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Shetty AA, Almalki SA, Al Jameel AH, Gowdar IM, Ronsivalle V, Cicciù M, Minervini G. Tobacco smoking and its impact on pain intensity of temporomandibular disorders: A systematic review and metanalysis. J Oral Rehabil 2024. [PMID: 39252210 DOI: 10.1111/joor.13845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 08/01/2024] [Accepted: 08/07/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND Temporomandibular disorders (TMDs) encompass a spectrum of orofacial conditions characterised by pain and dysfunction in the temporomandibular joint and surrounding structures. Tobacco smoking has been posited as a potential factor influencing the prevalence and intensity of TMD. However, the nature and extent of this relationship remain unclear due to variations in study outcomes. This systematic review aimed to consolidate existing research findings to elucidate the association between tobacco smoking and TMD pain intensity. METHODS A comprehensive search of electronic databases was conducted to identify relevant studies published up to June 2023. Studies investigating the relationship between tobacco smoking and TMD pain were included. Data extraction was conducted by two reviewers. Quality assessment was performed using the New Castle-Ottawa scale. Review Manager 5.4 was used to quantitatively analyse the results. RESULTS The review included four studies employing similar TMD assessment techniques. All studies reported elevated TMD pain intensity among tobacco users, with non-smokers exhibiting lower pain intensity. The quality of the included studies was good. Meta-analytic results showed that TMD pain intensity was higher in the smokers group compared to the non-smokers group, with a weighted mean difference (WMD) of 0.65 (BPM) (95% CI: [0.10, 1.19], p = .02). CONCLUSION This systematic review provides a comprehensive synthesis of the existing literature on tobacco smoking and TMD symptoms. The findings underscore the multifaceted nature of the relationship between smoking and TMD pain, highlighting its clinical relevance and the need for tailored interventions. Further research is warranted to elucidate underlying mechanisms and potential moderating factors, contributing to a more nuanced understanding of this complex association.
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Affiliation(s)
- Amarshree A Shetty
- Department of Paediatric and Preventive Dentistry, A.B Shetty Memorial Institute of Dental Sciences, NITTE (Deemed to Be University), Mangalore, Karnataka, India
| | - Sultan Abdulrahman Almalki
- Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin AbdulAziz University, Al-kharj, Saudi Arabia
| | - AlBandary Hassan Al Jameel
- Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
| | - Inderjit Murugendrappa Gowdar
- Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin AbdulAziz University, Al-kharj, Saudi Arabia
| | - Vincenzo Ronsivalle
- Department of Biomedical and Surgical and Biomedical Sciences, Catania University, Catania, Italy
| | - Marco Cicciù
- Department of Biomedical and Surgical and Biomedical Sciences, Catania University, Catania, Italy
| | - Giuseppe Minervini
- Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, Tamil Nadu, India
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
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Gammoh O, Mansour M, Al Hababbeh S, Ennab W, Aljabali AAA, Tambuwala MM, Binsaleh AY, Abdul Rahim Shilbayeh S. Insomnia and fibromyalgia-like symptoms among women diagnosed with relapsing remitting multiple sclerosis in Jordan: Prevalence and correlates. Int J Psychiatry Med 2024:912174241255420. [PMID: 38771967 DOI: 10.1177/00912174241255420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
OBJECTIVE This study investigated the prevalence and correlates of fibromyalgia and insomnia in a sample of Women with Multiple Sclerosis (WMS). METHODS The study was cross-sectional in design and recruited a sample of 163 women with Relapsing-Remitting Multiple Sclerosis (RRMS). Fibromyalgia was assessed using the Patient Self-Report Survey (PSRS), following criteria outlined by the American College of Rheumatology. Insomnia was measured using the Arabic version of the Insomnia Severity Index (ISI-A). RESULTS The prevalence of fibromyalgia and insomnia was 28.2% (n = 46) and 46.3% (n = 76), respectively. Multivariate analyses were used to determine significant independent correlates. Fibromyalgia was associated with age above 40 years (OR = 2.29, 95% CI = 1.01-5.18, P = .04), high school education (OR = 3.69, 95% CI = 1.62-8.37, P = .002), and non-use of analgesics (OR = .02, 95% CI = .004-.21, P = .001). Insomnia symptoms were significantly associated only with age above 40 years (OR = 2.16, 95% CI = 1.16-4.04, P = .01). CONCLUSION These findings highlight the need for increased attention by primary care physicians towards diagnosing and treating fibromyalgia and insomnia among women with RRMS in Jordan, particularly among older women.
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Affiliation(s)
- Omar Gammoh
- Faculty of Pharmacy, Department of Clinical Pharmacy and Pharmacy Practice, Yarmouk University, Irbid, Jordan
| | | | | | - Wail Ennab
- Department of Neurology, Al-Bashir Hospital, Amman, Jordan
| | - Alaa A A Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan
| | - Murtaza M Tambuwala
- Lincoln Medical School, University of Lincoln, Brayford Pool Campus, Lincoln, UK
| | - Ammena Y Binsaleh
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sireen Abdul Rahim Shilbayeh
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
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Kuzu D, Valentine TR, Kratz AL. Temporal associations between use of psychoactive substances and somatic symptoms in the daily lives of people with fibromyalgia. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1176-1182. [PMID: 37243707 PMCID: PMC10546481 DOI: 10.1093/pm/pnad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Consumption of psychoactive substances-alcohol, nicotine, caffeine, opioids, and cannabis-is common among people with fibromyalgia. Associations between the use of substances and somatic symptoms could reflect efforts to cope with symptoms, aggravation or alleviation of symptoms after the use of substances, or a combination of these. To date, no study has provided insight into temporal associations between the consumption of psychoactive substances and fluctuations in somatic symptoms. We explored whether changes in ratings of pain and fatigue (mental and physical) predicted the later use of psychoactive substances or vice versa (substance use predicting later change in symptoms). DESIGN Micro-longitudinal design. SETTING/SUBJECTS Fifty adults (88% female, 86% White, mean age of 44.9 years) with fibromyalgia. METHODS Participants completed ecological momentary assessments of substance use, pain intensity, and physical/mental fatigue 5 times per day for 8 days. RESULTS Results of multilevel models indicated that momentary increases in fatigue showed a consistent association with greater odds of later use of psychoactive substances, whereas momentary increases in pain were related to lower odds of later cannabis and nicotine use and higher odds of later alcohol use. Only nicotine use predicted later mental fatigue. CONCLUSION Findings highlight the importance of individualized interventions for symptom management or problems related to the use of psychoactive substances. We observed that although somatic symptoms predicted later use of substances, use of substances did not show appreciable effects with regard to alleviating somatic symptoms in people with fibromyalgia.
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Affiliation(s)
- Duygu Kuzu
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI 48109,United States
| | - Thomas R Valentine
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI 48109,United States
| | - Anna L Kratz
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI 48109,United States
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Tarar ZI, Farooq U, Nawaz A, Gandhi M, Ghouri YA, Bhatt A, Cash BD. Prevalence of Fibromyalgia and Chronic Fatigue Syndrome among Individuals with Irritable Bowel Syndrome: An Analysis of United States National Inpatient Sample Database. Biomedicines 2023; 11:2594. [PMID: 37892968 PMCID: PMC10604744 DOI: 10.3390/biomedicines11102594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 10/29/2023] Open
Abstract
Background and Aim: Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder associated with other somatic disorders. We studied the prevalence and predictors of fibromyalgia and chronic fatigue syndrome (CFS) in IBS patients. Methods: We used the National Inpatient Sample and included hospitalization of individuals with IBS, using ICD-10 codes, from 2016-2019. The prevalence and predictors of fibromyalgia and CFS in IBS patients were studied. Univariate and multivariate patient- and hospital-level regression models were used to calculate the adjusted odds of fibromyalgia and CFS in the IBS patient population. Results: Of 1,256,325 patients with an ICD-10 code of IBS included in the study, 10.73% (134,890) also had ICD-10 codes for fibromyalgia and 0.42% (5220) for CFS. The prevalence of fibromyalgia and CFS was significantly higher in IBS patients (adjusted odds ratio (AOR) 5.33, 95% confidence interval (CI) 5.24-5.41, p < 0.001, and AOR 5.40, 95% CI 5.04-5.78, p < 0.001, respectively) compared to the general adult population without IBS. IBS-diarrhea, IBS-constipation, and IBS-mixed types were independently associated with increased odds of fibromyalgia and CFS. Increasing age (AOR 1.02, 95% CI 1.01-1.04, p 0.003; AOR 1.02, 95% CI 1.01-1.03, p 0.001), female gender (AOR 11.2, 95% CI 11.1-11.4, p < 0.001; AOR 1.86, 95% CI 1.78-1.93, p < 0.001) and white race (AOR 2.04, 95% CI 1.95-2.12, p < 0.001; AOR 1.69, 95% CI 1.34-2.13, p < 0.001) were independent predictors of increased odds of fibromyalgia and CFS, respectively. Conclusions: It appears that IBS is associated with an increased prevalence of somatic disorders such as fibromyalgia and CFS.
