in modulating anxiety-like and depressive-like behaviors in naive animals with a significant change in the presence of nerve injury in female mice. Overall, these data demonstrate that Tmem97 could be a target to alleviate affective comorbidities of pain disorders.

The psychopathological repercussions on patients faced with pain: A focus on endometriosis

OBJECTIVES

Endometriosis is a chronic and progressive gynecological disease that affects 1 to 2 out of 10 women of childbearing age in France. The objective of this research was to understand the factors determining the quality of life of the patients who experience significant pain symptoms (75%), distinguished by the extent and depth of the lesions. The second objective was to evaluate the psychological repercussions of this pain. We will therefore assess the various psychological processes involved in explaining quality of life.

METHOD

In total, 1039 women aged 18-55 years completed a self-administered questionnaire, assessing different types of pain and intensity, body image (BIS), self-esteem (Rosenberg), anxiety-depressive symptomatology (HAD), and quality of life (SF-36). Socio-biographical and medical characteristics of the patients were also assessed.

RESULTS

Analyses of variance showed that patients with chronic pain had lower self-esteem and body image, more anxiety-depressive symptoms, and a poorer quality of life than women with cyclic pain and those without pain. Regression analyses showed that the determinants of physical and mental quality of life differed significantly according to the type of pain experienced.

CONCLUSION

The consequences of the pain associated with endometriosis reveal multiple problems that can be considered from a new perspective. Although psychological disorders can be a response to pain phenomena they can also contribute to their increase. This is where the challenge lies in providing comprehensive care.

Neurophysiological oscillatory markers of hypoalgesia in conditioned pain modulation

Introduction

Conditioned pain modulation (CPM) is an experimental procedure that consists of an ongoing noxious stimulus attenuating the pain perception caused by another noxious stimulus. A combination of the CPM paradigm with concurrent electrophysiological recordings can establish whether an association exists between experimentally modified pain perception and modulations of neural oscillations.

Objectives

We aimed to characterize how CPM modifies pain perception and underlying neural oscillations. We also interrogated whether these perceptual and/or neurophysiological effects are distinct in patients affected by chronic pain.

Methods

We presented noxious electrical stimuli to the right ankle before, during, and after CPM induced by an ice pack placed on the left forearm. Seventeen patients with chronic pain and 17 control participants rated the electrical pain in each experimental condition. We used magnetoencephalography to examine the anatomy-specific effects of CPM on the neural oscillatory responses to the electrical pain.

Results

Regardless of the participant groups, CPM induced a reduction in subjective pain ratings and neural responses (beta-band [15-35 Hz] oscillations in the sensorimotor cortex) to electrical pain.

Conclusion

Our findings of pain-induced beta-band activity may be associated with top-down modulations of pain, as reported in other perceptual modalities. Therefore, the reduced beta-band responses during CPM may indicate changes in top-down pain modulations.

Loneliness and Pain Catastrophizing Among Individuals with Chronic Pain: The Mediating Role of Depression

Purpose

Loneliness increased during the COVID-19 pandemic and social distancing guidelines, potentially exacerbating negative cognitions about pain. The present study investigated the longitudinal relationship between loneliness, assessed during the early weeks of the pandemic, and pain catastrophizing, assessed after living in the pandemic for approximately 1 year, among chronic pain patients. We also examined whether severity of depressive symptoms mediated this association.

Methods

This prospective longitudinal study recruited individuals with chronic pain (N=93) from Massachusetts using an online convenience sampling method via the platform Rally. Participants completed an initial survey early after the onset of social distancing (4/28/20–6/17/20; Time 1) and a follow-up survey 1 year later (5/21/21–6/7/21; Time 2). Participants completed validated assessments of loneliness (T1), pain catastrophizing (T2), and depression (T2). Spearman correlations and Mann–Whitney U-tests were used to explore associations among psychosocial, pain, and participant characteristics. A mediation analysis was conducted to test whether the association between loneliness and pain catastrophizing was mediated by depression.

Results

Participants had a mean age of 40.6 years and were majority female (80%) and White (82%). Greater loneliness was associated with subsequent higher pain catastrophizing (b=1.23, 95% CI [0.03, 2.44]). Mediation analysis showed a significant indirect effect (b=0.57, 95% CI [0.10, 1.18) of loneliness (T1) on catastrophizing (T2) through depression (T2) while accounting for several important covariates. The direct effect of loneliness on catastrophizing was no longer significant when depression was included in the model (b=0.66, 95% CI [−0.54, 1.87]).

Conclusion

Findings suggest that greater loneliness during the pandemic was associated with higher pain catastrophizing 1 year later, and severity of depression after living in the pandemic mediated this association. As loneliness, depression, and catastrophizing can all be modified with behavioral interventions, understanding the temporal associations among these variables is important for the employment of future empirically supported treatments.

Identifying the risk of opioid misuse in a chronic pain population: the utility of the MMPI-2-RF personality psychopathology five (PSY-5-RF) and higher-order scales

Prescription-related opioid misuse, especially in chronic pain populations, is an ongoing problem and is related to increased mortality. The purpose of this study was to assess the utility of two restructured scales of the MMPI-2-RF: the Personality Psychopathology Five (PSY-5-RF) and the Higher-Order Scales to determine which of their subscales may be beneficial for identifying the risk of opioid misuse in a chronic pain population. A sample of 136 patients with chronic disabling occupational musculoskeletal disorders completed the MMPI-2-RF and the Current Opioid Misuse Measure (COMM) upon admission to a functional restoration program. The PSY-5-RF and H-O subscales were correlated with the baseline COMM scores. Correlation analyses, ROC curve analyses, and multiple binary logistic regression models were developed to determine which subscales were most associated with elevated COMM scores. The results of the regression analyses suggest that Scale elevations on two of the PSY-5-RF Scales and two Higher-Order Scales of the MMPI-2-RF demonstrated significant associations with elevated COMM scores, thus exhibiting the utility of these subscales in identifying the risk of opioid misuse among chronic pain patients. These findings are clinically meaningful in underscoring the importance of identifying specific personality traits as potential predictors of opioid misuse, and identifying those at risk through careful screening. Clinical implications based on each of the PSY-5-RF and H-O scales significantly associated with elevated COMM scores are discussed.

Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence-Enabled App (Wysa): Protocol for a Prospective Pilot Study

BACKGROUND

Patients with chronic pain often suffer from coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial Intelligence Supported Cognitive Behavioral Therapy or AI-CBT interventions could offer cost-effective, accessible, and potentially effective resources to tackle this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain.

OBJECTIVE

This prospective cohort study aims to examine the efficacy and usage of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app), using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text-based conversational agent (CA).

