Moving Toward Integrated Behavioral Intervention for Treating Multimorbidity Among Chronic Pain, Depression, and Substance-use Disorders in Primary Care

Mobile health intervention to address chronic pain among those who engage in hazardous drinking: A pilot study

BACKGROUND

Hazardous drinking has been associated with chronic pain in community and medical samples. The purpose of this study was to develop a novel, integrated mobile health intervention that improves pain management and reduces hazardous drinking that may be implemented in primary care settings.

METHODS

Forty-eight participants with moderate or greater chronic pain and hazardous drinking were recruited from primary care clinics and through social media sites. Following baseline assessment, participants were randomized to a counselor-supported smartphone app intervention (INTV) or a counselor delivered treatment-as-usual control condition (CTL).

RESULTS

Results supported the feasibility and acceptability of the smartphone app intervention. Participants found it easy to use, reported high levels of satisfaction, and showed high levels of engagement with the app. Between-group effect size estimates at follow-up showed small effects for the intervention on pain ratings. However, using clinically meaningful change thresholds of 30% and 50% improvement in pain scores, 38% and 25% respectively of those in the INTV condition showed reductions compared to 20% and 12.5% respectively in the CTL condition. Effect size estimates did not indicate intervention superiority on alcohol outcomes as participants in both conditions showed considerable reductions in drinking over the course of the study.

CONCLUSIONS

Results supported the view that a mobile health intervention delivered via smartphone with electronic coaching is a feasible and acceptable method of addressing chronic pain among those who engage in hazardous drinking. Future work should test the efficacy of this approach in a fully powered trial.

Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation

INTRODUCTION

American Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can benefit from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care.

METHODS

The study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant interviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke's (2006) reflexive thematic analysis in qualitative research.

RESULTS

Eleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN providers adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively influenced MOUD maintenance.

CONCLUSIONS

Clinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the multiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes.

Pain Intensity Moderates the Association between Obsessive-Compulsive Symptoms and Problematic Alcohol Use among Emerging Adults

Objective: Emerging adulthood is a vulnerable period for problematic alcohol use, defined by a pattern of use associated with physical and functional impairment. Obsessive-compulsive psychopathology, which demonstrates high rates of onset in emerging adults, seems to be related to problematic alcohol use in this age group, consistent with research among the general population suggesting an association between emotional disorders and alcohol use in the context of coping drinking motives. Pain intensity, another risk factor of problematic alcohol use, may link obsessive-compulsive symptoms to problematic alcohol use among emerging adults. Therefore, the current study examined the moderating role of pain intensity on the association between obsessive-compulsive symptoms and problematic alcohol use among emerging adults. Methods: Participants were 198 college students (81.30% female, M_age = 22.33, SD = 4.38) who reported problematic alcohol use. Results: Results from the current study supported a significant moderation role of pain intensity for the association between obsessive-compulsive symptoms and problematic alcohol use, whereby the association between obsessive-compulsive symptoms and problematic alcohol use was stronger for emerging adults with high compared to low pain intensity. Conclusions: These results highlighted a clinically-relevant interaction between obsessive-compulsive symptoms and pain intensity concerning the risk of problematic alcohol use among emerging adults as a vulnerable population.

Genetic risk for chronic pain is associated with lower antidepressant effectiveness: Converging evidence for a depression subtype

INTRODUCTION

Chronic pain and depression are highly comorbid and difficult-to-treat disorders. We previously showed this comorbidity is associated with higher depression severity, lower antidepressant treatment effectiveness and poorer prognosis in the Australian Genetics of Depression Study.

OBJECTIVE

The current study aimed to assess whether a genetic liability to chronic pain is associated with antidepressant effectiveness over and above the effect of genetic factors for depression in a sample of 12,863 Australian Genetics of Depression Study participants.

METHODS

Polygenic risk scores were calculated using summary statistics from genome-wide association studies of multisite chronic pain and major depression. Cumulative linked regressions were employed to assess the association between polygenic risk scores and antidepressant treatment effectiveness across 10 different medications.

