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Mendez Araque SJ, Nguyen LT, Nadal CN. Outcomes of Psychotherapy for Co-Morbid Pain and Substance Use Disorders: A Review of the Literature. J Pain Palliat Care Pharmacother 2024:1-17. [PMID: 39186683 DOI: 10.1080/15360288.2024.2393842] [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: 03/18/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 08/28/2024]
Abstract
Chronic pain is often treated with opioids, placing patients at risk for misuse. An estimated 11.5% of these patients engage in opioid misuse behaviors such as self-medication. Non-pharmacological interventions have efficacy in managing chronic pain and substance use disorders separately; comorbid management may benefit from psychotherapy. This review provides perspective on novel and existing therapies and their efficacy. The literature search was conducted using PubMed. Boolean search terms were selected from DSM and ICD diagnoses. Studies were included if patients had comorbid substance use disorder and chronic pain diagnoses, participants were age 18 or older, and psychotherapeutic interventions were implemented. The PubMed search yielded 1937 references; 25 references were obtained through other means. 30 sources met inclusion criteria. Reported trials included: Acceptance and Commitment Therapy (ACT, 2 trials); Cognitive Behavioral Therapy (CBT, 11 trials); Mindfulness-Oriented Recovery Enhancement (MORE, 5 trials); and novel psychotherapies (12 trials). Unique features included primary care (4 trials), technology such as phone or Internet (6 trials), and group settings (9 trials). Several psychotherapies effectively treat co-occurring substance use disorders and chronic pain; novel treatments continue to be developed. Further investigation may lead to a wider variety of treatments for clinical use.
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Affiliation(s)
| | - Lynn T Nguyen
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Celeste N Nadal
- Mental Health & Behavioral Sciences Service, James A. Haley Veterans' Hospital & Clinics, Tampa, Florida, USA
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2
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Garland EL. Mindfulness-Oriented Recovery Enhancement: Implementing an evidence-based intervention for chronic pain, opioid use, and opioid addiction in clinical settings. Br J Clin Pharmacol 2024. [PMID: 39046159 DOI: 10.1111/bcp.16147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 07/25/2024] Open
Abstract
The opioid crisis emerged in part due to the overprescribing of opioid analgesics for chronic pain. Although not the only source of the current epidemic of opioid use disorder (OUD), the prescription of opioids for chronic pain remains one vector for the development of opioid misuse and OUD. However, opioid tapering is not appropriate for all patients, and some patients may need to remain on opioid therapy for the long term. To reduce the risk of opioid-related harm among people with chronic pain and to treat incipient or entrenched addictive behaviours, new interventions are needed. This review discusses the clinical outcomes, biobehavioural mechanisms and implementation considerations for a novel, evidence-based intervention for chronic pain, opioid use and OUD called Mindfulness-Oriented Recovery Enhancement (MORE). MORE unites complementary aspects of mindfulness training, cognitive behavioural therapy and principles from positive psychology to simultaneously address addictive behaviour, emotion dysregulation and chronic pain by targeting brain reward and stress systems. MORE has been tested in 13 completed randomized clinical trials, including over 1300 patients, and has demonstrated efficacy against a range of active control conditions for reducing opioid dosing, opioid misuse, illicit drug use, depression, post-traumatic stress symptoms and chronic pain. Opportunities for implementing MORE include facilitating opioid tapering and promoting safe opioid use in primary care and specialty pain clinics, decreasing opioid misuse and enhancing medication-assisted treatment for OUD. Given evidence of MORE's efficacy, it is now time to consider disseminating this evidence-based treatment in the United States, the United Kingdom and worldwide.
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Affiliation(s)
- Eric L Garland
- Department of Psychiatry, University of California-San Diego, La Jolla, California, USA
- Sanford Institute for Empathy and Compassion, University of California-San Diego, La Jolla, California, USA
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3
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Bonar EE, Goldstick JE, Rostker MJ, Dailey SE, Augustiniak AN, Brin C, Manderachia DA, Bourque C, Girard R, Sulkowski L, Lin LA. Testing a new model of telehealth-delivered treatment for primary care patients with alcohol use disorder: A randomized controlled trial protocol. Contemp Clin Trials 2024; 142:107549. [PMID: 38679140 DOI: 10.1016/j.cct.2024.107549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/05/2024] [Accepted: 04/25/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND The majority of adults suffering from alcohol use disorders (AUD) do not receive treatment. To address this gap in care, we must develop new models to increase identification, engagement and delivery of accessible and effective treatment. This paper describes the protocol for a randomized controlled trial (RCT) testing a novel telehealth treatment model for primary care patients with untreated AUD. METHODS We aim to recruit 300 adults across 2 healthcare systems for this two-arm RCT. Participants, initially identified for recruitment based on AUD-related indicators in their electronic health record (EHR), are RCT-eligible if they meet AUD criteria (mild, moderate, severe), report ≥ 3 drinking days/week in past 30 days, and have not received AUD psychotherapy in the past 90 days. Participants are randomized to an intervention or enhanced usual care control (EUC) condition, both individually-delivered. The intervention includes a telephone-delivered motivational interviewing (MI) engagement session and 8 sessions of MI-Cognitive Behavioral Therapy (MI-CBT). EUC involves AUD psychoeducation, advice to reduce drinking and seek treatment, and provision of community resources. Outcomes will be measured at 3-, 6-, and 12-months; primary outcomes include: AUD psychotherapy initiation and engagement (within the study and external community) and alcohol consumption (percent drinking days and heavy drinking days). CONCLUSIONS This study addresses whether proactive patient identification and engagement and delivery of patient-centered telehealth psychotherapy to patients with untreated AUD is effective in increasing treatment use and improving alcohol outcomes. If effective, this could be a highly scalable model for reducing the public health impact of AUD. TRIAL REGISTRATION ClinicalTrials.gov # NCT05410561. University of Michigan HUM00204315. Ann Arbor VA IRB #1655886.
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Affiliation(s)
- Erin E Bonar
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Michigan Innovations in Addiction Care through Research & Education, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Injury Prevention Center, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 10, Ann Arbor, MI 48109, USA.
| | - Jason E Goldstick
- Injury Prevention Center, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 10, Ann Arbor, MI 48109, USA; Department of Emergency Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 10, Ann Arbor, MI 48109, USA; Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Matthew J Rostker
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA
| | - Shayla E Dailey
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA
| | - Alyssa N Augustiniak
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA
| | - Carly Brin
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA
| | - Deborah A Manderachia
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Rd Bldg 16, Ann Arbor, MI 48109, USA
| | - Carrie Bourque
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA
| | - Rachel Girard
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Department of Psychology, University of Rhode Island, 142 Flagg Road, Kingston, RI 02881, USA
| | - Lisa Sulkowski
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA
| | - Lewei Allison Lin
- Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Michigan Innovations in Addiction Care through Research & Education, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 16, Ann Arbor, MI 48109, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Rd Bldg 16, Ann Arbor, MI 48109, USA
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Yang J, Jung M, Picco L, Grist E, Lloyd-Jones M, Giummarra M, Nielsen S. Pain in people seeking and receiving opioid agonist treatment: A systematic review and meta-analysis of prevalence and correlates. Addiction 2024. [PMID: 38886901 DOI: 10.1111/add.16574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/22/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND AND AIMS People with opioid use disorder (OUD) commonly experience pain including chronic pain. Despite the high prevalence, few studies have systematically examined the prevalence and correlates of pain among people seeking or receiving opioid agonist treatment (OAT) for OUD. This review aimed to determine the prevalence of pain in this population globally, and estimate the association between chronic pain and other demographic and clinical characteristics. METHODS Electronic searches were conducted in three databases (Medline, Embase and PsycINFO) from the inception until October 2022. Eligible studies reported prevalence rates of current and/or chronic pain. Meta-analyses examining the main prevalence estimates were conducted by Stata SE 18.0, and comorbid clinical conditions were analysed by Review Manager 5.4. RESULTS Fifty-six studies (n participants = 35 267) from sixty-seven publications were included. Prevalence estimates of current and chronic pain were reported in 27 (48.2%) and 40 studies (71.4%), respectively. Most studies were conducted in North America (71.4%, n = 40) and used cross-sectional designs (64.3%, n = 36). Meta-analyses revealed a pooled prevalence of 60.0% (95% confidence interval [CI]: 52.0-68.0) for current pain and 44.0% [95% CI: 40.0-49.0] for chronic pain. Chronic pain was positively associated with older age (mean deviation of mean age: 2.39 years, 95% CI: 1.40-3.37; I2 = 43%), unemployment (odds ratio [OR] = 0.57, 95% CI: 0.42-0.76; I2 = 78%), more severe mental health symptoms (e.g. more severe depression (standardised mean difference [SMD] of mean scores: 0.45, 95% CI: 0.20-0.70; I2 = 48%) and anxiety symptoms (SMD: 0.52, 95% CI: 0.17-0.88; I2 = 67%), and hepatitis C (OR = 1.41, 95% CI: 1.03-1.94; I2 = 0%). No association was observed between chronic pain and the onset and type of OAT, geographic location, study design, survey year, participant age or use of specific pain assessment tools. CONCLUSIONS There appears to be a high prevalence of pain among people seeking or receiving opioid agonist treatment for opioid use disorder compared with the general population, with positive associations for older age, unemployment, hepatitis C and the severity of some mental health symptoms.
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Affiliation(s)
- Jie Yang
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Elizabeth Grist
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Melita Giummarra
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Schwandt ML, Ramchandani VA, Upadhyay J, Ramsden C, Diazgranados N, Goldman D. Pain in alcohol use disorder: Evaluating effects of childhood trauma, perceived stress, and psychological comorbidity. Alcohol 2024; 117:43-54. [PMID: 38537764 PMCID: PMC11042973 DOI: 10.1016/j.alcohol.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/18/2024] [Accepted: 03/24/2024] [Indexed: 04/05/2024]
Abstract
The relationship between pain and alcohol use disorder (AUD) is complex and bidirectional. The current study examines risk factors for pain in a large comprehensively phenotyped sample including individuals from across the spectrum of alcohol use and misuse. Participants (n = 1101) were drawn from the National Institute on Alcohol Abuse and Alcoholism Natural History Protocol and included treatment-seeking AUD inpatients (AUD+Tx, n = 369), individuals with AUD not seeking treatment (AUD+, n = 161), and individuals without AUD (AUD-, n = 571). General linear models were utilized to test the effects of AUD status, history of childhood trauma exposure, perceived stress, and psychological comorbidity on daily percent time in pain, as well as change in daily percent time in pain across the inpatient stay in AUD+Tx individuals. Overall, 60.2% individuals reported any pain, with a significantly higher prevalence in the AUD+Tx group (82.1%) compared to the AUD+ (56.5%) and AUD- (47.1%) groups. Daily percent time in pain was also highest in the AUD+Tx group (30.2%) and was further increased in those with a history of childhood abuse and comorbid posttraumatic stress disorder (PTSD). Years of heavy drinking and craving were also associated with increased percent time in pain in the AUD+Tx group. Percent time in pain decreased following acute withdrawal in the AUD+Tx group but plateaued around 25% just prior to discharge. Individuals seeking inpatient treatment for AUD, especially those with a history of childhood trauma and/or comorbid PTSD, report greater percent time in pain compared to those not seeking treatment and those without AUD. The prolonged experience of pain in abstinent AUD inpatients after the resolution of acute withdrawal may signal the early stages of protracted withdrawal. Integrative treatments targeting pain and other symptoms of protracted withdrawal may be effective in improving overall function in people with severe AUD.