METHODS

Participants with self-reported chronic pain (N = 500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is taken from the participants within the app and the Wysa intervention is delivered remotely for 8 weeks. Outcome measures including NPRS (Numeric Pain Rating Scale), PROMIS PI (Patient-Reported Outcomes Measurement Information System Pain Interference), GAD-7 (Generalized Anxiety Disorder), and PHQ-9 (Patient Health Questionnaire) questionnaires will be administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the WAI-SR (Working Alliance Inventory-Short Revised). Retention and usage statistics will be observed for adherence and engagement.

RESULTS

The study will open for recruitment in April 2022 and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late-2022.

CONCLUSIONS

Mental health conversational agents driven by artificial intelligence (AI) could be effective in helping patients with chronic pain learn to self-manage their pain and deal with common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions with a human therapist in loop. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain.

CLINICALTRIAL

Patient perspectives from the multi-disciplinary chronic pain clinic: a qualitative study

Aim: The chronic pain clinic (CPC) is a multi-disciplinary program that incorporates pharmacological and non-pharmacological methods, including First Nations healing strategies, to manage pain, improve functioning and reduce opioid misuse among patients with chronic pain in Regina, Canada. Materials & methods: The care experiences of ten current clients were explored using a narrative interview approach. Results: The CPC provides high-quality and safe care for effective chronic pain management. Clients noted pain reduction and improvements in sleep, mobility, functionality, and mood. First Nation clients emphasized the importance of traditional healing strategies. Conclusion: This unique comprehensive multi-modal approach which incorporates First Nations healing strategies is effective in supporting the unique needs of local clients.

Effect of Yokukansan on sleep disturbance and neuropathic pain in chronic constriction injury using a rat model

Patients with chronic pain develop peripheral neuropathy and experience sleep disturbance. Yokukansan is used to treat insomnia and control neuropathic pain. We studied if Yokukansan affects neuropathic pain and sleep disturbance using a rat model of chronic constriction injury (CCI). Male Wistar rats (4-week age) were divided into the following groups (n = 7, per group): CCI rats fed normal chow (CCI-0); CCI rats fed powdered chow mixed with 1% Yokukansan (CCI-1); CCI rats fed powdered chow mixed with 3% Yokukansan (CCI-3); and sham-operated control rats fed normal chow (SHAM). We examined sleep duration and quality using electroencephalograms and assessed pain using the von Frey and Hargreaves tests. Results were analyzed by one-way analysis of variance and Bonferroni post hoc tests. The CCI-0 group exhibited an increased wake period, decreased non-rapid eye movement (REM) sleep time, and no change in REM sleep time in comparison to the SHAM group. The CCI-1 group exhibited a decreased wake period, increased non-REM sleep time, and no change in REM sleep time compared to the CCI-0 group. The CCI-3 group exhibited increased non-REM sleep time but no changes in wake and REM sleep times compared to the CCI-1 group. The von Frey and Hargreaves test findings revealed an increase in the pain threshold in the CCI-1 group compared to the CCI-0 group. There was no difference in pain threshold between the CCI-1 and CCI-3 groups. In our rat model of CCI, sleep disturbance was reflected. Yokukansan inhibited CCI-induced sleep disturbance.

Tinnitus-related distress and pain perceptions in patients with chronic tinnitus - Do psychological factors constitute a link?

OBJECTIVE

To investigate the co-occurrence of tinnitus-related distress and pain experiences alongside psychological factors that may underlie their association.

METHOD

Patients with chronic tinnitus (N = 1238) completed a questionnaire battery examining tinnitus-related distress and affective and sensory pain perceptions. A series of simple, parallel- and serial multiple mediator models examined indirect effects of psychological comorbidities as well as -process variables including depressivity, perceived stress and coping attitudes. Moderator and moderated mediation analyses examined differential relational patterns in patients with decompensated vs. compensated tinnitus.

RESULTS

There were significant associations between tinnitus-related distress and pain perceptions. These were partially mediated by most specified variables. Psychological comorbidities appeared to influence tinnitus-pain associations through their impact on depressivity, perceived stress, and coping attitudes. Some specific differences in affective vs. sensory pain perception pathways emerged. Patients with decompensated tinnitus yielded significantly higher symptom burden across all measured indices. Tinnitus decompensation was associated with heightened associations between [1] tinnitus-related distress and pain perceptions, depressivity and negative coping attitudes; and [2] most psychological comorbidities and sensory, but not affective pain perception. Moderated mediation analyses revealed stronger indirect effects of depressivity and anxiety in mediating affective-, and anxiety in mediating sensory pain perception in patients with decompensated tinnitus.

CONCLUSION

Psychological constructs mediate the co-occurrence of tinnitus- and pain-related symptoms across different levels of tinnitus-related distress. Psychological treatment approaches should conceptualize and address individualised interactions of common cognitive-emotional processes in addressing psychosomatic symptom clusters across syndromatic patients with varying distress levels.

Biological mechanism of post-herpetic neuralgia: Evidence from multiple patho-psychophysiological measures

BACKGROUND

Post-herpetic neuralgia (PHN), which develops after the resolution of a herpes zoster eruption, is an exceptionally drug-resistant neuropathic pain. The unsatisfactory management of PHN partly results from the difficulty in dissecting out its contributing factors due to the complexity of PHN mechanism.

METHODS

Here, to elaborate our understanding of the PHN mechanism and to establish a basis for effective therapeutic strategies, we comprehensively investigated the contributions of multiple factors to PHN severity.

RESULTS

Based on the comparison of somatosensory detection thresholds (C, Aδ and Aβ fibre thresholds) between affected and unaffected sides, 16 PHN patients with significant sensory deficits and 13 PHN patients without significant sensory deficits were identified and assigned to different groups. The different extents of lesions in the nociceptive system between patients with and without sensory deficits were confirmed using laser-evoked brain responses. Moreover, patients with sensory deficits had more severe pain and psychological disorders, e.g. anxiety and depression. Importantly, chronic pain severity was significantly influenced by various psychophysiological factors (sleep disturbances, psychological disorders and hypothalamic-pituitary-adrenal axis dysfunction) for patients with sensory deficits.

CONCLUSIONS

Our findings demonstrated the contribution of multiple patho-psychophysiological factors to PHN severity, which could help establish a basis for the development of a rational, patient-centred therapeutic strategy.

SIGNIFICANCE

This study revealed the contribution of multiple patho-psychophysiological factors to PHN severity, which expanded our understanding of the underlying PHN mechanism, and helped develop a rational, patient-centred therapeutic strategy targeting towards the corresponding etiology and psychophysiological disorders for individual patient.

