Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain?

Co-prescribing of Central Nervous System-Active Medications for COPD Patients: Impact on Emergency Room Visits and Hospitalization

BACKGROUND

Anxiety and chronic pain are common comorbidities in patients with chronic obstructive pulmonary disease (COPD), which are frequently managed with benzodiazepines (BZDs) and opioids, respectively.

OBJECTIVE

The purpose of this study was to determine whether different combinations of opioids, BZD, and their substitutes-gabapentinoids (GABA) and selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs)-are associated with lower risk of acute respiratory events in COPD patients with co-occurring chronic pain and anxiety.

METHODS

This retrospective cohort study used a nationally representative sample of Medicare beneficiaries with COPD, chronic pain, and anxiety. Patients were grouped based on drug combination (opioid + BZD/Z-hypnotics, opioid + GABA, opioid + SSRI/SNRI, BZD/Z-hypnotics + GABA, BZD/Z-hypnotics + SSRI/SNRI, GABA + SSRI/SNRI, or ≥3 drugs). The primary outcome was emergency room (ER) visit or hospitalization due to acute respiratory events assessed up to 180 days following initiation of drug combination. Overdose secondary to central nervous system (CNS)-related drugs was also assessed up to 180 days following initiation of drug combination.

RESULTS

The drug combination opioid + GABA was associated with decreased risk for ER visit (hazard ratio [HR] = 0.73; 95% CI = 0.61-0.87) and hospitalization (HR = 0.69; 95% CI = 0.55-0.85). Opioid + SSRI/SNRI also showed decreased risk for ER visit (HR = 0.84; 95% CI = 0.71-0.99). There was no significant difference in risk for CNS-related drug overdose among different drug combinations compared with opioid + BZD/Z-hypnotics.

CONCLUSION AND RELEVANCE

Opioids in combination with GABA and SSRI/SNRI demonstrate relatively lower risk for acute respiratory events among patients with COPD and comorbid chronic pain and anxiety. The findings emphasize the need for multimodal management in this vulnerable population.

Flourishing despite Chronic Obstructive Pulmonary Disease (COPD): Findings from a Nationally Representative Survey of Canadians Aged 50 and Older

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of mortality and is often associated with serious disability and depression. Little is known about the characteristics of those who are in complete mental health (CMH) despite having COPD. This study’s objectives are to: (1) estimate the prevalence and odds of absence of psychiatric disorders (APD) and CMH among older adults that reported having COPD, compared to their peers that did not; (2) identify factors associated with APD and with CMH. Bivariate and logistic regression analyses were conducted using the nationally representative Canadian Community Health Survey—Mental Health. The results indicate that there was a significantly (p < 0.001) lower prevalence of APD (86.7% vs. 95.0%) and CMH (66.7% vs. 77.0%) among older adults aged 50+ with COPD (n = 703) compared to those without COPD (n = 10,189). Half of the sample was female (50.5%) and the majority of whom were under age 70 (62.5%). Factors significantly (p < 0.05) associated with higher odds of APD and of CMH among older adults with COPD include being married, having a confidant, being physically active, and having no lifetime history of major depressive disorder or generalized anxiety disorder. For every additional adverse childhood experience, the odds of APD declined by 31%. The majority of those with COPD are mentally flourishing despite having this disabling and life-threatening disorder. These findings underline the importance of targeted interventions and outreach to those most vulnerable to poorer mental health outcomes including the socially isolated.

Clinical and Psychological Impact of Chronic Pain in People with Chronic Obstructive Pulmonary Disease

Purpose

The presence of pain can be associated with an exaggerated negative cognitive and emotional response, leading to worsening of existing symptoms. This study aimed to describe the multifaceted impact of chronic pain on cognition, emotional and physical health in people with chronic obstructive pulmonary diseases (COPD) and to explore the clinical impact of pain.

Patients and Methods

A prospective, cross-sectional multicenter study was carried out in 68 people with COPD (COPD group) and 65 community-dwelling age-matched participants (control group). Participants were assessed for the presence of chronic pain, pain location, intensity and catastrophizing, pain-related fear (kinesiophobia), anxiety and depression, physical activity, and sleep duration. The COPD group also completed assessments of dyspnea, exercise tolerance (6-minute walk distance [6MWD]), and activities of daily living (ADL).

