Race, ethnicity and pain

Perceived discrimination and pain outcomes among black adults with chronic musculoskeletal pain: identifying modifiable psychosocial risk factors

Chronic musculoskeletal pain (CMP) is highly prevalent, frequently associated with negative health outcomes, and disproportionately impacts Black Americans. Perceived racial and ethnic discrimination has emerged as a factor that may influence the experience of chronic pain in this population. Identifying modifiable psychosocial factors that influence the link between perceived discrimination and pain and that can be directly targeted in treatment is vital to reducing the disproportionate burden of CMP among Black individuals. The present study examines the moderating role of five risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) on the relationship between perceived discrimination and pain outcomes (i.e., pain intensity and interference) in a sample of 401 Black adults with CMP. We recruited 401 Black individuals (Mage = 35.98, 51.9% female) with self-reported CMP and assessed their self-reported perceived discrimination, pain intensity, pain interference, and pain-related psychosocial risk factors. Results indicated that higher scores on each of the psychosocial risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) were significantly associated with greater pain intensity and pain interference (all ps < 0.01). Further, pain avoidance (B = 0.12, p = .006), pain fusion (B = 0.13, p = .002), and pain anxiety (B = 0.13, p = .002) each significantly moderated the relation between perceived discrimination and pain intensity. Greater perceived discrimination was associated with greater pain intensity at higher levels of avoidance and fusion, and was associated with less pain intensity at lower levels of avoidance and pain anxiety. In interaction models predicting pain interference, both pain fusion (B = 0.14, p = .001) and pain anxiety (B = 0.10, p = .01) significantly moderated the relation between perceived discrimination and pain interference. Perceived discrimination was associated with greater pain interference at higher levels of pain fusion and pain anxiety, and was not associated with pain interference at lower levels of pain fusion and pain anxiety. The present findings provide important insights into psychosocial risk factors that moderate the link between perceived discrimination and pain outcomes, providing important clinical implications for the treatment of Black adults with chronic musculoskeletal pain.

Tolerability of electrodiagnostic studies in patients: a prospective study

Introduction

Nerve conduction study (NCS) and electromyography (EMG) are electrodiagnostic studies that are highly tolerated by patients despite their nature of causing pain and discomfort. However, few studies have focused on the true tolerability of these procedures in patients. This study aimed to determine the true tolerance rate of NCS and EMG in patient populations and the factors that might be associated with them.

Methods

Participants scheduled for electrodiagnostic studies were prospectively recruited between March 2023 and September 2023. After completion of the study, the physicians completed a questionnaire on each patient's tolerance of the studies.

Results

Of the 103 patients enrolled in the study, 98 were able to tolerate both tests, and 5 patients were intolerant to 1 or both tests. The overall tolerance rate of NCS and EMG was 95.1% (0.951, 95% CI 0.897 to 0.981). Age, sex, ethnicity, the type of NCS performed and the type of EMG performed were not associated with NCS or EMG intolerance.

Conclusion

Most patients tolerated the NCS and EMG; however, a small percentage of patients were intolerant. Clinicians should recognise the intolerance of certain patients when introducing and performing electrodiagnostic tests.

The effect of experimental emotion induction on experimental pain: a systematic review and meta-analysis

ABSTRACT

The idea that emotions can influence pain is generally recognized. However, a synthesis of the numerous individual experimental studies on this subject is lacking. The aim of the present systematic review and meta-analysis was to synthesize the existing evidence on the effect of experimental emotion induction on experimental pain in nonclinical adults. PsycInfo and PubMed were searched up until April 10, 2023, for studies assessing differences in self-reported pain between emotion induction groups and/or control groups or between conditions within group. Risk of bias was assessed for the individual studies. The literature search yielded 78 relevant records of 71 independent studies. When compared with control conditions, the pooled results revealed a statistically significant pain-attenuating effect of positive emotion induction (between-group: Hedges g = -0.48, 95% CI: -0.72; -0.25, K = 9; within-group: g = -0.24, 95% CI: -0.32; -0.15, K = 40), and a statistically significant pain-exacerbating effect of negative emotion induction in within-group analyses but not between-group analyses (between-group: g = -0.29, 95% CI: -0.66; 0.07, K = 10; within-group: g = 0.14, 95% CI: 0.06; 0.23, K = 39). Bayesian meta-analysis provided strong support for an effect of positive emotion induction but weak support for an effect of negative emotion induction. Taken together, the findings indicate a pain-attenuating effect of positive emotion induction, while the findings for negative emotion induction are less clear. The findings are discussed with reference to theoretical work emphasizing the role of motivational systems and distraction for pain. Limitations include considerable heterogeneity across studies limiting the generalizability of the findings.

Sociodemographic Profile: A Forgotten Factor in Temporomandibular Disorders? A Scoping Review

The literature on Temporomandibular Disorders (TMD) incidence commonly reports sociodemographic factors such as gender and age. However, the role and prevalence of other sociodemographic factors in TMD are not well defined. Therefore, this scoping review aimed to report the prevalence of sociodemographic factors in TMD patients. A systematic search was conducted in the PubMed and Web of Science databases to identify clinical trials in adult populations, using the Research Diagnostic Criteria for TMD (RDC/TMD) or the Diagnostic Criteria for TMD (DC/TMD) and reporting sociodemographic data in TMD patients. Twenty-seven studies meeting the criteria were included in this review. The most commonly reported sociodemographic factors assessed in the included studies were age, race, education, job, income, and marital status. TMD prevalence was observed to be higher among younger and divorced individuals among the included studies. However, conflicting results were found for education level, and employment was not considered a risk factor for TMD. Although this review has methodological limitations, it suggests an association between TMD incidence and certain sociodemographic factors; nevertheless, further studies are needed to establish this relationship more conclusively.

Predicting Pain Intensity after Mandibular Third Molar Surgery using Cold Pressor Testing: A Quasi-Experimental Study

BACKGROUND

Patients complain differently about their experiences of post-operative pain. However, clinicians are often guided by their own viewpoints despite the highly subjective nature of pain resulting in suboptimal post-operative pain management. This impacts negatively on the quality of life of patients in the immediate post-operative period. Investigating patients' pain behavior in the pre-operative period may therefore help to predict the intensity of post-operative pain, thereby assisting in identifying patients who are at risk of greater pain after third molar surgery, and allocating extra resources for pain control.

AIM

This study aims to predict the intensity of pain after third molar surgery by correlating post-operative pain perception with the sensory-discriminative dimension and affective response to a cold pressor stimulus.

MATERIALS AND METHODS

This study is a quasi-experimental study that was conducted in the oral surgery clinic of (name of hospital in the title page). The procedure was undertaken in an isolated clinic cubicle with well-controlled room temperature and minimal distraction. Study participants were recruited by convenience sampling. Forty-three consenting participants, 20 years and above, who met eligibility criteria were subjected to pre-operative cold pressor testing. Subsequently, third molar surgery was done and post-operative pain intensity was recorded at specific intervals. Data analyses were completed using IBM SPSS version 25. The Kolmogorov-Smirnov (KS) test was used to test for normality of continuous variables. Ordinal regression was used to test for contributory value of pre-operative measurement while Spearman's rank correlation test was used to test their degree of relationships with post-operative pain P < 0.05.

RESULT

The median pain threshold was 20 s (Interquartile Range, IQR 12.75-32.25) and the median pain tolerance was 33 s (IQR = 23.00-54.00) from the cold pressor test. The peak median pain score in this study was reached at 3-h after the last stitch. There was a statistically significant predictive effect of both variables on post-operative pain at 3-h.

CONCLUSION

Sensory-discriminative dimension and affective response to cold pressor test are significant predictors of peak post-operative pain after impacted mandibular third molar surgery.

Neural and Psychosocial Mechanisms Underlying Alcohol Use and Pain Interactions: Overview of Current Evidence and Future Directions

Purpose of Review

A growing body of research indicates bidirectional associations between alcohol use and pain. In this review, we highlight common neural and psychosocial mechanisms underlying pain and alcohol use and identify current gaps in the literature regarding alcohol/pain interactions. We also suggest future directions for the field moving forward, including more nuanced conceptualization of alcohol's negative reinforcing effects in the context of pain, broader use of clinically-relevant experimental pain induction modalities, and characterization of age, biological sex, gender, race, and ethnicity as moderators of pain/alcohol interactions.

Recent Findings

Acute alcohol intake has analgesic and negative-reinforcing effects in the context of pain, and chronic heavy alcohol use appears to increase risk for development of chronic pain. At the same time, pain, both acute and chronic, acts as a proximal antecedent for alcohol use and is associated with relapse risk for individuals in recovery from alcohol use disorder.