RESULTS

Mixed-effects logistic regressions showed that individual genetic propensity for chronic pain, but not major depression, was significantly associated with patient-reported chronic pain (Pain^PRS OR = 1.17 [1.12, 1.22]; MD^PRS OR = 1.01 [0.98, 1.06]). Significant associations were also found between lower antidepressant effectiveness and genetic risk for chronic pain or for major depression. However, a fully adjusted model showed the effect of Pain^PRS (adjOR = 0.93 [0.90, 0.96]) was independent of MD^PRS (adjOR = 0.96 [0.93, 0.99]). Sensitivity analyses were performed to assess the robustness of these results. After adjusting for depression severity measures (i.e. age of onset; number of depressive episodes; interval between age at study participation and at depression onset), the associations between Pain^PRS and patient-reported chronic pain with lower antidepressant effectiveness remained significant (0.95 [0.92, 0.98] and 0.84 [0.78, 0.90], respectively).

CONCLUSION

These results suggest genetic risk for chronic pain accounted for poorer antidepressant effectiveness, independent of the genetic risk for major depression. Our results, along with independent converging evidence from other studies, point towards a difficult-to-treat depression subtype characterised by comorbid chronic pain. This finding warrants further investigation into the implications for biologically based nosology frameworks in pain medicine and psychiatry.

Comorbid Chronic Pain and Depression: Shared Risk Factors and Differential Antidepressant Effectiveness

The bidirectional relationship between depression and chronic pain is well-recognized, but their clinical management remains challenging. Here we characterize the shared risk factors and outcomes for their comorbidity in the Australian Genetics of Depression cohort study (N = 13,839). Participants completed online questionnaires about chronic pain, psychiatric symptoms, comorbidities, treatment response and general health. Logistic regression models were used to examine the relationship between chronic pain and clinical and demographic factors. Cumulative linked logistic regressions assessed the effect of chronic pain on treatment response for 10 different antidepressants. Chronic pain was associated with an increased risk of depression (OR = 1.86 [1.37-2.54]), recent suicide attempt (OR = 1.88 [1.14-3.09]), higher use of tobacco (OR = 1.05 [1.02-1.09]) and misuse of painkillers (e.g., opioids; OR = 1.31 [1.06-1.62]). Participants with comorbid chronic pain and depression reported fewer functional benefits from antidepressant use and lower benefits from sertraline (OR = 0.75 [0.68-0.83]), escitalopram (OR = 0.75 [0.67-0.85]) and venlafaxine (OR = 0.78 [0.68-0.88]) when compared to participants without chronic pain. Furthermore, participants taking sertraline (OR = 0.45 [0.30-0.67]), escitalopram (OR = 0.45 [0.27-0.74]) and citalopram (OR = 0.32 [0.15-0.67]) specifically for chronic pain (among other indications) reported lower benefits compared to other participants taking these same medications but not for chronic pain. These findings reveal novel insights into the complex relationship between chronic pain and depression. Treatment response analyses indicate differential effectiveness between particular antidepressants and poorer functional outcomes for these comorbid conditions. Further examination is warranted in targeted interventional clinical trials, which also include neuroimaging genetics and pharmacogenomics protocols. This work will advance the delineation of disease risk indicators and novel aetiological pathways for therapeutic intervention in comorbid pain and depression as well as other psychiatric comorbidities.

Integrating patient perspectives in the development of a mobile health intervention to address chronic pain and heavy drinking in primary care: a qualitative study of patients in an urban, safety-net hospital setting

Background

Chronic pain and heavy drinking are conditions that commonly co-occur among primary care patients. Despite the availability of behavioral interventions that target these conditions individually, engagement and adherence to treatment remain a challenge, and there have been no interventions designed to address both of these conditions together for patients presenting to primary care. This study seeks to incorporate the perspectives of patients regarding symptoms, treatment experiences, views on behavior change, and technology use to develop a tailored, integrated mobile health intervention that addresses both pain and heavy drinking among patients in primary care.