Results

The prevalence of pain was higher in the COPD group (85% vs 51%, p<0.001). The COPD group reported pain located in neck/shoulder, upper back, thorax and upper limbs, while the control group had more pain in the lower back. Pain catastrophizing and kinesiophobia were reported by 28% and 67% vs 9% and 42%, in the COPD and control groups respectively (both p<0.05). People with COPD and pain (n=58) reported greater dyspnea (p<0.001), and impairment in ADL (p<0.05), and lower 6MWD and physical activity (both p<0.01) compared to COPD participants without pain (n=10).

Conclusion

This study demonstrated that, compared to community-dwelling participants, there is a higher prevalence of chronic pain in people with COPD. Pain combined with dyspnea may impact adversely on cognitive function and lead to anxiety and depression, as well as greater impairment in exercise tolerance, physical activity, and ADL. These results suggested that it is necessary to assess the symptoms of chronic pain and inflect in chronic pain coping strategies.

Chronic Pain in Patients with Chronic Obstructive Pulmonary Disease: A Cross Sectional Study

Background

Many individuals with chronic obstructive pulmonary disease (COPD) report suffering from chronic pain, which affects their quality of life. This study aimed to determine the prevalence, characteristics and impact of chronic pain in patients with COPD, and to explore its possible predictive and aggravating factors.

Materials and Methods

It was a cross-sectional study. Male individuals with COPD responded to a questionnaire, including mMRC, CAT, Brief Pain Inventory (BPI) (composed of Worst pain, Pain Severity Score (PSS) and Pain Interference Score (PIS)), and Hospital Anxiety and Depression Scale. Patients were divided into group 1 (G1) with chronic pain, and group 2 (G2) without chronic pain.

Results

Sixty eight patients were included. The general prevalence of chronic pain was 72.1% (CI95%:10.7%). The most common site of pain was the chest (54.4%). Analgesics were used in 38.8%. Patients from G1 had more hospital admissions in the past (OR=6.4[1.7-23.4]). Three variables were associated to pain in the multivariate analysis: socio-economic level (OR=4.6[1.1-19.2]), hospital admissions (OR=0.087[0.017-0.45]), and CAT (OR=0.18[0.05-0.72]). Dyspnea was associated to PIS (p<0.005). A correlation was found between PSS and PIS (r=0.73). Six patients (8.8%) retired because of pain. Patients who had CAT≥10 were more in G1 (OR=4.9[1.6-15.7]). CAT was correlated to PIS (r=0.5). G1 demonstrated higher anxiety scores (p<0.05). There was a moderate positive correlation between depression symptoms and PIS (r=0.33).

Conclusion

Pain should be systematically assessed in COPD patients, regarding its high prevalence. New guidelines should take into consideration pain management to ameliorate patients' quality of life.

The prevalence and assessment of pain and dyspnoea in acute exacerbations of COPD: A systematic review

BACKGROUND

Dyspnoea and pain are symptoms of chronic obstructive pulmonary disease (COPD). This review focused upon pain and dyspnoea during hospital admissions for acute exacerbations of COPD (AECOPD), with the aim of examining prevalence, assessment, clinical associations, and researcher-reported implications of these symptoms.

METHODS

Four electronic databases were searched from inception to 31 May 2021. Full text versions of studies were assessed for methodological quality and data were extracted independently by two reviewers. Where data permitted, pooled prevalence of pain and dyspnoea were calculated by meta-analysis.

RESULTS

Four studies were included. The pooled prevalence of pain and dyspnoea was 44% (95% confidence interval (CI) 35%-52%) and 91% (95% CI 87%-94%) respectively. An array of instruments with varying focal periods were reported (pain: six tools, dyspnoea: four tools). Associations and clinical implications between the two symptoms at the time of hospital admission were rarely reported.

CONCLUSIONS

Few studies reported prevalence of pain and dyspnoea during an AECOPD. A greater understanding into the prevalence, intensity and associations of these symptoms during AECOPD could be furthered by use of standardised assessment tools with clearly defined focal periods.

The relationship between vertebral deformities and thoracic arthropathy with back pain in Chronic Obstructive Pulmonary Disease

OBJECTIVES

The aim of the study was to investigate the relationship between back pain and thoracic vertebral deformities and arthropathy in patients with COPD who underwent thorax CT scans to screen for lung nodules and cancer.

MATERIALS AND METHODS

The data of patients who underwent thoracic CT and pulmonary function tests (PFTs) between July 2019 and February 2020 were retrospectively reviewed. The patients were divided into two groups: the COPD (n = 64) and control groups (n = 101), according to the PFT results. The CT images were evaluated for vertebral deformities, osteoporosis and thoracic vertebral joint arthropathy, and the Spinal Deformity Index (SDI) was calculated.