Summary

Although the links between alcohol use and pain are increasingly appreciated, significant gaps in understanding remain and systematic study of alcohol/pain interactions at all levels, including basic, preclinical, translational, and interventional, is needed.

Racial Disparities in Pain Among Women with Fibromyalgia: Secondary Data Analysis of Severity, Interference with Function, and Response to Guided Imagery

Background: Fibromyalgia syndrome (FMS) is characterized by widespread persistent musculoskeletal pain. Mostly prevalent among White women, little is known about FMS in other population cohorts. This study examined secondary data of a racially diverse sample of women with FMS that were collected as part of a randomized controlled clinical trial that examined the effect of a complementary therapy intervention over the course of a 10-week guided imagery intervention to identify demographic, social, or economic differences in self-reported pain. Materials and Methods: The Brief Pain Inventory (BPI), which measures pain severity and interference, was administered to 72 women (21 Black and 51 Whites) at baseline, 6 and 10 weeks. Student's t tests and time series regression models examined racial difference in pain dimensions and treatment response. Regression models accounted for age, race, income, duration of symptoms, treatment group, pain at baseline, smoking, alcohol use, comorbid conditions, and time. Results: Black women experienced significantly higher pain severity (β = 5.52, standard deviation [SD] = 2.13) and interference (β = 5.54, SD = 2.74) than Whites (severity β = 4.56, SD = 2.08; interference β = 4.72, SD = 2.76) (interference: t = 1.92, p = 0.05; severity: t = 2.95, p = 0.00). Disparities persisted over time. Controlling for differences in age, income, and previous pain levels, Black women had 0.26 (standard error [SE] = 0.065) higher pain severity and 0.36 (SE = 0.078) higher interference than Whites. Low-income earners also experienced 2.02 (SE = 0.38) and 2.19 (SE = 0.46) higher pain severity and interference, respectively, than other earners. Results were robust to inclusion of comorbidities. Conclusions: Black women and low-income earners experienced significantly higher levels of pain severity and interference and a lower dose response to the intervention. Differentials were robust to inclusion of demographic, health, and behavioral characteristics. Findings suggest that external factors may contribute to pain perception among women with FMS.

The heterogeneity of symptom reporting across study sites: a secondary analysis of a randomised placebo-controlled multicentre antimalarial trial

INTRODUCTION

Symptoms reported following the administration of investigational drugs play an important role in decisions for registration and treatment guidelines. However, symptoms are subjective, and interview methods to quantify them are difficult to standardise. We explored differences in symptom reporting across study sites of a multicentre antimalarial trial, with the aim of informing trial design and the interpretation of safety and tolerability data.

METHODS

Data were derived from the IMPROV trial, a randomised, placebo-controlled double blinded trial of high dose primaquine to prevent Plasmodium vivax recurrence conducted in eight study sites in Afghanistan, Ethiopia, Indonesia and Vietnam. At each follow up visit a 13-point symptom questionnaire was completed. The number and percentage of patients with clinically relevant symptoms following the administration of primaquine or placebo, were reported by study site including vomiting, diarrhoea, anorexia, nausea, abdominal pain and dizziness. Multivariable logistic regression was used to estimate the confounder-adjusted site-specific proportion of each symptom.

RESULTS

A total of 2,336 patients were included. The greatest variation between sites in the proportion of patients reporting symptoms was for anorexia between day 0 and day 13: 97.3% (361/371) of patients in Arba Minch, Ethiopia, reported the symptom compared with 4.7% (5/106) of patients in Krong Pa, Vietnam. Differences attenuated slightly after adjusting for treatment arm, age, sex, day 0 parasite density and fever; with the adjusted proportion for anorexia ranging from 4.8% to 97.0%. Differences between sites were greater for symptoms graded as mild or moderate compared to those rated as severe. Differences in symptom reporting were greater between study sites than between treatment arms within the same study site.

CONCLUSION

Despite standardised training, there was large variation in symptom reporting across trial sites. The reporting of severe symptoms was less skewed compared to mild and moderate symptoms, which are likely to be more subjective. Trialists should clearly distinguish between safety and tolerability outcomes. Differences between trial arms were much less variable across sites, suggesting that the relative difference in reported symptoms between intervention and control group is more relevant than absolute numbers and should be reported when possible.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01814683; March 20th, 2013.

Covariate Adjustment in Chronic Pain Trials: An Oft-Missed Opportunity

Self-reported pain intensity, frequently used as an outcome in randomized clinical trials (RCTs) of chronic pain, is often highly variable and could be associated with multiple baseline factors. Thus, the assay sensitivity of pain trials (ie, the ability of the trial to detect a true treatment effect) could be improved by including prespecified baseline factors in the primary statistical model. The objective of this focus article was to characterize the baseline factors included in statistical analyses of chronic pain RCTs. Seventy-three RCTs published between 2016 and 2021 that investigated interventions for chronic pain were included. The majority of trials identified a single primary analysis (72.6%; n = 53). Of these, 60.4% (n = 32) included one or more covariates in the primary statistical model, most commonly baseline value of the primary outcome, study site, sex, and age. Only one of the trials reported information regarding associations between covariates and outcomes (ie, information that could inform prioritization of covariates for prespecification in future analyses). These findings demonstrate inconsistent use of covariates in the statistical models in chronic pain clinical trials. Prespecified adjustments for baseline covariates that could increase precision and assay sensitivity should be considered in future clinical trials of chronic pain treatments. PERSPECTIVE: This review demonstrates inconsistent inclusion and potential underutilization of covariate adjustment in analyses of chronic pain RCTs. This article highlights areas for possible improvement in design and reporting related to covariate adjustment to improve efficiency in future RCTs.

Exploring the Effect of Ethnicity on Chronic Orofacial Pain: A Comparative Study of Jewish and Arab Israeli Patients

The relationship between ethnicity and chronic pain has been studied worldwide. The population of Israel includes two main ethnic groups, 75% Jews and 21% Arabs. The purpose of this study was to compare orofacial chronic pain characteristics and treatment outcomes between Jewish and Arab Israeli citizens. Two hundred patients admitted to the Orofacial Pain Clinic at Hebrew University-Hadassah School of Dental Medicine between 2017 and 2022 were selected randomly for this historical cohort study. Our cohort included 159 (79.5%) Jews and 41 (20.5%) Arabs. Twenty-six pain-related variables were compared of which only two differed significantly between the two groups, awakening due to pain and mean muscle sensitivity; both indicators were higher in the Arab group (p < 0.05). No differences were found in any of the other variables such as diagnosis, pain severity, onset, and treatment outcome. This minimal difference may be explained by the equal accessibility to medical services for all citizens, and the diversity of our staff that includes Jew as well as Arab service providers. These factors minimize or even eliminate racial bias, language, and cultural barriers, and is reflected in the minor differences in orofacial pain characteristics found between the two main ethnic groups in Israel.

Pain Catastrophizing and Clinical Outcomes Among Patients Receiving a Novel Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: An Experimental Therapeutics Approach

Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) condition treated by GI and primary care physicians. Although IBS symptoms (abdominal pain, bowel problems) are generally refractory to medical therapies, consistent research has shown that they improve following cognitive-behavioral therapy (CBT). Notwithstanding empirical support for CBT, there is less research explicating the reasons for why or how it works. Like other pain disorders, the focus on change mechanisms for behavioral pain treatments has focused on pain-specific cognitive-affective processes that modulate pain experience, few of which are more important than pain catastrophizing (PC). The fact that PC changes are seen across treatments of differing theoretical and technical orientation, including CBT, yoga, and physical therapy, suggests that it may be a nonspecific (vs. theory-based) change mechanism akin to therapeutic alliance and treatment expectancy. Therefore, the current study examined change in PC as a concurrent mediator of IBS symptoms severity, global GI symptom improvement, and quality of life among 436 Rome III-diagnosed IBS patients enrolled in a clinical trial undergoing two dosages of CBT versus a nonspecific comparator emphasizing education and support. Results from structural equation modeling parallel process mediation analyses suggest that reduction in PC during treatment are significantly associated with improvement in IBS clinical outcomes through 3-month follow-up. Results from the current study provide evidence that PC may be an important, albeit nonspecific change mechanism, during CBT for IBS. Overall, reducing the emotional unpleasantness of pain through cognitive processes is associated with improved outcomes for IBS.

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

BACKGROUND AND PURPOSE

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

METHODS

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

DISCUSSION

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

CONCLUSION

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

Effectiveness of physical stimulation for reducing injection pain in adults receiving intramuscular injections: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to synthesize the best available research evidence regarding the effectiveness of physical stimulation for reducing injection pain in adults receiving intramuscular injections.