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Affiliation(s)
- Zahid Ijaz Tarar
- Division of Gastroenterology and Hepatology, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | - Umer Farooq
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MO 63103, USA;
| | - Ahmad Nawaz
- Division of Gastroenterology and Hepatology, Suny Upstate Medical University, Syracuse, NY 13210, USA
| | - Mustafa Gandhi
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | - Yezaz A. Ghouri
- Division of Gastroenterology and Hepatology, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | - Asmeen Bhatt
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Elective Surgery, Department of Surgery, University of Texas Health Medical School, Houston, TX 77030, USA
| | - Brooks D. Cash
- Division of Gastroenterology & Hepatology, University of Texas Health-McGovern Medical School and UT Health Science Center at Houston, St. Houston, TX 77054, USA
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Abstract
OBJECTIVES Fibromyalgia (FM) patients have an increased risk for glucose metabolism disturbances, and impaired glucose tolerance may be associated with symptom severity. Elevated levels of plasma lactate have been detected in FM patients. Both pyruvate and lactate are produced in glucose metabolism and reflect oxidative metabolism. The objective of our study was to analyse disturbances in glucose, pyruvate, or lactate metabolism in FM patients. METHODS We measured plasma levels of glucose, pyruvate, and lactate during an oral glucose tolerance test in 40 non-diabetic, female FM patients and 30 age- and gender-matched healthy controls. RESULTS FM patients showed a higher glycaemic response to the glucose load at 1 hour (F [1,68] = 10.4, P = .006) and 2 hours (F [1,68] = 7.80, P = .02), and higher glucose area under the curve (13.8 [SD 2.92] vs 11.6 [SD 2.31], P < .01), than healthy controls. Group differences were explained by higher body mass index and percentage of smokers among the FM patients. Pyruvate and lactate levels were similar in both groups. DISCUSSION Impaired glucose regulation in FM patients is likely not due to FM itself, but to associated lifestyle factors. Our results highlight the importance of assessing the glucose regulation status and the lifestyle factors affecting glucose regulation in FM patients for prevention or early treatment of diabetes and associated complications. TRIAL REGISTRATION ClinicalTrials.gov (NCT03300635).
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Affiliation(s)
- Teemu Zetterman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Uusimaa, Finland
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; City of Vantaa Health Centre, Vantaa, Finland
| | - Ritva Markkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Uusimaa, Finland
| | - Eija Kalso
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Uusimaa, Finland
- Sleepwell Research Programme, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Gatta G, La Forgia D, Fanizzi A, Massafra R, Somma F, Belfiore MP, Pacella D, Cappabianca S, Salvia AAH. Prevalence of Patients Affected by Fibromyalgia in a Cohort of Women Underwent Mammography Screening. Healthcare (Basel) 2021; 9:1340. [PMID: 34683021 PMCID: PMC8544442 DOI: 10.3390/healthcare9101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/11/2021] [Accepted: 09/26/2021] [Indexed: 11/17/2022] Open
Abstract
Fibromyalgia is a widespread condition which is currently underdiagnosed; therefore we conceived this study in order to assess whether a diagnostic suspicion may be assumed during widespread screening procedures, so that patients for which a reasonable diagnostic suspicion exist may be redirected towards rheumatologic evaluation. We analyzed a sample of 1060 patients, all of whom were female and undergoing standard breast cancer screening procedures, and proceeded to evaluate the level of pain they endured during mammographic exam. We also acquired a range of other information which we related to the level of pain endured; we suggested a rheumatologic examination for those patients who endured the highest level of pain and then we evaluated how many patients in this subgroup were actually diagnosed with fibromyalgia. Out of the 1060 patients who participated to our study, 139 presented level 4 pain intensity; One patient did not go for rheumatologic examination; the remaining 138 underwent rheumatologic evaluation, and 50 (36%, 28-44, 95% CI) were diagnosed with fibromyalgia. Our study shows that assessing the level of pain endured by patients during standard widespread screening procedures may be an effective asset in deciding whether or not to suggest specialist rheumatologic evaluation for fibromyalgia.
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Affiliation(s)
- Gianluca Gatta
- Dipartimento di Medicina di Precisione Università Della Campania “Luigi Vanvitelli”, 80127 Napoli, Italy; (G.G.); (M.P.B.); (S.C.); (A.A.H.S.)
| | - Daniele La Forgia
- IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy; (A.F.); (R.M.)
| | - Annarita Fanizzi
- IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy; (A.F.); (R.M.)
| | - Raffaella Massafra
- IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy; (A.F.); (R.M.)
| | | | - Maria Paola Belfiore
- Dipartimento di Medicina di Precisione Università Della Campania “Luigi Vanvitelli”, 80127 Napoli, Italy; (G.G.); (M.P.B.); (S.C.); (A.A.H.S.)
| | - Daniela Pacella
- Dipartimento Sanità Pubblica, Università degli Studi di Napoli “Federico II”, 80127 Napoli, Italy;
| | - Salvatore Cappabianca
- Dipartimento di Medicina di Precisione Università Della Campania “Luigi Vanvitelli”, 80127 Napoli, Italy; (G.G.); (M.P.B.); (S.C.); (A.A.H.S.)
| | - Antonio Alessandro Heliot Salvia
- Dipartimento di Medicina di Precisione Università Della Campania “Luigi Vanvitelli”, 80127 Napoli, Italy; (G.G.); (M.P.B.); (S.C.); (A.A.H.S.)
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Allen EG, Charen K, Hipp HS, Shubeck L, Amin A, He W, Hunter JE, Shelly KE, Sherman SL. Predictors of Comorbid Conditions in Women Who Carry an FMR1 Premutation. Front Psychiatry 2021; 12:715922. [PMID: 34658954 PMCID: PMC8517131 DOI: 10.3389/fpsyt.2021.715922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose: Women who carry an FMR1 premutation (PM) can experience two well-established PM-associated disorders: fragile X-associated primary ovarian insufficiency (FXPOI, affects ~20-30% carriers) and fragile X-associated tremor-ataxia syndrome (FXTAS, affects ~6-15% carriers); however, emerging evidence indicates that some of these women experience complex health profiles beyond FXPOI and FXTAS. Methods: In an effort to better understand predictors for these comorbid conditions, we collected self-reported medical histories on 413 women who carry an FMR1 PM. Results: There were 22 health conditions reported by at least 9% of women. In an exploratory analysis, 12 variables were tested in logistic regression models for each comorbid condition, including demographic variables, environmental variables, PM-associated factors, and endorsement of depression and/or anxiety. More than half of the comorbid conditions studied were associated with women who self-reported having anxiety. Age, smoking, body mass index (BMI), and depression were also significant predictor variables for specific comorbid conditions. Conclusions: Age, smoking, and BMI were significantly associated with a subset of the comorbid conditions analyzed. Importantly, depression or anxiety were also significantly associated with many of the comorbid health conditions. This work highlights some of the modifiable factors associated with complex health profiles among women with an FMR1 PM.
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Affiliation(s)
- Emily Graves Allen
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Krista Charen
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Heather S. Hipp
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Lisa Shubeck
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Ashima Amin
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Weiya He
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Jessica Ezzell Hunter
- Genomics, Ethics, and Translational Research Program, RTI International, Triangle Park, NC, United States
| | - Katharine E. Shelly
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Stephanie L. Sherman
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
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Croghan IT, Hurt RT, Ganesh R, Bhagra O, Fischer KM, Vincent A, Hays JT, Bierle DM, Schroeder DR, Fuehrer DL, Nanda S. The Association of Current Tobacco Status With Pain and Symptom Severity in Fibromyalgia Patients. Mayo Clin Proc Innov Qual Outcomes 2021; 5:614-624. [PMID: 34195553 PMCID: PMC8240153 DOI: 10.1016/j.mayocpiqo.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To describe current tobacco use among patients with newly confirmed fibromyalgia and evaluate the association between tobacco use status and severity of reported pain and other fibromyalgia symptoms. Patients and Methods Participants in this study were adult patients (N=1068) with fibromyalgia who met American College of Rheumatology 2010/2011 clinical criteria for fibromyalgia at the time of initial presentation to a Midwest fibromyalgia clinic (June 1, 2018, through May 31, 2019). Multiple linear regression analyses were performed to assess the association of tobacco use status with the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS) scores. Covariates included in these analyses included age, sex, body mass index, depression, opioid medication use, and use of fibromyalgia-specific pharmacotherapy. Results The patients were largely women (87.0%; n=929), white (87.9%; n=939), and with an average ± SD age of 46.6±13.9 years. The WPI and SSS scores were significantly greater in current tobacco users compared with never tobacco users (WPI effect estimate [EE] = 1.03; 95% CI, 0.30 to 1.76; type III P=.020; SSS EE = 0.47; 95% CI, 0.11 to 0.84; type III P=.036). The WPI score was negatively associated with age (EE = −0.02 per year; 95% CI, −0.03 to −0.001 per year; P=.037) and no use of opioid medication (EE = −1.08; 95% CI, −1.59 to −0.57; P<.001) while positively associated with higher body mass index (EE = 0.03 per 1 kg/m2; 95% CI, 0.001 to 0.06 per kg/m2; P=.04) and higher Patient Health Questionnaire-9 score (EE = 0.12; 95% CI, 0.08 to 0.16; P<.001). Conclusion The results of our study suggest that tobacco use is associated with greater pain and other symptom severity in patients with fibromyalgia. These findings have important clinical and research implications for patients with fibromyalgia who use tobacco and who may benefit from early identification and timely implementation of tobacco cessation treatment to decrease pain and improve overall quality of life.
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Affiliation(s)
- Ivana T Croghan
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Ryan T Hurt
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ravindra Ganesh
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ojas Bhagra
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karen M Fischer
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Ann Vincent
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - J Taylor Hays
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Dennis M Bierle
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Debbie L Fuehrer
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Sanjeev Nanda
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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Ge L, D'Souza RS, Oh T, Vincent A, Mohabbat AB, Eldrige J, Jiang L, Whipple MO, McAllister SJ, Wang Z, Qu W, Mauck WD. Tobacco Use in Fibromyalgia Is Associated With Cognitive Dysfunction: A Prospective Questionnaire Study. Mayo Clin Proc Innov Qual Outcomes 2019; 3:78-85. [PMID: 30899911 PMCID: PMC6408684 DOI: 10.1016/j.mayocpiqo.2018.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/12/2022] Open
Abstract
Objective To evaluate the association between smoking and cognitive function in patients with fibromyalgia. Patients and Methods We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' t-tests and χ2 tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level. Results Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (P=.009) and greater subscale scores of perceived difficulty in language (P=.03), verbal memory (P=.003), visual-spatial memory (P=.02), and attention (P=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (P=.006), worse quality-of-life index in the mental component scale (P=.02), greater sleep problems (P=.01), and increased anxiety (P=.001) compared with nonsmokers who had fibromyalgia. Conclusion In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.
