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Themelis K, Gillett JL, Karadag P, Cheatle MD, Giordano NA, Balasubramanian S, Singh SP, Tang NK. Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis. J Pain 2023; 24:2079-2092. [PMID: 37392929 DOI: 10.1016/j.jpain.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/12/2023] [Accepted: 06/25/2023] [Indexed: 07/03/2023]
Abstract
Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n = 371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of the participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between 'low' and 'high' suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention. PERSPECTIVE: Results from this prospective cohort study suggest that mental defeat is a significant predictor of increased suicide risk among patients with chronic pain, along with depression, perceived stress, head pain, and active smoking status. These findings offer a novel avenue for assessment and preventative intervention before risk escalates.
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Affiliation(s)
- Kristy Themelis
- Department of Psychology, University of Warwick, Coventry, United Kingdom
| | - Jenna L Gillett
- Department of Psychology, University of Warwick, Coventry, United Kingdom
| | - Paige Karadag
- Department of Psychology, University of Warwick, Coventry, United Kingdom
| | - Martin D Cheatle
- Department of Psychiatry and Anaesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, United States
| | | | - Swaran P Singh
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom; Mental Health and Wellbeing, University of Warwick, Warwick Medical School, Coventry, United Kingdom
| | - Nicole Ky Tang
- Department of Psychology, University of Warwick, Coventry, United Kingdom
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Cheatle MD, Giordano NA, Themelis K, Tang NKY. Suicidal thoughts and behaviors in patients with chronic pain, with and without co-occurring opioid use disorder. Pain Med 2023; 24:941-948. [PMID: 37014415 PMCID: PMC10391589 DOI: 10.1093/pm/pnad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/07/2023] [Accepted: 03/25/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Individuals with chronic pain and a co-occurring substance use disorder present higher risk of suicide, but the individual and joint impacts of chronic pain and substance use disorders on suicide risk are not well defined. The objective of this study was to exam the factors associated with suicidal thoughts and behaviors in a cohort of patients with chronic non-cancer pain (CNCP), with or without concomitant opioid use disorder (OUD). DESIGN Cross sectional cohort design. SETTING Primary care clinics, pain clinics, and substance abuse treatment facilities in Pennsylvania, Washington, and Utah. SUBJECTS In total, 609 adults with CNCP treated with long-term opioid therapy (>/= 6 months) who either developed an OUD (cases, n = 175) or displayed no evidence of OUD (controls, n = 434). METHODS The predicted outcome was elevated suicidal behavior in patients with CNCP as indicated by a Suicide Behavior Questionnaire-Revised (SBQ-R) score of 8 or above. The presence of CNCP and OUD were key predictors. Covariates included demographics, pain severity, psychiatric history, pain coping, social support, depression, pain catastrophizing and mental defeat. RESULTS Participants with CNCP and co-occurring OUD had an increased odds ratio of 3.44 in reporting elevated suicide scores as compared to participants with chronic pain only. Multivariable modeling revealed that mental defeat, pain catastrophizing, depression, and having chronic pain, and co-occurring OUD significantly increased the odds of elevated suicide scores. CONCLUSIONS Patients with CNCP and co-morbid OUD are associated with a 3-fold increase in risk of suicide.
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Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry and Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19106, United States
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, United States
| | - Kristy Themelis
- Department of Psychology, University of Warwick, CV4 7AL Coventry, United Kingdom
| | - Nicole K Y Tang
- Department of Psychology, University of Warwick, CV4 7AL Coventry, United Kingdom
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Abstract
OBJECTIVE Although the great majority of individuals who take opioids for chronic pain use them appropriately and to good effect, a certain minority will develop the problematic outcome of opioid use disorder (OUD). Characteristics associated with the development of OUD in individuals with chronic pain have been described; however, relatively unexplored is how sensitivity to pain is associated with OUD outcomes. MATERIALS AND METHODS We examined for differences in response to static and dynamic experimental pain stimuli between individuals with chronic nonmalignant pain who developed OUD after starting opioid therapy (n=20) and those on opioid therapy who did not (n=20). During a single experimental session, participants underwent cold pressor and quantitative sensory testing pain assays, and objective and subjective responses were compared between groups; the role of pain catastrophizing in mediating pain responses was examined. RESULTS Results suggested that both groups of opioid-dependent patients were similarly hyperalgesic to the cold pressor pain stimulus, with nonparametric testing revealing worsened central pain sensitization (temporal summation) in those who developed OUD. Significant group differences were evident on subjective ratings of experimental pain, such that those who developed OUD rated the pain as more severe than those who did not. Pain catastrophizing was unrelated to pain responses. DISCUSSION Despite the small sample size and cross-sectional design, these findings suggest that experimental pain testing may be a novel technique in identifying patients with chronic pain likely to develop OUD, in that they are likely to evidence exacerbated temporal summation and to rate the associated pain as more severe.