RESULTS

Back pain was detected in 43.7% of the COPD patients and 20.9% of the controls. The patients with COPD had significantly higher rates of costotransverse, intervertebral, facet joint arthropathy, and osteoporosis than did the control group (P < .001). The OR analyses showed that the presence of a vertebral deformity (OR 4.42, 95% CI 2.26 - 8.63, P < .001), of facet joint arthropathy (OR 3.6, 95% CI 2.83-4.58, P < .001), and of costotransverse arthropathy (OR 2.20, 95% CI 1.47-2.77, P < .001) were associated with the presence of back pain. Although a strong positive correlation was found between the SDI and pain score, a moderate negative correlation was found between the FEV1% values and pain score.

CONCLUSIONS

Back pain was present in patients with COPD and was related to vertebral deformities and facet and costotransverse joint arthropathy. Additional studies are required to clarify the relationships of back pain with musculoskeletal system diseases, including cervical and lumbar spine arthropathy and vertebral deformities.

Are Fatigue and Pain Overlooked in Subjects with Stable Chronic Obstructive Pulmonary Disease?

Although there have been many published reports on fatigue and pain in patients with chronic obstructive pulmonary disease (COPD), it is considered that these symptoms are seldom, if ever, asked about during consultations in Japanese clinical practice. To bridge this gap between the literature and daily clinical experience, the authors attempted to gain a better understanding of fatigue and pain in Japanese subjects with COPD. The Brief Fatigue Inventory (BFI) to analyse and quantify the degree of fatigue, the revised Short–Form McGill Pain Questionnaire 2 (SF-MPQ-2) for measuring pain and the Kihon Checklist to judge whether a participant is frail and elderly were administered to 89 subjects with stable COPD. The median BFI and SF-MPQ-2 Total scores were 1.00 [IQR: 0.11–2.78] and 0.00 [IQR: 0.00–0.27], respectively. They were all skewed toward the milder end of the respective scales. A floor effect was noted in around a quarter on the BFI and over half on the SF-MPQ-2. The BFI scores were significantly different between groups regarding frailty determined by the Kihon Checklist but not between groups classified by the severity of airflow limitation. Compared to the literature, neither fatigue nor pain are considered to be frequent, important problems in a real-world Japanese clinical setting, especially among subjects with mild to moderate COPD. In addition, our results might suggest that fatigue is more closely related to frailty than COPD.

Prevalence and Determinants of Mental Health among COPD Patients in a Population-Based Sample in Spain

(1) Background: To assess the prevalence of mental disorders (depression and anxiety), psychological distress, and psychiatric medications consumption among persons suffering from COPD; to compare this prevalence with non-COPD controls and to identify which variables are associated with worse mental health. (2) Methods: This is an epidemiological case-control study. The data were obtained from the Spanish National Health Survey 2017. Subjects were classified as COPD if they reported suffering from COPD and the diagnosis of this condition had been confirmed by a physician. For each case, we selected a non-COPD control matched by sex, age, and province of residence. Conditional logistic regression was used for multivariable analysis. (3) Results: The prevalence of mental disorders (33.9% vs. 17.1%; p < 0.001), psychological distress (35.4% vs. 18.2%; p < 0.001), and psychiatric medications consumption (34.1% vs. 21.9%; p < 0.001) was higher among COPD cases compared with non-COPD controls. After controlling for possible confounding variables, such as comorbid conditions and lifestyles, using multivariable regression, the probability of reporting mental disorders (OR 1.41; 95% CI 1.10–1.82).), psychological distress (OR 1.48; 95% CI 1.12–1.91), and psychiatric medications consumption (OR 1.38 95% CI 1.11–1.71) remained associated with COPD. Among COPD cases, being a woman, poor self-perceived health, more use of health services, and active smoking increased the probability of suffering from mental disorders, psychological distress, and psychiatric medication use. Stroke and chronic pain were the comorbidities more strongly associated with these mental health variables. (4) Conclusions: COPD patients have worse mental health and higher psychological distress and consume more psychiatric medications than non-COPD matched controls. Variables associated with poorer mental health included being a woman, poor self-perceived health, use of health services, and active smoking.