INTRODUCTION

Pain associated with intramuscular injections continues to be a challenge for nurses. Various physical stimulation methods to alleviate pain and improve satisfaction for patients receiving intramuscular injections have been reported; however, the evidence surrounding the effectiveness of these methods remains inconclusive.

INCLUSION CRITERIA

This systematic review considered randomized and quasi-experimental studies that used any physical stimulation strategies (eg, skin tapping, manual pressure, massage, pinch, traction) for adults aged 18 years and over receiving intramuscular injections. Studies that evaluated pain using validated instruments were considered for inclusion.

METHODS

A three-step search strategy was conducted. MEDLINE, Embase, CINAHL, the Cochrane Library (Cochrane CENTRAL), Google Scholar, Dissertation Abstracts International, ProQuest Dissertations and Theses, and MedNar were searched from inception until 2020. We restricted the inclusion of studies to trials published in English. Two independent reviewers conducted the critical appraisal of eligible studies using the JBI checklists for randomized controlled and quasi-experimental trials. Data were extracted using the JBI data extraction tool, and meta-analysis and subgroup analysis were undertaken, where appropriate.

RESULTS

Twenty-five studies were included with a total sample size of 1956 patients. Pooled results demonstrated that pain was significantly less with the use of the Helfer skin tap technique compared to no intervention (two studies; RR 0.73; 95% CI 0.66, 0.81; P <0.00001) or standard intervention (three studies; SMD -2.25; 95% CI -3.65, -0.85; P =0.002). Intervention with acupressure using standard treatment as control showed significant reduction in pain intensity (MD -4.78; 95% CI -5.32, -4.24; P <0.00001). Similarly, pain was significantly lower with manual pressure (two studies; SMD -0.42; 95% CI -0.69, 0.15; P =0.002) when compared to standard treatment. Pain scores were significantly lower in patients who received pinch technique, ShotBlocker, massage, or combination intervention (skin traction, pressure, and rapid muscle release) compared with no intervention, standard treatment, or placebo control.

CONCLUSIONS

The evidence from this review demonstrates that physical stimulation - particularly the Helfer skin tap technique, acupressure, manual pressure, pinch technique, ShotBlocker, massage, and combination - can significantly lower intramuscular injection pain; however, this is based on low or very low certainty of evidence.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020168586.

Understanding ethnic minority service user experiences of being invited to and attending group pain programmes: A qualitative service evaluation

Introduction

Health inequalities continue to exist for individuals from an ethnic minority background who live with chronic pain. There is a growing recognition that an individual's experience of pain is shaped by their cultural beliefs, which may influence their decisions about managing their pain.

Aims

This service evaluation aimed to (a) understand experiences of service users from a Black, Asian or other ethnic minority background of being invited to and attending a group pain programme in one secondary care pain rehabilitation service. (b) Provide recommendations to develop culturally grounded services to better meet the diverse needs of all service users living with chronic pain.

Method

Semi-structured interviews were conducted with five service users who had been offered a place on a group pain programme within the last 3 years. The interviews were recorded and transcribed verbatim. An interpretative phenomenological analysis was used to identify themes in the data.

Results

The analysis produced three themes (1) Pain, Ethnicity and Coping: Perceptions of pain and coping in relation to ethnicity and intersectional factors, alignment to a self-management approach. (2) Communication for Decisions: Experiences of ethnicity and culture in relation to health professional communication about group pain programmes, participants' expectations and fears. (3) Feeling Included: Experiences of feeling included or excluded in group pain programme, relationships and empowerment during the group pain programme.

Discussion

The five service users shared a range of perspectives on how they felt ethnicity shaped their experience of the group pain programme. The findings suggest that adaptations to group pain programmes can make a meaningful difference for service users from ethnic minority backgrounds. 10 recommendations are suggested, including greater exploration of cultural beliefs during assessment, improving accessibility of information about the service and engaging more diverse attendees and facilitators.

Ethnocultural Minority Workers and Sustainable Return to Work Following Work Disability: A Qualitative Interpretive Description Study

Purpose This article provides a state-of-the-art review of issues and factors associated with the sustainable return to work (S-RTW) of ethnocultural minority workers experiencing disability situations attributable to one of four major causes: musculoskeletal disorders, common mental disorders, other chronic diseases or cancer. Methods Using an interpretive description method, an integrative review was conducted of the literature on ethnocultural factors influencing S-RTW issues and factors associated with these four major work-disability causes. An initial review of the 2006-2016 literature was subsequently updated for November 2016-May 2021. To explore and contextualize the results, four focus groups were held with RTW stakeholders representing workplaces, insurers, the healthcare system and workers. Qualitative thematic analysis was performed. Results A total of 56 articles were analyzed and 35 stakeholders participated in four focus groups. Two main findings emerged. First, belonging to an ethnocultural minority group appears associated with cumulative risk factors that may contribute to vulnerability situations and compound the complexity of S-RTW. Second, cultural differences with respect to the prevailing host-country culture may generate communication and trust issues, and conflicts in values and representations, in turn possibly hindering the establishment of positive relationships among all stakeholders and the ability to meet workers' needs. Being a woman in these groups and/or having a lower level of integration into the host country's culture also appear associated with greater S-RTW challenges. Conclusions Based on our findings, we recommend several possible strategies, such as the cultural humility model, for preventing differences from exacerbating the already significant vulnerability situation of some ethnocultural minority workers.

Relationship between behavioral and mood responses to monetary rewards in a sample of Indian students with and without reported pain

Physical pain has become a major health problem with many university students affected by it worldwide each year. Several studies have examined the prevalence of pain-related impairments in reward processing in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries but none of the studies have replicated these findings in a non-western cultural setting. Here, we aimed to investigate the prevalence of physical pain symptoms in a sample of university students in India and replicate our previous study conducted on university students in Switzerland, which showed reduced mood and behavioral responses to reward in students with significant pain symptoms. We grouped students into a sub-clinical (N = 40) and a control group (N = 48) to test the association between pain symptoms and reward processes. We used the Fribourg reward task and the pain sub-scale of the Symptom Checklist (SCL-27-plus) to assess physical symptoms of pain. We found that 45% of the students reported high levels of physical symptoms of pain and interestingly, our ANOVA results did not show any significant interaction between reward and the groups either for mood scores or for outcomes related to performance. These results might yield the first insights that pain-related impairment is not a universal phenomenon and can vary across cultures.

Time for Action: Understanding Health Care Professionals Views on Pain and Pain Management in a Pediatric Hospital

BACKGROUND

Children admitted to the hospital experience pain. ChildKind International (CKI) is an organization dedicated to improving the quality of pediatric pain care worldwide. In 2019, BC Children hospital (BCCH) clinicians set out to achieve this certification. A qualitative study was performed in order to fully comprehend the current state of pain assessment and management at BCCH.

AIM

The objective of this study is to characterize the perceptions of health care professionals (HCPs) about pediatric pain and pain management in a pediatric hospital.

METHODS

We choose a quantitative methodology as it allows us to delve more deeply into the HCPs' personal experience with pain and pain management of children in the hospital. We interviewed 31 pediatric healthcare professionals (N = 31).

RESULTS

HCPs believe there is a significant lack of resources, especially educational resources, to adequately assess and treat pain in children. There is a lack of time to evaluate each patient appropriately and use pain tools consistently for both verbal and non-verbal children. HCPs varied in their opinions as to whether a procedure is painful or uncomfortable, and this opinion often differs from the perception of the child. Additionally, staff recognize that cultural diversity of both staff and patients can influence pain assessment and management in children. Therefore, there is a need for increased cultural diversity training for staff.

CONCLUSIONS

Pain management and treatment of children in the hospital remain inconsistent and inadequate. ChildKind certification will help hospitals to address this gap in their clinical practice.

