Management of Chronic Noncancer Pain in Depressed Patients

Association between Depression and Mortality in Patients with Pain Conditions: A South Korean Nationwide Cohort Study

PURPOSE

Patients with pain conditions may experience depression that greatly complicates treatment. In this study, we examined risk factors for depression in patients with pain conditions and associations between depression and long-term mortality in such patients.

MATERIALS AND METHODS

Data from the National Health Insurance Service database in South Korea were used in this cohort study. A total of 2.5% of adult patients diagnosed with pain conditions in 2010 were selected using a stratified random sampling technique and included for analysis. We performed multivariate logistic regression modelling to identify risk factors associated with depression and multivariate Cox regression modelling to determine whether depression is associated with 10-year survival outcomes in patients with pain conditions.

RESULTS

In total, data from 1808043 patients with pain conditions in 2010 were analyzed. Among them, 70148 (3.9%) patients had depression. Multivariate logistic regression modelling identified older age, comorbidities, analgesics, female sex, living in an urban area, and other underlying psychiatric morbidities as potential risk factors for depression in patients with pain conditions. Multivariate Cox regression revealed that 10-year all-cause mortality in patients with depression was 1.13-fold (hazard ratio, 1.13; 95% confidence interval, 1.11-1.16; p<0.001) higher than that in patients without depression and pain conditions.

CONCLUSION

We identified a few potential risk factors for depression among South Korean patients with pain conditions. Depression was associated with elevated 10-year all-cause mortality in patients with pain conditions.

Aloe Vera-Containing Matrix in Transdermal Fentanyl Therapy Improves Adhesion, Skin Tolerance and Quality of Life: Results of a German Multicenter Study with a New Fentanyl Patch

BACKGROUND

Chronic pain represents a significant and costly healthcare problem especially in the older patient. Transdermal opioid therapy is easy to apply and ensures constant supply of active ingredients. However, skin irritation, poor adhesion and systemic side effects complicate transdermal pain therapy.

METHODS

In the Relief study, comprising 54 centers, all in Germany, 252 patients were recruited and data about the general care situation as well as the characteristics, effects and side effects of the Aloe vera fentanyl patch were collected. 92 patients had a prior treatment with fentanyl patch without Aloe vera, allowing a comparative analysis.

RESULTS

Compared to patches without Aloe vera, the new fentanyl patch showed better adhesion. Systemic and local tolerance and pain reduction were also significantly better. Patients also reported improvements in side effects and central parameters of quality of life. The data regarding the care situation in Germany showed remarkably low use of coanalgetics and laxatives in pain patients.

DISCUSSION

Aloe vera in transdermal pain treatment improves adhesion and local tolerance of the patch. Pain control and quality of life were also improved. Regional care data concerning cotreatment in pain therapy from this study indicate a lack of penetration of existing guidelines in general practitioners' pain therapy.

Clinical Perspective on Opioids in the Context of Suicide Risk

Psychiatrists are on the front lines of two simultaneous public health crises: the increasing rates of suicide and opioid-related deaths. In this review, the authors discuss ways in which these two classes of preventable deaths may be linked, with an emphasis on identifying and preventing both outcomes through increased understanding of their shared risk factors. As clinicians, it is crucial to maintain awareness of the ways in which opioid use may contribute to depression and suicidality, as well as how mood disorders may complicate opioid use. In light of this interplay, interventions which target risk factors for both suicide and overdose are key. Interventions include early treatment of substance dependence and depression, as well as harm reduction measures, such as provision of naloxone, medication-assisted treatments for dependency, and multidisciplinary approaches to chronic pain that do not rely solely on escalating opioid doses. It is also important to address social determinants of health, which may increase risk for both accidental and intentional overdose. The roads to overdose and suicide overlap considerably and cannot be considered separately.

Incidence and Health Related Quality of Life of Opioid-Induced Constipation in Chronic Noncancer Pain Patients: A Prospective Multicentre Cohort Study

Background

High rates of opioid use for chronic noncancer pain (CNCP) have been reported worldwide, despite its association with adverse events, inappropriate use, and limited analgesic effect. Opioid-induced constipation (OIC) is the most prevalent and disabling adverse effect associated with opioid therapy. Our aim was to assess the incidence, health related quality of life (HRQOL), and disability in OIC patients.

Methods

A prospective cohort study was performed, with 6 months of follow-up, of adult CNCP patients consecutively admitted in 4 multidisciplinary pain clinics (MPC). Demographic and clinical data have been collected. Brief Pain Inventory (BPI) and Short version of Treatment Outcomes in Pain Survey (S-TOPS) were used to measure functional outcomes and HRQOL. OIC was assessed using Bowel Function Index (BFI).

