Pain: The Silent Public Health Epidemic.

More than 50 million Americans suffer from chronic pain, costing our society an estimated 565 to 635 billion dollars annually. Its complexity and training deficits in healthcare providers result in many patients receiving ineffective care. Large health inequities also exist in access to effective pain care for vulnerable populations. The traumatic history of indigenous people and people of color in regards to the experience of pain care perpetuates a lack of trust in the healthcare system, causing many to hesitate to seek medical treatment for painful events and conditions. Other vulnerable populations include those with sickle cell disease or fibromyalgia, whose experience of pain has not been well-understood. There are both barriers to care and stigma for patients with pain, including those taking prescribed doses of long-term opioids, those with known substance use disorder, and those with mental health diagnoses. The suffering of patients with pain can be "invisible" to the clinician, and to one's community at large. Pain can affect all people; but those most vulnerable to not getting effective care may continue to suffer in silence because their voices are not heard. Since 1973, pain societies around the globe have worked tirelessly to bring clinicians together to advance pain and opioid education, research, and patient care. These improvements consist of pain education, integrative treatment, and the understanding that a therapeutic alliance is critical to effective pain management. Pain education for both pre and post-licensure health professionals has increased substantially over the last decade. In addition, integrative and interdisciplinary approaches for clinical pain management are now considered best practices in pain care for patients with moderate to severe pain in addition to the development of a strong therapeutic alliance.

Differential Pain Presentations Observed across Post-Traumatic Stress Disorder Symptom Trajectories after Combat Injury.

OBJECTIVE: This study evaluated the association between pain outcomes and post-traumatic stress disorder (PTSD) symptom trajectories after combat-related injury, while adjusting for receipt of regional anesthesia (RA) soon after injury. METHODS: The PTSD symptom trajectories of N = 288 combat-injured service members were examined from within a month of injury up to two-years after. Linear mixed-effects models evaluated the association between PTSD symptom trajectories and average pain and pain interference outcomes while adjusting for receipt of RA during combat casualty care. RESULTS: Four PTSD trajectories were characterized: resilient, recovering, worsening, and chronic. Differential pain presentations were associated with PTSD symptom trajectories, even after adjusting for receipt of RA. Compared to those with a resilient PTSD symptom trajectory, individuals presenting with chronic PTSD trajectories were estimated to experience average pain scores 2.61 points higher (95% CI: 1.71, 3.14). Participants presenting with worsening (ß = 1.42; 95% CI: 0.77, 1.78) and recovering PTSD trajectories (ß = 0.65; 95% CI: 0.09, 1.08) were estimated to experience higher average pain scores than participants with resilient PTSD trajectories. Significant differences in pain interference scores were observed across PTSD trajectories. Receiving RA was associated with improved pain up to two years after injury (ß = -0.31; 95% CI: -0.90, -0.04), however no statistically significant association was detected between RA and PTSD trajectories. CONCLUSIONS: Chronic and worsening PTSD trajectories were associated with greater pain intensity and interference following combat injury even when accounting for receipt of early RA for pain management. These findings underscore the need to jointly assess pain and PTSD symptoms across the trauma care continuum.

Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11.

OBJECTIVE: For many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS. METHODS: This article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established. RESULTS: 14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option-Persistent spinal pain syndrome-was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification. CONCLUSIONS: This project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.

Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial.

IMPORTANCE: The opioid crisis creates challenges for cancer pain management. Acupuncture confers clinical benefits for chronic nonmalignant pain, but its effectiveness in cancer survivors remains uncertain. OBJECTIVE: To determine the effectiveness of electroacupuncture or auricular acupuncture for chronic musculoskeletal pain in cancer survivors. DESIGN, SETTING, AND PARTICIPANTS: The Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) trial is a randomized clinical trial that was conducted from March 2017 to October 2019 (follow-up completed April 2020) across an urban academic cancer center and 5 suburban sites in New York and New Jersey. Study statisticians were blinded to treatment assignments. The 360 adults included in the study had a prior cancer diagnosis but no current evidence of disease, reported musculoskeletal pain for at least 3 months, and self-reported pain intensity on the Brief Pain Inventory (BPI) ranging from 0 (no pain) to 10 (worst pain imaginable). INTERVENTIONS: Patients were randomized 2:2:1 to electroacupuncture (n = 145), auricular acupuncture (n = 143), or usual care (n = 72). Intervention groups received 10 weekly sessions of electroacupuncture or auricular acupuncture. Ten acupuncture sessions were offered to the usual care group from weeks 12 through 24. MAIN OUTCOMES AND MEASURES: The primary outcome was change in average pain severity score on the BPI from baseline to week 12. Using a gatekeeping multiple-comparison procedure, electroacupuncture and auricular acupuncture were compared with usual care using a linear mixed model. Noninferiority of auricular acupuncture to electroacupuncture was tested if both interventions were superior to usual care. RESULTS: Among 360 cancer survivors (mean [SD] age, 62.1 [12.7] years; mean [SD] baseline BPI score, 5.2 [1.7] points; 251 [69.7%] women; and 88 [24.4%] non-White), 340 (94.4%) completed the primary end point. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P < .001) and auricular acupuncture reduced by 1.6 points (97.5% CI, 1.0-2.1 points; P < .001) from baseline to week 12. Noninferiority of auricular acupuncture to electroacupuncture was not demonstrated. Adverse events were mild; 15 of 143 (10.5%) patients receiving auricular acupuncture and 1 of 145 (0.7%) patients receiving electroacupuncture discontinued treatments due to adverse events (P < .001). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial among cancer survivors with chronic musculoskeletal pain, electroacupuncture and auricular acupuncture produced greater pain reduction than usual care. However, auricular acupuncture did not demonstrate noninferiority to electroacupuncture, and patients receiving it had more adverse events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02979574.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity.

