Use of Complementary Health Approaches Overall and for Pain Management by US Adults.

This study examines prevalence of use of complementary health approaches overall and for pain management among US adults.

Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020.

Importance: Chronic pain risk and prognosis estimates are needed to inform effective interventions. Objective: To estimate rates of chronic pain and high-impact chronic pain (HICP) incidence and persistence in US adults across demographic groups. Design, Setting, and Participants: This cohort study examined a nationally representative cohort with 1 year of follow-up (mean [SD], 1.3 [0.3] years). Data from the 2019-2020 National Health Interview Survey (NHIS) Longitudinal Cohort were used to assess the incidence rates of chronic pain across demographic groups. The cohort was created using random cluster probability sampling of noninstitutionalized civilian US adults 18 years or older in 2019. Of 21 161 baseline participants in the 2019 NHIS who were randomly chosen for follow-up, 1746 were excluded due to proxy response(s) or lack of contact information, and 334 were deceased or institutionalized. Of the 19 081 remaining, the final analytic sample of 10 415 adults also participated in the 2020 NHIS. Data were analyzed from January 2022 to March 2023. Exposures: Self-reported baseline sex, race, ethnicity, age, and college attainment. Main Outcomes and Measures: Primary outcomes were the incidence rates of chronic pain and HICP, and secondary outcomes were the demographic characteristics and rates across demographic groups. A validated measure of pain status ("In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?") yielded 3 discrete categories each year: pain free, nonchronic pain, or chronic pain (pain "most days" or "every day"). Chronic pain present in both survey years was considered persistent; HICP was defined as chronic pain that limited life or work activities on most days or every day. Rates were reported per 1000 person-years (PY) of follow-up, and age standardized based on the 2010 US adult population. Results: Among 10 415 participants included in the analytic sample, 51.7% (95% CI, 50.3%-53.1%) were female, 54.0% (95% CI, 52.4%-55.5%) were aged 18 to 49 years, 72.6% (95% CI, 70.7%-74.6%) were White, 84.5% (95% CI, 81.6%-85.3%) were non-Hispanic or non-Latino, and 70.5% (95% CI, 69.1%-71.9%) were not college graduates. Among pain-free adults in 2019, incidence rates of chronic pain and HICP in 2020 were 52.4 (95% CI, 44.9-59.9) and 12.0 (95% CI, 8.2-15.8) cases per 1000 PY, respectively. The rates of persistent chronic pain and persistent HICP in 2020 were 462.0 (95% CI, 439.7-484.3) and 361.2 (95% CI, 265.6-456.8) cases per 1000 PY, respectively. Conclusions and Relevance: In this cohort study, the incidence of chronic pain was high compared with other chronic diseases. These results emphasize the high disease burden of chronic pain in the US adult population and the need for early management of pain before it becomes chronic.

Chronic pain among U.S. sexual minority adults who identify as gay, lesbian, bisexual, or "something else".

ABSTRACT: This study assesses chronic pain prevalence among sexual minority U.S. adults who self-identify as gay/lesbian, bisexual, or "something else," and examines the role of select covariates in the observed patterns. Analyses are based on 2013 to 2018 waves of the National Health Interview Survey, a leading cross-sectional survey representative of the U.S. population. General chronic pain and chronic pain in 3+ sites among adults aged 18 to 64 years (N = 134,266 and 95,675, respectively) are analyzed using robust Poisson regression and nonlinear decomposition; covariates include demographic, socioeconomic, healthcare, and psychological distress measures. We find large disparities for both pain outcomes. Americans who self-identify as bisexual or "something else" have the highest general chronic pain prevalence (23.7% and 27.0%, respectively), compared with 21.7% among gay/lesbian and 17.2% straight adults. For pain in 3+ sites, disparities are even larger: Age-adjusted prevalence is over twice as high among adults who self-identify as bisexual or "something else" and 50% higher among gay/lesbian, compared with straight adults. Psychological distress is the most salient correlate of the disparities, whereas socioeconomic status and healthcare variables explain only a modest proportion. Findings thus indicate that even in an era of meaningful social and political advances, sexual minority American adults have significantly more chronic pain than their straight counterparts. We call for data collection efforts to include information on perceived discrimination, prejudice, and stigma as potential key upstream factors that drive pain disparities among members of these minoritized groups.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample.

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

Reasons Office-Based Physicians in the United States Recommend Common Complementary Health Approaches to Patients: An Exploratory Study Using a National Survey.