Results

694 patients were recruited. OIC prevalence at baseline was 25.8%. At 6 months, OIC incidence was 24.8%. Female gender (OR = 1.65, p = 0.039), opioid therapy (OR 1.65, p = 0.026), and interference pain score on BPI (OR 1.10, p = 0.009) were identified as OIC independent predictors. OIC patients presented higher disability and pain interference and severity scores. OIC patients reported less satisfaction with outcome (p = 0.038).

Discussion

Constipation is a common adverse event among opioid users with major functional and quality of life impairment. These findings emphasise the need of OIC adequate assessment and management.

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.

Effectiveness of Three Types of Interventions in Patients with Fibromyalgia in a Region of Southern Catalonia

Several pharmacological and nonpharmacological treatments can be used to alleviate the symptoms of fibromyalgia, although none of them are completely effective at present. In this study, we analyzed the effectiveness of different therapies in three groups of people diagnosed with fibromyalgia. The sample for this randomized controlled trial was made up of 66 people diagnosed with fibromyalgia in southern Catalonia. In turn, this sample was divided into three groups of 22 participants each, who were treated with: i) cervical infiltration with botulinum toxin, ii) group problem-solving therapy, or iii) both therapies. The variables recorded were quality of life, suicidal thoughts, perception of pain, quality of sleep, and satisfaction. Female patients composed 96.9% (n = 64) of the study sample. Satisfaction with the infiltration was 5.1 ± 2.7 points, while in group problem-solving therapy it was 6.6 ± 3.2. Self-perceived health in the infiltration group (p = .016) and the therapy group (p = .001) improved after the intervention took place. The risk of suicide decreased in the both treatments/groups (p = .049). Pain was reduced by 31.8% with infiltration, 13.6% with therapy, and 22.7% with both treatments. Anxiety/depression decreased by 45% with therapy, 36.3% with infiltration, and 36.3% with both treatments. The results also showed that the use of both treatments significantly reduces suicidal thoughts (p = .049). In conclusion, this study showed the complexity of reducing chronic pain and increasing the quality of life of people with fibromyalgia.

A Subgroup Analysis Found no Diminished Response to Buprenorphine Transdermal System Treatment for Chronic Low Back Pain Patients Classified with Depression

BACKGROUND

Chronic pain (CP) patients with depression typically exhibit worse post-treatment outcomes than nondepressed CP patients. The cause is often assumed to reflect a differential response to treatment, neglecting other potential explanations, such as the continuation of differences in pretreatment outcomes. This post hoc analysis examines whether worse post-treatment outcomes for depressed patients with chronic low back pain (CLBP) are driven by reduced treatment efficacy.

METHODS

Data were from opioid-naïve adult patients with moderate-to-severe CLBP who participated in a randomized, placebo-controlled, double-blind clinical trial of Butrans(®) (buprenorphine) Transdermal System (BTDS) for pain relief. Depression screening was based on baseline SF-36v2 Mental Health subscale scores. Patient-reported measures of pain severity, pain interference, quality of life, sleep problems, and functional disability were administered at screening and during the study. Differential treatment efficacy for each outcome was examined using analysis of covariance models that included interaction terms between treatment arm and depression status.

RESULTS

At baseline, patients classified as depressed showed greater pain interference, lower quality of life, more sleep problems, and greater functional disability than nondepressed patients; the two groups did not differ in pain severity. No statistically significant interactions between treatment arm and depression status were observed. The direction of improvement post-treatment favored the depressed group on nine of seventeen outcomes.

CONCLUSIONS

Results do not support a differential response to BTDS treatment between depressed and nondepressed CLBP patients across a variety of patient-reported outcomes. These findings raise the question of whether depressed mood actually moderates the effectiveness of treatment in CP patients.

Temporal associations between physical illnesses and mental disorders--results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

Clinical and epidemiologic evidence has documented the significant associations between medical illnesses and psychiatric disorders. However, extensive research has focused on the comorbidity of medical conditions and depression, and most were cross sectional, focused on clinical samples, and grounded in DSM-III or DSM-III-R diagnostic criteria. The current prospective investigation examined associations among medical conditions at baseline and incident psychiatric disorders over a 3-year follow-up, using data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Overall, the 3-year incidence rates of DSM-IV substance use, mood and anxiety disorders ranged from 0.65% (bipolar II) to 5.2% (alcohol abuse). Multiple regression analysis was conducted to examine the prospective physical-mental associations, while controlling for sociodemographic characteristics, psychological stress and health-related risk factors, and comorbid physical and psychiatric disorders. The present study represents, to our knowledge the largest population-based prospective study examining the physical-mental associations. Our results showed distinctly different patterns of comorbidity of medical illnesses with substance use, mood, and anxiety disorders. Stomach ulcer/gastritis, hypertension and arthritis emerged to be significant predictors of incident psychiatric disorders.

