Does association of opioid use with pain and function differ by fibromyalgia or widespread pain status?

STRategies to Improve Pain and Enjoy life (STRIPE): results of a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy

ABSTRACT

Because long-term opioid therapy (LtOT) for chronic pain has uncertain benefits and dose-dependent harms, safe and effective strategies for opioid tapering are needed. Adapting a promising pilot study intervention, we conducted the STRategies to Improve Pain and Enjoy life (STRIPE) pragmatic clinical trial. Patients in integrated health system on moderate-to-high dose of LtOT for chronic noncancer pain were randomized individually to usual care plus intervention (n = 79) or usual care only (n = 74). The intervention included pain coping skills training and optional support for opioid taper, delivered in 18 telephone sessions over a year, with pharmacologic guidance provided to participants' primary care providers by a pain physician. Coprimary outcomes were daily opioid dose (morphine milligram equivalent [MME]), calculated using pharmacy dispensing data, and the self-reported Pain, Enjoyment of Life and General Activity scale at 12 months (primary time point) and 6 months. Secondary outcomes included opioid misuse, opioid difficulties, opioid craving, pain self-efficacy, and global impression of change, depression, and anxiety. Only 41% randomized to the intervention completed all sessions. We did not observe significant differences between intervention and usual care for MME (adjusted mean difference: -2.3 MME; 95% confidence interval: -10.6, 5.9; P = 0.578), the Pain, Enjoyment of Life, General Activity scale (0.0 [95% confidence interval: -0.5, 0.5], P = 0.985), or most secondary outcomes. The intervention did not lower opioid dose or improve pain or functioning. Other strategies are needed to reduce opioid doses while improving pain and function for patients who have been on LtOT for years with high levels of medical, mental health, and substance use comorbidity.

Treatment patterns in fibromyalgia including the use of opioids

OBJECTIVE

Opioids (except for tramadol) have not been shown to be effective in patients with fibromyalgia, but they can increase the risk of adverse drug reactions. The aim was to determine the treatment patterns of a group of patients with fibromyalgia and to identify the factors associated with the use of opioids in Colombia.

METHODS

This was a cross-sectional study of a group of patients with fibromyalgia from a pain clinic in Colombia. Sociodemographic, clinical and pharmacological variables were identified. Descriptive, bivariate, and multivariate analyses were performed.

RESULTS

A total of 559 patients were analysed, 88.6% of whom were women, and the mean age was 53.4 ± 12.6 years. A total of 40.6% received nonpharmacological management, and the majority were treated with acetaminophen (96.1%) and pregabalin (62.8%). A total of 69.6% received opioids, the most common of which was hydrocodone (36.3%). The average morphine equivalent milligrammes was 36.9 ± 91.2 (range: 2.3-750 mg), and 43.8% had intermediate/high doses. Being male (OR: 3.12; 95% CI: 1.40-6.91), having arterial hypertension (OR: 1.67; 95% CI: 1.04-2.69), obesity (OR: 2.23; 95% CI: 1.18-4.24), degenerative disease of vertebral discs (OR: 2.32; 95% CI: 1.10-4.88) and comedication with gabapentinoids (OR: 1.75; 95% CI: 1,15-2.65) were associated with a higher probability of receiving opioids, while patients treated with muscle relaxants had a lower risk of opioid treatment (OR: 0.64; 95% CI: 0.41-0.98).

CONCLUSIONS

A significant proportion of patients were treated with opioids, the most common of which was hydrocodone, which goes against the recommendations of clinical practice guidelines.

Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain

Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0-10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP. TRIAL REGISTRATION: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843). PERSPECTIVE: Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.

STRategies to Improve Pain and Enjoy life (STRIPE): Protocol for a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy

High-dose, long-term opioid therapy (LtOT) is associated with risk for serious harms. Rapid opioid discontinuation may lead to increased pain, psychological distress, and illicit opioid use, but gradual, supported opioid taper may reduce these risks. We previously demonstrated that an opioid taper support and pain coping skills training intervention reduced opioid dose more than usual care (43% vs 19% dose reduction from baseline), with no increase in pain intensity and a significant reduction in activity interference. We aim to adapt and test this intervention in the Kaiser Permanente Washington healthcare system with STRategies to Improve Pain and Enjoy life (STRIPE), a pragmatic, randomized trial. Our goal was to randomize 215 participants on moderate-high dose (≥40 morphine milligram equivalent/day) LtOT to either cognitive-behavioral therapy-based pain coping skills training involving 18 telephone sessions over 52 weeks with optional opioid taper support or usual care. Data are collected from electronic health records, claims, and self-report. The primary outcomes are mean daily opioid dose and the pain intensity, interference with enjoyment of life, and interference with general activity (PEG) score at 12 months (primary time point) and 6 months (secondary time point). Secondary outcomes include having ≥30% opioid dose reduction from baseline, and patient-reported problem opioid use, opioid-related difficulties, pain self-efficacy, opioid craving, global impression of change, and anxiety and depressive symptoms at 6 and 12 months. If effective, this treatment could reduce opioid exposure and associated risks to patients, families, and communities while offering patients an alternative for managing pain. Trial registration: The study was first registered at Clinicaltrials.gov on November 16, 2018 (identifier: NCT03743402).