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Affiliation(s)
- Peggy A Compton
- Department of Family and Community Health, School of Nursing
| | | | - Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Benville JR, Compton P, Giordano NA, Cheatle MD. Perceived social support in patients with chronic pain with and without opioid use disorder and role of medication for opioid use disorder. Drug Alcohol Depend 2021; 221:108619. [PMID: 33667781 PMCID: PMC8796693 DOI: 10.1016/j.drugalcdep.2021.108619] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/31/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND A significant predictor of treatment outcomes for patients with chronic non-cancer pain (CNCP) and opioid use disorder (OUD) is the degree and quality of social support they receive. Specifically, in patients with CNCP and on long-term opioid therapy, the development of OUD tends to be associated with losses in social support, while engagement in treatment for OUD improves support networks. Delivery of the evidence-based OUD treatment medications, methadone and buprenorphine, occurs in clinical environments which patently differ with respect to social support resources. The aims of this study were to describe perceived social support in patients with CNCP without OUD (no-OUD), with OUD and on buprenorphine (OUD-BP), and with OUD and on methadone (OUD-methadone). METHODS Using the Duke Social Support Index (DSSI), perceived social support in a sample of Caucasian patients with CNCP and on opioid therapy was compared between no-OUDs (n = 834), OUD-methadone (n = 83) and OUD-BP (n = 99) therapy. Average DSSI scores were compared across groups and a linear regression model computed to describe association between group and perceived social support. RESULTS No difference was observed in DSSI scores between no-OUDs and OUD-methadone, however scores were lower among OUD-BP participants than those receiving methadone (x = -5.2; 95% CI: -7.5, -2.9) and (x = -6.5, 95% CI: -8.2, -4.9). CONCLUSIONS Patients with CNCP and OUD on methadone therapy endorse levels of social support comparable to those without OUD, however those on buprenorphine therapy report significantly less support, bringing implications for OUD treatment outcomes.
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Affiliation(s)
- Julia R Benville
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 500, Philadelphia, PA, 19104, United States; Department of Psychiatry, NYU School of Medicine, Bellevue Hospital, 462 First Avenue, Room A842, New York, NY 10016, United States.
| | - Peggy Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Claire Fagin Hall, Room 402, Philadelphia, PA, 19104, United States.
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, United States.
| | - Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 500, Philadelphia, PA, 19104, United States.
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Brintz CE, Cheatle MD, Dember LM, Heapy AA, Jhamb M, Shallcross AJ, Steel JL, Kimmel PL, Cukor D. Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease. Semin Nephrol 2021; 41:68-81. [PMID: 33896475 DOI: 10.1016/j.semnephrol.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.
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Affiliation(s)
- Carrie E Brintz
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alicia A Heapy
- Pain Research Informatics Multimorbidities and Education Center of Innovation, Veterans' Affairs Connecticut Healthcare System, West Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amanda J Shallcross
- Department of Population Health, New York University School of Medicine, New York, NY
| | - Jennifer L Steel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA; Department of Psychology, University of Pittsburgh, Pittsburgh, PA; Behavioral Health, The Rogosin Institute, New York, NY
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Daniel Cukor
- Behavioral Health, The Rogosin Institute, New York, NY
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Cheatle MD, Falcone M, Dhingra L, Lerman C. Independent association of tobacco use with opioid use disorder in patients of European ancestry with chronic non-cancer pain. Drug Alcohol Depend 2020; 209:107901. [PMID: 32126454 PMCID: PMC7219106 DOI: 10.1016/j.drugalcdep.2020.107901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The harms associated with prescription opioid abuse have become a public health crisis. There is a need for evidence-based objective markers of the risk of opioid use disorder (OUD) in patients with pain receiving opioid treatment. The objective of this study was to evaluate the independent association of tobacco use and OUD in patients with chronic non-cancer pain. METHODS This cross-sectional naturalistic study evaluated 798 adults ≥ 18 years with chronic non-cancer pain treated with long-term opioid therapy (≥ 6 months) who either developed an OUD (cases, n = 216) or displayed no evidence of an OUD (controls, n = 582). The primary outcome was presence of OUD. In addition to current self-reported tobacco use (primary predictor), covariates included demographics, pain severity, and psychiatric history. Data were collected between November 2012 and September 2018. RESULTS Current tobacco use independently was strongly associated with OUD [odds ratio (OR) 14.0, 95 % confidence interval (CI) 9.5-20.6, p < 0.001], and this association remained significant after adjusting for other risk factors [adjusted odds ratio (aOR) 7.6, 95 % CI 4.8-12.2, p < 0.001]. Other factors associated independently with development of OUD included age, marital status, financial status, education and pain severity. CONCLUSIONS AND RELEVANCE Current tobacco use is significantly associated with OUD in patients with chronic pain receiving long-term opioid therapy.