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Key Words
- BMI, body mass index
- FIQ-R, Revised Fibromyalgia Impact Questionnaire
- FM, fibromyalgia
- GAD-7, 7-item Generalized Anxiety Scale
- MASQ, Multiple Ability Self-Report Questionnaire
- MFI-20, Multidimensional Fatigue Inventory
- MOS-Sleep, Medical Outcomes Study Sleep Scale
- PHQ-9, 9-item Patient Health Questionnaire Depression Scale
- QOL, quality of life
- SF-36, 36-item Short Form Health Survey
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Affiliation(s)
- Lin Ge
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN.,Department of Rheumatology, Guang An Men Hospital, China Academy of Chinese Medical Science, Beijing, China
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Terry Oh
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Ann Vincent
- Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Jason Eldrige
- Department of Anesthesiology, Pain Division, Mayo Clinic, Rochester, MN
| | - Li Jiang
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | | | | | - Zhen Wang
- Department of Nursing, Mayo Clinic, Rochester, MN
| | - Wenchun Qu
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN.,Department of Anesthesiology, Pain Division, Mayo Clinic, Rochester, MN
| | - William D Mauck
- Department of Anesthesiology, Pain Division, Mayo Clinic, Rochester, MN
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Vun E, Turner S, Sareen J, Mota N, Afifi TO, El-Gabalawy R. Prevalence of comorbid chronic pain and mental health conditions in Canadian Armed Forces active personnel: analysis of a cross-sectional survey. CMAJ Open 2018; 6:E528-E536. [PMID: 30389752 PMCID: PMC6221807 DOI: 10.9778/cmajo.20180093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic pain conditions and mental disorders have high prevalence rates in military populations. However, few investigations have examined the comorbidity between chronic pain conditions and specific mental disorders among Canadian active military personnel. METHODS We conducted a secondary analysis of data from the 2013 Canadian Forces Mental Health Survey (CFMHS) concerning the population of regular members. Diagnostic interviews assessed the presence of mental disorders, and participants self-reported chronic pain conditions (i.e., arthritis, back problems, musculoskeletal conditions, migraines) and indicators of pain severity. We used multiple logistic regressions to assess associations between chronic pain conditions and mental disorders. We used cross-tabulations to assess the prevalence of pain severity indicators in comorbid relationships compared with the chronic pain condition alone. We used moderation analyses to examine the interactions between pain condition by pain severity, and pain condition by activity limitation, respectively, on mental disorders. RESULTS The CFMHS included data from 6696 regular members and had a response rate of 79.8%. About one-quarter (n = 1761) of military personnel reported having chronic pain. In the fully adjusted model, all assessed pain conditions were significantly associated with posttraumatic stress disorder (PTSD) (odds ratio [OR] range 1.86-2.55), and several pain conditions were associated with major depressive episode, generalized anxiety disorder and panic disorder. Back problems were significantly associated with all mental disorders apart from alcohol use disorders (OR range 1.40-2.17). Cross-tabulations showed higher prevalence estimates of endorsement for pain severity indicators among pain conditions and comorbid mental disorders, compared with pain conditions alone. Formal moderation analyses showed a significant relationship between migraine and activity limitation on PTSD. INTERPRETATION Chronic pain conditions are prevalent and co-occur with mental disorders among Canadian regular force members. Greater understanding of these chronic pain conditions and mental disorders and their impact on people's abilities to adapt to both military and civilian life is needed.
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Affiliation(s)
- Everett Vun
- Max Rady College of Medicine, University of Manitoba (Vun); Departments of Community Health Sciences (Turner, Afifi), Psychiatry (Sareen, Afifi, Mota, El-Gabalawy), Clinical Health Psychology (Mota, El-Gabalawy), Anesthesiology, Perioperative and Pain Medicine (El-Gabalawy), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man
| | - Sarah Turner
- Max Rady College of Medicine, University of Manitoba (Vun); Departments of Community Health Sciences (Turner, Afifi), Psychiatry (Sareen, Afifi, Mota, El-Gabalawy), Clinical Health Psychology (Mota, El-Gabalawy), Anesthesiology, Perioperative and Pain Medicine (El-Gabalawy), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man
| | - Jitender Sareen
- Max Rady College of Medicine, University of Manitoba (Vun); Departments of Community Health Sciences (Turner, Afifi), Psychiatry (Sareen, Afifi, Mota, El-Gabalawy), Clinical Health Psychology (Mota, El-Gabalawy), Anesthesiology, Perioperative and Pain Medicine (El-Gabalawy), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man
| | - Natalie Mota
- Max Rady College of Medicine, University of Manitoba (Vun); Departments of Community Health Sciences (Turner, Afifi), Psychiatry (Sareen, Afifi, Mota, El-Gabalawy), Clinical Health Psychology (Mota, El-Gabalawy), Anesthesiology, Perioperative and Pain Medicine (El-Gabalawy), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man
| | - Tracie O Afifi
- Max Rady College of Medicine, University of Manitoba (Vun); Departments of Community Health Sciences (Turner, Afifi), Psychiatry (Sareen, Afifi, Mota, El-Gabalawy), Clinical Health Psychology (Mota, El-Gabalawy), Anesthesiology, Perioperative and Pain Medicine (El-Gabalawy), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man
| | - Renée El-Gabalawy
- Max Rady College of Medicine, University of Manitoba (Vun); Departments of Community Health Sciences (Turner, Afifi), Psychiatry (Sareen, Afifi, Mota, El-Gabalawy), Clinical Health Psychology (Mota, El-Gabalawy), Anesthesiology, Perioperative and Pain Medicine (El-Gabalawy), Max Rady College of Medicine, University of Manitoba, Winnipeg, Man.
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11
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Paulus DJ, Garey L, Gallagher MW, Derrick JL, Jardin C, Langdon K, Ditre JW, Zvolensky MJ. Pain severity as a predictor of negative affect following a self-guided quit attempt: An ecological momentary assessment study. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2018; 44:543-550. [PMID: 29846094 PMCID: PMC6234120 DOI: 10.1080/00952990.2018.1467432] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 01/25/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Past work has documented bidirectional associations between pain and cigarette smoking behaviors such that those who smoke evidence greater pain, and those in pain tend to smoke more. However, such work has not focused on the role of pain in relation to negative affect, which plays an important role during cessation attempts. OBJECTIVE The current study evaluated pain as a predictor of negative affect as well as level of interference associated with negative affect among individuals undergoing a self-guided quit attempt. METHODS Study variables were assessed via ecological momentary assessment (EMA) during the 2 weeks following a self-guided quit attempt. Participants included 54 daily smokers (33.3% female; Mage = 34.7, SD = 13.9). RESULTS There were statistically significant within-person associations of pain ratings with negative affect and interference due to negative affect, such that greater pain was associated with higher levels of each dependent variable. Additionally, there was a within-person effect of smoking status (i.e., smoking vs. abstinence, measured via EMA) on negative affect, but not ratings of interference; smoking was associated with greater negative affect. CONCLUSION These findings highlight the importance of bodily pain in relation to negative mood following a quit attempt. Clinically, the results suggest a greater focus on the experience of pain during quit attempts may be warranted.
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Affiliation(s)
- Daniel J. Paulus
- University of Houston, Department of Psychology (Houston, Texas)
| | - Lorra Garey
- University of Houston, Department of Psychology (Houston, Texas)
| | - Matthew W. Gallagher
- University of Houston, Department of Psychology (Houston, Texas)
- University of Houston, Texas Institute for Measurement, Evaluation, and Statistics (Houston, Texas)
| | - Jaye L. Derrick
- University of Houston, Department of Psychology (Houston, Texas)
| | - Charles Jardin
- University of Houston, Department of Psychology (Houston, Texas)
| | - Kirsten Langdon
- Rhode Island Hospital, Department of Psychiatry (Providence, Rhode Island)
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior (Providence, Rhode Island)
| | - Joseph W. Ditre
- Syracuse University, Department of Psychology (Syracuse, New York)
| | - Michael J. Zvolensky
- University of Houston, Department of Psychology (Houston, Texas)
- The University of Texas MD Anderson Cancer Center, Department of Behavioral Science (Houston, Texas)
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12
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Özen B, Özdemir YÖ, Beştepe EE. Childhood trauma and dissociation among women with genito-pelvic pain/penetration disorder. Neuropsychiatr Dis Treat 2018; 14:641-646. [PMID: 29503548 PMCID: PMC5827676 DOI: 10.2147/ndt.s151920] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Causes such as childhood trauma, negative attitude about sexuality, inadequate sexual knowledge and education, relationship problems, and unconscious motivation are reported about psychosexual development in the etiology of genito-pelvic pain/penetration disorder (GPP/PD). There are few studies that focus directly on research etiology of GPP/PD and use structured scales. The aim of this study was to research childhood trauma and dissociation forms among women with GPP/PD. PATIENTS AND METHODS Fifty-five women with GPP/PD according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and 61 healthy women with no complaints of sexual function as a control group, in the age range of 18-60 years, were included in this study. Sociodemographic data form, Childhood Trauma Questionnaire (CTQ-28), Dissociative Experiences Scale (DES), and Somatoform Dissociation Questionnaire (SDQ-20) were administered to all participants. RESULTS Sexual abuse, emotional abuse, and emotional neglect scores, which comprise the subgroups of CTQ, were found high among women with GPP/PD compared with the control group (p=0.003, p=0.006, p=0.001). While a significant difference between the two groups' SDQ scores was obtained (p=0.000), no significant difference was detected between the two groups' DES scores (p=0.392). DISCUSSION The results evoke the question are genitopelvic pain conditions, vaginismus and dyspareunia, that cannot be explained with a medical cause and that cause penetration disorder, a kind of dissociative symptom prone to develop in some women with childhood psychogenic trauma.