Off-label use of duloxetine for pediatric neuropathic pain

Introduction

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, has been used successfully for adults for the management of neuropathic pain syndromes. Pediatric data are needed because inadequate neuropathic pain management in children and adolescents results in lower psychosocial functioning, delayed development, and decreased quality of life. We aim to describe a case series on the use of duloxetine for the management of symptoms associated with chronic neuropathic pain syndromes in a pediatric population.

Methods

Data were collected in a naturalistic, consecutive, case report format, from a pediatric pain management clinic for children prescribed duloxetine for analgesia for a variety of neuropathic-type pain conditions. Follow-up data, including self-report of pain, and type and frequency of adverse reactions, were collected to describe the efficacy and safety of duloxetine.

Results

Duloxetine was prescribed for the management of self-reported average pain scores of greater than 5 out of 10 on the Faces Pain Scale–Revised for pain that was resistant to other medications. Each of these patients had comorbid psychiatric diagnoses. Reduction in pain following duloxetine therapy was not universal, and all patients discontinued duloxetine therapy prematurely because of adverse effects.

Conclusion

Further evidence is needed to demonstrate the efficacy and safety of duloxetine for use in pediatric populations with neuropathic components to their pain. Based on our experience, we suggest considering its use only after failure of other agents. The best management of a pediatric patient's pain condition is likely accomplished through a combination of pharmacotherapy and nonpharmacotherapy interventions.

Gelsemine alleviates both neuropathic pain and sleep disturbance in partial sciatic nerve ligation mice

Aim:

Gelsemine, an alkaloid from the Chinese herb Gelsemium elegans (Gardn & Champ) Benth., is effective in mitigating chronic pain in rats. In the present study we investigated whether the alkaloid improved sleep disturbance, the most common comorbid symptoms of chronic pain, in a mouse model of neuropathic pain.

Methods:

Mice were subjected to partial sciatic nerve ligation (PSNL). After the mice were injected with gelsemine or pregabalin (the positive control) intraperitoneally, mechanical allodynia and thermal hyperalgesia were assessed, and electroencephalogram (EEG)/electromyogram (EMG) recording was performed. Motor performance of the mice was assessed using rota-rod test. c-Fos expression in the brain was analyzed with immunohistochemical staining.

Results:

In PSNL mice, gelsemine (2 and 4 mg/kg) increased the mechanical threshold for 4 h and prolonged the thermal latencies for 3 h. Furthermore, gelsemine (4 mg/kg, administered at 6:30 AM) increased non-rapid eye movement (non-REM, NREM) sleep, decreased wakefulness, but did not affect REM sleep during the first 3 h in PSNL mice. Sleep architecture analysis showed that gelsemine decreased the mean duration of wakefulness and increased the total number of episodes of NREM sleep during the first 3 h after the dosing. Gelsemine (4 mg/kg) did not impair motor coordination in PSNL mice. Immunohistochemical study showed that PSNL increased c-Fos expression in the neurons of the anterior cingulate cortex, and gelsemine (4 mg/kg) decreased c-Fos expression by 58%. Gelsemine (4 mg/kg, administered at either 6:30 AM or 8:30 PM) did not produce hypnotic effect in normal mice. Pregabalin produced similar antinociceptive and hypnotic effects, but impaired motor coordination in PSNL mice.

Conclusion:

Gelsemine is an effective agent for treatment of both neuropathic pain and sleep disturbance in PSNL mice; anterior cingulate cortex might play a role in the hypnotic effects of gelsemine.

Opioid Analgesics

Chronic pain is an international health issue of immense importance that is influenced by both physical and psychological factors. Opioids are useful in treating chronic pain but have accompanying complications. It is important for clinicians to understand the basics of opioid pharmacology, the benefits and adverse effects of opioids, and related problematic issues of tolerance, dependence, and opioid-induced hyperalgesia. In this article, the role of psychiatric comorbidity and the use of validated assessment tools to identify individuals who are at the greatest risk for opioid misuse are discussed. Additionally, interventional treatment strategies for patients with chronic pain who are at risk for opioid misuse are presented. Specific behavioral interventions designed to improve adherence with prescription opioids among persons treated for chronic pain, such as frequent monitoring, periodic urine screens, opioid therapy agreements, opioid checklists, and motivational counseling, are also reviewed. Use of state-sponsored prescription drug monitoring programs is also encouraged. Areas requiring additional investigation are identified, and the future role of abuse-deterrent opioids and innovative technology in addressing issues of opioid therapy and pain are presented.

Trigeminal Inflammatory Compression (TIC) injury induces chronic facial pain and susceptibility to anxiety-related behaviors

Our laboratory previously developed a novel neuropathic and inflammatory facial pain model for mice referred to as the Trigeminal Inflammatory Compression (TIC) model. Rather than inducing whole nerve ischemia and neuronal loss, this injury induces only slight peripheral nerve demyelination triggering long-term mechanical allodynia and cold hypersensitivity on the ipsilateral whisker pad. The aim of the present study is to further characterize the phenotype of the TIC injury model using specific behavioral assays (i.e. light-dark box, open field exploratory activity, and elevated plus maze) to explore pain- and anxiety-like behaviors associated with this model. Our findings determined that the TIC injury produces hypersensitivity 100% of the time after surgery that persists at least 21 weeks post injury (until the animals are euthanized). Three receptive field sensitivity pattern variations in mice with TIC injury are specified. Animals with TIC injury begin displaying anxiety-like behavior in the light-dark box preference and open field exploratory tests at week eight post injury as compared to sham and naïve animals. Panic anxiety-like behavior was shown in the elevated plus maze in mice with TIC injury if the test was preceded with acoustic startle. Thus, in addition to mechanical and cold hypersensitivity, the present study identified significant anxiety-like behaviors in mice with TIC injury resembling the clinical symptomatology and psychosocial impairments of patients with chronic facial pain. Overall, the TIC injury model's chronicity, reproducibility, and reliability in producing pain- and anxiety-like behaviors demonstrate its usefulness as a chronic neuropathic facial pain model.

Systematically searching for and assessing the literature for self-management of chronic pain: a lay users' perspective

BACKGROUND

The Engaging with older adults in the development of strategies for the self management of chronic pain (EOPIC) study aims to design and develop self management strategies to enable older adults to manage their own pain. Involving older adults in research into chronic pain management will better enable the identification and development of strategies that are more appropriate for their use, but how can perspectives really be utilised to the best possible outcomes?

METHOD

Seven older adults were recruited through a local advertising campaign to take part. We also invited participants from the local pain services, individuals who had been involved in earlier phase of the EOPIC study and a previous ESRC funded project. The group undertook library training and research skills training to facilitate searching of the literature and identified sources of material. A grading tool was developed using perceived essential criteria identified by the older adults and material was graded according to the criteria within this scale.