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Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry, Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Mary Falcone
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 99003, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Caryn Lerman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 99003, USA
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Cheatle MD, Compton PA, Dhingra L, Wasser TE, O'Brien CP. Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain. J Pain 2019; 20:842-851. [PMID: 30690168 DOI: 10.1016/j.jpain.2019.01.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/20/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022]
Abstract
The Opioid Risk Tool (ORT) is a commonly used measure of risk of aberrant drug-related behaviors in patients with chronic pain prescribed opioid therapy. In this study, the discriminant predictive validity of the ORT was evaluated in a unique cohort of patients with chronic nonmalignant pain (CNMP) on long-term opioid therapy who displayed no evidence of developing an opioid use disorder (OUD) and a sample of patients with CNMP who developed an OUD after commencing opioid therapy. Results revealed that the original ORT was able to discriminate between patients with and without OUDs (odds ratio = 1.624; 95% confidence interval [CI] = 1.539-1.715, P < .001). A weighted ORT eliminating the gender-specific history of preadolescent sexual abuse item revealed comparable results (odds ratio = 1.648, 95% CI = 1.539-1.742, P < .001). A revised unweighted ORT removing the history of preadolescent sexual abuse item was notably superior in predicting the development of OUD in patients with CNMP on long-term opioid therapy (odds ratio = 3.085; 95% CI = 2.725-3.493; P < .001) with high specificity (.851; 95% CI = .811-.885), sensitivity (.854; 95% CI = .799-.898), positive predictive value (.757; 95% CI = .709-.799), and negative predictive value (.914; 95% CI = .885-.937). Perspective: The revised ORT is the first tool developed on a unique cohort to predict the risk of developing an OUD in patients with CNMP receiving opioid therapy, as opposed to aberrant drug-related behaviors that can reflect a number of other issues. The revised ORT has clinical usefulness in providing clinicians a simple, validated method to rapidly screen for the risk of developing OUD in patients on or being considered for opioid therapy.
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Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Peggy A Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Thomas E Wasser
- Consult-Stat: Complete Statistical Services, Macungie, Pennsylvania
| | - Charles P O'Brien
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Cheatle MD. The Impact of Prescription Drug Monitoring Programs and Prescribing Guidelines on Opioid Prescribing Behaviors: A Time for Institutional and Regulatory Changes. Pain Med 2018; 18:823-824. [PMID: 28431089 DOI: 10.1093/pm/pnx083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cheatle MD, Gallagher RM, O’Brien CP. Response to Dr. McAuliffe. Pain Medicine 2018; 19:1102-1103. [DOI: 10.1093/pm/pny042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Martin D Cheatle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rollin M Gallagher
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Charles P O’Brien
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Cheatle MD, Gallagher RM, O’Brien CP. Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain. Pain Med 2018; 19:764-773. [PMID: 28379504 PMCID: PMC6659007 DOI: 10.1093/pm/pnx032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective To examine the risk of developing aberrant behaviors that might lead to a substance use disorder (addiction) when prescribing opioids for the relief of chronic noncancer pain in primary care settings. Design Longitudinal, prospective, descriptive design with repeated measures. Setting Private community-based internal medicine and family medicine clinics. Subjects Patients with chronic musculoskeletal pain. Methods Standardized measures of patient status (pain, functional impairment, psychiatric disorders, family history) and treatments provided, urine drug monitoring, and medical chart audits (presence of aberrant drug-related behaviors) were obtained in a cohort of 180 patients at the time of initiating opioids for chronic noncancer pain and at three, six, and 12 months thereafter. Results Over the 12-month follow-up period, subjects demonstrated stable, mild to moderate levels of depression (PHQ-9 scores ranging from 9.43 to 10.92), mild anxiety (BAI scores ranging from 11.80 to 14.67), minimal aberrant drug-related behaviors as assessed by chart reviews, and a low percentage of illicit drug use as revealed by results of urine drug monitoring. Less than 5% of our study population revealed any evidence of substance use disorder. Conclusions This prospective study suggests that patients without a recent or prior history of substance use disorder who were prescribed primarily short-acting opioids in low doses for chronic noncancer pain have a low risk for developing a substance use disorder. This finding supports the importance of prescreening patients being considered for opioid therapy and that prescription of opioids for noncancer pain may carry a lower risk of abuse in selected populations such as in private, community-based practices.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rollin M Gallagher
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Departments of Psychiatry and Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles P O’Brien
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Cheatle MD. Balancing the Risks and Benefits of Opioid Therapy for Patients with Chronic Nonmalignant Pain: Have We Gone Too Far or Not Far Enough? Pain Medicine 2018; 19:642-645. [DOI: 10.1093/pm/pny037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Martin D Cheatle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cheatle MD, Foster S, Pinkett A, Lesneski M, Qu D, Dhingra L. Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. Sleep Med Clin 2016; 11:531-541. [DOI: 10.1016/j.jsmc.2016.08.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Cheatle MD, Webster LR. Opioid Therapy and Sleep Disorders: Risks and Mitigation Strategies. Pain Med 2016; 16 Suppl 1:S22-6. [PMID: 26461072 DOI: 10.1111/pme.12910] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 08/08/2015] [Accepted: 08/10/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Patients with chronic pain frequently experience concomitant sleep disorders. There has been controversy on whether opioids have a beneficial or deleterious effect on sleep quality, duration and efficiency. There is also concern regarding the association between chronic opioid therapy (COT) and sleep disordered breathing (SDB) and the increased risk for unintentional opioid related overdose. This article provides a narrative review of the literature on the effect of opioids on sleep disorders and discusses risk assessment and mitigation strategies. DESIGN A narrative review of the current literature on the effect of prescription opioids on sleep quality and efficiency, the relationship between opioids and sleep disorders and potential risk factors in patients with chronic pain. RESULTS There is conflicting evidence regarding the benefit of opioids in improving sleep quality, duration and efficiency with several studies and reviews suggesting a beneficial effect of opioids on sleep and other studies demonstrating the opioids can cause sleep disturbance leading to hyperalgesia. There was credible evidence of a strong relationship between opioids and SDB with noted risk factors including use of methadone, high opioid dosing (>200 mg MED) and combining opioids with benzodiazepines. CONCLUSIONS Further research is required to elucidate the effect of prescription opioids on sleep quality and pain intensity and the risks associated with opioids and SDB. The risk of SDB should be routinely assessed in patients on COT.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
Chronic pain is associated with symptoms that may impair a patient's quality of life, including emotional distress, fatigue, and sleep disturbance. There is a high prevalence of concomitant pain and sleep disturbance. Studies support the hypothesis that sleep and pain have a bidirectional and reciprocal relationship. Clinicians who manage patients with chronic pain often focus on interventions that relieve pain, and assessing and treating sleep disturbance are secondary or not addressed. This article reviews the literature on pain and co-occurring sleep disturbance, describes the assessment of sleep disturbance, and outlines nonpharmacologic and pharmacologic treatment strategies to improve sleep in patients with chronic pain.