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Affiliation(s)
- Beliz Özen
- Erenköy Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey
| | - Y Özay Özdemir
- Erenköy Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey
| | - E Emrem Beştepe
- Erenköy Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey
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13
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Katyayan PA, Katyayan MK. Effect of smoking status and nicotine dependence on pain intensity and outcome of treatment in Indian patients with temporomandibular disorders: A longitudinal cohort study. J Indian Prosthodont Soc 2017; 17:156-166. [PMID: 28584417 PMCID: PMC5450888 DOI: 10.4103/jips.jips_277_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 01/30/2017] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Evidence regarding the association of smoking with various forms of chronic musculoskeletal pain is vast, but that with temporomandibular disorders (TMD) is scarce. AIMS The aims of this study are to evaluate the effect of smoking status (SS) and nicotine dependence (ND) on TMD pain intensity and treatment outcome in an Indian population with TMD. SUBJECTS AND METHODS Nine hundred and sixty-two patients with TMD were selected for this longitudinal cohort study. Lifetime SS was evaluated and patients were classified as current smokers (YS), former smokers (FS), or nonsmokers (NS). The Fagerstrom test was used to evaluate the ND of YS. Pain intensity was evaluated using visual analog scale scores. Six months posttreatment, the pain intensity was again recorded. The effect of treatment was evaluated using a global transition outcome measure and categorized as treatment success or failure. A minimum 30% reduction in pain was used as a criterion for categorizing patients as those who had gotten "better." Data obtained from the study were compared using Chi-square tests, paired samples t-tests, and one-way ANOVA tests. The criterion for statistical significance for all analyses was set at P = 0.05. RESULTS Among groups of SS, YS showed the maximum pain intensity at baseline and posttreatment. The outcome of treatment was most successful in NS and least in FS. The number of patients who had gotten "better" after treatment was significantly highest in NS. There was no significant difference between groups of ND with respect to pain intensity, treatment outcome, or "better" patients. CONCLUSIONS Among Indian patients with TMD, smokers reported significantly greater pain intensity and poorer response to treatment than NS. Pain intensity or treatment outcome was independent of ND.
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Affiliation(s)
| | - Manish Khan Katyayan
- Department of Dentistry, GMERS Medical College, Civil Hospital, Gandhinagar, Gujarat, India
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Holloway BM, Santoro MS, Cronan TA. Smoking, depression, & stress: predictors of fibromyalgia health status. PSYCHOL HEALTH MED 2016; 22:87-93. [PMID: 27650725 DOI: 10.1080/13548506.2016.1238493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The purpose of the present study was to examine the effects of smoking, stress, and depression on fibromyalgia health status. Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain condition that negatively affects health status. Health status is not only affected by the constellation of physical symptoms, but also by mood symptoms, stress levels, and patient behaviors (e.g. smoking). Participants were 491 individuals with a physician's diagnosis of FMS. They completed self-report measures of their current levels of depression, stress, the number of cigarettes smoked per day, and health status. A linear regression analysis was conducted to determine whether these measures predicted FMS health status. All three measures predicted worse health status, predicting 51.5% of the variance in health status. However, it is important to evaluate and treat more than just the physical symptoms of FMS. Attention should also be paid to mental health status and to engagement in unhealthy behaviors in order to reduce their effects on FMS health status. Future researchers should design and evaluate interventions that target these modifiable risk factors to determine the extent to which they could improve health outcomes.
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Affiliation(s)
| | - Maya S Santoro
- b California Joint Doctoral Program in Clinical Psychology , San Diego State University/University of San Diego , San Diego , CA , USA
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15
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Yim YR, Lee KE, Park DJ, Kim SH, Nah SS, Lee J, Kim SK, Lee YA, Hong SJ, Kim HS, Lee HS, Kim H, Joung CI, Kim SH, Lee SS. Identifying fibromyalgia subgroups using cluster analysis: Relationships with clinical variables. Eur J Pain 2016; 21:374-384. [DOI: 10.1002/ejp.935] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Y.-R. Yim
- Department of Rheumatology; Chonnam National University Hospital & Medical School; Gwangju Korea
| | - K.-E. Lee
- Department of Rheumatology; Chonnam National University Hospital & Medical School; Gwangju Korea
| | - D.-J. Park
- Department of Rheumatology; Chonnam National University Hospital & Medical School; Gwangju Korea
| | - S.-H. Kim
- Department of Internal Medicine; Inje University Haeundae Paik Hospital; Busan Korea
| | - S.-S. Nah
- Department of Internal Medicine; College of Medicine; Soonchunhyang University; Cheonan Korea
| | - J.H. Lee
- Department of Internal Medicine; Maryknoll Medical Center; Busan Korea
| | - S.-K. Kim
- Department of Internal Medicine; School of Medicine; Catholic University of Daegu; Korea
| | - Y.-A. Lee
- Department of Internal Medicine; School of Medicine; Kyung Hee University; Seoul Korea
| | - S.-J. Hong
- Department of Internal Medicine; School of Medicine; Kyung Hee University; Seoul Korea
| | - H.-S. Kim
- Department of Internal Medicine; Soonchunhyang University Seoul Hospital; Korea
| | - H.-S. Lee
- Hanyang University College of Medicine and the Hospital for Rheumatic Diseases; Seoul Korea
| | - H.A. Kim
- Department of Allergy and Rheumatology; Ajou University Hospital; Ajou University School of Medicine; Suwon Korea
| | - C.-I. Joung
- Department of Internal Medicine; Konyang University Medical School; Daejeon Korea
| | - S.-H. Kim
- Department of Internal Medicine; School of Medicine; Keimyung University; Daegu Korea
| | - S.-S. Lee
- Department of Rheumatology; Chonnam National University Hospital & Medical School; Gwangju Korea
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16
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Pain intensity and smoking behavior among treatment seeking smokers. Psychiatry Res 2016; 237:67-71. [PMID: 26921054 DOI: 10.1016/j.psychres.2016.01.073] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/31/2016] [Indexed: 11/23/2022]
Abstract
Empirical evidence supporting the interplay between pain intensity and tobacco smoking has been growing. The current investigation advances this work in three important ways: (1) controlling for negative affectivity and gender; (2) examining pain intensity in smokers from a community sample, rather than specialized pain treatment centers; and, (3) studying smokers who are highly motivated to quit. Participants were adult smokers (N=112; 35% female; Mage=41.4, SD=13.1) participating in a larger study examining barriers to cessation during a self-guided quit attempt. At baseline, participants completed self-report measures on pain intensity and smoking severity outcomes. As hypothesized, more intense pain was significantly associated with all four smoking severity variables: years as a daily smoker, current cigarettes per day, cigarettes per day during the heaviest lifetime smoking period, and current level of nicotine dependence. These associations remained when taking into account the variance accounted for by gender and negative affectivity. These data provide evidence that more intense pain is related to more severe smoking behavior and nicotine dependence. Pain reduction could be an important target in regard to smokers with chronic pain.
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Cash E, Salmon P, Weissbecker I, Rebholz WN, Bayley-Veloso R, Zimmaro LA, Floyd A, Dedert E, Sephton SE. Mindfulness meditation alleviates fibromyalgia symptoms in women: results of a randomized clinical trial. Ann Behav Med 2016; 49:319-30. [PMID: 25425224 DOI: 10.1007/s12160-014-9665-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Several recent reviews have evaluated evidence on the efficacy of Mindfulness-Based Stress Reduction (MBSR) among fibromyalgia sufferers, and concluded that more research should test effects on both psychological and physiological functioning. PURPOSE We conducted a randomized prospective trial of MBSR among female fibromyalgia patients. METHODS Effects on perceived stress, pain, sleep quality, fatigue, symptom severity, and salivary cortisol were tested in treatment (n=51) versus wait-list control participants (n=40) using data at baseline, post-program, and 2-month follow-up. RESULTS Analyses revealed that MBSR significantly reduced perceived stress, sleep disturbance, and symptom severity, with gains maintained at follow-up. Greater home practice at follow-up was associated with reduced symptom severity. MBSR did not significantly alter pain, physical functioning, or cortisol profiles. CONCLUSION MBSR ameliorated some of the major symptoms of fibromyalgia and reduced subjective illness burden. Further exploration of MBSR effects on physiological stress responses is warranted. These results support use of MBSR as a complementary treatment for women with fibromyalgia ( ISRCTN 34628811).