Effectiveness and cost-effectiveness of transmural collaborative care with consultation letter (TCCCL) and duloxetine for major depressive disorder (MDD) and (sub)chronic pain in collaboration with primary care: design of a randomized placebo-controlled multi-Centre trial: TCC:PAINDIP

BACKGROUND

The comorbidity of pain and depression is associated with high disease burden for patients in terms of disability, wellbeing, and use of medical care. Patients with major and minor depression often present themselves with pain to a general practitioner and recognition of depression in such cases is low, but evolving. Also, physical symptoms, including pain, in major depressive disorder, predict a poorer response to treatment. A multi-faceted, patient-tailored treatment programme, like collaborative care, is promising. However, treatment of chronic pain conditions in depressive patients has, so far, received limited attention in research. Cost effectiveness of an integrated approach of pain in depressed patients has not been studied.

METHODS/DESIGN

This study is a placebo controlled double blind, three armed randomized multi centre trial. Patients with (sub)chronic pain and a depressive disorder are randomized to either a) collaborative care with duloxetine, b) collaborative care with placebo or c) duloxetine alone. 189 completers are needed to attain sufficient power to show a clinically significant effect of 0.6 SD on the primary outcome measures (PHQ-9 score). Data on depression, anxiety, mental and physical health, medication adherence, medication tolerability, quality of life, patient-doctor relationship, coping, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months.

DISCUSSION

This study enables us to show the value of a closely monitored integrated treatment model above usual pharmacological treatment. Furthermore, a comparison with a placebo arm enables us to evaluate effectiveness of duloxetine in this population in a real life setting. Also, this study will provide evidence-based treatments and tools for their implementation in practice. This will facilitate generalization and implementation of results of this study. Moreover, patients included in this study are screened for pain symptoms, differentiating between nociceptive and neuropathic pain. Therefore, pain relief can be thoroughly evaluated.

TRIAL REGISTRATION

NTR1089.

Electrical stimulation of deep peroneal nerve mimicking acupuncture inhibits the pressor response via capsaicin-insensitive afferents in anesthetized rats

OBJECTIVE

To assess the inhibitory modulation of blood pressure by stimulation of the deep peroneal nerve (DPN) and to determine the involvement of nociceptive fibers in the modulation.

METHODS

All the animals were divided into six groups (A-F). The rats in groups A and B received no pretreatment. The rats in groups C and D received subcutaneous injection of capsaicin or control vehicle, respectively, near the DPN for 2 days. Those in groups E and F had the DPN exposed to capsaicin or control vehicle, respectively, for 20 min. Subsequently, pressor responses were induced by stimulation of paraventricular nucleus (PVN) either electrically (groups A and C C-F) or chemically via injection of glutamate (group B). After two stable pressor responses (baseline), all groups were subject to 5-min DPN stimulation followed by PVN stimulation for 10 s. Arterial blood pressure, heart rate, and electrocardiogram were recorded. The pressor response was calculated as the difference in the mean arterial pressure (MAP) before and after PVN stimulation, and changes from baseline in pressor response after DPN stimulation were compared between the groups.

RESULTS

Increases of MAP of 22.88±2.18 mm Hg and 20.32±5.25 mm Hg were induced by electrical (group A) or chemical (group B) stimulation of the PVN, respectively. These pressor responses were inhibited by stimulation of the DPN, and the MAP was reduced to 12.00±2.10 mm Hg in group A (n=6, P<0.01) and 7.00±2.85 mm Hg in group B (n=6, P<0.01). Subcutaneous injection of capsaicin (125 mg/kg) near the DPN in group C (n=7) had no effect on the inhibitory effect of DPN stimulation compared with the group D (n=9), and neither did blockade of nociceptive fibers with capsaicin in group E (n=6) compared with group F (n=8).

CONCLUSION

Stimulation of the DPN mimicking acupuncture has an inhibitory effect on the pressor response, and the effect is mediated by capsaicin-insensitive afferent fibers in the DPN.