Sex Differences in Pain and Its Treatment.

Pain is a highly personal experience. Pain is often considered to be a purely neurologic phenomenon, but in actuality, it is a combination of both sensory and emotional experiences. This has sometimes been translated clinically toward a more mechanistic approach to the assessment and treatment of pain instead of one that does not discount pain mechanisms, but also is more inclusive of the need for humanism - considering the individual. In today's medical environment, more than ever before there is a significant amount of attention being paid to educating clinicians to better understand that several physiological, neurophysiological, and psychosocial factors can significantly impact responses to pain. The composition of these factors will be unique to that individual's life narrative, context, sex, and prior life experiences. Thus, the concept that a templated approach to pain assessment and pharmacotherapeutic treatment planning should not be expected to provide optimal patient satisfaction and treatment outcomes in the majority. The hypotheses that there may be sex-based differences in the pain experience in a variety of ways including pain sensitivity, tolerance to pain, threshold at which something becomes painful, and the effectiveness of endogenous pain modulation systems are not new and have been well represented in the literature. This chapter reviews important key findings in the scientific literature with respect to sex-based differences in pain and pain responses to experimentally induced painful stimuli, pain experienced in commonly occurring painful medical conditions, and variations in responses to pain treatments. Possible explanations to account for observed differences or similarities will also be discussed.

Definitive urine drug test findings in patients prescribed opioids for pain from a large national database.

OBJECTIVE: Clinicians and policymakers have been wrestling with the appropriateness and safety of opioid therapy during the opioid crisis. Policy and clinical decisions have often been made without much current data on trends in drug use in patients with pain. Thus, we evaluated definitive urine drug test (UDT) results in patients being treated for pain to see if those taking their prescribed opioids were less likely to be positive for the primary illicit drugs currently driving overdose deaths: cocaine, heroin, fentanyl, and methamphetamine. DESIGN, SETTING, AND PATIENTS: A cross-sectional study of UDT results from January 1, 2015 to September 30, 2021, from 600,000 patient specimens submitted for testing by pain management specialists. INTERVENTIONS: UDT by liquid chromatography-tandem mass spectrometry as ordered by the treating clinician. MAIN OUTCOME MEASURES: Presence of other substances stratified by whether a patient's prescribed opioid was found. RESULTS: The presence of cocaine, heroin, fentanyl, and methamphetamine for the total population was low (<5 percent). Of the 347,092 patients prescribed opioids, 76 percent (n = 264,961) were positive on UDT for their prescribed opioid ("consistent"). Compared to patients without their prescribed opioid present ("inconsistent"), patients consistent with therapy were 54 percent (incidence rate ratio (IRR) 1.54, 95 percent confidence interval (CI) 1.47-1.59) less likely to be positive for cocaine, 47 percent [IRR 1.47, 95 percent CI 1.34-1.57] less likely to be positive for heroin, and 35 percent [IRR 1.35, 95 percent CI 1.24-1.45] less likely to be positive for methamphetamine, p < 0.001. Differences between the groups for fentanyl were not significant. CONCLUSIONS: Overall positivity rates for cocaine, heroin, fentanyl, and methamphetamine were low. Patients with prescribed opioid present were less likely to be positive for cocaine, heroin, or methamphetamine. Patterns of substance use within this pain management population should be used to inform ongoing policy decisions.

Early Refill of an Opioid Medication: Recognizing Personal Biases Through Clinical Vignettes and OSCEs.

Introduction: Efforts to improve pain education and knowledge about prescription opioid misuse and opioid/substance use disorder in undergraduate medical education continue to be inadequate. To advance educational practices and address training needs to counter the opioid epidemic, we created a longitudinal pain and addiction curriculum that includes three patient vignettes in which the patient requests an early refill of opioid medication. The goal was to introduce students to the potential impact of personal biases on health care delivery and medical decision-making with patients who have pain and/or substance use disorders. Methods: Three clinical vignettes were presented to early matriculating medical students (MS 1s) using a progressive case disclosure approach in the format of a PowerPoint presentation with embedded audio interactions and follow-up audience response system questions. The same vignettes were converted into OSCEs for early clinical clerkship students (MS 3s). Results: A total of 180 MS 1s participated in the case presentations, and 124 MS 3s participated in the OSCE session. There was a significant difference between students' level of comfort and individual patient requests for early prescription refills in both student cohorts. MS 1s were significantly more likely to provide the early refill to the elderly female patient compared to the two middle-age male patients, whereas a majority of MS 3s wanted more information. Discussion: This module can be presented to medical students who have little clinical exposure and to health care trainees at other levels of clinical exposure.

Education of our future physicians is key to addressing pain and the opioid epidemic.

We explore the opioid epidemic as an example of what an educationally-driven, forward-thinking approach to healing problematic substance use might entail. We review the current state of four topics in pain and substance use disorder/opioid use disorder education and conclude each section by identifying educational initiatives that we hope may pave the way for improved clinical management of these topics in the future. Although these initiatives will be discussed explicitly in the context of undergraduate medical education, they are offered in the hope that this philosophy may be adapted for training among all healthcare disciplines. Our ultimate purpose is to detail how the education of future clinicians is essential to changing the environment that enables the problem to persist.