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Affiliation(s)
- Elizabeth Cash
- Department of Surgery, Division of Otolaryngology, University of Louisville School of Medicine, Louisville, KY, USA
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18
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Weingarten TN, Vincent A, Luedtke CA, Beebe TJ, Welch TL, Chong EY, Schroeder DR, Warner DO. The Perception of Female Smokers with Fibromyalgia on the Effects of Smoking on Fibromyalgia Symptoms. Pain Pract 2015; 16:1054-1063. [PMID: 26603674 DOI: 10.1111/papr.12402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/20/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Smokers with fibromyalgia have greater pain intensity and function impairment compared to nonsmokers. Patients' perceptions of interactions between smoking and fibromyalgia symptoms have not been described. The primary aim of this study was to report the perceptions of female smokers with fibromyalgia on how smoking affects symptoms. METHODS Forty-eight daily smokers with fibromyalgia enrolled in the Mayo Clinic Fibromyalgia Treatment Center completed the Fibromyalgia Impact Questionnaire, Fagerstrom Test for Nicotine Dependence, Patient Health Questionnaire-9, General Anxiety Disorder-7 and a Fibromyalgia Symptoms and Smoking Survey which queried how smoking directly affected fibromyalgia symptoms (eg, pain, tiredness/fatigue, stiffness, nervousness/anxiety, depression/blueness, irritability, concentration, and overall) or indirectly as a coping mechanism. RESULTS The majority of subjects reported smoking had no direct effect on fibromyalgia physical symptoms (pain [60% reported no effect], fatigue [56%], stiffness [81%]) but direct improvement of emotional symptoms (anxiety [62% reported improvement], irritability [64%]). The majority of subjects used smoking to cope with pain (69%) via distraction (83%) and relaxation (77%), lessening emotional distress by reducing a sense of frustration (83%) or sadness (54%) because of pain, and as a justification for resting vis-à-vis "smoke breaks" (69%). Thirty-one smokers were mildly and 17 moderately/severely dependent on tobacco, and no difference in fibromyalgia impact score (P = 0.70), pain (P = 0.39), depression (P = 0.20), and anxiety (P = 0.64) scores were detected, but more moderately/severely dependent subjects reported smoking improved pain (50% vs. 17%, P = 0.04). DISCUSSION Smokers with fibromyalgia reported smoking helped to cope with fibromyalgia pain but generally did not directly ameliorate fibromyalgia physical symptoms.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Ann Vincent
- Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Connie A Luedtke
- Pain Rehabilitation Center, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Timothy J Beebe
- Health Services Research, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Tasha L Welch
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Elisa Y Chong
- Mayo Medical School, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - David O Warner
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A
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Orhurhu VJ, Pittelkow TP, Hooten WM. Prevalence of smoking in adults with chronic pain. Tob Induc Dis 2015; 13:17. [PMID: 26185492 PMCID: PMC4504349 DOI: 10.1186/s12971-015-0042-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 07/08/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction Cigarette smoking is common among adults with chronic pain. The primary objective of this study was to determine the period prevalence of smoking in patients with chronic pain. A secondary objective was to determine the prevalence of smoking among patients with commonly occurring pain diagnoses including fibromyalgia, low back pain, and headache. Methods This population study included 5350 patients (1256 smokers, 4094 nonsmokers) admitted to the Mayo Comprehensive Pain Rehabilitation Center from January 1998 through December 2012. Smoking status was determined using a self-report questionnaire. Results During the 15 year study period, the overall prevalence of smoking was 23.5 % (95 % CI 22.4 – 24.6). The prevalence of smoking in 2000, 2005, and 2010 was 24.2, 25.7, and 28.3 % respectively. The overall prevalence of smoking in patients with fibromyalgia, low back pain, and headache was 25.2 % (95 % CI 22.8 – 28.3), 22.8 % (95 % CI 21.3 – 25.9), and 21.2 % (95 % CI 17.9 – 24.7), respectively. In a multiple variable logistic model adjusted for age and sex, opioid use was significantly associated with status as a current smoker. Conclusion The prevalence of smoking in patients with chronic pain has not declined when compared to the general population. The higher prevalence of smoking was consistently observed in commonly occurring pain diagnoses including fibromyalgia, back pain, and headache. Further research is needed to identify the potential factors that contribute to the high prevalence of smoking in this patient population.
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Affiliation(s)
| | - Thomas P Pittelkow
- Department of Anesthesiology, Division of Pain Medicine, Mayo Graduate School of Medicine, Rochester, MN 55902 USA
| | - W Michael Hooten
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905 USA
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Goesling J, Brummett CM, Meraj TS, Moser SE, Hassett AL, Ditre JW. Associations Between Pain, Current Tobacco Smoking, Depression, and Fibromyalgia Status Among Treatment-Seeking Chronic Pain Patients. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:1433-42. [PMID: 25801019 PMCID: PMC4765172 DOI: 10.1111/pme.12747] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE As smoking impacts physiological pathways in the central nervous system, it is important to consider the association between smoking and fibromyalgia, a pain condition caused predominantly by central nervous system dysfunction. The objectives were to assess the prevalence of current smoking among treatment-seeking chronic pain patients with (FM+) and without (FM-) a fibromyalgia-like phenotype; test the individual and combined influence of smoking and fibromyalgia on pain severity and interference; and examine depression as a mediator of these processes. METHODS Questionnaire data from 1566 patients evaluated for a range of conditions at an outpatient pain clinic were used. The 2011 Survey Criteria for Fibromyalgia were used to assess the presence of symptoms associated with fibromyalgia. RESULTS Current smoking was reported by 38.7% of FM+ patients compared to 24.7% of FM- patients. FM+ smokers reported higher pain and greater interference compared to FM+ nonsmokers, FM- smokers, and FM- nonsmokers. There was no interaction between smoking and fibromyalgia. Significant indirect effects of fibromyalgia and smoking via greater depression were observed for pain severity and interference. CONCLUSIONS Current smoking and positive fibromyalgia status were associated with greater pain and impairment among chronic pain patients, possibly as a function of depression. Although FM+ smokers report the most negative clinical symptomatology (i.e., high pain, greater interference) smoking does not appear to have a unique association with pain or functioning in FM+ patients, rather the effect is additive. The 38.7% smoking rate in FM+ patients is high, suggesting FM+ smokers present a significant clinical challenge.
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Affiliation(s)
- Jenna Goesling
- Department of Anesthesiology, University of Michigan, Ann Arbor MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor MI
| | - Taha S. Meraj
- Medical School, University of Michigan, Ann Arbor, MI
| | | | - Afton L. Hassett
- Department of Anesthesiology, University of Michigan, Ann Arbor MI
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, New York, USA
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Lourenço S, Costa L, Rodrigues AM, Carnide F, Lucas R. Gender and psychosocial context as determinants of fibromyalgia symptoms (fibromyalgia research criteria) in young adults from the general population. Rheumatology (Oxford) 2015; 54:1806-15. [DOI: 10.1093/rheumatology/kev110] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Indexed: 12/24/2022] Open
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Abstract
Individuals with chronic pain often report using cigarettes to cope, and smoking and chronic pain appear prevalent among US veterans. Pain may be a barrier to cigarette cessation and abstinence in this population. Because of physiological effects, smoking cigarettes may also interfere with pain management. A better understanding of how cigarette use relates to pain may assist in veteran cigarette cessation and pain management efforts. To assist these efforts, we searched the literature using keywords, such as "pain," "smoking," and "veteran," to identify 23 journal articles published from 1993 to 2013 that reported on studies examining pain and smoking variables among military or veteran populations. Studies found that veterans reported using cigarettes to cope with pain, there was greater occurrence of pain and disability among smokers in the military, and smoking increased the odds of veterans receiving an opioid prescription for pain and misusing opioids. Studies also found increased odds of pain and smoking among Veterans Health Administration patients with post-traumatic stress disorder when compared with those without post-traumatic stress disorder. Studies support an interaction between pain and smoking among veterans. However, the mechanisms underlying this relationship remain unclear. Future studies focused on this interaction would benefit veteran populations.
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Smoking is associated with reduced leptin and neuropeptide Y levels and higher pain experience in patients with fibromyalgia. Mediators Inflamm 2014; 2014:627041. [PMID: 25197167 PMCID: PMC4150510 DOI: 10.1155/2014/627041] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/03/2014] [Accepted: 07/28/2014] [Indexed: 01/10/2023] Open
Abstract
Smoking deregulates neuroendocrine responses to pain supporting production of neuropeptide Y (NpY) by direct stimulation of nicotinic receptors or by inhibiting adipokine leptin.
Present study addressed the effect of cigarette smoking on adipokines and pain parameters, in 62 women with fibromyalgia (FM) pain syndrome with unknown etiology. Pain was characterized by a visual analogue scale, tender point (TP) counts, pressure pain threshold, and neuroendocrine markers NpY and substance P (sP). Levels of IGF-1, leptin, resistin, visfatin, and adiponectin were measured in blood and cerebrospinal fluid. Current smokers (n = 18) had lower levels of leptin compared to ex-smokers (n = 25, P = 0.002), while the expected NpY increase was absent in FM patients. In smokers, this was transcribed in higher VAS-pain (P = 0.04) and TP count (P = 0.03), lower pain threshold (P = 0.01), since NpY levels were directly related to the pain threshold (rho = 0.414) and inversely related to TP counts (rho = −0.375). This study shows that patients with FM have no increase of NpY levels in response to smoking despite the low levels of leptin. Deregulation of the balance between leptin and neuropeptide Y may be one of the essential mechanisms of chronic pain in FM.
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Albers KM, Zhang XL, Diges CM, Schwartz ES, Yang CI, Davis BM, Gold MS. Artemin growth factor increases nicotinic cholinergic receptor subunit expression and activity in nociceptive sensory neurons. Mol Pain 2014; 10:31. [PMID: 24886596 PMCID: PMC4036648 DOI: 10.1186/1744-8069-10-31] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
Background Artemin (Artn), a member of the glial cell line-derived growth factor (GDNF) family, supports the development and function of a subpopulation of peptidergic, TRPV1-positive sensory neurons. Artn (enovin, neublastin) is elevated in inflamed tissue and its injection in skin causes transient thermal hyperalgesia. A genome wide expression analysis of trigeminal ganglia of mice that overexpress Artn in the skin (ART-OE mice) showed elevation in nicotinic acetylcholine receptor (nAChR) subunits, suggesting these ion channels contribute to Artn-induced sensitivity. Here we have used gene expression, immunolabeling, patch clamp electrophysiology and behavioral testing assays to investigate the link between Artn, nicotinic subunit expression and thermal hypersensitivity. Results Reverse transcriptase-PCR validation showed increased levels of mRNAs encoding the nAChR subunits α3 (13.3-fold), β3 (4-fold) and β4 (7.7-fold) in trigeminal ganglia and α3 (4-fold) and β4 (2.8-fold) in dorsal root ganglia (DRG) of ART-OE mice. Sensory ganglia of ART-OE mice had increased immunoreactivity for nAChRα3 and exhibited increased overlap in labeling with GFRα3-positive neurons. Patch clamp analysis of back-labeled cutaneous afferents showed that while the majority of nicotine-evoked currents in DRG neurons had biophysical and pharmacological properties of α7-subunit containing nAChRs, the Artn-induced increase in α3 and β4 subunits resulted in functional channels. Behavioral analysis of ART-OE and wildtype mice showed that Artn-induced thermal hyperalgesia can be blocked by mecamylamine or hexamethonium. Complete Freund’s adjuvant (CFA) inflammation of paw skin, which causes an increase in Artn in the skin, also increased the level of nAChR mRNAs in DRG. Finally, the increase in nAChRs transcription was not dependent on the Artn-induced increase in TRPV1 or TRPA1 in ART-OE mice since nAChRs were elevated in ganglia of TRPV1/TRPA1 double knockout mice. Conclusions These findings suggest that Artn regulates the expression and composition of nAChRs in GFRα3 nociceptors and that these changes contribute to the thermal hypersensitivity that develops in response to Artn injection and perhaps to inflammation.