RESULTS

Fifty-seven resources from over twenty-eight sources were identified. These materials were identified as being easily accessible, readable and relevant. Many of the web based materials were not always easy to find or readily available so they were excluded by the participants. All but one were UK based. Forty-four items were identified as meeting the key criteria for inclusion in the study. This included five key categories as follows; books, internet, magazines, leaflets, CD's/Tapes.

CONCLUSION

This project was able to identify a number of exemplars of self management material along with some general rules regarding the categories identified. We must point out that the materials identified were not age specific, were often locally developed and would need to be adapted to older adults with chronic pain. For copyright issues we have not included them in this paper. The key message is really related to the format rather than the content. However, the group acknowledge that these may vary according to the requirements of each individual older adult and therefore recommend the development of a leaflet to help others in their search for resources. This leaflet has been developed as part of Phase IV of the EOPIC study.

Qualitative investigation of a Brief Chronic Pain Screening tool in HIV-infected patients

Chronic pain in HIV-infected patients is prevalent but understudied. A limitation of HIV/chronic pain research to date is the lack of a widely used chronic pain screening tool. A Brief Chronic Pain Screening tool (BCPS) has been described, but has not yet been tested in a clinical population. This study sought to evaluate how the BCPS is experienced by HIV-infected individuals, and adapt its questions if necessary. We conducted cognitive interviews using cognitive inquiry in participants from the UAB 1917 HIV Clinic Cohort. Data were analyzed using a process of inductive, iterative coding by three investigators.

RESULTS

Of 30 participants, most were male, African American, and less than 50 years old. Participants reported that the questions were understandable; however, feedback suggested concerns regarding lack of specificity in regard to the intensity and consistency of pain. An introductory statement aimed at improving clarity resulted in more divergent responses. This research team concluded that the version of the BCPS used in the first 30 interviews was optimum. Its inclusive language allows the respondent to decide what pain merits reporting. This study is the first investigation of the BCPS in a clinical population, and should lead to further quantitative validation studies of this tool.

Pain is independently associated with impaired physical function in HIV-infected patients

INTRODUCTION

Human immunodeficiency virus (HIV)-infected patients in the current treatment era can achieve normal life expectancies but experience a high degree of medical and psychiatric comorbidity. Impaired physical function and pain, often in the context of mood disorders and substance abuse, are common in HIV-infected patients. The objective of this study was to investigate the relationship of pain, a modifiable condition, to functional impairment in HIV-infected patients, independent of mood disorders and substance abuse.

METHODS

Participants in a prospective cohort of HIV-infected patients at the University of Alabama at Birmingham were included. Patient-reported outcome measures were used to cross-sectionally assess pain and physical function (EuroQOL), mood disorders (PHQ), and substance abuse (ASSIST). Univariate and multivariable models were built with pain as the principal independent variable of interest and three domains of physical function (mobility, self-care, and usual activities) as outcomes. Covariates included mood, substance abuse, age, race, sex, insurance status, HIV transmission risk factor, and CD4+ T-cell count.

RESULTS

Among 1,903 participants, 693 (37%) reported pain; 509 (27%) had a mood disorder; and 157 (8.4%) reported current substance abuse. In multivariable models, pain was independently associated with increased odds of impairment in all three domains of physical function investigated-mobility (aOR 10.5, 95% CI 7.6-14.6), self-care (aOR 4.1, 95% CI 2.2-7.4), and usual activities (aOR 5.4, 95% CI 4.0-7.4).

DISCUSSION

Pain was associated with substantially increased odds of impairment in physical function. Pain should be an important consideration in HIV primary care. Interventions to address pain and impaired physical function should be investigated.

Psychological screening/phenotyping as predictors for spinal cord stimulation

Spinal cord stimulation (SCS) is becoming a widely used treatment for a number of pain conditions and is frequently considered as a pain management option when conservative or less invasive techniques have proven to be ineffective. Potential indications for SCS include complex regional pain syndrome (CRPS), postherpetic neuralgia, traumatic nerve injury, failed back surgery syndrome, refractory angina pectoris, peripheral vascular disease, neuropathic pain, and visceral pain (Guttman et al. Pain Pract. 9:308-11, 2009). While research on SCS is in its infancy, it is clear that substantial variation exists in the degree of benefit obtained from SCS, and the procedure does not come without risks; thus focused patient selection is becoming very important. Psychological characteristics play an important role in shaping individual differences in the pain experience and may influence responses to SCS, as well as a variety of other pain treatments (Doleys Neurosurg Focus 21:E1, 2006). In addition to psychological assessment, quantitative sensory testing (QST) procedures offer another valuable resource in forecasting who may benefit most from SCS and may also shed light on mechanisms underlying the individual characteristics promoting the effectiveness of such procedures (Eisenberg et al. Pain Pract. 6:161-165, 2006). Here, we present a brief overview of recent studies examining these factors in their relationship with SCS outcomes.

Association of psychiatric co-morbidity and efficacy of treatment in chronic daily headache in Indian population

OBJECTIVE

To study the prevalence of psychiatric co-morbidity in patients of chronic daily headache (CDH) and compare the efficacy of treatment between various type of headache associated with psychiatric co-morbidity.

MATERIALS AND METHODS

Prospective case control cohort study, 92 consecutive patients of CDH meeting eligibility criteria. The diagnosis of various subtypes of CDH was made according to the IHS criteria. Age, sex, educational, marital and socioeconomic status, matched controls were also selected. Patients were evaluated with the Mini International Neuropsychiatric Interview (MINI) scale at the time of enrolment and at 3 months.

RESULTS

CDH accounted for 28% of all headache patients. The mean age of presentation was 30.2 ± 10.3 years, male: Female ratio of 28:64 and mean duration of 4.56 ± 0.56 years. Chronic migraine (CM) accounted for 59 patients, chronic tension type headache (CTTH) 22 patients, new daily persistent headache (NDPH) 3 patients and miscellaneous 8 patients. Psychiatric co-morbidity was present in 53.3% patients with CDH, and was more common in CM (62.7%) as compared to CTTH (36.4%). Single psychiatric co-morbidity was seen in 26 patients, while 23 patients had multiple co-morbidity. Major depressive episode, anxiety disorder, agoraphobia and dysthymia were significant psychiatric co-morbidities. Patients with CM were treated with topiramate or divalproex sodium ER and CTTH were treated with amitriptyline. 55 patients came for follow up at 3 months, improvement in headache was seen in 29 patients.

CONCLUSION

Psychiatric co-morbidity was present in more than 50% patients with CDH and its presence along with a duration of ≥2 years was associated with a poor response to treatment.