A Randomized Controlled Trial of the Effects of Online Pain Management Education on Primary Care Providers.

Objective: To improve pain management practices, we developed an online interactive continuing education (CE) program for primary care providers (PCPs). This program follows the flow of clinical decision-making through simulated cases at critical pain treatment points along the pain treatment continuum. Design: A randomized controlled trial was conducted to test the efficacy of this program. Participants were randomized to either the experimental condition or the control condition (online, text-based CE program). Subjects: A total of 238 primary care providers were recruited through hospitals, professional newsletters, and pain conferences. Results: Participants in both conditions reported significantly improved scores on knowledge (KNOW-PAIN 50), attitudes (CAOS), and pain practice behaviors (PPBS) scales over the four-month study. The experimental condition showed significantly greater change over time on the tamper-resistant formulations (TRFs) of opioids and dosing CAOS subscale compared with the control condition. Post hoc comparisons suggested that participants in the experimental condition were less likely to endorse use of opioid TRFs over time compared with the control condition. Exploratory analyses for potential moderators indicated a significant three-way interaction with time, condition, and discipline (i.e., physician vs other) for the impediments and concerns attitudes subscale and the early refill behaviors subscale. Post hoc comparisons indicated that physicians in the experimental condition exhibited the greatest change in attitudes and the nonphysicians exhibited the greatest change in reported behaviors in response to requests for early refills. Conclusions: Findings suggest online CE programs may positively impact PCPs' knowledge, attitudes, and pain practice behaviors but provide minimal evidence for the value of including interactivity.

Development of Short-Form Versions of the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R): A Proof-of-Principle Study.

BACKGROUND: The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a 24-item questionnaire designed to assess risk of aberrant medication-related behaviors in chronic pain patients. The introduction of short forms of the SOAPP-R may save time and increase utilization by practitioners. OBJECTIVE: To develop and evaluate candidate SOAPP-R short forms. DESIGN: Retrospective study. SETTING: Pain centers. SUBJECTS: Four hundred and twenty-eight patients with chronic noncancer pain. METHODS: Subjects had previously been administered the full-length version of the SOAPP-R and been categorized as positive or negative for aberrant medication-related behaviors via the Aberrant Drug Behavior Index (ADBI). Short forms of the SOAPP-R were developed using lasso logistic regression. Sensitivity, specificity, and area under the curve (AUC) of all forms were calculated with respect to the ADBI using the complete data set, training-test analysis, and 10-fold cross-validation. The coefficient alpha of each form was also calculated. An external set of 12 pain practitioners reviewed the forms for content. RESULTS: In the complete data set analysis, a form of 12 items exhibited sensitivity, specificity, and AUC greater than or equal to those of the full-length SOAPP-R (which were 0.74, 0.67, and 0.76, respectively). The short form had a coefficient alpha of 0.76. In the training-test analysis and 10-fold cross-validation, it exhibited an AUC value within 0.01 of that of the full-length SOAPP-R. The majority of external practitioners reported a preference for this short form. CONCLUSIONS: The 12-item version of the SOAPP-R has potential as a short risk screener and should be tested prospectively.

Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes?

OBJECTIVE: A comprehensive electronic self-report assessment, called PainCAS® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome. METHODS: In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later. RESULTS: Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function. CONCLUSIONS: Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.

Shortening the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R): A Proof-of-Principle Study for Customized Computer-Based Testing.

BACKGROUND: The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a 24-item self-report instrument that was developed to aid providers in predicting aberrant medication-related behaviors among chronic pain patients. Although the SOAPP-R has garnered widespread use, certain patients may be dissuaded from taking it because of its length. Administrative barriers associated with lengthy questionnaires further limit its utility. OBJECTIVE: To investigate the extent to which two techniques for computer-based administration (curtailment and stochastic curtailment) reduce the average test length of the SOAPP-R without unduly affecting sensitivity and specificity. DESIGN: Retrospective study. SETTING: Pain management centers. SUBJECTS: Four hundred and twenty-eight chronic non-cancer pain patients. METHODS: Subjects had taken the full-length SOAPP-R and been classified by the Aberrant Drug Behavior Index (ADBI) as having engaged or not engaged in aberrant medication-related behavior. Curtailment and stochastic curtailment were applied to the data in post-hoc simulation. Sensitivity and specificity with respect to the ADBI, as well as average test length, were computed for the full-length test, curtailment, and stochastic curtailment. RESULTS: The full-length SOAPP-R exhibited a sensitivity of 0.745 and a specificity of 0.671 for predicting the ADBI. Curtailment reduced the average test length by 26% while exhibiting the same sensitivity and specificity as the full-length test. Stochastic curtailment reduced the average test length by as much as 65% while always exhibiting sensitivity and specificity for the ADBI within 0.035 of those of the full-length test. CONCLUSIONS: Curtailment and stochastic curtailment have potential to improve the SOAPP-R's efficiency in computer-based administrations.