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Affiliation(s)
- Kathryn M Albers
- Center for Pain Research, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Burris JL, Perez C, Evans DR, Carlson CR. A preliminary study of cigarette smoking in female orofacial pain patients. Behav Med 2014; 39:73-9. [PMID: 23930899 DOI: 10.1080/08964289.2012.731439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The relationship between behavior (eg, diet, exercise, substance use) and the functioning of chronic-pain patients, including orofacial-pain patients, is poorly understood. This preliminary study examined cigarette smoking and both pain-related and psychological functioning in female orofacial-pain patients. Correlates of intentions to quit smoking were also explored. There were 48 participants in this cross-sectional study. Smokers reported significantly less self-control over pain (d = .66), lower general activity levels (d = .52), more fatigue (d = .80), and poorer sleep quality (d = .53) than non-smokers. The mean effect size for all dependent variables was .49 (range, .33-.80) with the smallest and largest effect found for negative mood and fatigue, respectively. More positive attitudes toward smoking cessation independently predicted stronger intentions to quit (β = .52, p = .03). Findings suggest smoking is significantly associated with pain-related and psychological functioning in female orofacial-pain patients. Smoking-cessation treatment for these patients should include motivational interviewing techniques directed toward attitudinal change.
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Affiliation(s)
- Jessica L Burris
- Hollings Cancer Center-Cancer Prevention & Control, Medical University of South Carolina, 86 Jonathan Lucas St., MSC 955, Charleston, SC 29425, USA.
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Mateos F, Valero C, Olmos JM, Casanueva B, Castillo J, Martínez J, Hernández JL, González Macías J. Bone mass and vitamin D levels in women with a diagnosis of fibromyalgia. Osteoporos Int 2014; 25:525-33. [PMID: 24008400 DOI: 10.1007/s00198-013-2434-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 06/21/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED No differences in either bone mineral density or serum 25OHD levels have been found between 205 women with fibromyalgia (both pre- and postmenopausal) and their controls. However, a lack of the expected 25OHD summer rise was observed in patients. INTRODUCTION Contradictory data have been published regarding a possible association between fibromyalgia and osteoporosis or hypovitaminosis D. Most studies, however, have been performed in small size samples and have excluded postmenopausal women. We decided to study this association in a larger sample of fibromyalgia patients including both pre- and postmenopausal women. METHODS Two hundred five patients were recruited from a clinic specializing in fibromyalgia and 205 healthy controls were enrolled from the census of a Primary Care Center. Controls were matched with patients by age and the time of the year they were included in the study. Bone mineral density (BMD) was measured by DXA. Serum 25OHD, iPTH, P1NP, and CTX were also determined. RESULTS BMD was similar in both groups (lumbar spine, 0.971 ± 0.146 g/cm(2) in patients and 0.970 ± 0.132 g/cm(2) in controls; femoral neck, 0.780 ± 0.122 g/cm(2) and 0.785 ± 0.117 g/cm(2), respectively). 25OHD levels were also similar: 23.0 ± 9.5 ng/ml and 24.1 ± 9.6 ng/ml. However, while controls showed the usual summer rise in 25OHD, fibromyalgia patients did not. PTH did not show seasonal changes, but on average was higher in patients (51 pg/ml vs. 48 pg/ml; p = 0.034). P1NP or CTX were similar in both groups. CONCLUSIONS No differences in BMD were found between patients and controls. As for 25OHD, a lack of its expected summer rise was observed. It is doubtful whether this has any homeostatic consequence. We consider that the association reported in other studies is merely circumstantial, and not due to the intrinsic characteristics of these disorders.
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Affiliation(s)
- F Mateos
- Department of Internal Medicine, University Hospital Marqués de Valdecilla. University of Cantabria. RETICEF. IFIMAV, 39005, Santander, Spain,
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Gill TK, Shanahan EM, Taylor AW, Buchbinder R, Hill CL. Shoulder Pain in the Community: An Examination of Associative Factors Using a Longitudinal Cohort Study. Arthritis Care Res (Hoboken) 2013; 65:2000-2007. [DOI: 10.1002/acr.22082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- T. K. Gill
- The University of Adelaide; Adelaide, South Australia Australia
| | - E. M. Shanahan
- Southern Adelaide Health Service, Adelaide, Repatriation General Hospital, Daw Park, and Flinders University; Bedford Park, South Australia Australia
| | - A. W. Taylor
- The University of Adelaide; Adelaide, South Australia Australia
| | - R. Buchbinder
- Cabrini Hospital and Monash University; Malvern, Victoria Australia
| | - C. L. Hill
- The Queen Elizabeth Hospital, Woodville, and The University of Adelaide; Adelaide, South Australia Australia
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Stipelman BA, Augustson E, McNeel T. The relationship among smoking, sleep, and chronic rheumatic conditions commonly associated with pain in the National Health Interview Survey. J Behav Med 2013; 36:539-48. [PMID: 22864597 PMCID: PMC3858964 DOI: 10.1007/s10865-012-9447-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 07/20/2012] [Indexed: 12/21/2022]
Abstract
Chronic rheumatic conditions are typically characterized by chronic pain and are uniquely associated with increased rates of cigarette smoking and poor sleep quality. However, no study has examined the possible additive or interactive effects of these two health behaviors in individuals diagnosed with a chronic rheumatic condition. The goal of this study is to examine the relationship between cigarette smoking and sleep in a population sample of individuals diagnosed with a chronic rheumatic condition and related functional impairment. Cross sectional survey data was obtained from the 2007 National Health Interview Survey. Individuals diagnosed with a chronic rheumatic condition were more likely to be a former or current smoker compared to non-diagnosed individuals. Individuals with a chronic rheumatic condition were more likely to report <6 h of sleep per night and endorsed significantly more insomnia and daytime sleepiness. There was no interaction between diagnosis of a chronic rheumatic condition and smoking status on any of the sleep outcomes assessed. Finally, an interaction was observed suggesting individuals with a chronic rheumatic condition who currently smoke are more likely to report averaging <6 h of sleep per night and frequent insomnia compared to individuals with a chronic rheumatic condition who never smoked. These results suggest both a unique and additive relationship between smoking and sleep in individuals with a chronic rheumatic condition. Findings can likely be generalized to other conditions commonly associated with chronic pain.
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Affiliation(s)
- Brooke A Stipelman
- Science of Research and Technology Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD 20892-7326, USA.
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Holley AL, Law EF, Tham SW, Myaing M, Noonan C, Strachan E, Palermo TM. Current smoking as a predictor of chronic musculoskeletal pain in young adult twins. THE JOURNAL OF PAIN 2013; 14:1131-9. [PMID: 23810151 DOI: 10.1016/j.jpain.2013.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 04/08/2013] [Accepted: 04/18/2013] [Indexed: 12/19/2022]
Abstract
UNLABELLED Chronic pain is common during adolescence and young adulthood and is associated with poor quality of life, depression, and functional disability. Recognizing that chronic pain has significant consequences, it is important to identify modifiable health behaviors that may place young adults at risk for chronic pain. This study examines associations between chronic musculoskeletal pain and smoking in young adult twins (n = 1,588, ages 18-30) participating in a statewide twin registry. Twins completed questionnaires assessing smoking, mood (anxiety, depressive symptoms, and stress), and chronic musculoskeletal pain. Analyses examined associations between chronic pain and smoking, particularly the role of genetics/shared familial factors and psychological symptoms. As predicted, results revealed a near-2-fold increased risk for chronic musculoskeletal pain in twins who currently smoked compared to nonsmokers, even when accounting for psychological factors. Results of within-pair analyses were only minimally attenuated, suggesting that associations between smoking and chronic musculoskeletal pain are better accounted for by nonshared factors than by shared familial factors/genetic effects. Future twin research is needed to identify what nonshared factors (eg, attitudes, direct effects of smoking on pain) contribute to these associations to further understand comorbidity. Longitudinal studies and recruitment of participants prior to smoking initiation and chronic pain onset will better identify causal associations. PERSPECTIVE This article describes associations between musculoskeletal pain and smoking in young adult twins, taking into account psychological symptoms. Findings highlight the importance of nonshared factors in associations between pain and smoking and the need to explore the roles of lifestyle, individual attitudes, and direct effects of smoking on pain.
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Affiliation(s)
- Amy Lewandowski Holley
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.
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Fishbain DA, Lewis JE, Bruns D, Meyer LJ, Gao J, Disorbio JM. The prevalence of smokers within chronic pain patients and highest pain levels versus comparison groups. PAIN MEDICINE 2012; 14:403-16. [PMID: 23279699 DOI: 10.1111/pme.12024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES.: The objectives of this study were to (1) compare the prevalence of smoking within chronic pain patients (CPPs) to community non-patients without pain (CNPWP), community patients with pain (CPWP), and acute pain patients (APPs); and (2) compare smokers to nonsmokers within CPPs, APPs, and CPWP for highest pain level. DESIGN.: CNPWP, CPWP, APPs, and CPPs were compared to each other for smoking status (nonsmoker, less than one pack per day, one pack/day or more, any amount per day). Within CPWP, APPs, and CPPs, smokers were also compared to nonsmokers by t-test for highest reported pain level. For both analyses, sub-analyses were performed controlling for age or gender, or race or education. RESULTS.: Utilizing all available patients, the prevalence of smokers within CPPs was significantly greater vs each of the comparison groups (CNPWP, CPWP, APPs). In the sub-analyses, only CPPs who were 38 or younger or male or White, or had some college or above were at greater risk than CPWP for smoking one pack or greater per day. CPP smokers were not significantly more likely than nonsmokers to have higher pain, and this was confirmed in the sub-analyses. CONCLUSIONS.: The prevalence of smokers could be significantly greater within CPPs vs CPWP. CPPs who smoke do not have higher levels of pain than nonsmoking CPPs.