Beyond Black vs White: racial/ethnic disparities in chronic pain including Hispanic, Asian, Native American, and multiracial US adults

ABSTRACT

Previous literature on race/ethnicity and pain has rarely included all major US racial groups or examined the sensitivity of findings to different pain operationalizations. Using data from the 2010 to 2018 National Health Interview Surveys on adults 18 years or older (N = 273,972), we calculated the weighted prevalence of 6 definitions of pain to provide a detailed description of chronic pain in White, Black, Hispanic, Asian, Native American, and multiracial groups. We also estimated modified Poisson models to obtain relative disparities, net of demographic and socioeconomic (SES) factors including educational attainment, family income, and home ownership; finally, we calculated average predicted probabilities to show prevalence disparities in absolute terms. We found that Asian Americans showed the lowest pain prevalence across all pain definitions and model specifications. By contrast, Native American and multiracial adults had the highest pain prevalence. This excess pain was due to the lower SES among Native Americans but remained significant and unexplained among multiracial adults. The pain prevalence in White, Black, and Hispanic adults fell in between the 2 extremes. In this trio, Hispanics showed the lowest prevalence, an advantage not attributable to immigrant status or SES. Although most previous research focuses on Black-White comparisons, these 2 groups differ relatively little. Blacks report lower prevalence of less severe pain definitions than Whites but slightly higher prevalence of severe pain. Net of SES, however, Blacks experienced significantly lower pain across all definitions. Overall, racial disparities are larger than previously recognized once all major racial groups are included, and these disparities are largely consistent across different operationalizations of pain.

Multi-level Pain Quantification using a Smartphone and Electrodermal Activity

Appropriate prescription of pain medication is challenging because pain is difficult to quantify due to the subjectiveness of pain assessment. Currently, clinicians must entirely rely on pain scales based on patients' assessments. This has been alleged to be one of the causes of drug overdose and addiction, and a contributor to the opioid crisis. Therefore, there is an urgent unmet need for objective pain assessment. Furthermore, as pain can occur anytime and anywhere, ambulatory pain monitoring would be welcomed in practice. In our previous study, we developed electrodermal activity (EDA)-derived indices and implemented them in a smartphone application that can communicate via Bluetooth to an EDA wearable device. While we previously showed high accuracy for high-level pain detection, multi-level pain detection has not been demonstrated. In this paper, we tested our smartphone application with a multi-level pain-induced dataset. The dataset was collected from fifteen subjects who underwent four levels of pain-inducing electrical pulse (EP) stimuli. We then performed statistical analyses and machine-learning techniques to classify multiple pain levels. Significant differences were observed in our EDA-derived indices among no-pain, low-pain, and high-pain segments. A random forest classifier showed 62.6% for the balanced accuracy, and a random forest regressor exhibited 0.441 for the coefficient of determination. Clinical Relevance - This is one of the first studies to present a smartphone application for detecting multiple levels of pain in real time using an EDA wearable device. This work shows the feasibility of ambulatory pain monitoring which can potentially be useful for chronic pain management.

Comparison of pain and psychosocial correlates among Hispanic and Non-Hispanic White youth with chronic pain

Introduction:

Despite well-documented pain disparities among adults from non-White and Hispanic groups, less is known about pain disparities in non-White and Hispanic pediatric populations.

Objectives:

We compare pain and related psychosocial factors at the individual (pain intensity, pain interference, pain catastrophizing, co-occurring symptoms), social (peer relations), and systemic (health insurance) levels among Hispanic and Non-Hispanic White (NHW) youth with chronic pain.

Methods:

Eight hundred thirty-seven (71.4% female) Hispanic (n = 268, 32%) and NHW (n = 569, 68%) youth ages 8 to 17 years (M = 14.00; SD = 2.54) completed a survey at their initial visit to a pain clinic. Independent sample t tests investigated mean differences in psychosocial factors at the individual and social levels. Chi-squared tests investigated differences at the systemic level. Bivariate correlations for each group were compared using Fisher r-to-z transformations.

Results:.

Hispanic youth reported higher levels of pain intensity (t[811] = −2.75, P = 0.006). Groups did not differ in reports of other individual or social factors. Non-Hispanic White youth were more likely to have private insurance (OR, 5.66). All examined variables were significantly correlated among NHW youth. Correlations were weaker or nonsignificant among Hispanic youth. Fisher r-to-z transformations revealed these group differences to be significant.

Conclusion:

Hispanic youth report higher pain levels than NHW counterparts and lower likelihood of having private insurance. Pain and psychosocial factors correlate differently among the 2 groups highlighting a need to better understand the chronic pain experiences of diverse youth because models derived primarily from NHW populations may not generalize across ethnic and racial groups.

Cybersickness Variability by Race: Findings From 6 Studies and a Mini Meta-analysis

Background

With the influx of medical virtual reality (VR) technologies, cybersickness has transitioned from a nuisance experienced during leisure activities to a potential safety and efficacy concern for patients and clinicians. To improve health equity, it is important to understand any potential differences in cybersickness propensity among demographic groups, including racial groups.

Objective

This study aims to explore whether cybersickness propensity differs across racial groups.

Methods

We collected self-reported cybersickness ratings from 6 racially diverse independent samples within 1 laboratory group (N=931). In these studies, the participants were asked to perform tasks in VR such as traversing environments, pointing at and selecting objects, and interacting with virtual humans.

Results

Significant racial differences in cybersickness were found in 50% (3/6) of studies. A mini meta-analysis revealed that, on average, Black participants reported approximately one-third of SD less cybersickness than White participants (Cohen d=−0.31; P<.001), regardless of the nature of the VR experience. There was no overall difference in reported cybersickness between the Asian and White participants (Cohen d=−0.11; P=.51).

Conclusions

Racial differences in cybersickness indicate that researchers, practitioners, and regulators should consider patient demographics when evaluating VR health intervention outcomes. These findings lay the groundwork for future studies that may explore racial differences in cybersickness directly.

The Relationship Between Experienced Discrimination and Pronociceptive Processes in Native Americans: Results From the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) have higher pain rates than the general U.S. population. It has been found that increased central sensitization and reduced pain inhibition are pronociceptive processes that increase pain risk; yet, little attention has focused on the influence of psychosocial factors. Discrimination is a psychosocial factor associated with increased pain in other minoritized groups; however, it is unclear whether it also promotes pain in NAs. This study analyzed data from 269 healthy, pain-free participants (N = 134 non-Hispanic whites [NHWs], N = 135 NAs) from the Oklahoma Study of Native American Pain Risk. Experienced discrimination was measured using the Everyday Discrimination Scale (EDS). Nociceptive processes were measured via static measures of spinal sensitivity (nociceptive flexion reflex [NFR] threshold, 3-stimulation NFR threshold), temporal summation of pain (TS-Pain) and nociceptive flexion reflex (TS-NFR), and conditioned pain modulation of pain (CPM-Pain) and NFR (CPM-NFR). Results demonstrated that greater discrimination was associated with enhanced TS-NFR and impaired CPM-NFR but not static measures of spinal sensitivity or measures of pain modulation (TS-Pain, CPM-Pain). Although the effects of discrimination on outcomes were similar in both groups (not moderated by ethnicity), NAs experienced higher levels of discrimination and therefore discrimination mediated a relationship between ethnicity and impaired CPM-NFR. This indicates experienced discrimination may promote a pain risk phenotype in NAs that involves spinal sensitization resulting from impaired inhibition of spinal nociception without sensitization of pain experience. PERSPECTIVE: This study found that discrimination was associated with spinal sensitization and impaired descending inhibition of spinal nociception. These findings bolster our understanding of how social stressors experienced disproportionately by minoritized groups can contribute to pain outcomes.

Differences in the association between kappa opioid receptors and pain among Black and White adults with alcohol use disorders

BACKGROUND

The relationship between alcohol and pain is complex. Associations between pain and alcohol use disorder (AUD) vary by race, but the underlying biological basis is not understood. We examined the association of the kappa opioid receptor (KOR) with responses to the cold-pressor test (CPT), before and after treatment with the opioid antagonist naltrexone, among individuals with AUD who self-identified as Black or White.

METHODS

Thirty-seven individuals (12 Black, 24 White, and 1 Multiracial) with AUD participated in two CPTs, separated by 1 week during which they received naltrexone 100 mg daily. During each CPT, pain reporting threshold (PRT), average pain increase rate (APIR), relative pain recovery (RPR), and alcohol craving were recorded. KOR availability was measured using [¹¹ C]-LY2795050 positron emission tomography (PET) prior to treatment with naltrexone.

RESULTS

Black participants reported higher PRT and APIR than White participants during the CPT before, but not after, naltrexone treatment. Among Black participants, KOR availability was positively associated with PRT and APIR before, but not after naltrexone. Greater KOR availability was associated with faster RPR for White, but not Black, participants. The CPT induced more alcohol craving in Black than White participants, particularly in individuals with low KOR availability, an effect that was not attenuated by naltrexone.

CONCLUSIONS

KOR involvement and naltrexone effects on responses to the CPT were different between Black and White participants. These preliminary findings suggest that further exploration of the differences in the opioid system and pain among Black and White individuals with AUD and their relationship with naltrexone's effects is warranted.