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Affiliation(s)
- M L Schwandt
- Office of the Clinical Director, National Institute on Alcoholism and Alcohol Abuse (NIAAA), Bethesda, MD, USA.
| | - V A Ramchandani
- Human Psychopharmacology Laboratory, NIAAA, Bethesda, MD, USA
| | - J Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, USA
| | - C Ramsden
- Laboratory of Clinical Investigation, National Institute on Aging, Baltimore, MD, USA
| | - N Diazgranados
- Office of the Clinical Director, National Institute on Alcoholism and Alcohol Abuse (NIAAA), Bethesda, MD, USA
| | - D Goldman
- Office of the Clinical Director, National Institute on Alcoholism and Alcohol Abuse (NIAAA), Bethesda, MD, USA; Laboratory of Neurogenetics, NIAAA, Rockville, MD, USA
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Ma R, Romano E, Ashworth M, Smith TO, Vancampfort D, Scott W, Gaughran F, Stewart R, Stubbs B. The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review. THE JOURNAL OF PAIN 2024; 25:104421. [PMID: 37952860 DOI: 10.1016/j.jpain.2023.11.004] [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: 06/27/2023] [Revised: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Abstract
Chronic pain (CP) and mental illness (MI) are leading causes of years lived with disability and commonly co-occur. However, it remains unclear if available interventions are effective in improving pain outcomes in patients with co-existing CP and MI. This systematic review synthesised evidence for the effectiveness of interventions to improve pain outcomes for people with comorbid CP and clinically diagnosed MI. Ten electronic databases were searched from inception until May 2023. Randomised controlled trials (RCTs) were included if they evaluated interventions for CP-related outcomes among people with comorbid CP and clinically diagnosed MI. Pain-related and mental health outcomes were reported as primary and secondary outcomes, respectively. 26 RCTs (2,311 participants) were included. Four trials evaluated the effectiveness of cognitive-behavioural therapy, 6 mindfulness-based interventions, 1 interpersonal psychotherapy, 5 body-based interventions, 5 multi-component interventions, and 5 examined pharmacological-based interventions. Overall, there was considerable heterogeneity in sample characteristics and interventions, and included studies were generally of poor quality with insufficient trial details being reported. Despite the inconsistency in results, preliminary evidence suggests interventions demonstrating a positive effect on CP may include cognitive-behavioural therapy for patients with depression (with a small to medium effect size) and multi-component intervention for people with substance use disorders (with a small effect size). Despite the high occurrence/burden of CP and MI, there is a relative paucity of RCTs investigating interventions and none in people with severe MI. More rigorously designed RCTs are needed to further support our findings. PERSPECTIVE: This systematic review presents current evidence evaluating interventions for CP-related and MH outcomes for people with comorbid CP and clinically diagnosed MI. Our findings could potentially help clinicians identify the most effective treatments to manage these symptoms for this vulnerable patient group.
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Affiliation(s)
- Ruimin Ma
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
| | - Eugenia Romano
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
| | - Mark Ashworth
- Department of Population Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Toby O Smith
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Davy Vancampfort
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium; Physiotherapy and Psychomotor Therapy Unit, University Psychiatric Centre KU Leuven, Kortenberg, Belgium
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; INPUT Pain Management Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK; National Psychosis Unit, South London and Maudsley NHS Foundation Trust, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK; Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
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7
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De Aquino JP, Sloan ME, Nunes JC, Costa GPA, Katz JL, de Oliveira D, Ra J, Tang VM, Petrakis IL. Alcohol Use Disorder and Chronic Pain: An Overlooked Epidemic. Am J Psychiatry 2024; 181:391-402. [PMID: 38706339 DOI: 10.1176/appi.ajp.20230886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Alcohol use disorder (AUD) and chronic pain disorders are pervasive, multifaceted medical conditions that often co-occur. However, their comorbidity is often overlooked, despite its prevalence and clinical relevance. Individuals with AUD are more likely to experience chronic pain than the general population. Conversely, individuals with chronic pain commonly alleviate their pain with alcohol, which may escalate into AUD. This narrative review discusses the intricate relationship between AUD and chronic pain. Based on the literature available, the authors present a theoretical model explaining the reciprocal relationship between AUD and chronic pain across alcohol intoxication and withdrawal. They propose that the use of alcohol for analgesia rapidly gives way to acute tolerance, triggering the need for higher levels of alcohol consumption. Attempts at abstinence lead to alcohol withdrawal syndrome and hyperalgesia, increasing the risk of relapse. Chronic neurobiological changes lead to preoccupation with pain and cravings for alcohol, further entrenching both conditions. To stimulate research in this area, the authors review methodologies to improve the assessment of pain in AUD studies, including self-report and psychophysical methods. Further, they discuss pharmacotherapies and psychotherapies that may target both conditions, potentially improving both AUD and chronic pain outcomes simultaneously. Finally, the authors emphasize the need to manage both conditions concurrently, and encourage both the scientific community and clinicians to ensure that these intertwined conditions are not overlooked given their clinical significance.
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Affiliation(s)
- Joao P De Aquino
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Matthew E Sloan
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Julio C Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Gabriel P A Costa
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Jasmin L Katz
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Debora de Oliveira
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Jocelyn Ra
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Victor M Tang
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
| | - Ismene L Petrakis
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (DeAquino, Nunes, Ra, Petrakis); Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Conn. (De Aquino, Ra); VA Connecticut Healthcare System, West Haven, Conn. (De Aquino, Petrakis); Addictions Division, Centre for Addiction and Mental Health, Toronto (Sloan, Katz, Tang); Division of Neurosciences and Clinical Translation, Department of Psychiatry, University of Toronto (Sloan); Department of Pharmacology & Toxicology, University of Toronto (Sloan); Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto (Sloan); Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto (Sloan); Institute of Medical Science, University of Toronto (Sloan, Tang); Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto (Sloan, Tang); University of Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil (Costa); St. Elizabeth's Hospital, Washington, D.C. (De Oliveira)
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8
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Palfai TP, Morone NE, Kratzer MPL, Murray GE, Otis JD, Maisto SA, Rowland BHP. Mobile health intervention to address chronic pain among those who engage in hazardous drinking: A pilot study. Drug Alcohol Depend 2024; 256:111121. [PMID: 38367537 PMCID: PMC11056789 DOI: 10.1016/j.drugalcdep.2024.111121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/28/2024] [Accepted: 02/04/2024] [Indexed: 02/19/2024]
Abstract
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.
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Affiliation(s)
- Tibor P Palfai
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA 02215, USA.
| | - Natalia E Morone
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA
| | - Maya P L Kratzer
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA 02215, USA
| | - Grace E Murray
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA 02215, USA
| | - John D Otis
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA 02215, USA
| | - Stephen A Maisto
- Department of Psychology, Syracuse University, 801 430 Huntington Hall, Syracuse NY 13210, USA
| | - Bonnie H P Rowland
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, Boston, MA 02215, USA
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9
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Ilgen MA, Olson-Madden JH, Price A, Brenner LA, King CA, Blow FC. Cognitive behavioral therapy for suicide prevention among Veterans receiving substance use disorder treatment: Results from a randomized trial. J Psychiatr Res 2023; 168:344-352. [PMID: 37956631 DOI: 10.1016/j.jpsychires.2023.10.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/29/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
Veterans receiving substance use disorder (SUD) treatment are at a clear elevated risk for engaging in suicidal behaviors. Intervening to reduce suicide risk during an episode of SUD treatment could meaningfully target a key high-risk group of Veterans. Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) was developed to reduce the frequency and duration of suicidal ideation, as well as decrease suicidal behaviors. The form of CBT-SP in this study progressed from building an understanding of the cognitive model to practicing new skills, and highlighted the links between substance use, craving, self-efficacy and suicidal ideation and attempts. CBT-SP was compared to an attention matched 8-session control condition (termed Supportive Psychoeducational Control [SPC]) during a multi-site randomized controlled trial for 299 Veterans receiving outpatient SUD treatment services within the Veterans Health Administration. The frequency of suicidal ideation remained relatively constant over 24-months of follow-up, however the duration of suicidal ideation decreased, and suicide attempts decreased relative to baseline in both conditions. Forty-two participants (14%) reported at least one suicide attempt during the 2-year follow-up period. No statistically significant differences were found between CBT-SP and SPC on any of these outcomes. Analyses of secondary outcomes indicate that preparatory behaviors for suicide were less common among those in the CBT-SP condition than SPC across the 24-month follow-up (OR, 95%CI = 0.44 (0.25, 0.79); p = 0.02). Veterans in SUD treatment are a high-risk group and delivery of suicide-specific interventions is feasible during SUD care. However, results did not indicate that CBT-SP was superior to SPC on any primary outcomes, underscoring the importance of identifying and testing alternative approaches that support suicide reduction in this group.