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Affiliation(s)
- David A Fishbain
- Department of Psychiatry, Miller School of Medicine at University of Miami, Miami, FL 33136, USA.
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Fishbain DA, Cole B, Lewis JE, Gao J. Is smoking associated with alcohol-drug dependence in patients with pain and chronic pain patients? An evidence-based structured review. PAIN MEDICINE 2012; 13:1212-26. [PMID: 22845022 DOI: 10.1111/j.1526-4637.2012.01446.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this study was to determine if there is consistent evidence for smoking to be considered a red flag for development of opioid dependence during opioid exposure in patients with pain and chronic pain patients (CPPs). METHODS Six hundred and twenty-three references were found that addressed the areas of smoking, pain, and drug-alcohol dependence. Fifteen studies remained after exclusion criteria were applied and sorted into four groupings addressing four hypotheses: patients with pain and CPPs who smoke are more likely than their nonsmoking counterparts to use opioids, require higher opioid doses, be drug-alcohol dependent, and demonstrate aberrant drug-taking behaviors (ADTBs). Each study was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 13 quality criteria to generate a quality score. The percentage of studies in each grouping supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence in each grouping was rated by the AHCPR guidelines. RESULTS In each grouping, 100% of the studies supported the hypothesis for that grouping. The strength and consistency of the evidence was rated as A (consistent multiple studies) for the first hypothesis and as B (generally consistent) for the other. CONCLUSIONS There is limited consistent indirect evidence that smoking status in patients with pain and CPPs is associated with alcohol-drug and opioid dependence. Smoking status could be a red flag for opioid-dependence development on opioid exposure.
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Affiliation(s)
- David A Fishbain
- Department of Psychiatry, Miller School of Medicine at the University of Miami, FL, USA.
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The role of physical therapists in smoking cessation: opportunities for improving treatment outcomes. Phys Ther 2012; 92:757-66. [PMID: 22228603 DOI: 10.2522/ptj.20110304] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ditre JW, Brandon TH, Zale EL, Meagher MM. Pain, nicotine, and smoking: research findings and mechanistic considerations. Psychol Bull 2012; 137:1065-93. [PMID: 21967450 DOI: 10.1037/a0025544] [Citation(s) in RCA: 237] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tobacco addiction and chronic pain represent 2 highly prevalent and comorbid conditions that engender substantial burdens upon individuals and systems. Interrelations between pain and smoking have been of clinical and empirical interest for decades, and research in this area has increased dramatically over the past 5 years. We conceptualize the interaction of pain and smoking as a prototypical example of the biopsychosocial model. Accordingly, we extrapolated from behavioral, cognitive, affective, biomedical, and social perspectives to propose causal mechanisms that may contribute to the observed comorbidity between these 2 conditions. The extant literature was 1st dichotomized into investigations of either effects of smoking on pain or effects of pain on smoking. We then integrated these findings to present a reciprocal model of pain and smoking that is hypothesized to interact in the manner of a positive feedback loop, resulting in greater pain and increased smoking. Finally, we proposed directions for future research and discussed clinical implications for smokers with comorbid pain disorders. We observed modest evidence that smoking may be a risk factor in the multifactorial etiology of some chronically painful conditions and that pain may come to serve as a potent motivator of smoking. We also found that whereas animal studies yielded consistent support for direct pain-inhibitory effects of nicotine and tobacco, results from human studies were much less consistent. Future research in the emerging area of pain and smoking has the potential to inform theoretical and clinical applications with respect to tobacco smoking, chronic pain, and their comorbid presentation. (PsycINFO Database Record (c) 2011 APA, all rights reserved).
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Affiliation(s)
- Joseph W Ditre
- Department of Psychology, Texas A&M University, College Station, USA.
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Smoking cigarettes as a coping strategy for chronic pain is associated with greater pain intensity and poorer pain-related function. THE JOURNAL OF PAIN 2012; 13:285-92. [PMID: 22325299 DOI: 10.1016/j.jpain.2011.11.008] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 11/22/2011] [Accepted: 11/28/2011] [Indexed: 11/22/2022]
Abstract
UNLABELLED Smoking cigarettes is prevalent among individuals with chronic pain. Some studies indicate nicotine reduces pain and others suggest it may cause or exacerbate pain. Participants in this cross-sectional study were 151 chronic pain patients from a large, urban VA medical center. Patients were divided into 3 groups: 1) nonsmokers; 2) smokers who deny using cigarettes to cope with pain; and 3) smokers who report using cigarettes to cope with pain. Patients who reported smoking as a coping strategy for chronic pain scored significantly worse compared with the other 2 groups on the majority of measures of pain-related outcome. Nonsmokers and smokers who denied smoking to cope did not differ on any variable examined. After controlling for the effects of demographic and clinical factors, smoking cigarettes as a coping strategy for pain was significantly and positively associated with pain intensity (P = .04), pain interference (P = .005), and fear of pain (P = .04). In addition to assessing general smoking status, a more specific assessment of the chronic pain patient's reasons for smoking may be an important consideration as part of interdisciplinary pain treatment. PERSPECTIVE This paper describes the relationship between smoking cigarettes as a mechanism to cope with chronic pain and pain-related outcome. Understanding this relationship may illuminate the broader relationship between smoking and chronic pain and provide new directions for effective interdisciplinary pain treatment.
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Smoking habits influence pain and functional and psychiatric features in fibromyalgia. Joint Bone Spine 2011; 78:259-65. [DOI: 10.1016/j.jbspin.2010.07.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 07/20/2010] [Indexed: 11/18/2022]
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TAJAR ABDELOUAHID, O’NEILL TERENCEW, LEE DAVIDM, O’CONNOR DARYLB, CORONA GIOVANNI, FINN JOSEPHD, BARTFAI GYORGY, BOONEN STEVEN, CASANUEVA FELIPEF, FORTI GIANNI, GIWERCMAN ALEKSANDER, HAN THANGS, HUHTANIEMI ILPOT, KULA KRZYSZTOF, LEAN MICHAELE, PENDLETON NEIL, PUNAB MARGUS, PURANDARE NITIN, SILMAN ALANJ, VANDERSCHUEREN DIRK, WU FREDERICKC, McBETH JOHN. The Effect of Musculoskeletal Pain on Sexual Function in Middle-aged and Elderly European Men: Results from the European Male Ageing Study. J Rheumatol 2010; 38:370-7. [DOI: 10.3899/jrheum.100604] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To determine whether musculoskeletal pain was associated with impaired sexual function in a population sample of middle-aged and older men.Methods.The European Male Ageing Study (EMAS), a multicenter population-based study of men aged 40–79 years, was used to investigate this hypothesis. A questionnaire asked about the presence and duration of musculoskeletal pain, allowing subjects to be classified into 1 of 3 groups: those reporting chronic widespread pain (CWP), those reporting pain but not CWP (“some pain”), and those with no pain. Subjects completed a sexual function questionnaire from which 3 domains were considered: overall sexual functioning (OSF), sexual functioning-related distress (SFD), and change in sexual functioning compared to 1 year ago (CSF).Results.A total of 3206 men [mean age 60 (SD 11) yrs] had complete data on pain status. Of these, 8.7% had CWP and 50.34% had “some pain.” Pain was associated with lower OSF, and higher SFD and CSF scores. After adjustment for putative confounding factors, the associations became non-significant with OSF and CSF but persisted for SFD. Associations between pain status and some items within the sexual functioning domains, including frequency of sexual intercourse, frequency of morning erections, sexual desire, and orgasm were also significant, although these associations varied by pain status.Conclusion.Musculoskeletal pain is associated with several aspects of sexual functioning. These relationships differ depending on the extent of the pain (chronic or not) and are also largely confounded by other health-related factors, primarily depression.
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Choi CJ, Knutsen R, Oda K, Fraser GE, Knutsen SF. The association between incident self-reported fibromyalgia and nonpsychiatric factors: 25-years follow-up of the Adventist Health Study. THE JOURNAL OF PAIN 2010; 11:994-1003. [PMID: 20400378 DOI: 10.1016/j.jpain.2010.01.267] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/07/2009] [Accepted: 01/21/2010] [Indexed: 12/12/2022]
Abstract
UNLABELLED The purpose of the study was to investigate the association between incident self-reported fibromyalgia (FM) and prior somatic diseases, lifestyle factors, and health behaviors among 3,136 women who participated in 2 cohort studies 25 to 26 years apart (the Adventist Health Study 1 and 2). The women completed a comprehensive lifestyle and medical history questionnaire at baseline in 1976. Information on new diagnosis of doctor-told FM was obtained at the second survey in 2002. A total of 136 women reported a diagnosis of FM during 25 years of follow-up, giving a period incidence of 43/1,000 or 1.72/1000 per year. In multivariable logistic regression analyses, a significant, dose-response association was found with number of allergies with OR of 1.61 (95% CI: .92-2.83) and 3.99 (95% CI: 2.31-6.88), (P[trend] < .0001), respectively, for 1 and 2 or more allergies versus none. A history of hyperemesis gravidarum was also associated with FM with OR of 1.32 (95% CI: .75-2.32) and 1.73 (95% CI: .99-3.03), (P[trend] < .05), respectively, for some or all pregnancies versus none. A positive association with smoking was also found with OR of 2.37 (95% CI: 1.33-4.23) for ever smokers versus never smokers. No significant association was found with number of surgeries, history of peptic ulcer, or taking medications to control various symptoms. PERSPECTIVE Smoking as well as prevalent allergies, and a history of hyperemesis gravidarum, seem to predict development of FM in women during 25 years of follow-up. This information may help in identifying persons at high risk of developing FM and thus initiate effective prevention strategies.