[Cytokines in psychoneuroendocrine immunological context of nonspecific musculoskeletal pain]

Cytokines are coordinators of immune homeostasis. Evidence for the participation of cytokines in neurogenic inflammation, peripheral and central sensitization and hyperalgesia as well as for induction of inflammatory immune responses by pain-related catastrophizing is well documented. A disproportion of proinflammatory and anti-inflammatory cytokines is known to be a contributory cause of pain and pain behavior. Embedded into psychoneuroendocrine immunological feedback control systems cytokines are able to perpetuate a virtuous circle between local inflammation and systemic pain behavior (pain/sickness behavior) thus contributing to chronification of nonspecific musculoskeletal pain.In this model avoidance and pain-related nonrecognition as key components of systemic pain behavior lead to maintenance of the virtuous circle by generating of a local inflammation with local and systemic consequences. This model can explain the success of established therapy concepts from the point of view of psychoneuroimmunology, such as fear avoidance, which are effectively used as principal components in multimodal pain therapy.

Pain, mood, and substance abuse in HIV: implications for clinic visit utilization, antiretroviral therapy adherence, and virologic failure

BACKGROUND

Cooccurring pain, mood disorders, and substance abuse are common in HIV-infected patients. Our objective was to investigate the relationship between pain, alone and in the context of mood disorders and substance abuse, on clinic utilization, antiretroviral therapy adherence, and virologic suppression.

METHODS

Pain, mood disorders, and substance abuse were assessed at the first visit. No-show and urgent visits were measured over a 1-year period. Models were adjusted for age, race, sex, insurance status, CD4(+) T-lymphocyte count, and HIV risk factor.

RESULTS

Among 1521 participants, 509 (34%) reported pain, 239 (16%) had pain alone, 189 (13%) had pain and a mood disorder, and 30 (2%) had pain and substance abuse. In univariate models, participants with pain, mood disorders, and substance abuse had higher odds of a no-show visit than those without these conditions [odds ratio (OR), 1.4; 95% confidence interval (CI), 1.1-1.8; OR, 1.5; 95% CI, 1.2-1.9; OR, 2.0; 95% CI, 1.4-2.8, respectively]. In the multivariable model, pain increased the odds of a no-show visit only in participants without substance abuse (OR, 1.5; 95% CI, 1.1-1.9) and pain reduced the odds of a no-show visit in participants with substance abuse (OR, 0.5; 95% CI, 0.2-0.9; P for interaction = 0.0022).

CONCLUSIONS

In this study, pain increased the odds of no-show visits but only for participants without substance abuse. Because pain, mood disorders, and substance abuse are highly prevalent in HIV-infected patients, our findings have implications for HIV treatment success. Interventions that incorporate pain management may be important for improving health outcomes in patients living with HIV infection.

Integrating pain management in clinical practice

There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. In this paper, we briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain.

Risk factor assessment for problematic use of opioids for chronic pain

Opioid analgesics provide effective treatment for noncancer pain, but many health providers have concerns about cognitive effects, tolerance, dependence, and addiction. Misuse of opioids is prominent in patients with chronic pain and early recognition of misuse risk could help providers offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. Many persons with chronic pain also have significant medical and psychiatric comorbidities that affect treatment decisions. Neuropsychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management. The assessment of different domains using semi-structured interviews, sensory and neuropsychological testing, and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral, and social issues in order to facilitate treatment planning. In this review we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic pain, and present an overview of assessment and treatment strategies that can be effective in improving outcomes associated with the use of prescription opioids for pain. Finally we briefly discuss the effect of opiate analgesics on cognition and review some intervention strategies for chronic pain patients.

Relationship of negative affect and outcome of an opioid therapy trial among low back pain patients

OBJECTIVES

Patients with chronic noncancer pain frequently report symptoms of depression and anxiety (negative affect), which are associated with higher ratings of pain intensity and a greater likelihood of being prescribed chronic opioid therapy. The purpose of this secondary analysis was to test the hypothesis that initial levels of negative affect can predict treatment-related outcomes in a double-blind, placebo-controlled study of extended-release (ER) hydromorphone among opioid-tolerant patients with chronic low back pain.

METHODS

Four hundred fifty-nine (N = 459) patients participated in the titration/conversion phase of a multicenter study, of which 268 were randomized to receive once-daily hydromorphone or placebo. All patients completed the Hospital Anxiety and Depression Scale (HADS) at baseline and were divided evenly into Low (N = 157), Moderate (N = 155), and High (N = 147) negative affect groups based on their scores. Group differences in numerical pain intensity measures at home and in the clinic, Roland-Morris Disability ratings, and measures of symptoms from the Subjective Opiate Withdrawal Scale (SOWS) throughout the trial were analyzed.

RESULTS

Two hundred sixty-eight of the initial 459 subjects who entered the 2 to 4-week titration/conversion phase (pretreatment) were successfully randomized to either placebo or ER hydromorphone; a total of 110 patients then completed this double-blind phase of the study. Those in the Moderate and High negative affect groups tended to drop out more often during the titration/conversion phase because of the adverse effects or lack of efficacy of their prescribed opioid than those in the Low negative mood group (P < 0.05). Overall, those patients in the Moderate and High groups reported significantly higher pain intensity scores in at-home and in-clinic pain intensity ratings (P < 0.05), greater disability on the Roland-Morris Scale (P < 0.01), and more withdrawal symptoms on the SOWS (P < 0.05) than those in the Low group. Higher negative affect scores also predicted less favorable ratings of the study drug during the titration phase (P < 0.05). Interestingly, the High negative affect group showed the most improvement in pain in the placebo condition (P < 0.05).

CONCLUSIONS

Negative affect is associated with diminished benefit during a trial of opioid therapy and is predictive of dropout in a controlled clinical trial.

Chronic Pain in the Outpatient Palliative Care Clinic

Chronic pain is common. Many patients with cancer and other life-limiting illnesses have chronic pain that is related to their disease, and some have comorbid chronic nonmalignant chronic pain. As palliative care continues to move upstream and outpatient palliative care programs develop, palliative care clinicians will be called upon to treat chronic pain. Chronic pain differs from acute pain in the setting of advanced disease and a short prognosis in terms of its etiology, comorbidities—especially psychiatric illness and substance abuse—and management. To successfully care for these patients, palliative care providers will need to learn new clinical competencies. This article will review chronic pain management core competencies for palliative care providers.

Psychiatric comorbidity in medication overuse headache patients with pre-existing headache type of episodic tension-type headache

BACKGROUND

Medication overuse headache (MOH) mostly evolves from migraine and episodic tension-type headache (ETTH). Chronic tension-type headache (CTTH) is another headache type that evolves over time from ETTH. It is well known that psychiatric comorbidity is high in MOH patients.