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Affiliation(s)
- Mark A Ilgen
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Jennifer H Olson-Madden
- VA Rocky Mountain Mental Illness Research Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA
| | - Amanda Price
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lisa A Brenner
- VA Rocky Mountain Mental Illness Research Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA; Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Cheryl A King
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Frederic C Blow
- Center for Clinical Management Research, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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10
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Lysandrou AE, Teitelbaum SA, Merlo L, Phalin B, Janner A, Solomon L, Hunt J, Lewis B. Co-occurring pain and addiction: prognostic implications for healthcare professionals in residential treatment for substance use disorder. J Addict Dis 2023:1-10. [PMID: 37380371 DOI: 10.1080/10550887.2023.2223505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Objectives: Chronic pain is both an important antecedent and consequence of substance use. Although evidence suggests healthcare professionals may be uniquely vulnerable to chronic pain, this vulnerability remains largely unexamined in the context of recovery from substance use disorders (SUDs). We characterized pain in a sample of treatment-seeking individuals, examined potential differences in pain trajectories between healthcare professionals and non-healthcare patients, and interrogated potential pain-related vulnerabilities in treatment outcomes between these groups. Methods: Patients with SUDs (n = 663; 251 women) completed questionnaires indexing pain intensity, craving, and abstinence self-efficacy (including self-efficacy in pain-related contexts). Assessments were conducted at treatment entry, 30 days, and discharge. Analyses included chi-square and longitudinal mixed models. Results: The proportion of healthcare and non-healthcare patients endorsing recent pain was equivalent (χ2=1.78, p=.18). Healthcare professionals reported lower pain intensity (p = 0.02) and higher abstinence self-efficacy (p < 0.001). Profession by pain interactions (ps <.040) revealed that among medical professionals, associations between pain and all three treatment outcomes of interest were more robust relative to the non-healthcare group. Conclusions: Results suggest that although healthcare professionals endorse similar rates of pain and lower average pain intensity, they may be uniquely vulnerable to pain-related disruptions in craving and abstinence self-efficacy.
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Affiliation(s)
- Apollonia E Lysandrou
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
- Center for Addiction Research & Education, Gainesville, FL, USA
| | - Scott A Teitelbaum
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
| | - Lisa Merlo
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- Center for Addiction Research & Education, Gainesville, FL, USA
| | - Ben Phalin
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
| | - Amanda Janner
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
| | - Laurie Solomon
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
| | - Jason Hunt
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
| | - Ben Lewis
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
- UF Health Florida Recovery Center, Gainesville, FL, USA
- Center for Addiction Research & Education, Gainesville, FL, USA
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11
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Hohenschurz-Schmidt D, Draper-Rodi J, Vase L, Scott W, McGregor A, Soliman N, MacMillan A, Olivier A, Cherian CA, Corcoran D, Abbey H, Freigang S, Chan J, Phalip J, Nørgaard Sørensen L, Delafin M, Baptista M, Medforth NR, Ruffini N, Skøtt Andresen S, Ytier S, Ali D, Hobday H, Santosa AANAA, Vollert J, Rice AS. Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article I): a systematic review and description of methods. Pain 2023; 164:469-484. [PMID: 36265391 PMCID: PMC9916059 DOI: 10.1097/j.pain.0000000000002723] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/17/2022] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Blinding is challenging in randomised controlled trials of physical, psychological, and self-management therapies for pain, mainly because of their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently used sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham-controlled randomised clinical trials of physical, psychological, and self-management treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods, and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (eg, duration and frequency of treatments) than others (eg, physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
| | - Jerry Draper-Rodi
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Lene Vase
- Section for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus C, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alison McGregor
- Human Performance Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Nadia Soliman
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
| | - Andrew MacMillan
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Axel Olivier
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Cybill Ann Cherian
- Chemical Engineering Department, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | - Hilary Abbey
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Sascha Freigang
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Jessica Chan
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Lea Nørgaard Sørensen
- Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Maite Delafin
- The Penn Clinic, Hertfordshire, Hatfield, United Kingdom
| | - Margarida Baptista
- Department of Psychology, Wolfson Centre for Age Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Nuria Ruffini
- National Centre Germany, Foundation C.O.M.E. Collaboration, Berlin, Germany
| | | | | | - Dorota Ali
- Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Harriet Hobday
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
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12
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Ferguson E, Lewis B, Teitelbaum S, Reisfield G, Robinson M, Boissoneault J. Longitudinal associations between pain and substance use disorder treatment outcomes. J Subst Abuse Treat 2022; 143:108892. [PMID: 36228338 PMCID: PMC11025107 DOI: 10.1016/j.jsat.2022.108892] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/29/2022] [Accepted: 09/19/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Pain is commonly reported among those in treatment for substance use disorders (SUD) and is associated with poorer SUD treatment outcomes. The current study examined the trajectory of pain over the course of SUD treatment and associations with substance use outcomes. METHODS This observational study included adults seeking treatment for alcohol, cannabis, or opioid use disorders (N = 811). Participants completed a battery of assessments at treatment admission, 30 days post admission, and at discharge, including measures of demographics, pain, quality of life, abstinence self-efficacy, and craving. RESULTS Analyses indicated linear reductions in pain intensity and interference over time. Significant interactive effects were observed for opioid use disorder (OUD) and time, such that participants with OUD had greater reductions in pain intensity and interference over time compared to those without OUD. Elevated pain intensity was associated with negative treatment outcomes, including reduced quality of life and abstinence self-efficacy, and greater craving and negative affect. CONCLUSIONS Reductions in pain occur over the course of SUD treatment, particularly for those with OUD. Greater pain was also associated with adverse SUD treatment outcomes. Results suggest that treatment and associated abstinence may be beneficial for those with co-occurring pain and SUD, highlighting an additional benefit of improving access to SUD treatment for patients and health care systems. Future research should replicate these findings among diverse samples and further characterize the trajectory of pain during and after SUD treatment.
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Affiliation(s)
- Erin Ferguson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL, USA
| | - Ben Lewis
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Scott Teitelbaum
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Gary Reisfield
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Michael Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL, USA
| | - Jeff Boissoneault
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL, USA.
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13
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Hartz SM, Culverhouse RC, Mintz CM, Ellis MS, Kasper ZA, Cavazos-Rehg P, Grucza RA, Bierut LJ, Cicero TJ. Association between recent overdose and chronic pain among individuals in treatment for opioid use disorder. PLoS One 2022; 17:e0271379. [PMID: 36441691 PMCID: PMC9704550 DOI: 10.1371/journal.pone.0271379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
Chronic pain increases risk for opioid overdose among individuals with opioid use disorder. The purpose of this study is to evaluate the relationship between recent overdose and whether or not chronic pain is active. 3,577 individuals in treatment for opioid use disorder in 2017 or 2018 were surveyed regarding recent overdoses and chronic pain. Demographics from the 2017 Treatment Episode Data Set, which includes all U.S. facilities licensed or certified to provide substance use care, were used to evaluate the generalizability of the sample. χ2 tests and logistic regression models were used to compare associations between recent overdoses and chronic pain. Specifically, active chronic pain was associated with opioid overdose among people in treatment for opioid use disorder. Individuals with active chronic pain were more likely to have had a past month opioid overdose than those with no history chronic pain (adjusted OR = 1.55, 95% CI 1.16-2.08, p = 0.0003). In contrast, individuals with prior chronic pain, but no symptoms in the past 30 days, had a risk of past month opioid overdose similar to those with no history of chronic pain (adjusted OR = 0.88, 95% CI 0.66-1.17, p = 0.38). This suggests that the incorporation of treatment for chronic pain into treatment for opioid use disorder may reduce opioid overdoses.
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Affiliation(s)
- Sarah M. Hartz
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Robert C. Culverhouse
- Department of Medicine and Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Carrie M. Mintz
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Matthew S. Ellis
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Zachary A. Kasper
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Richard A. Grucza
- Department of Family & Community Medicine, St. Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Laura J. Bierut
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Theodore J. Cicero
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
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14
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Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems. J Gen Intern Med 2022; 37:3937-3946. [PMID: 35048300 PMCID: PMC8769678 DOI: 10.1007/s11606-021-07370-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use. OBJECTIVE To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare. DESIGN Cross-sectional nationally representative study. PARTICIPANTS US military veterans (N = 2,836). MAIN MEASURES In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi). KEY RESULTS Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87). CONCLUSIONS Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.
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15
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Arnedt JT, Cardoni ME, Conroy DA, Graham M, Amin S, Bohnert KM, Krystal AD, Ilgen MA. Telemedicine-delivered cognitive-behavioral therapy for insomnia in alcohol use disorder (AUD): study protocol for a randomized controlled trial. Trials 2022; 23:59. [PMID: 35057834 PMCID: PMC8771184 DOI: 10.1186/s13063-021-05898-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/30/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Alcohol use disorder (AUD) is a leading preventable cause of morbidity and mortality, but relapse rates are high even with available treatments. Insomnia is a robust predictor of relapse and pilot studies have shown that CBT for insomnia improves insomnia and daytime functioning in adults with AUD and insomnia. The impact of CBT for insomnia on relapse, however, is unclear. This trial will compare telemedicine-delivered CBT for insomnia (CBT-TM) with sleep hygiene education (SHE-TM) on improving insomnia/sleep, daytime symptom, and drinking outcomes in treatment-seeking AUD adults with insomnia. The study will also determine the effects of treatment on sleep mechanisms and their association with clinical outcomes. METHODS This is a single-site randomized controlled trial with planned enrollment of 150 adults meeting criteria for both AUD and chronic insomnia. Eligible participants will be randomized 1:1 to 6 sessions of telemedicine-delivered Cognitive Behavioral Therapy for Insomnia (CBT-TM) or Sleep Hygiene Education (SHE-TM) with clinical assessments conducted at pre-treatment, post- treatment, and at 3, 6, and 12 months post-treatment. Overnight polysomnography will be conducted before and after treatment. Primary clinical outcomes will include post-treatment scores on the Insomnia Severity Index and the General Fatigue subscale of the Multidisciplinary Fatigue Inventory, and the percent of days abstinent (PDA) on the interview-administered Time Line Follow Back. EEG delta activity, derived from overnight polysomnography, will be the primary endpoint to assess the sleep homeostasis mechanism. DISCUSSION This adequately powered randomized controlled trial will provide clinically relevant information about whether targeting insomnia is effective for improving treatment outcomes among treatment-seeking adults with AUD. Additionally, the study will offer new scientific insights on the impact of an evidence-based non-medication treatment for insomnia on a candidate mechanism of sleep dysfunction in this population - sleep homeostasis. TRIAL REGISTRATION CClinicalTrials.gov NCT # 04457674 . Registered on 07 July 2020.