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Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry, Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA 19104, USA; Department of Psychiatry, Behavioral Medicine Center, Reading Health System, 560 Van Reed Road, Suite 204, Wyomissing, PA 19610, USA.
| | - Simmie Foster
- Kirby Center for Neurobiology, 3 Blackfan Circle, CLS 12-260, Boston, MA 02115, USA
| | - Aaron Pinkett
- Department of Psychiatry, Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA 19104, USA
| | - Matthew Lesneski
- RA Pain Services, 1500 Midatlantic Drive Suite 102, Mount Laurel, NJ 0854, USA
| | - David Qu
- Highpoint Pain and Rehabilitation Physicians P.C., 700 Horizon Circle Suite 206, Chalfont, PA 18914, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY 10006, USA
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Affiliation(s)
- Martin D Cheatle
- a Department of Psychiatry, Center for Studies of Addiction, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
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Abstract
Chronic pain affects nearly one-third of the American population. Chronic pain can lead to a variety of problems for a pain sufferer, including developing secondary medical problems, depression, functional and vocational disability, opioid abuse and suicide. Current pain care models are deficient in providing a necessary comprehensive approach. Most patients with chronic pain are managed by primary care clinicians who are typically ill prepared to effectively and efficiently manage these cases. A biopsychosocial approach to evaluate and treat chronic pain is clinically and economically efficacious, but unique delivery systems are required to meet the challenge of access to specialty care.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA 19104, USA.
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Cheatle MD. Prescription Opioid Misuse, Abuse, Morbidity, and Mortality: Balancing Effective Pain Management and Safety. Pain Med 2015; 16 Suppl 1:S3-8. [DOI: 10.1111/pme.12904] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Peppin JF, Cheatle MD, Kirsh KL, McCarberg BH. The Complexity Model: A Novel Approach to Improve Chronic Pain Care. Pain Med 2015; 16:653-66. [DOI: 10.1111/pme.12621] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cheatle MD. Suicidal ideation in patients with chronic pain: The risk–benefit of pharmacotherapy. Pain 2014; 155:2446-2447. [DOI: 10.1016/j.pain.2014.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
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Abstract
Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cody Barker
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Cheatle MD. Assessing suicide risk in patients with chronic pain and depression. J Fam Pract 2014; 63:S6-S11. [PMID: 25061631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Nearly one-half of all patients seen in primary care experience persistent pain, and major depressive disorder is a common comorbidity with chronic pain.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Background: Patients with chronic pain often experience co-occurring depression and in some
cases suicidal ideation. It is critical to discover risk factors for suicide in this vulnerable patient
population.
Objective: To assess the prevalence of suicidal ideation and identify potential risk factors in
patients with chronic non-cancer pain.
Study Design: Retrospective chart review.
Setting: Four hundred and sixty-six patients with chronic non-cancer pain referred to a behaviorally
based pain program in a community health system.
Methods: Data collected included pain intensity and level of pain interference (Brief Pain
Inventory), pain duration, pain site, depression level (Beck Depression Inventory Fast Screen for
Medical Patients), anxiety (Beck Anxiety Inventory), personal and family psychiatric and substance
use disorder history, level of isolation, and demographic data. Univariate and logistic regression
analyses were performed.
Results: Results showed a high rate of suicidal ideation in this patient population (28%).
Univariate analyses stratified by level of suicide (no suicidal ideation or passive/active suicidal
ideation) revealed statistically significant group differences on pain location (extremity P = 0.046,
generalized P = 0.047), work disruption (P = 0.049), social withdrawal (P < 0.001), pre-pain history
of depression (P < 0.001), family history of depression (P < 0.001), and history of sexual/physical
abuse (P < 0.001). Logistic regression revealed that history of sexual/physical abuse (Beta = 0.825;
P = 0.020; OR = 2.657 [95% CI = 1.447 – 4.877]), family history of depression (Beta = 0.471; P =
0.006; OR = 1.985 [95% CI = 1.234 – 3.070]), and being socially withdrawn (Beta = 0.482; P <
0.001; OR = 2.226 [95% CI = 1.431 – 3.505]) were predictive of suicidal ideation.
Limitations: Measure of depression was not included in data analysis to reduce effect of colinearity. Also the study population was a specialty pain clinic allowing for possible subject selection
bias.