OBJECTIVE: Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. METHODS: We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. RESULTS: The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42). CONCLUSIONS: Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Prospective cohort study examining the use of regional anesthesia for early pain management after combat-related extremity injury.

BACKGROUND: No studies have examined the long-term benefits of regional anesthesia (RA) for pain management after combat-related injury. The objective of this prospective cohort study was to examine the relationship between RA administration and patient-reported pain-related outcomes among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members sustaining a combat-related extremity injury. METHODS: Between 2007 and 2013, n=358 American military personnel injured in OEF/OIF were enrolled at two military treatment facilities. Individuals were followed for up to 2 years after injury. Cohorts were defined based on whether participants were administered RA within 7 days after sustaining a combat-related injury, or not. Linear mixed effects models examined the association between RA and average pain intensity. Secondary outcomes included pain relief, pain interference, neuropathic pain symptoms, treatment outcomes related to pain management, and mental health symptoms. RESULTS: Receiving early RA was associated with improved average pain over the first 6 months after injury (ß=-0.57; p=0.012) adjusting for injury severity and length of stay at the primary treatment facility. This difference was observed up to 24 months after injury (ß=-0.36; p=0.046). Individuals receiving early RA reported greater pain relief, improved neuropathic pain intensity, and higher satisfaction with pain outcomes; however, by 24 months, mean scores did not significantly differ between cohorts. CONCLUSION: Findings indicate that when administered soon after traumatic injury, RA is a valuable pain management intervention. Future longitudinal studies investigating the timely delivery of RA for optimal pain management in civilian trauma settings are needed. TRIAL REGISTRATION NUMBER: NCT00431847.

The Socioeconomic Burden of Pain From War.

War's burden on the health and well-being of combatants, civilians, and societies is well documented. Although the examination of soldiers' injuries in modern combat is both detailed and comprehensive, less is known about war-related injuries to civilians and refugees, including victims of torture. The societal burden of war-related disabilities persists for decades in war's aftermath. The complex injuries of combat survivors, including multiple pain conditions and neuropsychiatric comorbidities, challenge health care systems to reorganize care to meet these survivors' special needs.We use the case study method to illustrate the change in pain management strategies for injured combat survivors in one national health system, the US Department of Veterans Affairs (VA). The care of veterans' disabling injuries suffered in Vietnam contrasts with the care resulting from the VA's congressional mandate to design and implement a pain management policy that provides effective pain management to veterans injured in the recent Middle East conflicts.The outcomes-driven, patient-centric Stepped Care Model of biopsychosocial pain management requires system-wide patient education, clinician training, social networking, and administrative monitoring. Societies are encouraged to develop their health care system's capacity to effectively respond to the victims of warfare, including combatants and refugees.

Sport-related injury and pain classification.

Pain is common in athletes, and pain management in sport has traditionally been equated with injury management. Although both pain and injury interfere with sport performance, they are not synonymous. Acute musculoskeletal injury commonly manifests as nociceptive pain, inflammatory pain, or both. Pain that persists beyond expected injury recovery must account for all potential contributors to pain, including ongoing biomechanical abnormalities, underlying pathophysiology, and psychosocial issues. Pain chronification involves multiple pathophysiologic and neurobehavioral processes that lead from acute injury-related pain to subacute and chronic pain, and must be distinguished from an ongoing biomechanical overuse pattern. The foundation of pain management in athletes is proper pain classification, which involves assessing for any combination of nociceptive/inflammatory pain, neuropathic pain, central sensitization, and autonomic/motor/affective manifestations of pain. Understanding this foundation is critical because there are scant evidence-based guidelines for the management of pain in sport. This chapter will explore the relationship of sport-related injury and pain, and will provide a management framework that is consistent with International Olympic Committee consensus.