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Affiliation(s)
- J Todd Arnedt
- Sleep and Circadian Research Laboratory, Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-2700, USA.
| | - M Elizabeth Cardoni
- Sleep and Circadian Research Laboratory, Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-2700, USA
| | - Deirdre A Conroy
- Sleep and Circadian Research Laboratory, Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-2700, USA
| | - Mandilyn Graham
- Sleep and Circadian Research Laboratory, Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-2700, USA
| | - Sajni Amin
- Sleep and Circadian Research Laboratory, Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109-2700, USA
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, USA
| | - Andrew D Krystal
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, USA
| | - Mark A Ilgen
- University of Michigan Addiction Treatment Services, Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA
- VA Center for Clinical Management Research (CCMR) Department of Veterans Affairs Healthcare System, Michigan, Ann Arbor, USA
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16
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Hung HY, Chien WC, Chung CH, Kao LT, Chow LH, Chen YH, Kotlińska JH, Silberring J, Huang EYK. Patients with alcohol use disorder increase pain and analgesics use: A nationwide population-based cohort study. Drug Alcohol Depend 2021; 229:109102. [PMID: 34634646 DOI: 10.1016/j.drugalcdep.2021.109102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/15/2021] [Accepted: 09/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alcohol has dual effects on many systems, including the pain system. We will test whether and how chronic alcohol consumption enhances pain sensation to develop pain disorder. METHODS We conducted a retrospective matched cohort study using data from the National Health Insurance Research Database (NHIRD) in Taiwan, in patients with and without alcohol use disorder (AUD). This study enrolled 19,174 individuals with AUD as study cohort and 19,174 propensity score-matched individuals without AUD as comparison cohort. The outcome was the incidence of pain disorders and the need for analgesics. The hazard ratios of pain disorders and the need for analgesics were evaluated using Cox proportional hazard regression analysis after adjusting for age, sex, index year, comorbidities, urbanization, areas of residence, and insurance premium. RESULTS The 14 years of follow-up showed that AUD patients had a higher adjusted hazard ratio (aHR) for developing pain disorders than in non-AUD controls [aHR= 1.290, 95% confidence interval (CI): 1.045-1.591]. Besides, AUD patients had a higher risk of analgesic use (aHR = 1.081, 95% CI: 1.064-1.312), including opioids and non-opioid analgesics. Most importantly, AUD patients required more days of analgesic use, increased dose of analgesics, and higher costs of analgesics. Moreover, AUD patients had more anemia (aHR=2.772, 95% CI: 2.581-2.872), which could be a mediating factor. CONCLUSIONS AUD patients had higher risks of developing pain disorders and subsequently increased analgesic demand. These results suggest that AUD worsened pain, and pain syndrome is correlated with the duration of chronic alcohol exposure.
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Affiliation(s)
- Hao-Yuan Hung
- Department of Pharmacology, National Defense Medical Center, Taipei 11490, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 11490, Taiwan; Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Wu-Chien Chien
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 11490, Taiwan; School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; Taiwanese Injury Prevention and Safety Promotion Association, Taipei 11490, Taiwan
| | - Li-Ting Kao
- Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan; Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 11490, Taiwan; School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan; School of Pharmacy, National Defense Medical Center, Taipei 11490, Taiwan
| | - Lok-Hi Chow
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei 11217, Taiwan; Department of Anesthesiology, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan; Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yuan-Hao Chen
- Department of Pharmacology, National Defense Medical Center, Taipei 11490, Taiwan; Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Jolanta H Kotlińska
- Department of Pharmacology and Pharmacodynamics, Faculty of Pharmacy with Division of Medical Analytics, Medical University of Lublin, Lublin 20-093, Poland
| | - Jerzy Silberring
- Department of Biochemistry and Neurobiology, Faculty of Materials Science and Ceramics, AGH University of Science and Technology, Krakow 30-059, Poland
| | - Eagle Yi-Kung Huang
- Department of Pharmacology, National Defense Medical Center, Taipei 11490, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 11490, Taiwan.
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17
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Wyse J, Lovejoy J, Holloway J, Morasco BJ, Dobscha SK, Hagedorn H, Lovejoy TI. Patients' perceptions of the pathways linking chronic pain with problematic substance use. Pain 2021; 162:787-793. [PMID: 32947546 PMCID: PMC7886942 DOI: 10.1097/j.pain.0000000000002077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Approximately one-half of patients with substance use disorders (SUDs) experience chronic pain. Yet, how patients perceive the relationship between their substance use and chronic pain remains poorly understood. We sought to identify how patients with comorbid SUD and chronic pain describe the relationship between, and mechanisms linking, these conditions. We conducted qualitative interviews with 34 patients engaged in SUD treatment who were also diagnosed with chronic pain. Interviews were transcribed verbatim and coded by both primary and secondary coders. Qualitative content analysis guided coding and analysis. Patient interviews revealed 3 primary pathways. One group of participants described SUD as developing independently from their experiences of chronic pain. A second group of participants described turning to substances to self-manage or cope with the physical and emotional aspects of chronic pain. A third group of participants described encounters with opioid medications as the causal agent initiating a SUD. Our findings build on research that has identified chronic pain and SUD as developmentally similar and mutually reinforcing, by revealing the ways in which patients themselves understand and experience the interconnections between their substance use and chronic pain.
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Affiliation(s)
- Jessica Wyse
- School of Public Health, Oregon Health & Science University
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System
| | | | - Julia Holloway
- College of Health and Behavioral Sciences, Chapman University
| | - Benjamin J. Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System
- Department of Psychiatry, Oregon Health & Science University
| | - Steven K. Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System
- Department of Psychiatry, Oregon Health & Science University
| | - Hildi Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System
- Department of Psychiatry, University of Minnesota School of Medicine
| | - Travis I. Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System
- Department of Psychiatry, Oregon Health & Science University
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18
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Mazanec P, Paice J, Campbell G, Ginex PK, Harris M, Matzo M. Managing pain in seriously ill patients with substance use disorders. Nursing 2021; 51:32-39. [PMID: 33346615 DOI: 10.1097/01.nurse.0000724344.85870.b2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
ABSTRACT Managing pain can be challenging, especially in patients with serious illnesses and a history of substance use disorders. This article discusses the challenges of addressing pain in these patients and offers perspectives regarding their clinical management.
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Affiliation(s)
- Polly Mazanec
- Polly Mazanec is a visiting associate professor at Case Western Reserve University in Cleveland, Ohio; Judy Paice is director of the cancer pain program at Northwestern University in Chicago, Ill.; Grace Campbell is an assistant professor at the University of Pittsburgh in Pittsburgh, Pa.; Pamela K. Ginex is a senior manager of evidence-based practice and inquiry at the Oncology Nursing Society in Pittsburgh, Pa.; Melodee Harris is an associate professor at the University of Arkansas in Little Rock, Ark.; and. Marianne Matzo is the former director of research at the Hospice and Palliative Nurses Association in Pittsburgh, Pa
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19
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Frank JW, Bohnert ASB, Sandbrink F, McGuire M, Drexler K. Implementation and Policy Recommendations from the VHA State-of-the-Art Conference on Strategies to Improve Opioid Safety. J Gen Intern Med 2020; 35:983-987. [PMID: 33145691 PMCID: PMC7609348 DOI: 10.1007/s11606-020-06295-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/05/2020] [Indexed: 01/25/2023]
Abstract
Evidence-based treatment of opioid use disorder, the prevention of opioid overdose and other opioid-related harms, and safe and effective pain management are priorities for the Veterans Health Administration (VHA). The VHA Office of Health Services Research and Development hosted a State-of-the-Art Conference on "Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety" on September 10-11, 2019. This conference convened a multidisciplinary group to discuss and achieve consensus on a research agenda and on implementation and policy recommendations to improve opioid safety for Veterans. Participants were organized into three workgroups: (1) managing opioid use disorder; (2) Long-term opioid therapy and opioid tapering; (3) managing co-occurring pain and substance use disorder. Here we summarize the implementation and policy recommendations of each workgroup and highlight important cross-cutting issues related to telehealth, care coordination, and stepped care model implementation.
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Affiliation(s)
- Joseph W Frank
- VA Eastern Colorado Health Care System, Aurora, CO, USA. .,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Amy S B Bohnert
- University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Friedhelm Sandbrink
- Washington DC VA Medical Center, Washington, DC, USA.,Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA.,George Washington University, Washington, DC, USA
| | - Marsden McGuire
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Karen Drexler
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA.,Atlanta VA Medical Center, Decatur, GA, USA.,Emory University School of Medicine, Atlanta, GA, USA
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20
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Ilgen MA, Coughlin LN, Bohnert ASB, Chermack S, Price A, Kim HM, Jannausch M, Blow FC. Efficacy of a Psychosocial Pain Management Intervention for Men and Women With Substance Use Disorders and Chronic Pain: A Randomized Clinical Trial. JAMA Psychiatry 2020; 77:1225-1234. [PMID: 32725178 PMCID: PMC7391182 DOI: 10.1001/jamapsychiatry.2020.2369] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Chronic pain is common in those with substance use disorders (SUDs) and predicts poorer addiction treatment outcomes. A critical challenge for addiction treatment is to develop effective methods to improve pain-related and substance use-related outcomes for those in treatment for SUDs. OBJECTIVE To examine the efficacy of an integrated behavioral pain management intervention (Improving Pain During Addiction Treatment [ImPAT]) for men and women with SUDs to treat pain, functioning, and substance use. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 8 sessions of ImPAT were compared with 8 sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up occurred at 3, 6, and 12 months postbaseline. A total of 1372 adults were screened, including 960 men and 412 women, and 510 adults were randomized, including 264 men and 246 women. The goal was to recruit approximately equal numbers of men and women to examine results separately in men and women. A total of 470 of 510 participants (92.2%) completed at least 1 follow-up assessment. Data were collected from October 3, 2011, to January 14, 2016. Data were analyzed from February 1, 2016, to May 1, 2020. INTERVENTIONS ImPAT focused on how a psychosocial model of pain was associated with functioning and relapse prevention and provides skills to manage pain. SPC served as the active control condition and involved discussions of topics like nutrition and the course of addiction, which were intended to be relevant to the patient population and to have face validity but be distinct from the content of ImPAT. MAIN OUTCOMES AND MEASUREMENTS The primary outcomes were pain intensity, pain-related functioning, and behavioral pain tolerance at 12 months. Secondary outcomes were frequency of alcohol and drug use over 12 months. RESULTS Of the 510 included participants, the mean (SD) age was 34.8 (10.3) years. A total of 133 men and 122 women were assigned to ImPAT, and a total of 131 men and 124 women were assigned to the SPC condition. Over 12 months of follow-up, randomization to the ImPAT intervention was associated with higher tolerance of pain among men, higher by a mean score of 0.11 (95% CI, 0.03 to 0.18; P = .004; Cohen d = 0.40) at 3 months and by 0.07 (95% CI, -0.01 to 0.19; P = .11; Cohen d = 0.25) at 12 months. Women receiving the ImPAT intervention experienced a reduction in pain intensity from 3 to 12 months, while women receiving the SPC condition experienced an increase in pain intensity, resulting in lower pain in the ImPAT condition by a mean score of 0.58 (95% CI, -0.07 to 1.22; P = .08; Cohen d = -0.22) at 12 months. No differences were found between the ImPAT and SPC conditions on alcohol or drug use. CONCLUSIONS AND RELEVANCE Behavioral pain management is not typically included in addiction treatment, but the present results indicate that this type of intervention was associated with better pain-related outcomes, including pain tolerance in men and pain intensity in women. Improvements in substance use-related outcomes beyond that achieved by treatment as usual were not observed. Treatment programs should consider providing psychosocial pain management services to augment standard addiction treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01372267.