Methods

Twelve participants with moderate or greater chronic pain intensity and heavy drinking were recruited from primary care clinics in a large urban safety-net hospital. One-on-one interviews were recorded and transcribed. Codes were developed from interview transcripts, followed by thematic analysis in which specific meanings were assigned to codes. Participants also completed a series of Likert-based rating scales to evaluate components of the proposed intervention to supplement qualitative interviews.

Results

A number of themes were identified that had implications for intervention tailoring including: ambivalence about changing drinking, low expectations about pain treatment success, desire for contact with a designated provider, common use of smartphones but lack of familiarity with functions as a potential barrier to use, and strategies to maintain engagement and adherence. Evaluative ratings indicated that the proposed intervention content was perceived as helpful and the proposed structure, layout and design of the mobile intervention was acceptable to patients.

Conclusions

Results supported the view that a mobile health intervention delivered via smartphone with electronic coaching is an acceptable method of addressing chronic pain and heavy drinking among patients in primary care. The interviews highlight the need to utilize an intervention approach that addresses motivation to change drinking, sets realistic expectations for change, provides careful attention to training/education of the use of technology components, and fosters engagement through the use of reminders, feedback, and personalized activities.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Effects of craving on opioid use are attenuated after pain coping counseling in adults with chronic pain and prescription opioid addiction

OBJECTIVE

Risk for prescription opioid addiction is an endemic public health concern, especially for adults with chronic pain. This study examined craving as a mediator from pain to opioid use outcomes during prescription opioid addiction treatment and tested whether counseling in pain coping skills moderated the effects of craving on treatment outcomes.

METHOD

Secondary analysis on a sample (N = 148) randomized to standard or enhanced counseling for 12 weeks with adjunct opioid maintenance medication. Multilevel analyses examined mediated effects between weekly pain, craving, and opioid use, and tested the interaction between craving and a counseling module on pain coping skills.

RESULTS

Greater pain predicted greater craving (β = 0.25, p < .001), which predicted next-week opioid use (β = 0.17, p < .001). A statistically significant indirect effect of craving (β = 0.04, 95% CI [0.02, 0.06]) mediated 95% of the total effect from pain to opioid use. A significant interaction (b = -0.22, p < .01) revealed that after receiving the pain coping module, the association between craving and next-week opioid use was reduced, with greater exposure to the module associated with stronger effects (b = -0.12, p < .01).

CONCLUSION

More severe pain predicts greater opioid use due to the association between pain and cravings. Pain coping skills counseling suppressed the association between cravings and opioid use. For adults with chronic pain receiving treatment for prescription opioid addiction, interventions that address cravings through behavioral pain coping skills may be crucial for achieving optimal treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A pilot study assessing acceptability and feasibility of hatha yoga for chronic pain in people receiving opioid agonist therapy for opioid use disorder

The purpose of this project was to assess the feasibility and acceptability of a hatha yoga program designed to target chronic pain in people receiving opioid agonist therapy for opioid use disorder. We conducted a pilot randomized trial in which people with chronic pain who were receiving either methadone maintenance therapy (n = 20) or buprenorphine (n = 20) were randomly assigned to weekly hatha yoga or health education (HE) classes for 3 months. We demonstrated feasibility in many domains, including recruitment of participants (58% female, mean age 43), retention for follow-up assessments, and ability of teachers to provide interventions with high fidelity to the manuals. Fifty percent of participants in yoga (95% CI: 0.28-0.72) and 65% of participants in HE (95% CI: 0.44-0.87) attended at least 6 of 12 possible classes (p = 0.62). Sixty-one percent in the yoga group reported practicing yoga at home, with a mean number of times practicing per week of 2.67 (SD = 2.37). Participant mood improved pre-class to post-class, with greater decreases in anxiety and pain for those in the yoga group (p < 0.05). In conclusion, yoga can be delivered on-site at opioid agonist treatment programs with home practice taken up by the majority of participants. Future research may explore ways of increasing the yoga "dosage" received. This may involve testing strategies for increasing either class attendance or the amount of home practice or both.