Objective: To examine the reasons why office-based physicians do or do not recommend four selected complementary health approaches to their patients in the context of the Andersen Behavioral Model. Design: Descriptive estimates of physician-level data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Induction Interview, a nationally representative survey of office-based physicians (N = 5622, weighted response rate = 59.7%). Setting/Location: The United States. Outcome measures: Reasons for the recommendation or lack thereof to patients for: herbs and other non-vitamin supplements, chiropractic/osteopathic manipulation, acupuncture, and mind-body therapies (including meditation, guided imagery, and progressive relaxation). Differences by physician sex and medical specialty were described. Results: For each of the four complementary health approaches, more than half of the physicians who made recommendations indicated that they were influenced by scientific evidence in peer-reviewed journals (ranging from 52.0% for chiropractic/osteopathic manipulation [95% confidence interval, CI = 47.6-56.3] to 71.3% for herbs and other non-vitamin supplements [95% CI = 66.9-75.4]). More than 60% of all physicians recommended each of the four complementary health approaches because of patient requests. A higher percentage of female physicians reported evidence in peer-reviewed journals as a rationale for recommending herbs and non-vitamin supplements or chiropractic/osteopathic manipulation when compared with male physicians (herbs and non-vitamin supplements: 78.8% [95% CI = 72.4-84.3] vs. 66.6% [95% CI = 60.8-72.2]; chiropractic/osteopathic manipulation: 62.3% [95% CI = 54.7-69.4] vs. 47.5% [95% CI = 42.3-52.7]). For each of the four complementary health approaches, a lack of perceived benefit was the most frequently reported reason by both sexes for not recommending. Lack of information sources was reported more often by female versus male physicians as a reason to not recommend herbs and non-vitamin supplements (31.4% [95% CI = 26.8-36.3] vs. 23.4% [95% CI = 21.0-25.9]). Conclusions: There are limited nationally representative data on the reasons as to why office-based physicians decide to recommend complementary health approaches to patients. Developing a more nuanced understanding of influencing factors in physicians' decision making regarding complementary health approaches may better inform researchers and educators, and aid physicians in making evidence-based recommendations for patients.

Physician Office Visits That Included Complementary Health Approaches in U.S. Adults: 2005-2015.

Introduction: The Institute of Medicine has described the need for comparing models of care delivery involving complementary health approaches and conventional medical practitioners. As a step toward addressing this need, we used a nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided. Methods: NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. We examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for health visit. We ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide development of logistic regression models. Results: Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem. Conclusion: We present an overview of the first study of office-based physician visits where complementary health approaches were recommended or ordered to their patients. These data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

A Review of Potential National Chronic Pain Surveillance Systems in the United States.

Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (ie, chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past 2 decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic noncancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomena. PERSPECTIVE: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against 8 surveillance attributes.

Cross-Sectional Analyses of High-Impact Pain Across Pregnancy Status by Race and Ethnicity.

Background: Preclinical and clinical research has suggested the existence of pregnancy-associated analgesia, wherein responses to painful stimulation or pain from disease decrease during pregnancy. Materials and Methods: We combined data from multiple years (2012-2015) of the National Health Interview Survey to examine high-impact pain by Hispanic ethnicity and race in women with no prior pregnancy, during pregnancy, and previously pregnant. Results: High-impact pain was less common for women during pregnancy (10.3%; 95% confidence interval [CI]: 7.0%-13.7%) than it was for women who had never been pregnant (13.7%; 95% CI: 12.8%-14.5%) and for women who had previously been pregnant (19.8%; 95% CI: 16.0%-23.7%). However, when we examined the data by Hispanic ethnicity and race, we found that non-Hispanic White (NHW) women were less likely to report high-impact pain during pregnancy, but non-Hispanic Black (NHB) women and Hispanic White women were not. In women who reported no prior pregnancy, NHW women were most likely to report high-impact pain, followed by NHB women and Hispanic women. In post hoc analyses, we found that while menstrual problems were associated with increased odds of having high-impact pain, an interaction was not observed between menstrual problems and race/ethnicity (p = 0.48). Conclusions: This cross-sectional study presents a nationally representative examination of the prevalence of high-impact pain across pregnancy status. Using a nationally representative sample of women, we have demonstrated that the prevalence of high-impact pain varies across pregnancy status and that race/ethnicity and the presence of menstrual problems independently affect this prevalence.

Specialty Differences in Initial Evaluation of Patients With Non-Acute Musculoskeletal Pain.