Impact of Parental Primary Spoken Language on Postoperative Pain Management in Children, a Retrospective Cohort Study

Background: Healthcare providers encounter varying languages every day in patient care. The goal of this study was to examine whether a difference exists in pain scoring and treatment amongst pediatric patients whose families’ primary language was not English. We hypothesized that patients of both Arabic-speaking (AS) and Spanish-speaking (SS) backgrounds received higher pain scores and higher daily opioid equivalents (OEs) postoperatively compared to English-speaking (ES) patients. Methods: This was a retrospective cohort study of patients undergoing surgery for treatment of various esophageal and airway disorders from 2014 to 2019. Records were queried for patients undergoing thoracotomies for treatment of esophageal and airway disorders. Analysis was focused on the three most common languages in this selected population: English, Arabic, and Spanish. Propensity score matching was utilized for comparisons of pain scores between AS, SS, and ES patient groups. Primary outcomes were opioid equivalents (OEs) and pain scores postoperatively. Multivariable median regression analysis was used to perform an adjusted comparison of pain scores as well as OEs. Results: A total of 610 patient encounters were included in our analysis. In propensity matched analysis, there were no significant differences in OEs between all groups postoperatively. However, statistically significant higher pain scores were reported in the ES group matched AS groups. Conclusions: Language differences did not lead to difference in pain assessment and treatment.

Racial disparities in observers' attention to and estimations of others' pain

ABSTRACT

Research has demonstrated racial disparities in pain care such that Black patients often receive poorer pain care than White patients. Little is known about mechanisms accounting for the emergence of such disparities. The present study had 2 aims. First, we examined whether White observers' attentional processing of pain (using a visual search task [VST] indexing attentional engagement to and attentional disengagement from pain) and estimation of pain experience differed between White vs Black faces. Second, we examined whether these differences were moderated by (1) racially biased beliefs about pain experience and (2) the level of pain expressed by Black vs White faces. Participants consisted of 102 observers (87 females) who performed a VST assessing pain-related attention to White vs Black avatar pain faces. Participants also reported on racially biased beliefs about White vs Black individuals' pain experience and rated the pain intensities expressed by White and Black avatar faces. Results indicated facilitated attentional engagement towards Black (vs White) pain faces. Furthermore, observers who more strongly endorsed the belief that White individuals experience pain more easily than Black individuals had less difficulty disengaging from Black (vs White) pain faces. Regarding pain estimations, observers gave higher pain ratings to Black (vs White) faces expressing high pain and White (vs Black) faces expressing no pain. The current findings attest to the importance of future research into the role of observer attentional processing of sufferers' pain in understanding racial disparities in pain care. Theoretical and clinical implications are discussed, and future research directions are outlined.

Patient Characteristics Independently Associated With Knee Osteoarthritis Symptom Severity at Initial Orthopedic Consultation

BACKGROUND/OBJECTIVE

The objective of this study was to identify patient and disease characteristics associated with the symptomatic severity of knee osteoarthritis (OA) at the time of initial knee OA diagnosis by an orthopedist.

METHODS

This medical records review included patients initially diagnosed with knee OA during 2016 to 2017 by a single orthopedic surgeon in a university-based tertiary care setting. All variables were assessed at first OA diagnosis. Main outcomes were subscales of the Knee Injury and Osteoarthritis Outcome Score-Pain, other Symptoms, knee-related quality of life, and function in daily living. Multivariable regression analyses examined the following predictors of main outcomes: sex, race, age, insurance type, body mass index, Charlson comorbidity index, and radiographic OA severity (Kellgren-Lawrence grade).

RESULTS

Of the 559 patients included in the study, most were African American (52.1%), female (71.7%), and had severe radiographic OA (Kellgren-Lawrence grade, 4; 68.7%). Female sex, African American racial/ethnic group, Medicaid insurance, younger age, and severe radiographic OA were independently statistically significantly associated with worse symptoms, pain, and function (p < 0.05 for all). Body mass index and Charlson comorbidity index were not statistically significant predictors of any outcome.

CONCLUSIONS

This study identified disparities in the perception of knee OA problems at initial orthopedist diagnosis based on sex, age, race, insurance, and radiographic OA severity. Because most of these variables are also associated with more rapid progression of OA, identifying their biopsychosocial underpinnings may help determine which interventions are most likely to redress these disparities and delay progression to end-stage knee OA.

Relationship between diet and relative risk of pain in a cross-sectional analysis of the REGARDS longitudinal study

Aim: Determine if dietary patterns affect risk of pain. Methods: Data from 16,061 participants (55.4% females, 32.3% Black, age 65 ± 9 years) in the REGARDS study were categorized based on the adherence to previous dietary patterns reflecting the prevalent foods within each (convenience, alcohol/salads, plant-based, sweets/fats and 'Southern'). A modified Poisson regression model was used to determine whether dietary patterns were associated with relative risk (RR) of pain. Results: High adherence to 'Southern' dietary pattern was associated with a 41% (95% CI: 23, 61%) increase in RR of pain. High adherence to a plant-based dietary pattern showed a 22% (95% CI: 11, 31%) decrease in the RR of pain. Conclusion: Poor quality dietary patterns increase the RR of pain, while plant-based patterns lowered the RR. Diet patterns should be incorporated into medical history.

Racial Differences in Pain, Nutrition, and Oxidative Stress

Investigating the disproportionate rates of chronic pain and their related comorbidities between Black and non-Hispanic White (White) individuals is a growing area of interest, both in the healthcare community and in general society. Researchers have identified racial differences in chronic pain prevalence and severity, but still very little is known about the mechanisms underlying them. Current explanations for these differences have primarily focused on socioeconomic status and unequal healthcare between races as causal factors. Whereas these factors are informative, a racial gap still exists between Black and White individuals when these factors are controlled for. One potential cause of this racial gap in chronic pain is the differences in nutrition and dietary intake between groups. Certain foods play a key role in the inflammatory and oxidative stress pathways in the human body and could potentially influence the severity of the pain experience. Here, we review the previous literature on the surrounding topics and propose a potential mechanism to explain racial differences in the chronic pain population, based on established racial differences in diet and oxidative stress.

Patient traits shape health-care stakeholders' choices on how to best allocate life-saving care

During global pandemics, health-care decision makers often face critical shortages of life-saving medical equipment. How do medical stakeholders prioritize which patients are most deserving of scarce treatment? We report the results of three conjoint experiments conducted in the United States in 2020, testing for biases in US physicians', citizens' and elected politicians' preferences for scarce ventilator distribution. We found that all stakeholders prioritized younger patients and patients who had a higher probability of surviving with ventilator access. When patients' survivability was tied, physicians prioritized patients from racial/ethnic minorities (that is, Asian, Black and Hispanic patients) over all-else-equal white patients, religious minorities (that is, Muslim patients) over religious majority group members (that is, Catholic patients) and patients of lower socio-economic status over wealthier patients. The public also prioritized Black and Hispanic patients over white patients but were biased against religious minorities (that is, Atheist and Muslim patients) relative to religious majority group members. Elected politicians were also biased against Atheist patients. Our effects varied by political party-with Republican physicians, politicians and members of the public showing bias against religious minority patients and Democratic physicians showing preferential treatment of racial and religious minorities. Our results suggest that health-care stakeholders' personal biases impact decisions on who deserves life-saving medical equipment.

Reciprocal Effects Between Depressive Symptoms and Pain in Veterans over 50 Years of Age or Older

OBJECTIVE

Depression and chronic pain are major problems in American veterans, yet there is limited long-term research examining how they relate to one another in this population. This study examined the relationship between depressive symptoms and pain in U.S. veterans 50 years of age or older.

METHODS

This study used data on veterans from the 2002-2016 waves of the Health and Retirement Study (n = 4,302), a large-scale observational study of Americans 50 years of age or older. Measures included a short form of the Center for Epidemiologic Studies Depression scale and two items assessing the presence and degree of pain. Analyses included random-intercept cross-lagged panel models (RI-CLPM).

RESULTS

In the RI-CLPM, there were roughly equivalent cross-lagged effects between depressive symptoms and pain. There was also evidence that depressive symptoms and pain have a trait-like component and that these trait-like characteristics are associated.

CONCLUSIONS

These findings indicate that depressive symptoms and pain in veterans are stable characteristics in American veterans 50 years of age or older. There appear to be reciprocal effects between the two, whereby deviations in one's typical depressive symptoms predict subsequent deviations in one's pain level and vice versa; however, the size of these effects is very small. These findings suggest that clinicians should treat both depressive symptoms and pain, rather than assume that treatment benefits in one domain will lead to major benefits in another.