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Affiliation(s)
- Mark A. Ilgen
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Lara N. Coughlin
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Stephen Chermack
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Amanda Price
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - H. Myra Kim
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Mary Jannausch
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Frederic C. Blow
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan,Department of Psychiatry, University of Michigan Medical School, Ann Arbor
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21
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Becker WC, Krebs EE, Edmond SN, Lin LA, Sullivan MD, Weiss RD, Gordon AJ. A Research Agenda for Advancing Strategies to Improve Opioid Safety: Findings from a VHA State of the Art Conference. J Gen Intern Med 2020; 35:978-982. [PMID: 33145681 PMCID: PMC7728950 DOI: 10.1007/s11606-020-06260-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/21/2020] [Indexed: 11/27/2022]
Abstract
US military Veterans have been disproportionately impacted by the US opioid overdose crisis. In the fall of 2019, the Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of opioid safety, including both use of opioid analgesics and managing opioid use disorder. We present the methods and consensus recommendations from the SOTA. A core group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: managing opioid use disorder, long-term opioid therapy for pain including consideration for opioid tapering, and treatment of co-occurring pain and substance use disorders. The SOTA participants divided into three workgroups and identified key questions and seminal studies related to those three areas of focus. The strongest recommendations included testing implementation strategies in the VHA for expanding access to medication treatment for opioid use disorder, testing collaborative tapering programs for patients prescribed long-term opioids, and larger trials of behavioral and exercise/movement interventions for pain among patients with substance use disorders.
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Affiliation(s)
- William C Becker
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mark D Sullivan
- University of Washington School of Medicine, Seattle, WA, USA
| | - Roger D Weiss
- Harvard Medical School, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient Aligned Care Team Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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22
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Ferguson E, Zale E, Ditre J, Wesolowicz D, Stennett B, Robinson M, Boissoneault J. CANUE: A Theoretical Model of Pain as an Antecedent for Substance Use. Ann Behav Med 2020; 55:489-502. [PMID: 32914834 DOI: 10.1093/abm/kaaa072] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pain and substance use are frequently comorbid and have been shown to exert bidirectional effects. Self-medication of pain and distress via substance use is common and can be understood via negative reinforcement, ultimately strengthening the pathway between pain to substance use over time. As such, a testable model of the potentially modifiable candidate mechanisms that underlie the pain to substance use pathway is needed. PURPOSE This review proposes a testable model of pain as an antecedent to substance use to guide future research and inform clinical practice. METHODS An integrative review of current evidence regarding pain, substance use, and associated risk factors (i.e., negative affect, pain-related attitudes, negative urgency, and substance use outcome expectancies) was conducted. RESULTS The Catastrophizing, Anxiety, Negative Urgency, and Expectancy (CANUE) model highlights modifiable risk factors for self-medicating pain with substance use, including increased negative affect and maladaptive pain-related attitudes (i.e., pain catastrophizing, pain anxiety, and fear of pain), negative urgency, and substance-related outcome expectancies for pain relief and enhanced pain coping. CONCLUSIONS Targeted behavioral and psychological interventions that address these factors may facilitate more adaptive pain-coping responses, thereby reducing the impacts of pain on substance use. Systematic research is needed to evaluate the validity and clinical utility of this model.
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Affiliation(s)
- Erin Ferguson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.,Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL USA
| | - Emily Zale
- Department of Psychology, Binghamton University, State University of New York, Binghamton, NY, USA
| | - Joseph Ditre
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Danielle Wesolowicz
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.,Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL USA
| | - Bethany Stennett
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.,Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL USA
| | - Michael Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.,Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL USA
| | - Jeff Boissoneault
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA.,Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL USA
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23
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Ashrafioun L, Zerbo KRA, Bishop TM, Britton PC. Opioid use disorders, psychiatric comorbidities, and risk for suicide attempts among veterans seeking pain care. Psychol Med 2020; 50:2107-2112. [PMID: 31522694 DOI: 10.1017/s0033291719002307] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The purpose of this study was to assess the associations of comorbid opioid use disorders and psychiatric disorders with suicide attempts among veterans seeking pain care. METHODS The cohort (N = 226 444) was selected by identifying pain care initiation from 2012 to 2014 using national Veterans Health Administration (VHA) data. Data on opioid use disorders (OUD), psychiatric disorders, medical comorbidity, demographics at baseline, and suicide attempts in the year following the initiation of pain care were extracted from VHA databases. Relative excess risk due to interaction (RERI) was used to assess departure from additivity of effects. RESULTS Adjusted models indicated that both comorbid OUD and depression (RERI = 1.07) and comorbid OUD and AUD (RERI = 1.23) were significantly associated with additive risk of suicide attempt. In adjusted multiplicative interaction models, only comorbid OUD and bipolar disorder was significantly associated with suicide attempts; however, this association was protective (HR = 0.54). CONCLUSIONS The current findings highlight the importance of addressing opioid use disorders and alcohol use disorders and depression together to mitigate the risk of suicidal behavior.
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Affiliation(s)
- Lisham Ashrafioun
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, 300 Crittenden Boulevard, Rochester, NY14642, USA
| | - Kotwoallama R A Zerbo
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
| | - Todd M Bishop
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, 300 Crittenden Boulevard, Rochester, NY14642, USA
| | - Peter C Britton
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, 300 Crittenden Boulevard, Rochester, NY14642, USA
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24
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Chronic non-cancer pain among adults with substance use disorders: Prevalence, characteristics, and association with opioid overdose and healthcare utilization. Drug Alcohol Depend 2020; 209:107902. [PMID: 32088587 PMCID: PMC7127943 DOI: 10.1016/j.drugalcdep.2020.107902] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic non-cancer pain (CNCP) among patients with substance use disorder (SUD) poses a risk for worse treatment outcomes. Understanding the association of CNCP with SUD is important for informing the need and potential benefits of pain assessment/management among those with SUDs. METHODS We analyzed electronic health record data from 2013 to 2018 among adults aged ≥18 years (N = 951,533; mean age: 48.4 years; 57.4 % female) in a large academic healthcare system. Adjusted logistic regression models were conducted to estimate the association of CNCP conditions with opioid overdose, emergency department utilization, and inpatient hospitalization stratified by different SUD diagnoses and by gender. RESULTS Among the total sample, the prevalence of CNCP was 46.6 % and any SUD was 11.2 %. The majority of patients with a SUD had CNCP (opioid: 74.7 %; sedative: 72.3 %; cannabis: 64.3 %; alcohol: 58.7 %; tobacco: 59.5 %). The prevalence of CNCP was greater in females vs. males for most SUD diagnoses. The presence of CNCP was associated with more mental health disorders and chronic medical conditions among each SUD group. CNCP was associated with significantly decreased odds of overdose among those with opioid use disorder but increased odds of overdose and healthcare utilization among other SUDs. CNCP was positively associated with overdose in females, but not males, with alcohol or non-opioid drug use disorders. CONCLUSIONS The direction and magnitude of the association between CNCP and negative health indicators differed as a function of SUD type and gender, respectively. Greater awareness of potential unmet pain treatment need may have implications for improving SUD outcomes.
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25
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Clinician Response to Aberrant Urine Drug Test Results of Patients Prescribed Opioid Therapy for Chronic Pain. Clin J Pain 2020; 35:1-6. [PMID: 30222612 DOI: 10.1097/ajp.0000000000000652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Urine drug testing (UDT) is recommended for patients who are prescribed opioid medications, but little is known about the various strategies clinicians use to respond to aberrant UDT results. We sought to examine changes in opioid prescribing and implementation of other risk reduction activities following an aberrant UDT. METHODS In a national cohort of Veterans Affairs patients with new initiations of opioid therapy through 2013, we identified a random sample of 100 patients who had aberrant positive UDTs (results positive for nonprescribed/illicit substance), 100 who had aberrant negative UDTs (results negative for prescribed opioid), and 100 who had expected UDT results. We examined medical record data for opioid prescribing changes and risk reduction strategies in the 12 months following UDT. RESULTS Following an aberrant UDT, 17.5% of clinicians documented planning to discontinue or change the opioid dose and 52.5% initiated another strategy to reduce opioid-related risk. In multivariate analyses, variables associated with a planned change in opioid prescription status were having an aberrant positive UDT (odds ratio [OR], 30.77; 95% confidence interval [CI], 5.92-160.10) and higher prescription opioid dose (OR, 1.01; 95% CI, 1.01-1.02). The only variable associated with implementation of other risk reduction activities was having an aberrant positive UDT (OR, 0.29; 95% CI, 0.16-0.55). DISCUSSION The majority of clinicians enacted some type of opioid prescribing or other change to reduce risk following an aberrant UDT, and the action depended on whether the result was an aberrant positive or aberrant negative UDT. Experimental studies are needed to develop and test strategies for managing aberrant UDT results.
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26
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Fernandez AC, Bush C, Bonar EE, Blow FC, Walton MA, Bohnert AA. Alcohol and Drug Overdose and the Influence of Pain Conditions in an Addiction Treatment Sample. J Addict Med 2020; 13:61-68. [PMID: 30161038 PMCID: PMC6533535 DOI: 10.1097/adm.0000000000000451] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Overdose from alcohol and/or drugs kills tens of thousands of Americans annually, with a large number of deaths attributed to opioid pain medications. Addiction treatment patients are known to be at high risk for overdose; however, the relationship between pain and overdose history within this group is understudied, especially in relation to alcohol overdoses. In the present study, we evaluated whether nonfatal overdose history was more likely among addiction treatment patients with pain, and examined the characteristics of overdoses among those with and without pain. METHODS We analyzed cross-sectional data from 739 patients at a large residential addiction treatment center (median age 37, 25.7% female). We used 2-stepped binary regression models to evaluate whether demographics, pain type (chronic, acute, or both), depression symptoms, and opioid misuse were associated with lifetime history of nonfatal (1) alcohol and (2) drug overdose (lifetime yes/no), and conducted follow-up analyses examining overdose characteristics. RESULTS In adjusted analyses, history of chronic pain (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.59, 4.27) and illicit drug use (OR 1.99, 95% CI 1.07, 3.68) were associated with an increased likelihood of nonfatal alcohol overdose. Opioid misuse (OR 3.11, 95% CI 2.51, 3.86), depression symptoms (OR 1.33, 95% CI 1.14, 1.55), and younger age (OR 0.96, 95% CI 0.94, 0.97) were associated with increased likelihood of drug overdose. Those with pain reported a higher number of lifetime alcohol overdoses and were more likely to combine numerous drugs with alcohol before overdose. CONCLUSIONS Pain conditions may play an under-recognized role in the overdose epidemic, particularly alcohol-related overdose. Addiction treatment and overdose prevention interventions should incorporate appropriate assessment and treatment of pain including education about the risks of polysubstance use, particularly combining alcohol with sedatives and prescription pain relievers.