PURPOSE: To explore medical diagnostic testing of new cases of musculoskeletal (MSK) conditions associated with chronic pain. METHODS: We analyzed nationally representative cross-sectional data of people having visits with a new likely chronic MSK pain condition. We documented depression screening and prescribing of diagnostic imaging and blood tests and explored associations between patient and provider factors for each. RESULTS: Over the 9 years of the survey, there were 11,994 initial visits for chronic MSK pain, an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions for depression screening, prescribed imaging, and blood tests were 1.79%, 36.34%, and 9.70%, respectively. People on any public health insurance had twice the increased relative odds to be screened for depression. Orthopedists had 3 times increased relative odds to prescribe imaging compared with family physicians; oncologists had 4 times increased relative odds to prescribe blood tests. Survey year was significantly associated with depression screening and ordering any type of imaging. CONCLUSIONS: Observed rates of depression screening and nonindicated imaging for patients with chronic MSK pain have fluctuated over time. The impact of these fluctuations on clinical practice is as yet unknown. The type of nonrecommended actions varied by specialty of physician.

Longitudinal Analysis of Complementary Health Approaches in Adults Aged 25-74 Years from the Midlife in the U.S. Survey Sample.

Objectives: Complementary health approaches include herbal products and mind-body practices. Several studies have identified predictors for complementary health approach use, yet there are two gaps: (1) How does use change? (2) Do factors associated with use influence this change over time? Using the Midlife in the United States (MIDUS), we examined how sociodemographic factors affected use longitudinally, and whether these associations differed between new and continued/discontinued use of herbal products, meditation, chiropractic, and massage therapy. Design: MIDUS is a national probability sample of adults aged 25 or older that has collected more than 20 years of longitudinal data, including the use of complementary health approaches. We employed the Andersen Model as a framework to identify predisposing, enabling, and health need factors associated with complementary health approach use based on previously identified and hypothesized factors. We ran Chi-square analyses to first test bivariate associations between our independent variables and four modalities to further guide logistic regression models. Results: Each of the four approaches examined saw substantial increases in prevalent use. However, only about 25% to 38% of individuals continued use from one wave to the next, whereas only 2%-9% of individuals who did not use a given approach in a wave reported use in the subsequent wave. Age, spiritual importance, and previous wave one use were all significantly associated with new use across all four modalities. Previous wave one use was associated with continued/discontinued use for all modalities. Age and education were significantly associated with discontinued use of chiropractic. Conclusion: We present the first longitudinal analysis of complementary health approaches in a nationally representative sample. These data distinguish between new and continued/discontinued use of complementary health approaches over time and provide insights into the interpretation of complementary health approach prevalence data, as well as important predictors of use.

National Estimates of Chronic Musculoskeletal Pain and Its Treatment in Children, Adolescents, and Young Adults in the United States: Data From the 2007-2015 National Ambulatory Medical Care Survey.

OBJECTIVES: To portray physician office visits by young Americans with chronic musculoskeletal pain; to describe clinical management in this group; and to explore factors associated with prescribed treatments. STUDY DESIGN: Using nationally representative data of ambulatory physician office visits (2007-2015 United States National Ambulatory Medical Care Survey), we identified and cross-sectionally analyzed visits by persons <25 years of age diagnosed with a chronic musculoskeletal pain condition. RESULTS: There were 28.6 million visits over the 9-year period for chronic musculoskeletal pain for persons <25 years of age, (average 3.2 million visits/year). There were more visits among older age groups, female persons, non-Hispanic White ethnicity/race, and those with more medical visits in the past year. Nonopioid medications were the most frequent treatments in all age groups (range 38.5%-48.8%). Opioids were rarely prescribed for children and adolescents but were prescribed in 23% of visits among young adults (18-24 years of age). Health education and counseling were consistently prescribed at 20% of visits and physical therapy (range 9.5%-23.7%) and other treatments were less frequently prescribed. Age, sex, payment source, and physician specialty were associated with various treatments. CONCLUSION: There were over 3 million annual visits for chronic musculoskeletal pain in young Americans; these increased with age. Pharmacologic treatment is used more than nonpharmacologic approaches, and opioid prescribing in the 18- to 24-year-old age group approaches estimates in adults with musculoskeletal pain.

Pain Prevalence, Chronicity and Impact Within Subpopulations Based on Both Hispanic Ancestry and Race: United States, 2010-2017.