Cross-sectional study of the effects of self-efficacy on fatigue and pain interference in black women with systemic lupus erythematosus: the role of depression, age and education

Objective

While fatigue and pain are pervasive symptoms in SLE, self-efficacy can mitigate their intensity and impact on patients’ daily activity. We examined the relationships of these domains and their interactions with demographics and depression in black women with SLE.

Methods

This is a cross-sectional analysis of data collected among 699 black women with SLE. We used validated, self-reported measures of fatigue, pain interference, symptom self-efficacy, treatment self-efficacy and depression. Linear regression analyses were conducted to examine the relationships between each outcome (fatigue and pain interference) and each predictor (symptom self-efficacy and treatment self-efficacy), and the interaction of demographics and depression.

Results

We found inverse associations between fatigue and each of symptom self-efficacy (slope −0.556, p<0.001) and treatment self-efficacy (slope −0.282, p<0.001), as well as between pain interference and each of symptom self-efficacy (slope −0.394, p<0.001) and treatment self-efficacy (slope −0.152, p<0.001). After adjusting for confounders, symptom self-efficacy remained significantly associated with each outcome (adjusted slope −0.241 (p<0.001) and −0.103 (p=0.008) for fatigue and pain, respectively). The amount of decrease in fatigue and pain interference differed by depression severity (p<0.05 for the interaction of symptom self-efficacy and depression). The difference in fatigue by depression widened as symptom self-efficacy increased; the adjusted fatigue scores for moderate/severe depression compared with no depression were 6.8 and 8.7 points higher at mean and high symptom self-efficacy, respectively (p<0.001). Age and education significantly changed the relationship between outcomes and self-efficacy.

Conclusions

Symptom self-efficacy and treatment self-efficacy were inversely related to fatigue and pain interference in black women with SLE. Depression disproportionately increased the intensity of these outcomes. While older women with low symptom self-efficacy reported disproportionately higher pain interference, those with higher education and mean or high levels of symptom self-efficacy reported lower pain interference. These findings may help predict who might benefit most from self-efficacy-enhancing interventions.

Culture and musculoskeletal pain: strategies, challenges, and future directions to develop culturally sensitive physical therapy care

BACKGROUND

Pain experience has a multidimensional nature. Assessment and treatment recommendations for pain conditions suggest clinicians use biopsychosocial approaches to treat pain and disability. The current pain research is overwhelmingly skewed towards the study of biological and psychological factors including interventions, whereas, cultural factors are often ignored.

OBJECTIVE

The aims of this Masterclass is threefold: (1) to discuss cultural influences on pain, (2) to provide strategies for delivering appropriate pain education and exercises in culturally diverse people with chronic pain, and (3) to present challenges and future directions to clinicians and researchers.

DISCUSSION

Cultural factors have a relevant influence on the way individuals experience and manage health and illness. Thus, people with different cultural experience perceive, respond, communicate and manage their pain in different ways. In this aspect, the contents of pain education should be presented using different culturally appropriate examples, metaphors, images, and delivery methods that may enhance the impact of the message. Efforts should be made to produce and spread culturally adapted evidence-based materials and resources. In addition, a culturally sensitive approach may help to introduce patients to graded activities, so that they can apply these strategies in culturally acceptable and meaningful ways. Future studies should investigate the effectiveness of culturally-adapted interventions in pain-related outcomes in different pain conditions in patients with different cultural backgrounds.

Differential DNA methylation in Black and White individuals with chronic low back pain enrich different genomic pathways

Compared to Non-Hispanic Whites (NHWs), individuals who self-identify as Non-Hispanic Blacks (NHBs) in the United States experience more severe and disabling chronic low back pain (cLBP). We hypothesized that differences in DNA methylation (DNAm) play a role in racial disparities in cLBP.

PURPOSE

To determine the relationship between DNAm levels and racial group differences in adults with cLBP. Our study's secondary purpose was to perform a race-stratified comparison of adults with cLBP and pain-free controls and identify functional genomic pathways enriched by annotated differentially methylated genes.

PATIENTS AND METHODS

We recruited 49 NHBs and 49 NHWs (49 cLBP and 49 pain-free controls, PFCs), analyzed DNAm from whole blood using reduced representation bisulfite sequencing, and identified enriched genomic pathways.

RESULTS

Among participants with cLBP, we identified 2873 differentially methylated loci (DML; methylation differences of at least 10% and p < 0.0001), many of which were annotated to genes of importance to pain pathology. These DMLs significantly enriched pathways to involved in nociception/pain processing (Dopamine-DARPP32 Feedback in cAMP signaling, GABA Receptor Signaling, Opioid Signaling) and neuronal differentiation (e.g., Calcium Signaling, Axon Guidance Signaling, and Endocannabinoid Neuronal Synapse). Our race stratified analyses of individuals with cLBP versus PFCs revealed 2356 DMLs in NHBs and 772 DMLs in NHWs with p < 0.0001 and > 10% methylation difference. Ingenuity Pathway Analysis revealed that many pathways of significance to pain such as Corticotropin Releasing Hormone Signaling, White Adipose Tissue Browning, and GABA Receptor Signaling pathways, were more significant in NHBs than NHWs.

CONCLUSION

Even though an individual's self-identified race is a social construct, not a biological variable, racism associated with that classification affects virtually every aspect of life, including disease risk. DNAm induced alterations in stress signaling pathways may explain worse pain outcomes in NHBs.

More than Hurt Feelings: The Wear and Tear of Day-to-Day Discrimination in Adults with Chronic Pain

OBJECTIVE

To examine the extent to which self-reported experiences of discrimination are associated with pain interference among men and women with chronic non-cancer pain.

METHODS

Data are from the Study of Midlife in the United States (MIDUS) Refresher Cohort. The analytic sample consisted of 207 adults with chronic pain (54.2 ± 12.8 years; 53.6% female) who completed the Major Experiences of Discrimination and Everyday Discrimination scales. Regression analyses examined cross-sectional relations between discrimination and pain interference.

RESULTS

On average, the level of pain interference was moderate in the sample (mean = 3.46, standard deviation = 2.66; observed range 0-10). Approximately a third of respondents reported at least one major discriminatory event in their lifetime, while 22% reported three or more discriminatory lifetime events. Everyday discrimination scores averaged 14.19 ± 5.46 (observed range 0-33). With adjustment for sociodemographics, physical health, cognitive and psychological factors, social isolation, and loneliness, everyday discrimination was associated with increased pain interference (B = 0.099; 95% confidence interval [CI]: 0.02 to 0.17).

CONCLUSION

These findings add weight to the importance of day-to-day experiences of interpersonal discrimination by documenting independent associations with functional interference in adults with chronic pain.

Is ABO Blood Group a Predictive Factor for the Amount of Opioid Consumption in the First 24 Hours After Cesarean Section?

Background

Cesarean section is the most common major surgery performed globally. Blood group O has been found as a factor affecting pain severity after cesarean section. We aimed to evaluate the predictive factors, including ABO blood group, for the amount of opioid consumption (measured as milligrams of morphine equivalent [MME]) within the first 24 hrs after cesarean section.

Methods

This retrospective study was done in 1530 pregnant women who had a cesarean section under the same regimen of spinal anesthesia (2.2 mL of 0.5% hyperbaric bupivacaine and morphine 0.2 mg). All were prescribed regular paracetamol and ibuprofen for postoperative pain control. Univariate and multinomial regression analyses were performed to identify the predictive factors for opioid consumption in the first 24 hrs postoperatively.

Results

About 2/5 of them (43.3%) received 0 mg MME, while 25.6%, 23.7% and 7.4% received 1–5, 6–10 and >10 mg MME, respectively. The majority have blood group O (40.6%), while 23.4%, 28% and 8% have blood group A, B and AB, respectively. After univariate and multinomial regression analyses, operation time, opioid consumption in PACU, maximum VNRS within the first 24 hrs and consumption of both paracetamol and ibuprofen were identified as predictive factors for postoperative opioid consumption. ABO blood group exhibited no correlation for opioid requirement postoperatively.

Conclusion

ABO blood group is not a predictive factor for opioid requirement within the first 24 hrs following cesarean section. Duration of operation, opioid given in PACU, maximum VNRS on ward and consumption of both paracetamol and ibuprofen have been found to be predictive factors for postcesarean opioid requirement.

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

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

Pain and mortality among older adults in Korea

OBJECTIVES

With the increasing elderly population with chronic disease, understanding pain and designing appropriate policy interventions to it have become crucial. While pain is a noted mortality risk factor, limited studies exist due to the various causes of pain and the subjectivity of pain expression. This study aimed to examine the relationship between pain and mortality, controlling for other diseases and socio-cultural factors.