Tobacco and alcohol use disorders: Evaluating multimorbidity

There is growing interest in applying the multimorbidity model for mental health disorders - i.e. the interactive effects of co-occurring diagnoses. Alcohol use disorder (AUD) and tobacco use disorder (TUD) often occur together, but distinctive correlates of their co-occurrence have not been studied. Veterans treated by the Veterans Health Administration (VHA) nationally in FY 2012 with diagnoses of both AUD and TUD were compared to those with only AUD or only TUD on socio-environmental factors, medical and psychiatric diagnoses, and service use. Multimorbid effects were defined as those in which patients with both AUD and TUD had more serious problems greater likelihood of specific co-occurring conditions than those with either AUD alone or TUD alone. Veterans with concurrent AUD and TUD (N=153,397), as compared to those with AUD only (N=191,900) or with TUD only (N=643,377), had significantly higher rates of homelessness [odd ratios (ORs)=1.24, 1.68], hepatic disease (ORs=1.11, 2.18), substance use disorders (ORs=1.42, 3.14), receipt of a VA disability pension (ORs=1.26, 1.30) and use of substance and mental health outpatient services (ORs=1.04, 1.12). Veterans with AUD and TUD appear to have more severe problems in some, but not all, socio-environmental, medical, psychiatric, and service use domains than veterans with either of these diagnoses alone. The combination of AUD and TUD yield generally more adverse effects in diverse areas and thus reflect an emergent phenomenon that may a require a distinctive treatment approach.

Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review

BACKGROUND

In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity.

METHODS

A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US.

RESULTS

In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2).

CONCLUSION

Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.

The effectiveness of strength-based, solution-focused brief therapy in medical settings: a systematic review and meta-analysis of randomized controlled trials

This meta-analysis synthesized randomized controlled trials of solution focused brief therapy (SFBT) in medical settings for patients' health-related psychosocial (e.g., depression, psychosocial adjustment to illness), behavioral (e.g., physical activity, nutrition score), and functional health (e.g., BMI, individual strength) outcomes. Medical setting is defined in this study as any healthcare setting that primarily focuses on patients' physical wellbeing. A comprehensive search strategy across five electronic databases, four academic journals, three professional websites, and reference lists of included articles resulted in a final sample of nine studies for meta-analytic synthesis. Combining outcomes indicated an overall significant effect of SFBT for health-related psychosocial outcomes (d = 0.34, p < .05.) and a nearly significant outcome for health-related behavioral outcomes (d = 0.28, p = .06), but not for functional health outcomes. Results indicated SFBT being an effective intervention for psychosocial outcomes and a promising approach for behavioral outcomes in medical settings.

Integrated care coordination by an interprofessional team reduces emergency department visits and hospitalisations at an academic health centre

People with chronic behavioural and physical health conditions have higher healthcare costs and mortality rates than patients with chronic physical conditions alone. As a result, there has been promotion of integrated care for this group. It is important to train primary care residents to practice in integrated models of care with interprofessional teams and to evaluate the effectiveness of integrated care models to promote high-quality care for this at-risk group. We implemented an integrated, interprofessional care management programme for adults with chronic mental and physical health needs as part of a curriculum for family medicine and family medicine psychiatry residents. We then evaluated the clinical effectiveness of this programme by describing participants' healthcare utilisation patterns pre- and post-enrolment. Patients enrolled in the programme were approximately 60-70% less likely to utilise the emergency room and 50% less likely to be admitted to the hospital after enrolment in the programme compared to before enrolment. The odds of individual attendance at outpatient primary care and mental health visits improved after enrolment. In the context of the implementation of integrated behavioural and physical healthcare in primary care, this interprofessional care management programme reduced emergency department utilisation and hospitalisations while improving utilisation of primary care and psychiatry outpatient care. Further studies should focus on replication of this model to further discern the model's cost-savings and health promotion effects.