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Affiliation(s)
- Chan-Jin Choi
- Department of Epidemiology and Biostatistics, School of Public Health, Loma Linda University, Loma Linda, California 92399, USA
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Effective Pain Palliation in Fibromyalgia Syndrome Patients with Botulinum Toxin Type-A: Case Series of 25. ACTA ACUST UNITED AC 2010. [DOI: 10.1300/j094v15n04_07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Arnson Y, Shoenfeld Y, Amital H. Effects of tobacco smoke on immunity, inflammation and autoimmunity. J Autoimmun 2009; 34:J258-65. [PMID: 20042314 DOI: 10.1016/j.jaut.2009.12.003] [Citation(s) in RCA: 623] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Smoking is a central factor in many pathological conditions. Its role in neoplasm, lung and cardiovascular diseases has been well established for years. However it is less acknowledged the cigarette smoking affects both the innate and adoptive immune arms. Cigarette smoke was shown to augment the production of numerous pro-inflammatory cytokines such as TNF-alpha, IL-1, IL-6, IL-8 GM-CSF and to decrease the levels of anti-inflammatory cytokines such as IL-10. Tobacco smoke via multiple mechanisms leads to elevated IgE concentrations and to the subsequent development of atopic diseases and asthma. Cigarette smoke has also been shown activate in many ways macrophage and dendritic cell activity. While it is better evident how cigarette smoke evokes airway diseases more mechanisms are being revealed linking this social hazard to autoimmune disorders, for instance via the production of antibodies recognizing citrullinated proteins in rheumatoid arthritis or by the elevation of anti-dsDNA titers in systemic lupus erythematosus. The current review underlines the importance of smoking prevention and eradication not only in respiratory disorders but also in autoimmune conditions as well.
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Affiliation(s)
- Yoav Arnson
- Department of Medicine D, Meir Medical Center, Kfar Saba, Israel
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Impact of tobacco use on the symptoms of painful temporomandibular joint disorders. Pain 2009; 147:67-71. [DOI: 10.1016/j.pain.2009.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 07/12/2009] [Accepted: 08/12/2009] [Indexed: 11/24/2022]
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Costallat BL, da Silva PC, Martinez JE. Does Smoking Influence Fibromyalgia Syndrome Patients' Health Status? ACTA ACUST UNITED AC 2009. [DOI: 10.1080/10582450902816349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pamuk ÖN, Dönmez S, Çakır N. The frequency of smoking in fibromyalgia patients and its association with symptoms. Rheumatol Int 2009; 29:1311-4. [DOI: 10.1007/s00296-009-0851-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 01/05/2009] [Indexed: 11/24/2022]
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Weingarten TN, Podduturu VR, Hooten WM, Thompson JM, Luedtke CA, Oh TH. Impact of Tobacco Use in Patients Presenting to a Multidisciplinary Outpatient Treatment Program for Fibromyalgia. Clin J Pain 2009; 25:39-43. [DOI: 10.1097/ajp.0b013e31817d105e] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Domino E. Tobacco smoking and MRI/MRS brain abnormalities compared to nonsmokers. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:1778-81. [PMID: 18817837 PMCID: PMC2631356 DOI: 10.1016/j.pnpbp.2008.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 09/04/2008] [Accepted: 09/05/2008] [Indexed: 10/21/2022]
Abstract
This mini review emphasizes the fact that tobacco smoking causes small but real biologic brain changes that need to be studied in depth. A crucial question is whether these anatomical/chemical changes reverse toward normal when smokers quit. This review is presented to stimulate further research to answer this question.
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Affiliation(s)
- E.F. Domino
- Corresponding Author: E.F. Domino M.D., Department of Pharmacology, University of Michigan, Ann Arbor MI 48109-0632, Telephone: 734 764-9115, Fax: 734 763-4450,
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Ditre JW, Brandon TH. Pain as a motivator of smoking: effects of pain induction on smoking urge and behavior. JOURNAL OF ABNORMAL PSYCHOLOGY 2008; 117:467-72. [PMID: 18489224 DOI: 10.1037/0021-843x.117.2.467] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tobacco smoking has been associated with the development and exacerbation of chronically painful conditions. Conversely, there is reason to believe that smokers may be motivated to use tobacco as a means of coping with their pain. To date, no controlled, experimental studies have tested for a causal relationship between pain and smoking motivation. The primary aim of the current study was to test the hypothesis that laboratory-induced cold pressor pain would enhance smoking motivation, as measured by self-reported urge to smoke and observation of immediate smoking behavior. Smokers (N=132) were randomly assigned to either pain or no pain conditions. Results indicated that situational pain increased urge ratings and produced shorter latencies to smoke. The relationship between pain and increased urge to smoke was partially mediated by pain-induced negative affect. The relationship between pain and shorter latency to smoke was fully mediated by pain-induced urge to smoke. This study provides the 1st experimental evidence that situational pain can be a potent motivator of smoking.
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Affiliation(s)
- Joseph W Ditre
- Department of Psychology, University of South Florida, Tampa, Florida, USA
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Xue Y, Domino EF. Tobacco/nicotine and endogenous brain opioids. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:1131-8. [PMID: 18215788 PMCID: PMC2582831 DOI: 10.1016/j.pnpbp.2007.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 12/04/2007] [Accepted: 12/12/2007] [Indexed: 11/25/2022]
Abstract
Smoking is a major public health problem with devastating health consequences. Although many cigarette smokers are able to quit, equal numbers of others cannot! Standard medications to assist in smoking cessation, such as nicotine replacement therapies and bupropion, are ineffective in many remaining smokers. Recent developments in the neurobiology of nicotine dependence have identified several neurotransmitter systems that may contribute to the process of smoking maintenance and relapse. These include: especially dopamine, but also norepinephrine, 5-hydroxytryptamine, acetylcholine, endogenous opioids, gamma-aminobutyric acid (GABA), glutamate, and endocannabinoids. The present review examines the limited contribution of the endogenous opioid system to the complex effects of nicotine/tobacco smoking.
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Affiliation(s)
| | - Edward F. Domino
- Corresponding author. E.F. Domino, M.D., Tel#: 734-764-9115, Fax#: 734-763-4450,
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Abstract
This chapter reviews the impact of chronic musculoskeletal pain on patients' health-related quality of life. In addition to the physical health consequences, chronic musculoskeletal pain can have a profound negative impact on an individual's emotional and social well-being. Although efforts in the health sector are obviously of crucial importance in the management of chronic musculoskeletal pain, a high level of patient and societal involvement is key to reducing the burden of this condition. Patients should work in partnership with health-care professionals, actively participating in their care. Family members should encourage their loved ones to be as independent as possible. The employer of a person with chronic musculoskeletal pain has a vital role in returning him or her to work as soon as possible. Removing all barriers to the use of preventive and therapeutic services will help us to reduce the burden of musculoskeletal pain conditions on both patients and society.
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Affiliation(s)
- Emine Handan Tüzün
- Department of Physical Therapy and Rehabilitation, Faculty of Health Sciences, Başkent University, Eskişehir Yolu 20.Km, Baglica, Ankara, Turkey.
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Abstract
The rate of musculoskeletal pain in adolescent and adult populations is examined, with a focus on three commonly reported pain disorders: shoulder pain, low back pain and fibromyalgia/chronic widespread pain. There is a paucity of data on musculoskeletal pain in adolescent populations. Those studies available suggest that pain is common, although the actual rates are unclear. This is probably due to differences in study methodologies and populations. Pain is commonly reported among adult populations, with almost one fifth reporting widespread pain, one third shoulder pain, and up to one half reporting low back pain in a 1-month period. The prevalence of pain varies within specific population subgroups; group factors (including socioeconomic status, ethnicity and race) and individual factors (smoking, diet, and psychological status) are all associated with the reporting of musculoskeletal pain. However, the precise nature of these relationships, and particularly the mechanisms of association, are unclear and require further investigation.
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Affiliation(s)
- John McBeth
- ARC Epidemiology Unit, The Medical School, The University of Manchester, Manchester, M13 9PT, UK.
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Lough C, Young T, Parker R, Wittenauer S, Vincler M. Increased spinal dynorphin contributes to chronic nicotine-induced mechanical hypersensitivity in the rat. Neurosci Lett 2007; 422:54-8. [PMID: 17597300 PMCID: PMC2175268 DOI: 10.1016/j.neulet.2007.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 05/31/2007] [Accepted: 06/05/2007] [Indexed: 11/19/2022]
Abstract
Chronic nicotine administration has been shown previously to produce mechanical hypersensitivity in the rat although the mechanism of this effect is unknown. Rats treated with chronic systemic nicotine 3.6 or 8.6 mg/(kg day) for 14-21 days displayed mechanical hypersensitivity coincident with an increase of prodynorphin immunoreactivity and dynorphin content within the spinal cord. The administration of dynorphin antiserum intrathecally significantly attenuated chronic nicotine-induced mechanical hypersensitivity. Our results suggest that chronic nicotine administration produces an increase in spinal dynorphin content and release that contributes to mechanical hypersensitivity.
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Affiliation(s)
- Chris Lough
- Department of Biology, Wake Forest University, Winston-Salem, NC 27109, USA
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Abstract
Anesthesiologists daily witness the consequences of tobacco use, the most common preventable cause of death. Smoking-related diseases such as atherosclerosis and chronic obstructive pulmonary disease increase anesthetic risk, and even smokers without overt disease are at increased risk for morbidity such as pulmonary and wound-related complications. Evidence suggests that stopping smoking will reduce the frequency of these complications. Nicotine and the other constituents of cigarette smoke, such as carbon monoxide, have important physiologic effects that may affect perioperative management. In addition, it is now apparent that the scheduling of elective surgery represents an excellent opportunity for smokers to quit in the long term. This review serves as an introduction to tobacco control for anesthesiologists, first examining issues of importance to perioperative management. It then discusses how anesthesiologists and other perioperative physicians can help address tobacco use, both at an individual level with their patients, and by contributing to the implementation of effective public health strategies in their countries. Anesthesiologists can play a key role in helping their patients quit smoking. Effective tobacco control measures applied to surgical patients will not only improve immediate perioperative outcomes but also long-term health.
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Affiliation(s)
- David O Warner
- Department of Anesthesiology, the Anesthesia Clinical Research Unit, and the Nicotine Dependence Center, Mayo Clinic, Rochester, MN, USA
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