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Affiliation(s)
- Anne C. Fernandez
- Department of Psychiatry & Addiction Center, Michigan Medicine, Ann Arbor, MI, 48109 USA
| | - Christopher Bush
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Erin E. Bonar
- Department of Psychiatry & Addiction Center, Michigan Medicine, Ann Arbor, MI, 48109 USA
- Injury Prevention Center, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Frederic C. Blow
- Department of Psychiatry & Addiction Center, Michigan Medicine, Ann Arbor, MI, 48109 USA
- VA Center for Clinical Management Research, Ann Arbor, MI, 48109, USA
| | - Maureen A. Walton
- Department of Psychiatry & Addiction Center, Michigan Medicine, Ann Arbor, MI, 48109 USA
- Injury Prevention Center, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Amy A.S.B. Bohnert
- Department of Psychiatry & Addiction Center, Michigan Medicine, Ann Arbor, MI, 48109 USA
- VA Center for Clinical Management Research, Ann Arbor, MI, 48109, USA
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Morasco BJ, Smith N, Dobscha SK, Deyo RA, Hyde S, Yarborough BJH. Outcomes of prescription opioid dose escalation for chronic pain: results from a prospective cohort study. Pain 2020; 161:1332-1340. [DOI: 10.1097/j.pain.0000000000001817] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
PURPOSE OF REVIEW To review and discuss recent advances in evidence-based interventions (EBIs) for youth suicide risk. RECENT FINDINGS There is a growing body of research on the effectiveness of interventions targeting suicidal ideation and behavior among adolescents. Dialectical Behavioral Therapy-Adolescent has shown effectiveness across two independent randomized controlled trials (RCTs). Several other interventions have shown effectiveness in only one trial and are in need of replication. New interventions are also being developed that incorporate developments in technology and adaptive intervention designs. It is recommended that future research focus on strategies for engaging underserved youth with interventions, consider the broader needs of youth living in poverty, and further tailor interventions to subgroups with distinct risk profiles. Limited EBIs exist for preadolescents, despite evidence for an increasing rate of suicidal behavior for these youth. Several interventions for youth suicide risk are highly promising, but further investigation is necessary. EBIs that are effective for preadolescents are needed, and greater efforts to tailor interventions for distinct subgroups of youth at risk are recommended.
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St Marie B, Broglio K. Managing Pain in the Setting of Opioid Use Disorder. Pain Manag Nurs 2019; 21:26-34. [PMID: 31648905 DOI: 10.1016/j.pmn.2019.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/27/2019] [Accepted: 08/03/2019] [Indexed: 12/11/2022]
Abstract
SPECIFIC CLINICAL ISSUE Healthcare providers are challenged with managing pain and minimizing morbidity and mortality associated with opioid use disorder. MAJOR PRACTICE RECOMMENDATIONS BASED ON BEST EVIDENCE The purpose of this article is to guide acute and ambulatory care clinicians in managing pain in patients with opioid use disorder. Included in this article is a review of medications used for opioid use disorder, a discussion of the management of patients with active opioid use disorder and acute or chronic pain, and a discussion of the management of acute and chronic pain in people in recovery both on and off medications for opioid use disorder.
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Affiliation(s)
| | - Kathleen Broglio
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Collaboratory for Implementation Sciences at Dartmouth, Lebanon, New Hampshire
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Smallwood RF, Price LR, Campbell JL, Garrett AS, Atalla SW, Monroe TB, Aytur SA, Potter JS, Robin DA. Network Alterations in Comorbid Chronic Pain and Opioid Addiction: An Exploratory Approach. Front Hum Neurosci 2019; 13:174. [PMID: 31191279 PMCID: PMC6548857 DOI: 10.3389/fnhum.2019.00174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/13/2019] [Indexed: 12/17/2022] Open
Abstract
The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction were compared with eighteen age- and sex-matched healthy individuals in a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually.
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Affiliation(s)
- Rachel F Smallwood
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Larry R Price
- Metholology, Measurement and Statistical Analysis, Texas State University, San Marcos, TX, United States
| | - Jenna L Campbell
- Department of Communication Sciences and Disorders, University of New Hampshire, Durham, NH, United States
| | - Amy S Garrett
- Department of Psychiatry, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - Sebastian W Atalla
- College of Nursing, The Ohio State University, Columbus, OH, United States
| | - Todd B Monroe
- College of Nursing, The Ohio State University, Columbus, OH, United States
| | - Semra A Aytur
- Department of Health Management and Policy, University of New Hampshire, Durham, NH, United States
| | - Jennifer S Potter
- Department of Psychiatry, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - Donald A Robin
- Department of Communication Sciences and Disorders, University of New Hampshire, Durham, NH, United States.,Interdisciplinary Program in Neuroscience and Behavior, University of New Hampshire, Durham, NH, United States
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31
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Moore AA, Lake JE, Glasner S, Karlamangla A, Kuerbis A, Preciado D, Jenkins J, Dominguez BX, Candelario J, Liao DH, Tang L, Reid MC. Establishing the feasibility, acceptability and preliminary efficacy of a multi-component behavioral intervention to reduce pain and substance use and improve physical performance in older persons living with HIV. J Subst Abuse Treat 2019; 100:29-38. [PMID: 30898325 DOI: 10.1016/j.jsat.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 01/21/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022]
Abstract
Older persons living with HIV (PLWH), often defined as age 50 years and older, are a rapidly growing population, with high rates of chronic pain, substance use, and decreased physical functioning. No interventions currently exist that address all three of these health outcomes simultaneously. An 8-week behavioral intervention combining cognitive-behavioral therapy and tai chi reinforced with text messaging (CBT/TC/TXT) was developed and pilot tested in a community-based AIDS service organization with substance using PLWH aged 50 years and older who experienced chronic pain. Fifty-five participants were enrolled in a three arm randomized controlled trial that compared the CBT/TC/TXT intervention (N = 18) to routine Support Group (SG) (N = 19) and Assessment Only (AO) (N = 18) to assess the intervention's feasibility, acceptability and preliminary efficacy to reduce pain and substance use and improve physical performance. Participants were assessed at baseline, treatment-end (week 8) and week 12. Feasibility and acceptability indicators showed moderate levels of participant enrollment (62% of those eligible), excellent 12-week assessment completion (84%) and high attendance at CBT and tai chi sessions (>60% attended at least 6 of 8 sessions). Efficacy indicators showed within-group improvements from baseline to week 12 in the CBT/TC/TXT group, including all four substance use outcomes, percent pain relief in the past 24 h, and in two physical performance measures. Observed between-group changes included greater reductions in days of heavy drinking in the past 30 days for both CBT/TC/TXT (19%) and SG (13%) compared to the AO group. Percent pain relief in the past 24 h improved in the CBT/TC/TXT group relative to SG, and the CBT/TC/TXT's physical performance score improved relative to both the SG and AO groups. Findings demonstrate that the CBT/TC/TXT intervention is feasible to implement, acceptable and has preliminary efficacy for reducing substance use and pain and improving physical performance among a vulnerable population of older PLWH.
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Affiliation(s)
- Alison A Moore
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America.
| | - Jordan E Lake
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, CA, United States of America
| | - Suzette Glasner
- Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences and School of Nursing, University of California, Los Angeles, CA, United States of America
| | - Arun Karlamangla
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Alexis Kuerbis
- Silberman School of Social Work, Hunter College at City University of New York, New York, NY, United States of America
| | - Diane Preciado
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Jessica Jenkins
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Blanca X Dominguez
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Jury Candelario
- APAIT, A Division of Special Services for Groups, Los Angeles, CA, United States of America
| | - Diana H Liao
- Division of Geriatrics, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Lingqi Tang
- Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, United States of America; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, United States of America
| | - M Carrington Reid
- Division of Geriatrics and Palliative Care, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
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Barry DT, Beitel M, Cutter CJ, Fiellin DA, Kerns RD, Moore BA, Oberleitner L, Madden LM, Liong C, Ginn J, Schottenfeld RS. An evaluation of the feasibility, acceptability, and preliminary efficacy of cognitive-behavioral therapy for opioid use disorder and chronic pain. Drug Alcohol Depend 2019; 194:460-467. [PMID: 30508769 PMCID: PMC6312460 DOI: 10.1016/j.drugalcdep.2018.10.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 12/28/2022]
Abstract
AIMS The primary study aim was to evaluate the feasibility and acceptability of cognitive-behavioral therapy (CBT) for opioid use disorder and chronic pain. The secondary aim was to examine its preliminary efficacy. METHODS In a 12-week pilot randomized clinical trial, 40 methadone-maintained patients were assigned to receive weekly manualized CBT (n = 21) or Methadone Drug Counseling (MDC) to approximate usual drug counseling (n = 19). RESULTS Twenty of 21 patients assigned to CBT and 18 of 19 assigned to MDC completed the pilot study. Mean (SD) sessions attended were 8.4 (2.9) for CBT (out of 12 possible) and 3.8 (1.1) for MDC (out of 4 possible); mean (SD) patient satisfaction ratings (scored on 1-7 Likert-type scales) were 6.6 (0.5) for CBT and 6.0 (0.4) for MDC (p < .001). The proportion of patients abstinent during the baseline and each successive 4-week interval was higher for patients assigned to CBT than for those assigned to MDC [Wald χ2 (1) = 5.47, p = .02]; time effects (p = .69) and interaction effects between treatment condition and time (p = .10) were not significant. Rates of clinically significant change from baseline to end of treatment on pain interference (42.9% vs. 42.1%, [χ2 (1, N = 40) = 0.002, p = 0.96]) did not differ significantly for patients assigned to CBT or MDC. CONCLUSIONS We found support for the feasibility, acceptability, and preliminary efficacy of cognitive-behavioral therapy relative to standard drug counseling in promoting abstinence from nonmedical opioid use among patients with opioid use disorder and chronic pain. Overall, patients exhibited improved pain outcomes, but these improvements did not differ significantly by treatment condition.