AIM

To investigate the frequency of psychiatric comorbidity, and the intensity of depression and anxiety in MOH patients evolving from ETTH and to compare results with CTTH patients and MOH patients evolving from migraine.

METHODS

Twenty-eight CTTH (Group C) and 89 MOH patients were included into the study. MOH patients were divided into two groups according to their pre-existing headache types: MOH patients with pre-existing ETTH (Group E, n = 31), and with pre-existing migraine (Group M, n = 58). All patients were interviewed with a psychiatrist and SCID-CV and SCID-II were applied. Beck Anxiety Inventory and Beck Depression Inventory scales were also performed.

RESULTS

Eleven patients (39.3%) in Group C, 21 patients (67.7%) in Group E, and 31 patients (53.7%) in Group M were diagnosed to have comorbid psychiatric disorders. The psychiatric comorbidity was found significantly higher in Group E than Group C. In Group E, mood disorders were found significantly higher, but the difference between the two groups with regard to anxiety disorders was insignificant. Mean depression scores were significantly higher in Group E than Group C. The mostly diagnosed type was obsessive-compulsive personality disorder in all the three groups, and was statistically significant in Group M than Group C.

CONCLUSION

Psychiatric comorbidity in MOH patients with pre-existing ETTH is common as in those with pre-existing migraine headache and MOH with regard to developing psychiatric disorders should be interpreted as a risk factor in chronic daily headache patients.

Screening for addictive disorders within a workers' compensation clinic: an exploratory study

We conducted a cross-sectional study investigating the extent of addictive disorders within a workers' compensation (WC) clinic. We also examined the feasibility of substance abuse screening within the same clinic. In 2009 , 100 patients were asked to complete the World Health Organization's Alcohol, Smoking, Substance Involvement Screening Test (WHO-ASSIST) and the Current Opioid Misuse Measure (COMM). According to the WHO-ASSIST, we found that 46% of WC patients required intervention for at least one substance-related disorder (25% tobacco, 23% sedatives, 8% opioids), and according to the COMM, 46% screened positive for prescription opioid misuse. Importantly, the addition of this screening was brief, economical, and well accepted by patients. Further research should analyze the costs and benefits of detection and intervention of substance-related disorders in this setting.

Assessment and treatment of abuse risk in opioid prescribing for chronic pain

Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no "gold standard" for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.

Prevalence of and factors associated with psychiatric morbidity in chronic pain patients

OBJECTIVE

The reported prevalence of psychiatric morbidity in chronic pain patients (CCPs) was high, although it varied tremendously since structured diagnostic instruments were seldom used for diagnosis in previous studies. Study in this area after the launching of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was scarce. This study serves to estimate the prevalence of psychiatric morbidity in patients attending a chronic pain clinic by using the Structured Clinical Interview for DSM-IV (SCID) Axis I disorders and to identify factors highly associated with psychiatric disorders, particularly depression, which is treatable.

METHOD

Consecutive patients attending a chronic pain clinic were recruited during a 6-month period. Psychiatric diagnoses were made by using the SCID. Logistic regression was used to identify factors predicting overall psychiatric morbidity and depression.

RESULTS

Prevalence of psychiatric disorders in this 89-patient sample was 62.9%. Current major depressive disorder was present in 31.5% and somatoform disorders in 33.7%. Anxiety disorders and current substance use disorders each constituted 18. "Younger age of onset of pain" (odds ratio [OR]=0.956, P<.05) and "higher pain intensity" (OR=1.544, P<.001) were independently associated with presence of psychiatric disorders. "Higher pain intensity" (OR=13.7, P<.05), "negative pain cognition" (OR=0.967, P<.05) and "problems with social and leisure activities" (OR=38.5, P<.05) were associated with depression.

CONCLUSION

Prevalence of psychiatric disorders in this Chinese chronic pain clinic sample with reference to the DSM-IV was similar to that reported in previous studies. Specific factors were identified to alert pain physicians to underlying psychiatric disorders.

The role of psychological interventions in the management of patients with chronic pain

Chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient's physiological state, thoughts, emotions, behaviors, and sociocultural influences. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress - improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, psychologists can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives.

Understanding and managing patients with chronic pain

The specialty of oral and maxillofacial surgery has had at its core the foundations of anesthesia and pain and anxiety control. This article attempts to refamiliarize the reader with clinical pearls helpful in the management of patients with chronic pain conditions. The authors also hope to highlight the interplay of chronic pain and psychology as it relates to the oral and maxillofacial surgery patient. To that end, the article outlines and reviews the neurophysiology of pain, the definitions of pain, conditions encountered by the oral and maxillofacial surgeon that produce chronic pain, the psychological impact and comorbidities associated with patients experiencing chronic pain conditions, and concepts of multimodal treatment for patients experiencing chronic pain conditions.

Influence of comorbidity with depression on interdisciplinary therapy: outcomes in patients with chronic low back pain

INTRODUCTION

Our previous work showed higher tumour necrosis factor (TNF)-α levels in patients with chronic low back pain (cLBP) compared to healthy controls. However, patients with depression as a comorbidity did not have higher TNF-α levels in comparison to patients without depression. In this study we investigated the influence of depression on therapy outcomes such as TNF-α serum levels, pain intensity and back function in patients with cLBP. Our hypothesis was that patients with both cLBP and depression benefit no less than patients with cLBP alone from the multidisciplinary pain therapy.

METHODS

A total of 58 patients with cLBP alone or with both cLBP and depression were age- and sex-matched with 29 healthy controls. Serum concentrations of TNF-α were assayed at the beginning of the study (T0) and 10 days (T1), 21 days (T2), and 180 days (T3) later. The clinical outcomes such as pain intensity, as well as back function, sleep, exercise, alcohol and nicotine consumption were documented. In the first three weeks, all patients underwent multidisciplinary therapy based upon biological, psychological, physical and psychosocial components.

RESULTS

Over the whole course there were no differences in TNF-α level between cLBP patients with and without depression. At T0, both cLBP patients with (cLBP+DE) and without (cLBP) depression showed significantly higher TNF-α serum levels (P = 0.002 for cLBP+DE, P = 0.004 for cLBP) than healthy controls (HC) that normalized after 10 days of therapy and remained similar to healthy controls. During the follow-up, the depression scales were normalised and pain intensity was significantly reduced. Both evidences processed parallel to the reduction of TNF-α levels, which correlates neither with depression score nor with pain intensity at any time point.