We provide national surveillance estimates of pain chronicity, severity and impact in adult subpopulations defined by both Hispanic Ancestry and Race. Data are from 144,434 adults who completed validated questionnaires in the 2010-2017 National Health Interview Survey asking about pain status within the last 3 (N = 84,664) or 6 months (N = 59,770). Multivariable logistic regression was used to assess the relationship between pain and ethnicity/race. Compared to White Puerto Rican participants, White participants with Central/South American and Mexican ancestry had reduced odds of reporting Category 3-4 pain and High-Impact Chronic Pain (HICP), while those of Cuban ancestry had reduced odds of only HICP - eg, White participants with Mexican ancestry had 32% lower odds of having Category 3-4 pain and 50% lower odds of having HICP. While no differences were seen between White Puerto Rican and White Non-Hispanic participants for Category 3-4 pain, White Non-Hispanics had 40% lower odds of reporting HICP. Asian Non-Hispanic and Black Non-Hispanic participants had significantly lower odds of reporting Category 3-4 pain and HICP compared to White Puerto Rican participants, eg, Black Non-Hispanic participants had 26% lower odds off having Category 3-4 pain and 42% lower odds of having HICP. Perspective: By examining pain status in discrete demographic groups based on Hispanic Ancestry and Race, this report further documents substantial difference in health status among underserved populations and provides a baseline for continuing surveillance research on pain, with the eventual goal of eliminating disparities in pain assessment and treatment.

Comorbid Pain and Cognitive Impairment in a Nationally Representative Adult Population: Prevalence and Associations With Health Status, Health Care Utilization, and Satisfaction With Care.

OBJECTIVE: Using a nationally representative sample of adults and pain definitions consistent with the United States National Pain Strategy, we examined the associations of pain and cognitive impairment (CI) with each other and with measures of health status, physical impairment, social impairment, health care utilization, and dissatisfaction with health care. MATERIALS AND METHODS: Prevalence estimates and multivariable logistic regression analyses of the 2017 National Health Interview Survey were performed. RESULTS: As the level of reported pain increased from "no pain" to high-impact chronic pain (HICP), there was an increase in the prevalence of CI from 2.99% in those with no pain to 18.19% in those with HICP. Similarly, as the level of CI increased from no impairment to substantial CI, the prevalence of any pain increased from 62.44% to 83.20%. As pain severity and CI increased, we found increased prevalence for all outcomes examined, with the highest prevalence seen in participants with HICP and substantial CI. While 4.15% of individuals without either pain or CI reported poor/fair health, this increased to 33.98% in those with substantial CI or "dementia" but no pain, to 52.22% in those with HICP but no CI, and to 81.8% in individuals reporting both HICP and substantial CI or "dementia." DISCUSSION: Our data suggest that individuals with comorbid chronic pain and CI are in a much higher state of self-reported disability than those with chronic pain or CI alone. Best practice guidelines are generally silent on multidisciplinary, integrated care for these comorbid conditions, increasing the potential for inadequate care.

Possible differential benefits of edetate disodium in post-myocardial infarction patients with diabetes treated with different hypoglycemic strategies in the Trial to Assess Chelation Therapy (TACT).

BACKGROUND: The NIH-funded Trial to Assess Chelation Therapy (TACT) randomized 1708 stable patients age ≥50 who were ≥6 months post myocardial infarction to 40 infusions of an edetate disodium-based regimen or placebo. In 633 patients with diabetes, edetate disodium significantly reduced the primary composite endpoint of mortality, recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.44-0.79, p < 0.001). The principal secondary endpoint of a composite of cardiovascular death, myocardial infarction, or stroke was also reduced (HR 0.60, 95% CI 0.39-0.91, p = 0.017). It is unknown if the treatment effect differs by diabetes therapy. METHODS: We grouped the subset of 633 patients with diabetes according to glucose-lowering therapy at time of randomization. The log-rank test was used to compare active therapy versus placebo. All treatment comparisons were performed using 2-sided significance tests at the significance level of 0.05 and were as randomized. Relative risks were expressed as HR with associated 95% CI, calculated using the Cox proportional hazards model. RESULTS: There were 162 (25.7%) patients treated with insulin; 301 (47.5%) with oral hypoglycemics only; and 170 (26.8%) receiving no pharmacologic treatment for diabetes. Patients on insulin reached the primary endpoint more frequently than patients on no pharmacologic treatment [61 (38%) vs 49 (29%) (HR 1.56, 95% CI 1.07-2.27, p = 0.022)] or oral hypoglycemics [61 (38%) vs 87 (29%) (HR 1.46, 1.05-2.03, p = 0.024)]. The primary endpoint occurred less frequently with edetate disodium based therapy versus placebo in patients on insulin [19 (26%) vs 42 (48%) (HR 0.42, 95% CI 0.25-0.74, log-rank p = 0.002)], marginally in patients on oral hypoglycemics [38 (25%) vs 49 (34%) (HR 0.66, 95% CI 0.43-1.01, log-rank p = 0.041)], and no significant difference in patients not treated with a pharmacologic therapy [23 (25%) vs 26 (34%) (HR 0.69, 95% CI 0.39-1.20, log-rank p = 0.225)]. The interaction between randomized intravenous treatment and type of diabetes therapy was not statistically significant (p = 0.203). CONCLUSIONS: Edetate disodium treatment in stable, post-myocardial infarction patients with diabetes suggests that patients on insulin therapy at baseline may accrue the greatest benefit. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov identifier: http://clinicaltrials.gov/ct2/show/NCT00044213?term=TACT&rank=7 identifier Trial to Assess Chelation Therapy (TACT), NCT00044213.