Conclusions: Results of this study are consistent with the prevailing literature on pain and
suicide demonstrating a high prevalence of suicidal ideation in the chronic pain population. Novel
predictive variables were also identified that will provide the basis for developing a risk stratification
model that can be further tested prospectively in chronic pain patients.
Key words: Chronic pain, suicide, depression
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Affiliation(s)
- Martin D. Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 2 Reading Health System, West Reading, PA
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Cheatle MD, Wasser T, Foster C, Olugbodi A, Bryan J. Prevalence of suicidal ideation in patients with chronic non-cancer pain referred to a behaviorally based pain program. Pain Physician 2014; 17:E359-E367. [PMID: 24850117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Patients with chronic pain often experience co-occurring depression and in some cases suicidal ideation. It is critical to discover risk factors for suicide in this vulnerable patient population. OBJECTIVE To assess the prevalence of suicidal ideation and identify potential risk factors in patients with chronic non-cancer pain. STUDY DESIGN Retrospective chart review. SETTING Four hundred and sixty-six patients with chronic non-cancer pain referred to a behaviorally based pain program in a community health system. METHODS Data collected included pain intensity and level of pain interference (Brief Pain Inventory), pain duration, pain site, depression level (Beck Depression Inventory Fast Screen for Medical Patients), anxiety (Beck Anxiety Inventory), personal and family psychiatric and substance use disorder history, level of isolation, and demographic data. Univariate and logistic regression analyses were performed. RESULTS Results showed a high rate of suicidal ideation in this patient population (28%). Univariate analyses stratified by level of suicide (no suicidal ideation or passive/active suicidal ideation) revealed statistically significant group differences on pain location (extremity P = 0.046, generalized P = 0.047), work disruption (P = 0.049), social withdrawal (P < 0.001), pre-pain history of depression (P < 0.001), family history of depression (P < 0.001), and history of sexual/physical abuse (P < 0.001). Logistic regression revealed that history of sexual/physical abuse (Beta = 0.825; P = 0.020; OR = 2.657 [95% CI = 1.447 - 4.877]), family history of depression (Beta = 0.471; P = 0.006; OR = 1.985 [95% CI = 1.234 - 3.070]), and being socially withdrawn (Beta = 0.482; P < 0.001; OR = 2.226 [95% CI = 1.431 - 3.505]) were predictive of suicidal ideation. LIMITATIONS Measure of depression was not included in data analysis to reduce effect of co-linearity. Also the study population was a specialty pain clinic allowing for possible subject selection bias. CONCLUSIONS Results of this study are consistent with the prevailing literature on pain and suicide demonstrating a high prevalence of suicidal ideation in the chronic pain population. Novel predictive variables were also identified that will provide the basis for developing a risk stratification model that can be further tested prospectively in chronic pain patients.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Reading Health System, West Reading, PA; Senior Scientist for Biostatistics, Allentown, PA
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Cheatle MD, O'Brien CP, Mathai K, Hansen M, Grasso M, Yi P. Aberrant behaviors in a primary care-based cohort of patients with chronic pain identified as misusing prescription opioids. J Opioid Manag 2013; 9:315-324. [PMID: 24353044 DOI: 10.5055/jom.2013.0174] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 03/08/2013] [Accepted: 07/08/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess aberrant drug-related behaviors (ADRBs) in patients discharged from a community primary care practice for opioid misuse and treating physician's ability to identify predictive aberrant behaviors. DESIGN Retrospective chart review of patients with chronic noncancer pain (CNCP) identified by their treating physician as misusing opioid analgesics, and patients with similar characteristics who had not been identified as misusing opioids. A survey of attending and resident physicians from these clinics on their knowledge of ADRBs was also collected. SETTING Community primary care clinic. PATIENTS, PARTICIPANTS Thirty-three patients with CNCP identified by their treating physician as misusing prescription opioid analgesics, and 33 patients randomly selected from the same clinic setting, with similar characteristics who had not been identified as misusing opioids. Twenty-four attending physicians and 42 resident physicians were surveyed on their training and knowledge of predictive aberrant behaviors. RESULTS More identified misusers than nonmisusers reported positive history of substance abuse (p=0.001), tobacco use (p=0.011), taking multiple doses of prescribed opioids together (0.024), multiple complaints of pain requiring opioid treatment (p=0.006), and multiple phone calls to the clinic requesting opioid medications (p=0.027). Logistic regression on continuous variables revealed that only the number of phone calls to the clinic regarding opioids in the last 12 months achieved significance (p=0.028). CONCLUSIONS Previously postulated and novel ADRBs suggestive of opioid misuse were identified in a community primary care setting. Differences in resident and attending physician's ability to identify key predictive ADRBs and lack of training in pain or addiction underscores the need for changes in medical school and residency programs.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania; Behavioral Medicine Center, Reading Health System, West Reading, Pennsylvania
| | - Charles P O'Brien
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Koshy Mathai
- Comprehensive Pain Management, Baton Rouge, Louisiana
| | - Matthew Hansen
- Department of Pain Management, MedStar Franklin Square Medical Center, Baltimore, Maryland
| | - Mario Grasso
- Morris Anesthesia Group, Phillipsburg, New Jersey
| | - Peter Yi
- Department of Anesthesia, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