METHODS

We analyzed 6,258 individuals aged 45 years or older, the population with the highest prevalence of pain, using the Korean Longitudinal Study of Aging (2006-2016) data and the Cox proportional-hazards model. Further subgroup analyses were conducted by sex and education level to examine differences in the relationship between pain and mortality.

RESULTS

The adjusted hazard ratios of mortality were 1.16 (95% confidence interval [CI], 1.00 to 1.34, model 1) and 1.12 (95% CI, 0.97 to 1.29, model 2) for the individuals in pain depending on the models used, where additional socio-cultural factors were accounted for in model 2. For individuals in severe pain, ratios were significantly higher with 1.23 (95% CI, 1.08 to 1.41, model 1) and 1.16 (95% CI, 1.02 to 1.32, model 2). Further subgroup analyses showed that severe pain was more associated with mortality for males and more educated individuals, with adjusted hazard ratios of 1.29 (95% CI, 1.08 to 1.55, model 2) and 1.62 (95% CI, 1.15 to 2.28, model 2), respectively.

CONCLUSIONS

Pain showed a statistically significant relationship with mortality risk. Family members or medical staff should pay proper attention to pain, particularly severe pain in males and highly educated individuals.

Classifying chronic pain using multidimensional pain-agnostic symptom assessments and clustering analysis

Chronic pain conditions present in various forms, yet all feature symptomatic impairments in physical, mental, and social domains. Rather than assessing symptoms as manifestations of illness, we used them to develop a chronic pain classification system. A cohort of real-world treatment-seeking patients completed a multidimensional patient-reported registry as part of a routine initial evaluation in a multidisciplinary academic pain clinic. We applied hierarchical clustering on a training subset of 11,448 patients using nine pain-agnostic symptoms. We then validated a three-cluster solution reflecting a graded scale of severity across all symptoms and eight independent pain-specific measures in additional subsets of 3817 and 1273 patients. Negative affect–related factors were key determinants of cluster assignment. The smallest subset included follow-up assessments that were predicted by baseline cluster assignment. Findings provide a cost-effective classification system that promises to improve clinical care and alleviate suffering by providing putative markers for personalized diagnosis and prognosis.

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

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

Gender and Sex Are Key Determinants in Osteoarthritis Not Only Confounding Variables. A Systematic Review of Clinical Data

Many risk factors for osteoarthritis (OA) have been noted, while gender/sex differences have been understated. The work aimed to systematically review literature investigating as primary aim the relationship between gender/sex related discriminants and OA. The search was performed in PubMed, Science Direct and Web of Knowledge in the last 10 years. Inclusion criteria were limited to clinical studies of patients affected by OA in any joints, analyzing as primary aim gender/sex differences. Exclusion criteria were review articles, in vitro, in vivo and ex vivo studies, case series studies and papers in which gender/sex differences were adjusted as confounding variable. Of the 120 records screened, 42 studies were included. Different clinical outcomes were analyzed: morphometric differences, followed by kinematics, pain, functional outcomes after arthroplasty and health care needs of patients. Women appear to use more health care, have higher OA prevalence, clinical pain and inflammation, decreased cartilage volume, physical difficulty, and smaller joint parameters and dimensions, as compared to men. No in-depth studies or mechanistic studies analyzing biomarker differential expressions, molecular pathways and omic profiles were found that might drive preclinical and clinical research towards sex-/gender-oriented protocols.

Cross-Sectional Examination of Musculoskeletal Pain and Physical Function in a Racially and Socioeconomically Diverse Sample of Adults

BACKGROUND

Musculoskeletal pain alters physiological function, which may be evidenced as early as middle age. Previous research has concluded that middle-aged adults are a high-risk group for musculoskeletal pain and report functional limitations similar to older adults. However, few studies have examined the relationships between musculoskeletal pain and physical function, using objective performance measures in a sample of racially and socioeconomically diverse adults. Thus, this study examined musculoskeletal pain in relation to physical function in middle-aged (30-64 years) White and Black adults and investigated whether the relationship varied by sociodemographic characteristics.

METHODS

This cross-sectional examination incorporated data from the Healthy Aging in Neighborhoods of Diversity across the Life-Span Study. Participants (n = 875) completed measures of musculoskeletal pain and objective measures of physical performance (ie, lower and upper body strength, balance, and gait abnormalities). Physical performance measures were standardized to derive a global measure of physical function as the dependent variable.

RESULTS

Approximately, 59% of participants identified at least 1 pain sites (n = 518). Multivariable regression analyses identified significant relationships between greater musculoskeletal pain and poorer physical function (β = -0.07, p = .031), in mid midlife (β = -0.04, p = .041; age 40-54) and late midlife (β = -0.05, p = .027; age 55-64).

CONCLUSIONS

This study observed that musculoskeletal pain was associated with poorer physical function within a diverse group of middle-aged adults. Future research should longitudinally explore whether chronic musculoskeletal pain identified at younger ages is associated with greater risk for functional limitation and dependence in later life.

Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear.

OBJECTIVE

To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse.

DESIGN, SETTING, AND PARTICIPANTS

This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain.

INTERVENTIONS

The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse.

MAIN OUTCOMES AND MEASURES

Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge.

RESULTS

Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03134092.

The impact of race on postpartum opioid prescribing practices: a retrospective cohort study

BACKGROUND

To identify the association between inpatient postpartum opioid consumption, race, and amount of opioids prescribed at discharge after vaginal or cesarean delivery.

METHODS

A total of 416 women who were prescribed an oral opioid following vaginal or cesarean delivery at a single tertiary academic institution between July 2018 and October 2018 were identified. Women with postoperative wound complications, third and fourth degree lacerations, cesarean hysterectomy, or a history of opioid abuse were excluded. The primary outcome was the number of oxycodone 5 mg tablets prescribed at discharge, stratified by race and mode of delivery. Only "Black" and "White" women were included in analyses due to low absolute numbers of other identities. Black women were compared to white women using multivariable logistic regression. Multiple sensitivity analyses were performed.

RESULTS

The median number of oxycodone tablets consumed during hospitalization following cesarean delivery was seven (IQR: 2.5-12 tablets) and following vaginal delivery was one (IQR: 0-3). White women were more likely to be older at delivery regardless of route (median 32 vs. 30 years for cesarean delivery, and 29 vs. 27 years for vaginal delivery; p < 0.01 for both). White women undergoing cesarean delivery did so at a lower maternal BMI (31.6 vs. 34.5; p = 0.02). White women were also significantly more likely to have private insurance and to experience perineal lacerations following vaginal delivery. The number of inpatient opioid tablets consumed, as well as the number prescribed at discharge, were not statistically different between Black and White women, regardless of mode of delivery. These findings persisted in sensitivity analyses.

CONCLUSION

At our large, academic hospital the number of tablets prescribed at discharge had no association with patient race or inpatient usage regardless of mode of delivery.

Real-Time High-Level Acute Pain Detection Using a Smartphone and a Wrist-Worn Electrodermal Activity Sensor

The subjectiveness of pain can lead to inaccurate prescribing of pain medication, which can exacerbate drug addiction and overdose. Given that pain is often experienced in patients' homes, there is an urgent need for ambulatory devices that can quantify pain in real-time. We implemented three time- and frequency-domain electrodermal activity (EDA) indices in our smartphone application that collects EDA signals using a wrist-worn device. We then evaluated our computational algorithms using thermal grill data from ten subjects. The thermal grill delivered a level of pain that was calibrated for each subject to be 8 out of 10 on a visual analog scale (VAS). Furthermore, we simulated the real-time processing of the smartphone application using a dataset pre-collected from another group of fifteen subjects who underwent pain stimulation using electrical pulses, which elicited a VAS pain score level 7 out of 10. All EDA features showed significant difference between painless and pain segments, termed for the 5-s segments before and after each pain stimulus. Random forest showed the highest accuracy in detecting pain, 81.5%, with 78.9% sensitivity and 84.2% specificity with leave-one-subject-out cross-validation approach. Our results show the potential of a smartphone application to provide near real-time objective pain detection.

The Adaptation of Pain Assessment Tools from High-Income to Low- and Middle-Income Countries: Psychometric Properties of a Set of Chronic Pain Questionnaires in Mongolian and New Zealand Patient Samples

OBJECTIVE

Chronic pain is a leading cause of disability in low- and middle-income countries; however, pain assessment tools have generally been developed and validated in high-income countries. This study examines the psychometric properties of a set of translated pain (and distress) questionnaires in Mongolia and documents the characteristics of people seeking treatment for chronic pain in Mongolia, compared with those in New Zealand, which is representative of high-income countries.