Differential Outcomes With Edetate Disodium-Based Treatment Among Stable Post Anterior vs. Non-Anterior Myocardial Infarction Patients.

BACKGROUND: The Trial to Assess Chelation Therapy (TACT) found that chelation therapy significantly reduced clinical events in patients with a history of myocardial infarction (MI). The initial report of TACT included the observation of an interaction between edetate disodium infusions and MI location, as well as diabetes. Thus, we examined in greater detail the effect of edetate disodium chelation therapy as a function of MI location and diabetes. METHODS: Patients (n = 1708) at least 6 weeks post-MI and age ≥ 50 were randomized to receive 40 infusions of a 500 mL chelation solution or placebo (median follow-up 55 months). The effect of edetate disodium on the primary outcome (all-cause mortality, MI, stroke, hospitalization for angina, or coronary revascularization) was assessed as a function of MI location using log-rank test and Cox regression model, adjusting for other prognostic variables. RESULTS: Among patients with post anterior MI (n = 674), chelation was associated with a lower risk of the primary endpoint (HR 0.63, 95% CI 0.47-0.86, p = 0.003) among anterior MI patients, but not in post non-anterior MI (n = 1034) patients (HR 0.96, 95% CI 0.77-1.20, p = 0.702) (p-for-interaction = 0.032). The point estimates for each component of the primary endpoint favored chelation therapy. The differing treatment effect in patients with post anterior vs. non-anterior MI was consistent among patients with or without diabetes and remained significant after adjusting for other prognostic variables (p < 0.01). CONCLUSIONS: Edetate disodium infusions reduced the risk of cardiovascular events among patients with a prior anterior MI. Future studies should focus on replicating these results and understanding the mechanisms of benefit.

Management of Patients with a Musculoskeletal Pain Condition that is Likely Chronic: Results from a National Cross Sectional Survey.

The purpose of the study was to explore clinical management for new cases of musculoskeletal pain that are likely chronic. We used data from the National Ambulatory Medical Care Survey, 2007-2015, identifying visits with a new chronic musculoskeletal pain condition using predetermined ICD-9 codes. We documented prescribing of nonopioid pain medication, opioids, physical therapy (PT), counseling, and other nonpharmacologic treatments and explored associations between patient and provider factors for each of these treatments. There were 11,994 visits over the 9-year period for a new case of chronic musculoskeletal pain, representing an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions that were prescribed nonopioid medication, opioids, PT, counseling and other nonpharmacologic treatments were: 40.2, 21.5, 10.0, 15.2 and 14.3 respectively. Patient age was associated with type of treatment with a young to old gradient for other nonpharmacologic treatments, PT, opioids, counseling and other medications. Orthopedists were less likely to prescribe pharmacological treatments than family practice physicians and more likely to prescribe PT. Physicians who used the electronic medical record were more likely to prescribe opioids. Contrary to practice guidelines for managing musculoskeletal pain, many patients are prescribed opioids for a new chronic musculoskeletal problem. PERSPECTIVE: We outlined in a representative sample of Americans what treatments are being prescribed for new cases of likely chronic musculoskeletal pain. Opioid prescription was double that of physical therapy. Using the electronic medical record was associated with more opioid prescription- a novel finding that should be corroborated by future research.

Alcohol Consumption and Risk of Dementia and Cognitive Decline Among Older Adults With or Without Mild Cognitive Impairment.