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Peppin JF, Passik SD, Couto JE, Fine PG, Christo PJ, Argoff C, Aronoff GM, Bennett D, Cheatle MD, Slevin KA, Goldfarb NI. Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain. Pain Med 2012; 13:886-96. [DOI: 10.1111/j.1526-4637.2012.01414.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Most patients receiving opioids for the spectrum of pain disorders tolerate opioids well without major complications. However, a subset of this population encounters significant difficulties with opioid therapy (OT). These problems include protracted adverse effects, as well as misuse, abuse, and addiction, which can result in significant morbidity and mortality and make informed consent an important consideration. Opioid treatment agreements (OTAs), which may include documentation of informed consent, have been used to promote the safe use of opioids for pain. There is a debate regarding the effectiveness of OTAs in reducing the risk of opioid misuse; however, most practitioners recognize that OTAs provide an opportunity to discuss the potential risks and benefits of OT and establish mutually agreed-on treatment goals, a clear plan of treatment, and circumstances for continuation and discontinuation of opioids. Informed consent is an important component of an OTA but not often the focus of consideration in discussions of OTAs. This article examines the principles, process, and content of informed consent for OT of pain in the context of OTAs.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Abstract
Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the "true" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th floor, Philadelphia, PA 19104 USA ; Behavioral Medicine Center, The Reading Hospital and Medical Center, West Reading, PA USA
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Abstract
Comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain. The true numbers of failed attempts and successful suicides are unknown and may never be determined. Yet, risk factors for suicidal ideation are so high in this population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain. The purpose of this manuscript is to highlight to clinicians the important association between chronic pain and intentional self-harm. Contemporary understanding of the epidemiology of depression and suicide and the relationship to chronic pain will be reviewed. Recommendations for the use of validated and practical screening tools as part of a comprehensive clinical assessment and for approaches to suicide prevention and interventions as crucial components of chronic pain management are outlined.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Cheatle MD, O'Brien CP. Opioid therapy in patients with chronic noncancer pain: diagnostic and clinical challenges. Adv Psychosom Med 2011; 30:61-91. [PMID: 21508626 DOI: 10.1159/000324067] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic opioid therapy for patients with chronic noncancer pain has become controversial, given the rising prevalence of opioid abuse. The prevailing literature suggests that the rate of addiction in chronic noncancer pain patients exposed to opioid therapy is relatively low, especially in those patients without significant concomitant psychiatric disorders and personal and family history of addiction. However, the escalating rate of misuse of prescription opioids has resulted in many clinicians caring for these patients to be more judicious in prescribing opioids. Accurately diagnos ing addiction in chronic pain patients receiving opioids is complex. Managing the patient with pain and co-occurring opioid abuse is equally challenging. Diagnostic issues, current guidelines for the appropriate use of opioids in the chronic pain population and risk stratification models are examined. Pharmacologic and nonpharmacologic treatment strategies for the patient with pain and opioid addiction are reviewed.
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Abstract
Chronic pain is a colossal health care problem that is devastating to the individual afflicted with unremitting pain and frustrating to the beleaguered health care provider attempting to adequately manage this multifaceted disease. The biopsychosocial model of pain management is a promising approach that emphasizes evidence-based medication management in conjunction with cognitive-behavioral therapy and a graded exercise program. The patient with chronic pain and concomitant mood and/or substance use disorders is exceptionally challenging. Effective pharmacologic management of pain and comorbid mood disorders, including the thoughtful use of opioids, can have a dramatic effect in improving the quality of life in patients with chronic pain. The high prevalence of chronic pain in our society and the scarcity of experienced pain medicine physicians necessitate the development of a community-based systems approach to this complex patient population.
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Affiliation(s)
- Martin D Cheatle
- Behavioral Medicine Center, The Reading Hospital and Medical Center, P.O. Box 16052, Reading, PA 19612-6052, USA.
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Tan V, Cheatle MD, Mackin S, Moberg PJ, Esterhai JL. Goal setting as a predictor of return to work in a population of chronic musculoskeletal pain patients. Int J Neurosci 1997; 92:161-70. [PMID: 9522264 DOI: 10.3109/00207459708986399] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To assess prospectively the association between personal attributes, vocational factors, and the return to work outcome for patients with chronic, nonmalignant, musculoskeletal pain, we assessed return to work (RTW) motivation though an open-format listing of treatment goals in 59 chronic pain patients admitted to a university pain management program. Patients were then followed (average of 17.9 months) in the posttreatment period to determine whether they had in fact returned to employment. Results indicated that a number of pretreatment factors predicted future employment status in this patient population. Age, marital status, education and decreased length of unemployment were predictive of RTW outcome. Overall, RTW goal was the single best predictor of return to work outcome. In contrast, increased number of premorbid jobs, compensation status, patient's race and sex were not predictive. The present study suggests that the assessment of an individual's motivation as defined by goal-setting may be a key factor in predicting a favorable outcome in this typically refractory population of patients.