CONCLUSIONS

Depression as a comorbidity to chronic low back pain did not influence the serum TNF-α level in the course of six months, but seemed to affect the success of therapy. cLBP patients with comorbidity of depression benefit from multidisciplinary pain therapy not only to the same extent but also to a greater degree than cLBP patients without depression.

Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial

Chronic pain patients who show aberrant drug-related behavior often are discontinued from treatment when they are noncompliant with their use of opioids for pain. The purpose of this study was to conduct a randomized trial in patients who were prescribed opioids for noncancer back pain and who showed risk potential for or demonstration of opioid misuse to see if close monitoring and cognitive behavioral substance misuse counseling could increase overall compliance with opioids. Forty-two patients meeting criteria for high-risk for opioid misuse were randomized to either standard control (High-Risk Control; N=21) or experimental compliance treatment consisting of monthly urine screens, compliance checklists, and individual and group motivational counseling (High-Risk Experimental; N=21). Twenty patients who met criteria indicating low potential for misuse were recruited to a low-risk control group (Low-Risk Control). Patients were followed for 6 months and completed pre- and post-study questionnaires and monthly electronic diaries. Outcomes consisted of the percent with a positive Drug Misuse Index (DMI), which was a composite score of self-reported drug misuse (Prescription Drug Use Questionnaire), physician-reported abuse behavior (Addiction Behavior Checklist), and abnormal urine toxicology results. Significant differences were found between groups with 73.7% of the High-Risk Control patients demonstrating positive scores on the DMI compared with 26.3% from the High-Risk Experimental group and 25.0% from the Low-Risk Controls (p<0.05). The results of this study demonstrate support for the benefits of a brief behavioral intervention in the management of opioid compliance among chronic back pain patient at high-risk for prescription opioid misuse.

Psychiatric comorbidity and suicide risk in patients with chronic migraine

The aim of this study was to explore the impact of mental illness among patients with migraine. We performed MedLine and PsycINFO searches from 1980 to 2008. Research has systematically documented a strong bidirectional association between migraine and psychiatric disorders. The relationship between migraine and psychopathology has often been clinically discussed rather than systematically studied. Future research should include sound methodologically-based studies focusing on the interplay of factors behind the relationship between migraine, suicide risk, and mental illness.

Surgical incision induces anxiety-like behavior and amygdala sensitization: effects of morphine and gabapentin

The role of affective dimension in the postoperative pain is still poorly understood. The present study investigated the development of anxiety-like behavior and amygdala sensitization in incisional pain. Using hind-paw incision model in rats, we showed that surgical incision induced the anxiety-like behavior as determined by elevated plus-maze and open-field tests. Intraperitoneal (IP) morphine administration reversed mechanical allodynia and anxiety-like behavior in a dose-dependent manner. Gabapentin also partially reduced incision-evoked mechanical allodynia and anxiety-like behavior in a dose-dependent manner. After incision, the expression of phosphorylated cAMP response elements (CRE-) binding protein (p-CREB) was transiently upregulated in the central and basolateral nuclei in the bilateral amygdala. The upregulation of p-CREB was inhibited by morphine and gabapentin. The present study suggested that surgical incision could induce anxiety and amygdala sensitization that can be inhibited by morphine and gabapentin. Thus treatment of surgery-induced affective disturbances by morphine and gabapentin may be a potential important adjunct therapy in the postoperative pain management.

Anxiety and depression in patients with chronic temporomandibular pain and in controls

OBJECTIVES

The purpose of this study was to assess the prevalence of anxiety and depression in temporomandibular disorders (TMD) patient subgroups and in controls with or without chronic facial pain (CFP).

METHODS

Our sample consisted of 61 men and 161 women. All TMD patients had suffered from pain for at least 6 months and were divided into two subgroups-an exclusively myofascial pain group and an exclusively joint pain group. Subjects without signs or symptoms of TMD but with and without CFP served as controls. All subjects were examined by calibrated examiners in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders. The German version of the Hospital Anxiety and Depression Scale was used for assessment of anxiety and depression. Analysis of covariance was used to determine the effects of sex, age, and subgroup on anxiety and depression scores. Additional t-tests were performed and the subgroups were then compared with those from a general population sample.

RESULTS

Females from the exclusively myofascial pain group were significantly more depressed than those from the general population or from the exclusively joint pain group. Male controls with CFP were significantly more depressed than female CFP controls. For anxiety, no significant effect of sex or subgroup was found.

CONCLUSIONS

Depression may play an important role in women with chronic myofascial pain whereas anxiety does not seem to be relevant for either females or males. Further anxiety screening of patients with temporomandibular pain could not be justified.

A randomized, double-blind, placebo-controlled study of preemptively administered intravenous parecoxib: effect on anxiety levels and procedural pain during epidural catheter placement for surgical operations or for chronic pain therapy

BACKGROUND

The effect of parecoxib, when used perioperatively or during interventional techniques, is well demonstrated in the literature. Little is known about its effects on anxiety levels before the analgesic technique application. The aim of this prospective, randomized, double-blind, placebo-controlled, clinical study is to investigate whether parecoxib, preemptively administrated, has an effect on anxiety levels reported prior to an epidural puncture, and if it influences the reported pain of the interventional technique itself.

MATERIAL AND METHODS

The study protocol involved 110 patients, scheduled for epidural catheter placement for chronic pain therapy--Group I, as well as 112 patients scheduled for orthopedic operations under epidural anesthesia--Group II. Patients in each group were randomly allocated into two subgroups in relation to parecoxib/placebo administration before epidural catheter placement: Group Ia, parecoxib 40 mg i.v. (n = 54), Group Ib, placebo (n = 56), Group IIa, parecoxib 40 mg i.v. (n = 57), Group IIb, placebo (n = 55). Patients were given a self-administered inventory to measure the anxiety level of the presurgical/preprocedural state (State-Trait Spielberger Anxiety Inventory) and anxiety levels were recorded 1 hour before epidural puncture, 20 minutes postdosing, and 1 hour after epidural catheter placement. Anxiety levels were also measured and recorded using visual analog scale (VAS). One hour after epidural puncture, reported procedural pain was recorded (VAS). One hour and 6 hours postepidural, patients' satisfaction was also recorded, on a 4-point scale.

RESULTS

All four subgroups were similar regarding demographic, operative/procedural data, and coexisting diseases. Preprocedural anxiety levels were significantly decreased with parecoxib administration in comparison with placebo in both groups (P < 0.05). Reported VAS regarding pain from epidural puncture was lower in Groups IA and Ib. Patients' satisfaction was greater with parecoxib in comparison with placebo.