Importance: Substantial heterogeneity and uncertainty exist in the observed associations between alcohol consumption and dementia. Objective: To assess the association between alcohol consumption and dementia and the roles of mild cognitive impairment (MCI) and apolipoprotein E ε4 (APOE E4) genotype in modifying this association. Design, Setting, and Participants: This cohort study used data from the Ginkgo Evaluation of Memory Study, conducted from 2000 to 2008 among US community-dwelling participants. This study analyzed 3021 participants aged 72 years and older who were free of dementia. Data analysis was performed from 2017 to 2018. Exposures: Self-reported alcohol consumption, drinking frequency, and quantity. Main Outcomes and Measures: Using multivariable proportional hazards regression and linear mixed models, the risk of dementia and the rate of change over time in the Modified Mini-Mental State Examination were estimated. Results: Among 3021 participants, the median (interquartile range) age was 78 (76-80) years; 1395 (46.2%) were female. During a median (interquartile range) follow-up of 6.0 (4.9-6.5) years, 512 cases of dementia occurred. For 7.1 to 14.0 drinks per week compared with less than 1.0 drink per week, the hazard ratios for dementia were 0.63 (95% CI, 0.38-1.06) among 2548 participants without MCI and 0.93 (95% CI, 0.47-1.84) among 473 participants with MCI. Among participants with MCI, the hazard ratio for dementia was 1.72 (95% CI, 0.87-3.40) for more than 14.0 drinks per week compared with less than 1.0 drink per week. The association of alcohol intake with dementia differed for participants with and without baseline MCI (P for interaction = .03). Among participants without MCI, daily low-quantity drinking was associated with lower dementia risk than infrequent higher-quantity drinking (hazard ratio, 0.45; 95% CI, 0.23-0.89; P = .02). Findings were consistent when stratified by sex, age, and APOE E4 genotype. Compared with drinking less than 1.0 drink per week, complete abstention (in participants without MCI) and the consumption of more than 14.0 drinks per week (in participants with MCI) were associated with lower Modified Mini-Mental State Examination scores (mean difference at follow-up compared with baseline, -0.46 point [95% CI, -0.87 to -0.04 point] and -3.51 points [95% CI, -5.75 to -1.27 points], respectively). Conclusions and Relevance: In this study, complete abstention and consuming more than 14.0 drinks per week (compared with drinking <1.0 drink per week) were associated with lower cognitive scores among participants aged 72 years and older. Particular caution is needed among individuals with MCI who continue to drink alcohol.

Eighteen-Year Trends in the Prevalence of, and Health Care Use for, Noncancer Pain in the United States: Data from the Medical Expenditure Panel Survey.

We used data from the nationally representative Medical Expenditure Panel Survey to determine the 18-year trends in the overall rates of noncancer pain prevalence and pain-related interference, as well as in health care use attributable directly to pain management. The proportion of adults reporting painful health condition(s) increased from 32.9% (99.7% confidence interval [CI] = 31.6-34.2%;120 million adults) in 1997/1998 to 41.0% (99.7% CI = 39.2-42.4%; 178 million adults) in 2013/2014 (Ptrend < .0001). Among adults with severe pain-related interference associated with their painful health condition(s), the use of strong opioids specifically for pain management more than doubled from 11.5% (99.7% CI = 9.6-13.4%) in 2001/2002 to 24.3% (99.7% CI = 21.3-27.3%) in 2013/2014 (Ptrend < .0001). A smaller increase (Pinteraction < .0001) in strong opioid use was seen in those with minimal pain-related interference: 1.2% (99.7% CI = 1.0-1.4%) in 2001/2002 to 2.3% (99.7% CI = 1.9-2.7%) in 2013/2014. Small but statistically significant decreases (Ptrend < .0001) were seen in 1) the percentage of adults with painful health condition(s) who had ≥1 ambulatory office visit for their pain: 56.1% (99.7% CI = 54.2-58.0%) in 1997/1998 and 53.3% (99.7% CI = 51.4-55.4%) in 2013/2014; 2) the percentage who had ≥1 emergency room visit for their pain; 9.9% (99.7% CI = 8.6-11.2%) to 8.8% (99.7% CI = 7.9-9.7%); and 3) the percentage with ≥1 overnight hospitalization for their pain: 3.2% (99.7% CI = 2.6-4.0%) to 2.3% (99.7% CI = 1.8-2.8%). PERSPECTIVE: Our data illustrate changes in the management of painful health conditions over the last 2 decades in the United States. Strong opioid use remains high, especially in those with severe pain-related interference. Additional education of health care providers and the public concerning the risk/benefit ratio of opioids appears warranted.