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Affiliation(s)
- V Tan
- Department of Orthopedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
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Lerner RK, Esterhai JL, Polomano RC, Cheatle MD, Heppenstall RB. Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower-extremity amputation. Clin Orthop Relat Res 1993:28-36. [PMID: 8403662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
One hundred nine patients with long-bone fracture nonunion, chronic refractory osteomyelitis, and posttraumatic amputation were evaluated to assess the impact of chronic disability on the quality of life. The quality of life parameters were defined by a functional assessment instrument, the Arthritis Impact Measurement Scale (AIMS), and a Psychosocial Adjustment to Illness Scale (PAIS). A spouse PAIS self-report instrument was administered to assess the psychosocial adjustment of spouses or significant others. A final questionnaire was developed to determine the reasons, in order of their importance, for either continuing medical therapy or accepting amputation. The PAIS scores differed significantly between osteomyelitis patients and nonunion or amputation patients. The presence or absence of pain produced significant differences in AIMS and PAIS scores of nonunion and osteomyelitis patients. Subscale analysis of AIMS scores showed significant differences among the three groups with respect to health perception and scale of orthopaedic problem. The osteomyelitis patients were more severely affected than the nonunion or amputation patients. The PAIS was unable to detect any statistically significant differences in psychosocial adjustment of the spouses of patients in each of the three population groups. The most frequent reason for continuing medical and surgical management of nonunion and osteomyelitis was hopeful expectation for cure. The group who chose amputation did so in an attempt to put an end to the need for medical and surgical treatment. Differences in psychosocial and functional ability were related to disease diagnosis, pain, status of fracture healing, and timing of amputation. This study provides further insight into the quality of life experience for patients with long-term orthopaedic problems.
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Affiliation(s)
- R K Lerner
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia 19104
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Affiliation(s)
- M D Cheatle
- Department of Orthopaedic Surgery, University of Pennsylvania Medical Center, Philadelphia
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Cheatle MD. The effect of chronic orthopedic infection on quality of life. Orthop Clin North Am 1991; 22:539-47. [PMID: 1852430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The patient with chronic orthopedic infection presents a unique challenge to the orthopedic surgeon. The orthopedic surgeon must not only possess an expertise in constantly evolving diagnostic and treatment techniques but also be able to identify numerous related problems and direct the patient in receiving the most appropriate treatment. This demands a commitment of time by the treating surgeon to the individual patient to properly assess the need for support, the extent of psychologic distress, the intensity of pain, and the requirement for medication management. The effective utilization of a multidisciplinary team of health care providers (e.g., specialists in infectious disease, physical medicine and rehabilitation, psychiatry, nursing, pharmacology) can provide an optimal treatment program for this multifaceted problem and maximize the potential for a favorable outcome.
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Affiliation(s)
- M D Cheatle
- Orthopaedic Pain Center, University of Pennsylvania School of Medicine, Philadelophia
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Abstract
Twenty consecutive, chronic low back pain patients admitted to our pain treatment unit completed the Attributional Style Questionnaire (an instrument that detects a cognitive style that is correlated with, and that predicts, depression) and the Beck Depression Inventory. An age, sex, and education-matched group of normal subjects, a group of patients with asymptomatic essential hypertension, and a group of patients with end-stage renal disease receiving dialysis treatment served as controls. The majority of the chronic-pain and renal-dialysis patients had elevated depression scores, whereas none of the normal subjects or hypertensive patients were outside the nondepressed range. The Attributional Style scores of the pain and renal dialysis patients were significantly deviant from the normal control group, but no more so than those of the patients with hypertension. The results of this study suggest that individuals with a chronic medical condition, either symptomatic (chronic low back pain or renal disease) or asymptomatic (essential hypertension) in nature, develop an attributional style characteristic of depression. These data neither lend support nor refute the thesis that chronic pain syndromes are a variant of, or a masked, depression. Rather, this research implies that a more important question is what identifiable risk factors (for example, attributional style) predispose patients with chronic pain to develop a depressive illness.
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Affiliation(s)
- M D Cheatle
- Department of Orthopaedic Surgery, School of Medicine, University of Pennsylvania, Philadelphia
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Abstract
Ten patients with premature ventricular contractions (PVCs) were studied to assess the effects of adaptation and relaxation practice on arrhythmia frequency. They had 48 hr of ambulatory ECG monitoring on three occasions: 1) at entry into the study; 2) 4 wk later, after no intervention; and 3) after 4 wk of practicing the relaxation response. Results showed a significant decrease in PVC frequency from the first to the second monitoring, i.e., before relaxation practice. Of eight patients who completed the third monitoring, only three showed a decline in PVC frequency below baseline levels. The group as a whole showed an increase in PVC frequency with relaxation practice, although this was not statistically significant. These findings suggest that there is an important adaptational effect to repeated ambulatory ECG monitoring in PVC patients--namely, a decrease in arrhythmia frequency. Relaxation practice did not produce any clear effect for the overall group.
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Abstract
The influence of LiCl preexposure on odor-aversion conditioning produced by an odor-LiCl pairing was studied in rats 7-31 days old. LiCl preexposure interfered with the acquisition of the odor aversion in both young and old pups. The time course of this effect depended, however, on the age of the pups. It lasted much longer (over 24 hr) if pups 8-17 days old were preexposed to LiCl than if the pups were preexposed when 30 days old (less 12 hr). Alternative interpretations of these data were discussed, and it was suggested that the age-dependent differences in the time course of the LiCl preexposed effect may be determined in part by age-related differences in the rat's excretory processes that clear lithium from the circulatory system.