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Affiliation(s)
- Declan T Barry
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States.
| | - Mark Beitel
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States
| | - Christopher J Cutter
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States
| | - David A Fiellin
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT, 06519, United States
| | - Robert D Kerns
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; VA Connecticut Healthcare System, West Haven, CT, 06516, United States
| | - Brent A Moore
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; VA Connecticut Healthcare System, West Haven, CT, 06516, United States
| | - Lindsay Oberleitner
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States
| | - Lynn M Madden
- Yale School of Medicine, Department of Psychiatry, New Haven, CT, 06511, United States; APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States
| | - Christopher Liong
- APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States
| | - Joel Ginn
- APT Foundation Pain Treatment Services, New Haven, CT, 06519, United States
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Wilson‐Poe AR, Morón JA. The dynamic interaction between pain and opioid misuse. Br J Pharmacol 2018; 175:2770-2777. [PMID: 28602044 PMCID: PMC6016619 DOI: 10.1111/bph.13873] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/21/2017] [Accepted: 05/09/2017] [Indexed: 12/22/2022] Open
Abstract
In 2014, drug overdose surpassed automobile accidents as the number one cause of accidental death for the first time in the history of the United States. The overdose epidemic is largely driven by opioids, and genuine prescription opioid analgesics play the biggest role in this phenomenon. Despite advancements in abuse deterrent formulations, prescription drug monitoring programmes and clinical assessments for the detection of abuse potential, drug overdoses continue to escalate. The Center for Disease Control has recently issued new guidelines for opioid prescription, yet even these recommendations have their shortcomings. Furthermore, undertreated pain in patients with comorbid substance use disorder poses a major clinical challenge, particularly for patients on opioid replacement therapy. Despite the seemingly obvious interaction between the presence of pain and the abuse of pain-relieving opioids, there is surprisingly little mechanistic data to further our understanding of this vitally important topic. The need for novel pain interventions that minimize abuse liability is critical. Without a fundamental characterization of pain neurobiology and the interaction between chronic pain and the brain's reward system, we are unlikely to make progress in the alleviation of the opioid epidemic. LINKED ARTICLES This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.
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Affiliation(s)
- Adrianne R Wilson‐Poe
- Pain Center, Department of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
| | - Jose A Morón
- Pain Center, Department of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
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Abstract
PURPOSE OF REVIEW Chronic pain impacts millions of people in the USA. At the heart of the problem of chronic pain remains the complex psychosocial aspects associated with living with chronic pain. Given the overlap between chronic pain and mental health, a promising treatment approach is to improve how we integrate psychiatry into pain management. RECENT FINDINGS Treatment of chronic pain and comorbid mental health issues requires a multidisciplinary approach. Advancements in how pain is understood, especially centralized pain, have helped inform both pharmacological and behavioral interventions for pain. Given the growing concerns about the opioid epidemic and the lack of data supporting the use of opioids for long-term pain management, new treatment approaches are needed. Psychiatrist may be uniquely suited to help address comorbid mental health disorders and addiction in the context of chronic pain management. Addressing the psychiatric needs of chronic pain patients remains challenging and there is much room to improve how we address the complex issues associated with living with chronic pain. We believe psychiatrists are an important piece of the pain management puzzle.
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Affiliation(s)
- Jenna Goesling
- Department of Anesthesiology, Back & Pain Center, University of Michigan, Burlington Building 1, Suite 100, 325 E. Eisenhower Parkway, Ann Arbor, MI, 48108, USA.
| | - Lewei A Lin
- Department of Psychiatry, North Campus Research Complex, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Veterans Affairs Healthcare System, North Campus Research Complex, VA Center for Clinical Management Research (CCMR), 2800 Plymouth Rd, Ann Arbor, MI, 48109, USA
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan Health System, Domino's Farms, Lobby M, 24 Frank Lloyd Wright Dr, PO Box 385, Ann Arbor, MI, 48106, USA
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Moskal D, Maisto SA, De Vita M, Ditre JW. Effects of experimental pain induction on alcohol urge, intention to consume alcohol, and alcohol demand. Exp Clin Psychopharmacol 2018; 26:65-76. [PMID: 29323505 PMCID: PMC5794517 DOI: 10.1037/pha0000170] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Research suggests one determinant of alcohol consumption may be physical pain, but there is no empirical evidence that pain has a causal effect on drinking. Therefore, the primary aim of this study was to test experimental pain as a determinant of several alcohol consumption proxies: self-reported urge to drink, intention to consume alcohol, and alcohol demand. This study also was designed to test negative affect as a mediator of the effects of pain on alcohol use proxies. We hypothesized that participants randomized to experimental pain induction (vs. no pain) would report greater urge, intention, and alcohol demand, and that these effects would be mediated by increased negative affect. Participants were healthy undergraduates who were moderate-heavy drinkers (N = 61). Experimental pain was induced using a novel capsaicin-heat model intended to approximate key features of clinical pain. Results indicated that participants in the pain condition subsequently endorsed greater urge and intention to drink. Furthermore, these effects were mediated by pain-induced negative affect. We observed no effect of pain on alcohol demand. This is the first study to demonstrate a causal effect of acute pain on urge and intention to drink. Given the close association between alcohol consumption, urge and intention to drink, these findings suggest that pain may influence alcohol consumption, which can have implications for individuals with co-occurring pain and alcohol use disorder (AUD). Specifically, individuals with co-occurring pain and AUD may drink to alleviate pain-related negative affect. Therefore, improving pain-coping skills may enhance pain-management abilities, subsequently reducing coping-motivated drinking. (PsycINFO Database Record
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36
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Nugent SM, Yarborough BJ, Smith NX, Dobscha SK, Deyo RA, Green CA, Morasco BJ. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. Gen Hosp Psychiatry 2018; 50:104-110. [PMID: 29153783 PMCID: PMC5788035 DOI: 10.1016/j.genhosppsych.2017.11.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/03/2017] [Accepted: 11/04/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Little is known about co-occurring long-term opioid therapy (LTOT) and medical cannabis use. We compared characteristics of patients prescribed LTOT who endorsed using medical cannabis for pain to patients who did not report cannabis use. METHOD Participants (n=371) prescribed LTOT completed self-report measures about pain, substance use, and mental health. RESULTS Eighteen percent of participants endorsed using medical cannabis for pain. No significant differences were detected on pain-related variables, depression, or anxiety between those who endorsed medical cannabis use and those who did not. Medical cannabis users had higher scores of risk for prescription opioid misuse (median=17.0 vs. 11.5, p<0.001), rates of hazardous alcohol use (25% vs. 16%, p<0.05), and rates of nicotine use (42% vs. 26%, p=0.01). Multivariable analyses indicated that medical cannabis use was significantly associated with risk of prescription opioid misuse (β=0.17, p=0.001), but not hazardous alcohol use (aOR=1.96, 95% CI=0.96-4.00, p=0.06) or nicotine use (aOR=1.61, 95% CI=0.90-2.88, p=0.11). CONCLUSION There are potential risks associated with co-occurring LTOT and medical cannabis for pain. Study findings highlight the need for further clinical evaluation in this population. Future research is needed to examine the longitudinal impact of medical cannabis use on pain-related and substance use outcomes.
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Affiliation(s)
- Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
| | | | - Ning X. Smith
- Kaiser Permanente Northwest Center for Health Research
| | - Steven K. Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
| | - Richard A. Deyo
- Kaiser Permanente Northwest Center for Health Research,Departments of Family Medicine, Internal Medicine, and the Oregon Institute for Occupational Health Sciences, Oregon Health & Science University,Public Health and Preventive Medicine, Oregon Health & Science University
| | - Carla A. Green
- Kaiser Permanente Northwest Center for Health Research,Public Health and Preventive Medicine, Oregon Health & Science University
| | - Benjamin J. Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
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37
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Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain 2017; 158:526-534. [PMID: 28192376 DOI: 10.1097/j.pain.0000000000000796] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Several factors may accelerate opioid discontinuation rates, including lack of information about the long-term effectiveness of opioids for chronic pain, heightened awareness about opioid-related adverse events, closer monitoring of patients for opioid-related aberrant behaviors, and greater restrictions around opioid prescribing. Rates of discontinuation may be most pronounced in patients deemed to be at "high risk." The purpose of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between patients with and without substance use disorder (SUD) diagnoses receiving care within a major U.S. health care system. This retrospective cohort study assembled a cohort of Veterans Health Administration patients prescribed opioid therapy for at least 12 consecutive months who subsequently discontinued opioid therapy for at least 12 months. From this cohort, we randomly selected 300 patients with SUD diagnoses and propensity score-matched 300 patients without SUD diagnoses. A comprehensive manual review of patients' medical records ascertained reasons for LTOT discontinuation. Most patients (85%) were discontinued as a result of clinician, rather than patient, decisions. For patients whose clinicians initiated discontinuation, 75% were discontinued because of opioid-related aberrant behaviors. Relative to patients without SUD diagnoses, those with SUD diagnoses were more likely to discontinue LTOT because of aberrant behaviors (81% vs 68%), most notably abuse of alcohol or other substances. This is the first study to document reasons for discontinuation of LTOT in a sample of patients with and without SUD diagnoses. Treatments that concurrently address SUD and chronic pain are needed for this high-risk population.
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Nugent SM, Dobscha SK, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Lovejoy TI. Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test. J Gen Intern Med 2017; 32:1076-1082. [PMID: 28600754 PMCID: PMC5602757 DOI: 10.1007/s11606-017-4084-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/12/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is unclear whether substance use disorder (SUD) treatment is offered to, or utilized by, patients who are discontinued from long-term opioid therapy (LTOT) following aberrant urine drug tests (UDTs). OBJECTIVE To describe the proportion of patients who were referred to, and engaged in, SUD treatment following LTOT discontinuation and to examine differences in SUD treatment referral and engagement based on the substances that led to discontinuation. DESIGN From a sample of 600 patients selected from a national cohort of Veterans Health Administration patients who were discontinued from LTOT, we used manual chart review to identify 169 patients who were discontinued because of a UDT that was positive for alcohol, cannabis, or other illicit or non-prescribed controlled substances. MAIN MEASURES We extracted sociodemographic, clinical, and health care utilization data from patients' electronic medical records. KEY RESULTS Forty-three percent of patients (n = 73) received an SUD treatment referral following LTOT discontinuation and 20% (n = 34) engaged in a new episode of SUD treatment in the year following discontinuation. Logistic regression models controlling for sociodemographic and clinical variables demonstrated that patients who tested positive for cannabis were less likely than patients who tested positive for non-cannabis substances to receive referrals for SUD treatment (aOR = 0.44, 95% CI = 0.23-0.84, p = 0.01) or engage in SUD treatment (aOR = 0.42, 95% CI = 0.19-0.94, p = 0.04). Conversely, those who tested positive for cocaine were more likely to receive an SUD treatment referral (aOR = 3.32, 95% CI = 1.57-7.06, p = 0.002) and engage in SUD treatment (aOR = 2.44, 95% CI = 1.00-5.96, p = 0.05) compared to those who did not have a cocaine-positive UDT. CONCLUSIONS There may be substance-specific differences in clinician referrals to, and patient engagement in, SUD treatment. This suggests a need for more standardized implementation of clinical guidelines that recommend SUD care, when appropriate, following LTOT discontinuation.