Military and veteran health behavior research and practice: challenges and opportunities

There are 2.1 million current military servicemembers and 21 million living veterans in the United States. Although they were healthier upon entering military service compared to the general U.S. population, in the longer term veterans tend to be of equivalent or worse health than civilians. One primary explanation for the veterans' health disparity is poorer health behaviors during or after military service, especially areas of physical activity, nutrition, tobacco, and alcohol. In response, the Department of Defense and Department of Veterans Affairs continue to develop, evaluate, and improve health promotion programs and healthcare services for military and veteran health behavior in an integrated approach. Future research and practice is needed to better understand and promote positive health behavior during key transition periods in the military and veteran life course. Also paramount is implementation and evaluation of existing interventions, programs, and policies across the population using an integrated and person centered approach.

Development of the Chronic Pain Coding System (CPCS) for Characterizing Patient-Clinician Discussions About Chronic Pain and Opioids

OBJECTIVE

To describe the development and initial application of the Chronic Pain Coding System.

DESIGN

Secondary analysis of data from a randomized clinical trial.

SETTING

Six primary care clinics in northern California.

SUBJECTS

Forty-five primary care visits involving 33 clinicians and 45 patients on opioids for chronic noncancer pain.

METHODS

The authors developed a structured coding system to accurately and objectively characterize discussions about pain and opioids. Two coders applied the final system to visit transcripts. Intercoder agreement for major coding categories was moderate to substantial (kappa = 0.5-0.7). Mixed effects regression was used to test six hypotheses to assess preliminary construct validity.

RESULTS

Greater baseline pain interference was associated with longer pain discussions (P = 0.007) and more patient requests for clinician action (P = 0.02) but not more frequent negative patient evaluations of pain (P = 0.15). Greater clinician-reported visit difficulty was associated with more frequent disagreements with clinician recommendations (P = 0.003) and longer discussions of opioid risks (P = 0.049) but not more frequent requests for clinician action (P = 0.11). Rates of agreement versus disagreement with patient requests and clinician recommendations were similar for opioid-related and non-opioid-related utterances.

CONCLUSIONS

This coding system appears to be a reliable and valid tool for characterizing patient-clinician communication about opioids and chronic pain during clinic visits. Objective data on how patients and clinicians discuss chronic pain and opioids are necessary to identify communication patterns and strategies for improving the quality and productivity of discussions about chronic pain that may lead to more effective pain management and reduce inappropriate opioid prescribing.

A systematic review of motivational interviewing in healthcare: the potential of motivational interviewing to address the lifestyle factors relevant to multimorbidity

Internationally, health systems face an increasing demand for services from people living with multimorbidity. Multimorbidity is often associated with high levels of treatment burden. Targeting lifestyle factors that impact across multiple conditions may promote quality of life and better health outcomes for people with multimorbidity. Motivational interviewing (MI) has been studied as one approach to supporting lifestyle behaviour change. A systematic review was conducted to assess the effectiveness of MI in healthcare settings and to consider its relevance for multimorbidity. Twelve meta-analyses pertinent to multimorbidity lifestyle factors were identified. As an intervention, MI has been found to have a small-to-medium statistically significant effect across a wide variety of single diseases and for a range of behavioural outcomes. This review highlights the need for specific research into the application of MI to determine if the benefits of MI seen with single diseases are also present in the context of multimorbidity.