American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain

BACKGROUND

The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care.

OBJECTIVE

These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD.

METHODS

ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery.

CONCLUSIONS

Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.

Multi-site Pain Is Associated with Long-term Patient-Reported Outcomes in Older Adults with Persistent Back Pain

OBJECTIVE

To estimate the prevalence of co-occurring pain sites among older adults with persistent back pain and associations of multisite pain with longitudinal outcomes.

DESIGN

Secondary analysis of a cohort study.

SETTING

Three integrated health systems in the United States.

SUBJECTS

Eight hundred ninety-nine older adults with persistent back pain.

METHODS

Participants reported pain in the following sites: stomach, arms/legs/joints, headaches, neck, pelvis/groin, and widespread pain. Over 18 months, we measured back-related disability (Roland Morris, scored 0-24), pain intensity (11-point numerical rating scale), health-related quality of life (EuroQol-5D [EQ-5D], utility from 0-1), and falls in the past three weeks. We used mixed-effects models to test the association of number and type of pain sites with each outcome.

RESULTS

Nearly all (N = 839, 93%) respondents reported at least one additional pain site. There were 216 (24%) with one additional site and 623 (69%) with multiple additional sites. The most prevalent comorbid pain site was the arms/legs/joints (N = 801, 89.1%). Adjusted mixed-effects models showed that for every additional pain site, RMDQ worsened by 0.65 points (95% confidence interval [CI] = 0.43 to 0.86), back pain intensity increased by 0.14 points (95% CI = 0.07 to 0.22), EQ-5D worsened by 0.012 points (95% CI = -0.018 to -0.006), and the odds of falling increased by 27% (odds ratio = 1.27, 95% CI = 1.12 to 1.43). Some specific pain sites (extremity pain, widespread pain, and pelvis/groin pain) were associated with greater long-term disability.

CONCLUSIONS

Multisite pain is common among older adults with persistent back pain. Number of pain sites was associated with all outcomes; individual pain sites were less consistently associated with outcomes.

Fibromyalgia-Like Syndrome Associated with Parkinson's Disease-A Cohort Study

Parkinson’s disease (PD) and fibromyalgia (FM) are two relatively common disorders that are considered distinct diagnoses. The aim of this study was to investigate the epidemiological characteristics of patients with both PD and FM, as well as their comorbidities and medication use. We performed a population-based retrospective cohort study in Israel from 2000 to 2015. We identified patients with PD according to a refined medication tracer algorithm and patients with FM according to their medical records. Using the algorithm, we identified 2606 patients diagnosed with PD, 60 of them (2.3%) were also diagnosed with FM. Most of the patients were females (88.3%) and the mean age of FM diagnosis was 63.95 ± 12.27 years. These patients had a higher prevalence of depression, anxiety, and dementia. Of the patients diagnosed with PD + FM, 46 (76.7%) were diagnosed with FM after the diagnosis of PD. Patients with PD + FM used analgesics of distinct kinds in higher rates, as well as more anti-PD medications. We suggest that patients with PD + FM represent a distinct subgroup with a fibromyalgia-like syndrome associated with Parkinson’s disease (FLISPAD). Their PD is more treatment resistant, and they take more medications, both analgesics and anti-PD.

Motivational Non-directive Resonance Breathing as a Treatment for Chronic Widespread Pain

Chronic widespread pain (CWP) is one of the most difficult pain conditions to treat due to an unknown etiology and a lack of innovative treatment design and effectiveness. Based upon preliminary findings within the fields of motivational psychology, integrative neuroscience, diaphragmatic breathing, and vagal nerve stimulation, we propose a new treatment intervention, motivational non-directive (ND) resonance breathing, as a means of reducing pain and suffering in patients with CWP. Motivational ND resonance breathing provides patients with a noninvasive means of potentially modulating five psychophysiological mechanisms imperative for endogenously treating pain and increasing overall quality of life.

A Model of the Intersection of Pain and Opioid Misuse in Children and Adolescents

Despite being a significant public health concern, the role of opioid prescriptions in potentiating risk of opioid misuse in the context of pediatric pain has been under-investigated. To address this gap, the present review identifies theory-based hypotheses about these associations, reviews the extant literature on opioid prescriptions that supports these hypotheses, and provides routes for future empirical studies. A multi-level model of mechanisms through which opioid prescriptions may impact pain and other negative outcomes in youth, including risk for opioid misuse and related problems, is proposed with particular attention paid to the role that psychologists can play in informing policies and developing preventative interventions in healthcare settings.