Pain Prevalence, Localization, and Intensity in Adults with and without COPD: Results from the Danish Health and Morbidity Survey (a Self-reported Survey)

Introduction

Pain is a clinical complication to chronic obstructive pulmonary disease (COPD) that interferes negatively with physical activity level (PAL), quality of life (QOL) and pulmonary interventions. Yet, research in pain characteristics including prevalence, localization, and intensity in people with COPD are sparsely researched.

Aim

To investigate self-reported pain prevalence, localization and intensity of pain in people with and without COPD, and to investigate the association between pain intensity and PAL among participants with COPD.

Methods

Data were derived from the Danish Health and Morbidity Survey in 2017. The study population was restricted to individuals aged ≥35 years. Data included pain intensity assessed on the Numeric Rating Scale (NRS) and localization, PAL, QoL, sleep disturbance, comorbidities, sociodemographic and behavioral factors.

Results

In all, 528 participants with COPD and 8184 participants without COPD (51% females, mean ±SD age 67.1±11.4 years) were analyzed. Pain prevalence within the past 14 days was significantly higher in participants with COPD vs nonCOPD (72.7% vs 57.7%, p<0.001) and mainly located in the limbs, thorax, and lower back. COPD was associated with the prevalence of chronic pain (≥6 months) (OR: 2.78, 95%CI: 2.32; 3.34, p<0.001). Participants with COPD reported a higher pain intensity compared to those with nonCOPD with a mean difference of 1.04 points (95%CI: 0.75; 1.32, p<0.001) on the NRS. In the adjusted multiple logistic regression analysis, pain intensity was negatively associated with odds of being physical active (OR: 0.72, 95%CI: 0.61; 0.85, p<0.001).

Conclusion

Pain is more prevalent in people with self-reported COPD. After adjustment for age and gender, COPD was associated with an elevated pain intensity. Sleep disturbance and multimorbidity had the most pronounced impacts on pain intensity in the multiple linear regression model. In participants with COPD, increased pain intensity was negatively associated with being physically active.

Extra-pulmonary manifestations of COPD and the role of pulmonary rehabilitation: a symptom-centered approach

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogenous disease that is associated with a range of respiratory and non-respiratory symptoms, which highly contribute to the daily burden of the disease. Symptoms burden remains high despite optimal bronchodilator therapy, but pulmonary rehabilitation (PR) is an effective intervention to improve patients' symptoms. A comprehensive interdisciplinary approach within the framework of a PR program is warranted to tackle these complex symptoms and their consequences. Areas covered: This narrative review describes how symptoms of dyspnea, fatigue, cough, sputum, anxiety, depression, pain, sleep disturbances, and cognitive decline arise in COPD and can contribute to several non-pulmonary manifestations of the disease. It also describes evidence of the effectiveness of interdisciplinary PR programs to counteract these symptoms. A literature search was performed on PubMed and Scopus between June and July 2020. Expert opinion: Respiratory and non-respiratory symptoms are highly prevalent, often not comprehensively assessed, and result in several extra-pulmonary manifestations of the disease (physical, emotional and social). Interdisciplinary PR programs can improve these negative manifestations through different pathways, contributing for an effective symptoms' management. A thorough assessment of symptoms (beyond dyspnea) should be routinely performed and may support the identification of treatable traits, allowing the tailoring of PR interventions and assessment of their real-life impact.

COPD is Associated with Higher Prevalence of Back Pain: Results of a Population-Based Case-Control Study, 2017

Objective

We aimed to assess whether patients suffering from COPD have a higher prevalence of chronic back pain (neck and low back pain) than age-, sex-, and residence-matched non-COPD controls. We also aimed to identify which variables are associated with chronic neck pain (CNP) and chronic low back pain (CLBP) among COPD patients.

Methods

We carried out a retrospective case-control study using data obtained from the Spanish National Health Survey conducted in 2017.

Results

We analyzed data from 1034 COPD and 1034 matched non-COPD controls. The prevalence of CNP and CLBP was 38.20% and 45.16%, respectively, among COPD patients and 22.82% and 28.34% for non-COPD controls, respectively (p<0.001 for both). Multivariable analysis showed that COPD patients had a 1.62-fold (95% CI 1.50-1.74) higher risk of CNP and a 1.83-fold (95% CI 1.73-1.91) higher risk of CLBP than non-COPD controls. Experiencing one type of pain greatly increased the risk of having the other. Factors associated with the presence of both types of pain among COPD patients included female sex, "fair/poor/very poor" self-rated health, migraine or frequent headache and use of pain medication. Being aged from 70 to 79 years was a risk factor for CLBP, and suffering from a mental disorder was a risk factor for CNP.