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Cheatle MD, Rudy JW. Ontogeny of second-order odor-aversion conditioning in neonatal rats. J Exp Psychol Anim Behav Process 1979. [PMID: 528883 DOI: 10.1037//0097-7403.5.2.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In Experimental 1, rat pups 1, 3, 5, or 7 days old received a Phase 1 S1-US (Stimulus 1-unconditioned stimulus) pairing calculated to establish a first-order conditioned aversion to S1 (lemon scent). On the next day each pup received a Phase 2 S2-S1 pairing designed to establish a second-order aversion to S2 (orange scent). Pups at all ages displayed a first-order aversion to S1, but only pups given Phase 2 training when 6 or 8 days old displayed a second-order aversion to S2. Experiment 2 revealed that pups that received the S1-US pairing when 3 days old acquired an aversion to S2 if they were 6 days old when they received the S2-S1 pairing but not if they received the pairing when 4 days old. In Experiment 3, two Phase 2 treatments were compared. One was identical to that employed in Experiments 1 and 2: Pups 4 days old received a sequential exposure to S2 and S1. Another set of pups received a modified treatment: They were exposed first to S2 and then jointly to both S2 and S1. Only pups in the latter set displayed an aversion to S2. It is suggested that these results reflect developmental differences in the memory processes mediating the rat's experience with olfactory stimulation.
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Abstract
In Experimental 1, rat pups 1, 3, 5, or 7 days old received a Phase 1 S1-US (Stimulus 1-unconditioned stimulus) pairing calculated to establish a first-order conditioned aversion to S1 (lemon scent). On the next day each pup received a Phase 2 S2-S1 pairing designed to establish a second-order aversion to S2 (orange scent). Pups at all ages displayed a first-order aversion to S1, but only pups given Phase 2 training when 6 or 8 days old displayed a second-order aversion to S2. Experiment 2 revealed that pups that received the S1-US pairing when 3 days old acquired an aversion to S2 if they were 6 days old when they received the S2-S1 pairing but not if they received the pairing when 4 days old. In Experiment 3, two Phase 2 treatments were compared. One was identical to that employed in Experiments 1 and 2: Pups 4 days old received a sequential exposure to S2 and S1. Another set of pups received a modified treatment: They were exposed first to S2 and then jointly to both S2 and S1. Only pups in the latter set displayed an aversion to S2. It is suggested that these results reflect developmental differences in the memory processes mediating the rat's experience with olfactory stimulation.
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Rudy JW, Cheatle MD. A role for conditioned stimulus duration in toxiphobia conditioning. J Exp Psychol Anim Behav Process 1978. [PMID: 712331 DOI: 10.1037//0097-7403.4.4.399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The effect of conditioned stimulus (CS) exposure duration on toxiphobia conditioning was investigated. When a relatively long (20--30 min) CS exposure was administered on the conditioning trial, rats subsequently displayed a reduced conditioned aversion in comparison with when CS exposure was relatively brief (5--10 min). This result was obtained in an odor-aversion learning task with neonatal rats as subjects (Experiments 1 and 2) and in a flavor-aversion learning task with adult rats (Experiment 3). This phenomenon was further investigated in the odor-aversion task by presenting neonates with two discrete 10-min exposures to the odor CS and by varying both the temporal proximity of the two CS presentations to each other and to the occurrence of the unconditioned stimulus (US). Two exposures to the CS reduced conditioning in comparison with a single exposure but only when the second CS presentation preceded US occurrence by at least 5 min (Experiments 4 and 5). Both nonassociative and associative interpretations of the data were discussed.
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Cheatle MD, Rudy JW. Analysis of second-order odor-aversion conditioning in neonatal rats: implications for Kamin's blocking effect. J Exp Psychol Anim Behav Process 1978. [PMID: 690564 DOI: 10.1037//0097-7403.4.3.237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Cheatle MD, Rudy JW. Analysis of second-order odor-aversion conditioning in neonatal rats: Implications for Kamin's blocking effect. ACTA ACUST UNITED AC 1978; 4:237-49. [PMID: 690564 DOI: 10.1037/0097-7403.4.3.237] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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46
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Abstract
The effect of conditioned stimulus (CS) exposure duration on toxiphobia conditioning was investigated. When a relatively long (20--30 min) CS exposure was administered on the conditioning trial, rats subsequently displayed a reduced conditioned aversion in comparison with when CS exposure was relatively brief (5--10 min). This result was obtained in an odor-aversion learning task with neonatal rats as subjects (Experiments 1 and 2) and in a flavor-aversion learning task with adult rats (Experiment 3). This phenomenon was further investigated in the odor-aversion task by presenting neonates with two discrete 10-min exposures to the odor CS and by varying both the temporal proximity of the two CS presentations to each other and to the occurrence of the unconditioned stimulus (US). Two exposures to the CS reduced conditioning in comparison with a single exposure but only when the second CS presentation preceded US occurrence by at least 5 min (Experiments 4 and 5). Both nonassociative and associative interpretations of the data were discussed.
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Abstract
Two-day-old rats were exposed to a novel odor and injected with an illness-inducing drug, lithium chloride. When tested at 8 days of age, these pups avoided pine shavings scented with the odor, whereas control pups did not. These results imply that rat pups are capable of associative learning at a much earlier age than was thought possible.
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