DESIGN

Cross-sectional, observational.

SETTING

Hospital-based pain treatment centers in New Zealand and Mongolia.

SUBJECTS

People seeking treatment for chronic pain in Mongolia (N = 142) and New Zealand (N = 159).

METHODS

The Brief Pain Inventory, the Depression Anxiety Stress Scale-21, the Pain Catastrophizing Scale, and the Pain Self-Efficacy Questionnaire were translated into Mongolian and administered to patients attending a hospital-based pain service. Questionnaires that were completed by patients in New Zealand were used for comparisons. Internal reliability, convergent validity, and factor structure were assessed in both groups.

RESULTS

Patients in Mongolia were older and reported lower pain intensity, interference, and distress and higher pain self-efficacy than those in New Zealand. The translated questionnaires had good internal consistencies, and the relationships between pain variables were similar across both groups. The factor structure for the Pain Catastrophizing Scale was consistent across both groups, but this was not the case for the Brief Pain Inventory or the Depression Anxiety Stress Scale-21.

CONCLUSIONS

Findings indicate that some pain outcome measures may be appropriate for use in Mongolia and should be investigated in other low- and middle-income countries.

Fear of Pain Across the Adult Life Span

BACKGROUND

Pain continues to be an important public health concern, especially given the opioid crisis in industrialized countries. It is important to understand the association between emotions such as fear and anxiety and the experience of pain as both a physiological and affective experience. Fear or anxiety about pain is in fact a well-known predictor of and close associate of pain. Nociception and pain history differ depending on age, yet little empirical evidence exists on how fear of pain varies over the life span. The purpose of this study was to provide a cross-sectional examination of the relations between age and fear of pain across the adult life span.

METHODS

Using cross-sectional data from 4,122 participants who completed the Fear of Pain Questionnaire-9, structural equation modeling and regression techniques were used to examine the association between fear of pain and age.

RESULTS

A positive linear association was discovered between age and fear of severe or minor pain, and a negative association was discovered between age and fear of medical or dental pain. Quadratic and cubic relations were also significant for fear of severe pain, fear of medical and dental pain, and overall fear of pain, but not for fear of minor pain.

CONCLUSIONS

Unique trajectories for different components of pain-related fear exist across the adult life span and may be affected by increased exposure to medical and dental experiences over time and by the awareness of a greater likelihood of experiencing pain later in the life span.

Improving access to healthcare for paediatric sickle cell disease patients: a qualitative study on healthcare professionals' views

BACKGROUND

In well-resourced countries, comprehensive care programs have increased life expectancy of patients with sickle cell disease, with almost all infants surviving into adulthood. However, families affected by sickle cell disease are more likely to be economically disenfranchised because of their racial or ethnic minority status. As every individual child has the right to the highest attainable standard of health under the United Nations Convention on the Rights of the Child, it is essential to identify both barriers and facilitators with regard to the delivery of adequate healthcare. Optimal healthcare accessibility will improve healthcare outcomes for children with sickle cell disease and their families. Healthcare professionals in the field of sickle cell care have first-hand experience of the barriers that patients encounter when it comes to effective care. We therefore hypothesised that these medical professionals have a clear picture of what is necessary to overcome these barriers and which facilitators will be most feasible. Therefore, this study aims to map best practises and lessons learnt in order to attain more optimal healthcare accessibility for paediatric patients with sickle cell disease and their families.

METHODS

Healthcare professionals working with young patients with sickle cell disease were recruited for semi-structured interviews. An interview guide was used to ensure the four healthcare accessibility dimensions were covered. The interviews were transcribed and coded. Based on field notes, initial codes were generated, to collate data (both barriers and solutions) to main themes (such as "transportation", or "telecommunication"). Through ongoing thematic analysis, definitive themes were formulated and best practices were reported as recommendations. Quotations were selected to highlight or illustrate the themes and link the reported results to the empirical data.

RESULTS

In 2019, 22 healthcare professionals from five different university hospitals in the Netherlands were interviewed. Participants included (paediatric) haematologists, nurses and allied health professionals. Six themes emerged, all associated with best practices on topics related to the improvement of healthcare accessibility for children with sickle cell disease and their families. Firstly, the full reimbursement of invisible costs made by caregivers. Secondly, clustering of healthcare appointments on the same day to help patients seeing all required specialists without having to visit the hospital frequently. Thirdly, organisation of care according to shared care principles to deliver specialised services as close as possible to the patient's home without compromising quality. Fourthly, optimising verbal and written communication methods with special consideration for families with language barriers, low literacy skills, or both. Fifthly, improving the use of eHealth services tailored to users' health literacy skills, including accessible mobile telephone contact between healthcare professionals and caregivers of children with sickle cell disease. Finally, increasing knowledge and interest in sickle cell disease among key stakeholders and the public to ensure that preventive and acute healthcare measures are understood and safeguarded in all settings.

CONCLUSION

This qualitative study describes the views of healthcare professionals on overcoming barriers of healthcare accessibility that arise from the intersecting vulnerabilities faced by patients with sickle cell disease and their families. The recommendations gathered in this report provide high-income countries with a practical resource to meet their obligations towards individual children under the United Nations Convention on the Rights of the Child.

Low Back Pain-Related Disability Is Associated with Pain-Related Beliefs Across Divergent Non-English-Speaking Populations: Systematic Review and Meta-Analysis

OBJECTIVES

This systematic review and meta-analysis examined relationships between low back pain (LBP)-related disability and pain beliefs, including pain catastrophizing, pain-related fear, self-efficacy, and back pain beliefs, in non-English-speaking populations. Additionally, the effects of selected cultural factors (i.e., language/geographic area) on the strength of relationships were examined.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Nine databases were searched. Studies included observational or randomized control clinical trials. Eligible studies had to report estimates of the association between pain beliefs and disability. Pooled estimates of correlation coefficients were obtained through random-effects meta-analysis methods.

RESULTS

Fifty-nine studies, (n = 15,383) were included. Moderate correlations were identified between disability and pain self-efficacy (chronic LBP r = -0.51, P ≤ 0.001), between disability and pain catastrophizing (acute LBP r = 0.47, P ≤ 0.001; chronic LBP r = 0.44, P ≤ 0.001), and also between disability and pain-related fear (chronic LBP r = 0.41, P ≤ 0.001). Otherwise, weak correlations were identified between disability and most pain beliefs (range r = -0.23 to 0.35, P ≤ 0.001). Pooled correlation coefficients between disability and all pain beliefs (except the Fear Avoidance Belief Questionnaire-Work subscale) represent medium effects and suggest that lower disability was associated with greater pain self-efficacy, less pain-related fear, less catastrophic thinking, and less negative back pain beliefs about the nature and cause of back pain. Results were consistent across most language groups and geographic regions; few studies reported ethnicity or religion.

DISCUSSION

LBP-related disability was associated with pain-related beliefs, with consistency demonstrated for each pain belief construct across divergent non-English-speaking populations. Further research examining cultural factors, such as ethnicity or religion, and with a more diverse population is warranted.

Risk factors for postoperative eye pain in patients with non-painful eye disease undergoing pars plana vitrectomy: the VItrectomy Pain (VIP) study

BACKGROUND

Pars plana vitrectomy (PPV), a surgical procedure used to treat different ophthalmic pathologies, could be associated with moderate to severe eye pain. The aim of the present study was to evaluate the incidence of postoperative eye pain and its risk factors following PPV in a selected population of patients with non-painful eye disease, receiving regional anesthesia and moderate sedation with benzodiazepines, without use of narcotics.

METHODS

Single-center, prospective observational cohort study. We recorded the presence of pain at operating room discharge, at 6 and 24 hours, using the numeric rating scale (NRS). We recorded also age, sex, ethnic origin, American Society of Anaesthesia physical status (ASA PS) classification, Charlson Comorbidity Index, the etiology of the vitreoretinal pathology, length of surgery, and type of surgical procedure performed.

RESULTS

Eye pain (NRS>3) was present in three patients (0.7%) at operating room discharge, 59 (13.2%) at six and 65 (14.6%) at 24 hours after surgery. LASSO logistic regression analysis identified age, ASA PS, race, along with tamponade as independent risk factors for eye pain at six hours. Scleral buckling was selected for eye pain at 24 hrs.

CONCLUSIONS

A protocol for pain control after PPV should be considered, especially in younger, non-Caucasian people, and patients with high ASA PS grade. Moreover, attention must be paid when additional surgical procedures are requested, restricting them to selected patients, and using the appropriate agent for intraocular tamponade.