Conclusion

The prevalence of CNP and CLBP was significantly higher among COPD patients than among non-COPD controls after adjusting for age, sex and other relevant clinical variables. Our findings add new data to the knowledge of chronic pain in COPD patients.

Chronic Obstructive Pulmonary Disease: Proprioception Exercises as an Addition to the Rehabilitation Process

Respiratory rehabilitation in patients with chronic obstructive pulmonary disease (COPD) is recognized as a cornerstone for the therapeutic path. Physiotherapy involves physical activity with aerobic and anaerobic exercises, which can improve the patient's symptomatic picture, such as motor function, emotional status (depression and anxiety), and improve the pain perception. The training of proprioception is not included in the structure of the exercises proposed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The training of proprioception is a very useful strategy for stimulating the cerebellum, a neurological suffering area in patients with COPD. The cerebellum sorts information about pain and emotions, as well as motor stimuli. The article discusses the need to introduce proprioception in respiratory rehabilitation protocols, highlighting the neurological relationships with the management of comorbidities.

The Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD

Chronic pain affects up to 88% of people with chronic obstructive pulmonary disease (COPD) and has been associated with comorbidities. However, with pain not evaluated during pulmonary rehabilitation (PR) assessments, it is unclear whether PR impacts pain intensity and coping ability. This study aimed to 1) determine the effect of PR on pain qualities, coping behavior and psychological symptoms in those with COPD and chronic pain; and 2) assess the impact of PR on exercise capacity and quality of life in individuals with COPD and chronic pain compared to those without pain. Patients with COPD and comorbidities enrolling in outpatient PR were assessed for chronic pain. Those with chronic pain completed the Brief Pain Inventory, Coping Strategies Questionnaire-24, Fear Avoidance Behavior Questionnaire and measures of anxiety and depression. Changes in HRQOL and 6-minute walk distance (6MWD) following PR were compared between participants with and without chronic pain. Thirty-four participants with chronic pain and 34 participants without pain were included (mean ± SD, FEV₁ 47 ± 19% predicted). In those with chronic pain, PR did not affect pain intensity (median[IQR] pre/post PR 3[2-5] vs. 4[2-6] points, p = 0.21), anxiety (7[2-9] vs. 5[3-8] points, p = 0.82) or depression (4[2-8] vs. 3[1-6] points, p = 0.38) and did not change pain coping strategies. Both groups improved in 6MWD (mean difference [95% CI] 17[-39 to 72] m), and those without pain had greater improvement in mastery (p = 0.013). PR was effective in patients with moderate to severe COPD whether or not they reported chronic pain at the time of their initial assessment.

Prevalence and Characteristics of Pain in Patients of Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study in China

The purposes of this study were to: (1) study the prevalence of pain in patients with mild-to-very severe chronic obstructive pulmonary disease (COPD) in China; (2) compare the differences in pain characteristics between stable COPD and acute exacerbation of COPD (AECOPD); (3) explore the clinical associations with pain in those with COPD. This cross-sectional study was conducted in China from October 24, 2017, to January 11, 2019. A face-to-face interview was conducted to collect data. The Chinese version of the brief pain inventory (BPI-C) was applied to investigate the pain characteristics in patients with COPD. Of the 901 patients in this study, 226 (25.1%) patients reported pain problems. The prevalence of pain in patients with mild to very severe COPD was 32.9%, 23.9%, 25.2%, and 23.5%, respectively (p = 0.447). According to the BPI-C results, 31.3% (31/99) of patients reported pain of AECOPD, compared to 24.3% (195/802) of stable COPD (p = 0.13). Reported pain intensity and pain interference evaluated by the BPI-C were significantly higher in AECOPD than stable COPD (p < 0.001, p < 0.05, respectively). Those with body mass index (BMI) ≥ 24kg/m² or COPD assessment test (CAT) score > 20 were significantly more likely to have pain problems than BMI < 24kg/m² (aOR = 1.568, a95IC = 1.132-2.170, p = 0.007) or CAT ≤ 20 (aOR= 1.754, a95IC = 1.213-2.536, p = 0.003). Pain was common in patients with both stable COPD and AECOPD. AECOPD patients had a significantly higher pain intensity than stable COPD. Overweight and CAT > 20 were significantly related to higher prevalence of pain.