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Affiliation(s)
- Shannon M Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
- VA Portland Health Care System (R&D 66), 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA.
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Michael I Demidenko
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Thomas H A Meath
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, USA
| | - Joseph W Frank
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
- School of Public Health, Oregon Health & Science University, Portland, OR, USA
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Przekop P, Przekop A, Haviland MG, Oda K. Comprehensive treatment for patients with chronic pain in a 12-step based substance use disorder program. J Bodyw Mov Ther 2017; 22:685-692. [PMID: 30100297 DOI: 10.1016/j.jbmt.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with chronic pain (CP) and substance use disorder (SUD) are complex, not yet adequately described, and in need of comprehensive treatments that address both diseases concurrently. Our objectives were to (a) describe a cohort of CP patients who failed traditional treatment (mainly opioids) - then developed opioid use disorder (OUD) and other SUDs and (b) evaluate a comprehensive inpatient treatment program for these patients. Patients were enrolled in an inpatient CP program. Treatment consisted of medical detoxification, group process/education, external and internal qigong, osteopathic manual medicine, and qigong-based mindfulness. Patients also received 20 h per week of 12-step recovery-based SUD treatment. Patients were evaluated at the beginning of treatment (first assessment, day 1-5 range) and at days 30 and 45. Assessments were: Beck Depression Inventory-II, Brief Pain Inventory, West Haven-Yale Multidimensional Pain Inventory (patient section), and McGill Pain Questionnaire. The Global Impression of Change Scale was administered at day 45. A mixed model analysis was used to evaluate treatment progress. Demographic data revealed an older cohort with OUD, other SUDs, and multiple pain diagnoses who failed traditional treatment. Questionnaire evaluations were consistent and similar across all of the above measures: patients' scores showed marked, statistically significant improvements in depression, pain, and quality of life ratings. The most substantial improvements occurred between the first and second assessments. The findings are sufficiently encouraging to warrant further evaluation of the protocol and to plan comparative studies.
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Affiliation(s)
- Peter Przekop
- The Pain Free Kids Foundation, Redlands, CA 92373, USA; Department of Psychiatry, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA
| | - Allison Przekop
- The Pain Free Kids Foundation, Redlands, CA 92373, USA; Hawaii Pacific Neuroscience, Honolulu, HI 96817, USA
| | - Mark G Haviland
- The Pain Free Kids Foundation, Redlands, CA 92373, USA; Department of Psychiatry, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA.
| | - Keiji Oda
- Department of Epidemiology and Biostatistics, Loma Linda University School of Public Health, Loma Linda, CA 92350, USA
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Lin LA, Bohnert ASB, Jannausch M, Goesling J, Ilgen MA. Use of non-pharmacological strategies for pain relief in addiction treatment patients with chronic pain. Am J Addict 2017; 26:564-567. [PMID: 28800184 DOI: 10.1111/ajad.12600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 07/03/2017] [Accepted: 07/15/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We examined use of non-pharmacological treatments for pain in addiction treatment patients. METHODS Patients in addiction treatment with chronic pain (N = 501) were classified based on use of non-pharmacological pain treatments. Demographic and clinical correlates were compared. RESULTS A total of 49% (N = 243) of patients used a non-pharmacological treatment in the past year versus 72% (N = 361) who used opioids. Non-pharmacological treatment users were more likely to use opioids and other pain medications. CONCLUSIONS Non-pharmacological treatments are less commonly used than opioids by addiction treatment patients. SCIENTIFIC SIGNIFICANCE Findings highlight the need to better understand pain treatment decision-making among addiction treatment patients. (Am J Addict 2017;26:564-567).
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Affiliation(s)
- Lewei Allison Lin
- Department of Psychiatry, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, Michigan, 48109.,VA Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Rd, Ann Arbor, Michigan, 48109
| | - Amy S B Bohnert
- Department of Psychiatry, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, Michigan, 48109.,VA Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Rd, Ann Arbor, Michigan, 48109
| | - Mary Jannausch
- VA Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Rd, Ann Arbor, Michigan, 48109
| | - Jenna Goesling
- Department of Anesthesiology, Back & Pain Center, University of Michigan, 325 E. Eisenhower Parkway, Ann Arbor, Michigan, 48108
| | - Mark A Ilgen
- Department of Psychiatry, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, Michigan, 48109.,VA Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Rd, Ann Arbor, Michigan, 48109
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Busch AC, Denduluri M, Glass J, Hetzel S, Gugnani SP, Gassman M, Krahn D, Deyo B, Brown R. Predischarge Injectable Versus Oral Naltrexone to Improve Postdischarge Treatment Engagement Among Hospitalized Veterans with Alcohol Use Disorder: A Randomized Pilot Proof-of-Concept Study. Alcohol Clin Exp Res 2017; 41:1352-1360. [PMID: 28605827 DOI: 10.1111/acer.13410] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 04/21/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Injectable naltrexone for alcohol use disorders (AUDs) has been efficacious in several studies. It has not been (i) compared head-to-head with oral naltrexone or (ii) examined in the hospital setting as an intervention that might facilitate treatment attendance after hospital discharge. METHODS Fifty-four hospitalized veterans identified as having DSM-IV-TR alcohol dependence were randomized to receive (i) a 50 mg oral naltrexone plus a 30-day prescription or (ii) a 380 mg intramuscular naltrexone injection prior to discharge. Of 113 veteran inpatients deemed eligible based on screening criteria, 54 met final eligibility criteria and were enrolled and randomized. Baseline data included demographics, alcohol consumption, and comorbidity. Measures of treatment initiation and engagement and alcohol consumption were reassessed at 14- and 45-day follow-ups. RESULTS Thirty-five participants (64.8%) completed the entire study protocol (received a study medication and completed 14- and 45-day follow-ups). Among those who received a study medication (n = 45), 77.8% completed all follow-up interviews. This pilot study was not designed to have sufficient statistical power for hypothesis testing, and thus, as expected, there were no significant differences between groups in medication adherence (self-report of >80% of daily doses taken in oral group; receipt of second injection in the injection group), treatment engagement (at least treatment 3 visits in the 30 days postdischarge, and 2 or more visits per month in each of the 3 months following discharge) or alcohol consumption at 14 or at 45 days (p > 0.05). The median number of drinks among the entire cohort in the 2 weeks prior to hospitalization (128 drinks) was significantly higher than at day 14 (0 drinks, p < 0.001) or day 45 (0 drinks, p < 0.001). Rates of medication adherence were 62% in the oral group and 61% in the injection group. CONCLUSIONS Results indicate feasibility for larger, more definitive study. Both groups had significant reductions in alcohol consumption over time and high-treatment engagement rates. Both oral and injectable formulations are feasible to initiate prior to discharge for hospital inpatients identified as having an AUD.
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Affiliation(s)
- Angela Christina Busch
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Family Medicine & Community Health, University of Wisconsin, Madison, Wisconsin
| | | | - Joseph Glass
- Kaiser Permanente Washington Health Research Institute, Kaiser Foundation Health Plan of Washington, Seattle, Wisconsin
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin
| | - Shalu P Gugnani
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Family Medicine & Community Health, University of Wisconsin, Madison, Wisconsin
| | - Michele Gassman
- Department of Psychiatry, University of Wisconsin, Madison, Wisconsin
| | - Dean Krahn
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Psychiatry, University of Wisconsin, Madison, Wisconsin
| | - Brienna Deyo
- Department of Family Medicine & Community Health, University of Wisconsin, Madison, Wisconsin
| | - Randall Brown
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Family Medicine & Community Health, University of Wisconsin, Madison, Wisconsin
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Garland EL, Bryan CJ, Finan PH, Thomas EA, Priddy SE, Riquino MR, Howard MO. Pain, hedonic regulation, and opioid misuse: Modulation of momentary experience by Mindfulness-Oriented Recovery Enhancement in opioid-treated chronic pain patients. Drug Alcohol Depend 2017; 173 Suppl 1:S65-S72. [PMID: 28363322 DOI: 10.1016/j.drugalcdep.2016.07.033] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/11/2016] [Accepted: 07/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Given the risk of opioid misuse among chronic pain patients being treated with long-term opioid pharmacotherapy, non-pharmacological treatments are needed. Further, in light of hedonic deficits in this population, therapies that enhance positive affect may be useful. The purpose of this study was to examine effects of a Mindfulness-Oriented Recovery Enhancement (MORE) intervention on ecological momentary assessments (EMA) of pain and positive affective experience, and to determine if changes in pain, affect, and their interaction were associated with opioid misuse at post-treatment. METHODS This study examined unpublished EMA data from a subset of participants (N=55) in a previously published RCT (NCT01505101) of MORE versus a support group (SG) control. Across 8 weeks of treatment, patients completed up to 224 EMA measures of pain and affect. Multilevel models and generalized estimating equations examined effects of treatment on momentary pain and positive affect, and generalized linear models examined associations between pain and affect and changes in opioid misuse by post-treatment. RESULTS Patients in MORE reported significantly greater improvements in momentary pain (p=0.01) and positive affect (p=0.004) than patients in the SG. Further, over the entire course of treatment, patients in MORE were significantly more likely to exhibit positive affect regulation (OR=2.75) than patients in the SG. Finally, improvements in positive affect (but not pain) over the course of intervention were associated with reduced risk of misusing opioids by post-treatment (p=0.02). CONCLUSION MORE may be a useful non-pharmacological treatment for pain and hedonic deficits among chronic pain patients at risk for opioid misuse.
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Becker WC. Commentary on Ilgen et al. (2016): Integrating chronic pain programs into addiction treatment-full steam ahead. Addiction 2016; 111:1394-5. [PMID: 27396463 DOI: 10.1111/add.13426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/02/2016] [Accepted: 04/12/2016] [Indexed: 12/23/2022]
Affiliation(s)
- William C Becker
- VA Connecticut Healthcare System, West Haven, CT, USA. .,Yale University School of Medicine, New Haven, CT, USA.
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