Beneficial Effects of Improvement in Depression, Pain Catastrophizing, and Anxiety on Pain Outcomes: A 12-Month Longitudinal Analysis

Depression, pain catastrophizing, and anxiety commonly co-occur with chronic pain. However, the degree to which improvement in these psychological comorbidities predicts subsequent pain outcomes and, in particular, the relative effects of these 3 psychological factors with respect to each other is only partially known. Longitudinal analysis of 250 primary care patients with chronic musculoskeletal pain enrolled in the Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial was examined, using data gathered at baseline, and at 3 and 12 months. Mixed effects model repeated measures analyses were used to determine if changes in depression, pain catastrophizing, and anxiety predicted a subsequent reduction in pain intensity or interference and pain-related disability. Defining a clinically significant change as twice the standard error of measurement for each predictor, we found that a 2-standard error of measurement improvement in depression, pain catastrophizing, and anxiety resulted in, respectively, an effect size decrease in pain intensity or interference of .45, .33, and .12; a 14%, 12%, and 6% reduction in the number of pain-specific disability days; and a 43%, 30%, and 28% decreased likelihood of high disability (defined as ≥10 pain-specific disability days in the past 4 weeks). In summary, improvements in 3 common psychological comorbidities predicted better pain outcomes.

PERSPECTIVE

Because depression, pain catastrophizing, and anxiety commonly accompany chronic pain and might adversely affect pain outcomes, treatment of these modifiable psychological factors is warranted to optimize the effectiveness of pain-specific therapies.

The association between psychosis and severe pain in community-dwelling adults: Findings from 44 low- and middle-income countries

Previous studies examining the association between schizophrenia and pain have produced mixed results and data on sub-threshold psychosis or psychotic symptoms and pain are scarce. This study assessed the association between psychosis and severe pain among community-dwelling adults in 44 low- and middle-income countries (LMICs) where no data exists. Data on 235,370 adults aged ≥18 years from the World Health Survey (WHS) 2002-2004 were analyzed. The presence of past 12-month psychotic symptoms was established using four questions from the Composite International Diagnostic Interview. Participants were categorized into four mutually exclusive groups based on whether they had at least one psychotic symptom and/or a lifetime psychosis or schizophrenia diagnosis. Multivariable logistic regression was used to estimate the association between psychosis and past 30-day severe pain. The prevalence of severe pain among those with 0, 1, 2, ≥3 psychotic symptoms was 8.7%, 16.7%, 21.8%, 30.5% respectively. Compared to those with no psychotic symptoms or diagnosis, the ORs (95% CIs) were: at least one symptom without diagnosis [2.17 (1.99-2.38)]; no symptom with diagnosis [2.33 (1.71-3.17)]; at least one symptom and diagnosis [4.27 (3.20-5.71)]. Associations were partly mediated by chronic physical conditions, anxiety, and depression. Despite some limitations such as the use of a single-item question to assess pain, the results of this study suggest that individuals with psychotic symptoms or a psychosis diagnosis should be systematically assessed for pain, and if necessary, receive treatment for pain and its underlying conditions. Future research on the effect of pain management on psychosis outcome is warranted.

Patient's experience with comorbidity management in primary care: a qualitative study of comorbid pain and obesity

AIM

The aim of this research is to examine perceptions of those with comorbid chronic pain and obesity regarding their experience of comorbidity management in primary care settings.

BACKGROUND

Chronic pain and obesity are common comorbidities frequently managed in primary care settings. Evidence suggests individuals with this comorbidity may be at risk for suboptimal clinical interactions; however, treatment experiences and preferences of those with comorbid chronic pain and obesity have received little attention.

METHODS

Semi-structured interviews conducted with 30 primary care patients with mean body mass index=36.8 and comorbid persistent pain. The constant comparative method was used to analyze data.

FINDINGS

Participants discussed frustration with a perceived lack of information tailored to their needs and a desire for a personalized treatment experience. Participants found available medical approaches unsatisfying and sought a more holistic approach to management. Discussions also focused around the need for providers to initiate efforts at education and motivation enhancement and to show concern for and understanding of the unique difficulties associated with comorbidity. Findings suggest providers should engage in integrated communication regarding weight and pain, targeting this multimorbidity using methods aligned with priorities discussed by patients.