CONCLUSION

The levels of anxiety have been investigated in several medical procedures and early, in the study of pain. The higher the expectation of pain and the anxiety are, the higher the intensity of the pain. Parecoxib seems to exert positive influence on pain and anxiety levels of interventional procedure. Further studies are needed to elucidate the actual mechanisms that are involved.

Neuropathic pain: could nurses become more involved?

Neuropathic pain can take a heavy toll on quality of life, impacting negatively on emotions, disrupting sleep, and impairing energy and mobility. It can destroy the enjoyment of life and the opportunity to continue in employment. In some cases, it can lead to suicidal thoughts and intentions. Nurses are well placed to become more effective in identifying and treating this challenging condition. This article outlines what we currently understand are the causes or 'generators' of neuropathic pain and the mechanisms that maintain pain. It explores strategies for the diagnosis of neuropathic pain and reviews a couple of typical case studies from clinical practice. Using these case studies, this article discusses assessment, patient expectation, treatment options and realistic outcomes. Finally, it is intended to stimulate debate as to why, when, how and where nurses could become key practitioners in identifying the development of neuropathic pain, assessing its impact on patients and encouraging the initiation of treatment.

Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients

OBJECTIVE

To assess the relationship between depression and anxiety comorbidity on pain intensity, pain-related disability, and health-related quality of life (HRQL).

METHODS

Analysis of baseline data from the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study. All patients (n = 500) had chronic pain (>or=3-month duration) of the low back, hip, or knee. Patients with depression were oversampled for the clinical trial component of SCAMP and thus represented 50% of the study population. Patients were categorized according to pain comorbid with depression, anxiety, or both. We used analysis of variance and multivariate analysis of variance models to assess the relationships between independent and dependent variables.

RESULTS

Participants had a mean age of 59 years; they were 55% women, 56% White, and 40% Black. Fifty-four percent (n = 271) reported pain only, 20% (n = 98) had pain and depression, 3% (n = 15) had pain and anxiety, and 23% (n = 116) had pain, depression, and anxiety. Patients with pain and both depression and anxiety experienced the greatest pain severity (p < .0001) and pain-related disability (p < .0001). Psychiatric comorbidity was strongly associated with disability days in the past 3 months (p < .0001), with 18.1 days reported by patients with pain only, 32.2 days by those with pain and anxiety, 38.0 days by those with pain and depression, and 42.6 days in those with all three conditions. We found a similar pattern of poorer HRQL (p < .0001) in those with pain, depression, and anxiety.

CONCLUSIONS

The added morbidity of depression and anxiety with chronic pain is strongly associated with more severe pain, greater disability, and poorer HRQL.

[Treatment of neuropathic pain in HIV-infected patients]

Neuropathic pain of various etiologies is a frequent symptom in HIV-infected patients that is underdiagnosed and inadequately treated. It requires a multidisciplinary pain approach based on psychosocial factors, diet and exercise, etiologic treatment whenever possible, symptomatic medical treatment, and sometimes, interventional techniques. Medical treatment should be individualized and introduced gradually, with a mind to potential drug interactions. Neuropathic pain responds poorly to conventional analgesics, such as nonsteroidal antiinflammatory drugs and opiates; tricyclic antidepressants and anticonvulsants are the drugs of choice. Before establishing an analgesic treatment, possible drug interactions should be ruled out, mainly those occurring with antiretroviral agents.

Anxiety-like behaviour in rats with mononeuropathy is reduced by the analgesic drugs morphine and gabapentin

Anxiety has been described as an important comorbidity in patients suffering from chronic pain. However, in animals the connection between persistent pain and anxiety has hardly been investigated. Therefore, in the current study it was assessed whether chronic pain also causes anxiety-like behaviour in animals and if it can be reversed by analgesic or anxiolytic drugs. Neuropathic pain was induced in rats by partial sciatic nerve ligation (PNL) and chronic constriction injury (CCI). Mechanical hypersensitivity was assessed by the "electronic algometer", while anxiety-like behaviour was measured by using the elevated plus maze. In both neuropathic pain models, rats exhibited mechanical hypersensitivity, whereas a significant increase in anxiety-like behaviour was observed only in CCI rats (time spent in open arms decreased significantly from 99+/-15.8s in sham animals to 33.4+/-7.5s in CCI animals). Furthermore, midazolam (0.5mg/kg; i.p.) significantly reduced anxiety-like behaviour in both sham- and CCI-operated animals without influencing mechanical hypersensitivity. Morphine (3mg/kg; i.p.) and gabapentin (30 mg/kg; i.p.) significantly attenuated anxiety-like behaviour in the CCI lesioned rats: morphine increased entries into open arms from 3.0+/-0.4 to 7.7+/-1.4 (P=0.01), gabapentin elevated this value from 4.7+/-1 to 7.5+/-0.9 (P=0.02). These data suggest that rats subjected to neuropathic pain models develop anxiety-like behaviour which can be reversed by appropriate analgesic treatment. Morphine and gabapentin had no anxiolytic-like effect in sham treated animals, thus their effect on anxiety-like behaviour in the neuropathic pain model is likely indirect via their anti-nociceptive properties.

Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain

OBJECTIVE

To investigate the role of psychiatric history and psychologic adjustment on aberrant drug-related behavior among patients prescribed opioids for noncancer pain.

METHODS

Two hundred twenty-eight patients prescribed opioids for chronic pain were classified as either high or low on psychiatric morbidity on the basis of their responses on the psychiatric subscale of the Prescription Drug Use Questionnaire (PDUQ). They also completed the Brief Pain Inventory (BPI), Screener and Opioid Assessment for Pain Patients (SOAPP), and the Current Medication Misuse Measure (COMM). Patients were followed for 5 months and submitted a urine toxicology screen, and their treating physician completed the Prescription Opioid Therapy Questionnaire (POTQ). On the basis of the results from the SOAPP, COMM, POTQ, and urine screens, patients were classified as positive or negative on the Drug Misuse Index (DMI).

RESULTS

One hundred and three (N=103) of the patients (45%) were classified in the low psychiatric group (Low Psych) whereas 55% (N=125) were classified in the high psychiatric morbidity group (High Psych). High Psych patients were significantly younger than Low Psych patients and had been taking opioids longer (P<0.05). The High Psych group showed significantly higher SOAPP and COMM scores than the Low Psych patients (P<0.001), had a greater frequency of abnormal urine toxicology screens (P<0.01), and significantly higher scores on the DMI (P<0.001). A consistent association was found between psychiatric morbidity and prescription opioid misuse in chronic pain patients.

DISCUSSION

Psychiatric factors, such as a history of mood disorder, psychologic problems, and psychosocial stressors, may place patients at risk for misuse of prescription opioids. Future studies to elucidate the risk of medication misuse and aberrant drug behavior among this patient population are needed.