A randomized controlled trial of an online self-management program for adults with arthritis pain.

The objective of this RCT was to assess the efficacy of an online pain self-management program with adults who had a self-reported doctor diagnosis of arthritis pain (N = 228). Participants were recruited via flyers and online postings then randomized to the experimental condition or the wait-list control condition. Individuals in the experimental condition reported significantly (1) increased arthritis self-efficacy and (2) reduced pain catastrophizing from baseline to follow up compared to those in the control condition. High user engagement (>204.5 min on the website) was also significantly associated with improved self-management outcomes. These findings suggest that use of an online self-management program may positively impact self-efficacy and catastrophizing among adults with arthritis pain at 6 month follow up. Nonsignificant findings for hypothesized variables such as pain intensity and health behaviors are also discussed. Future longitudinal research is needed to assess if cognitive changes associated with participation in an online self-management program leads to reduced pain.

Electronic opioid risk assessment program for chronic pain patients: barriers and benefits of implementation.

OBJECTIVES: A preliminary electronic pain assessment program known as Pain Assessment Interview Network, Clinical Advisory System (painCAS), was implemented in 2 pain centers over the course of 10 months to understand the tool's impact on opioid risk assessment documentation and clinical workflow. The program contains validated electronic versions of screeners for opioid misuse risk (SOAPP-R and Current Opioid Misuse Measure). METHODS: Charts of patients with an initial and 2 follow-up visits were randomly selected for review of presence of opioid risk assessments before and after implementation of the electronic assessment program. Clinical and administrative staff members were interviewed to gain their perceptions of the impact of the program. RESULTS: Significant increases were observed in the documentation of opioid risk assessments between the baseline patient chart reviews before implementation of the program (n = 66) and the postintervention patient chart reviews after the implementation of the program (n = 39), for both initial and follow-up clinic visits (P < 0.001). Specific benefits of the program identified by 7 clinicians and 8 administrators included ease of use, reduced paperwork, completion of the assessment before the clinic visit, and incorporation of information directly into an electronic medical record (EMR). Perceived barriers to implementation included poor patient compliance, changes in administration workflow, and difficulties associated with patients with no email addresses, and limited computer skills. CONCLUSIONS: Implementation of an opioid risk electronic pain assessment program significantly increased the likelihood that a risk assessment would be included in the medical record, which has implications for improvement of quality of care.

Spanish translation and linguistic validation of the screener and opioid assessment for patients with pain-revised (SOAPP-R).

INTRODUCTION: Given the increase in misuse and abuse of prescription opioids, clinicians clearly benefit from a standardized tool to screen patients being considered for chronic opioid therapy. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a widely used opioid risk assessment tool in clinical practice. As one third of the US population experiences chronic noncancer pain at any given time, and the Hispanic population now accounts for about 16% of the nation's population, the availability of a Spanish-language SOAPP-R fills an important clinical need. OBJECTIVE: To derive a linguistically validated Spanish-language version of the SOAPP®-R. METHOD: Each step of Spanish translation and linguistic validation of the SOAPP-R was based on the US Food and Drug Administration and the International Society for Pharmacoeconomics and Outcomes Research translation process. RESULT: A linguistically validated Spanish-language version of the SOAPP-R. CONCLUSION: The Spanish SOAPP-R may be useful as a risk assessment tool, considered along with other clinical information, by clinicians who prescribe opioid therapy for patients whose preferred language is Spanish.

A randomized trial of a web-based intervention to improve migraine self-management and coping.

OBJECTIVE: To test the clinical efficacy of a web-based intervention designed to increase patient self-efficacy to perform headache self-management activities and symptom management strategies, and reduce migraine-related psychological distress. BACKGROUND: In spite of their demonstrated efficacy, behavioral interventions are used infrequently as an adjunct in medical treatment of migraine. Little clinical attention is paid to the behavioral factors that can help manage migraine more effectively and improve the quality of care and quality of life. Access to evidenced-based, tailored, behavioral treatment is limited for many people with migraine. DESIGN: The study is a parallel group design with 2 conditions: (1) an experimental group exposed to the web intervention; and (2) a no-treatment control group that was not exposed to the intervention. Assessments for both groups were conducted at baseline (T1), 1-month (T2), 3-months (T3), and 6-months (T4). RESULTS: Compared with controls, participants in the experimental group reported significantly: increased headache self-efficacy, increased use of relaxation, increased use of social support, decreased pain catastrophizing, decreased depression, and decreased stress. The hypothesis that the intervention would reduce pain could not be tested. CONCLUSIONS: Demonstrated increases in self-efficacy to perform headache self-management, increased use of positive symptom management strategies, and reported decreased migraine-related depression and stress suggest that the intervention may be a useful behavioral adjunct to a comprehensive medical approach to managing migraine.

Identifying primary care skills and competencies in opioid risk management.

INTRODUCTION: Primary care physicians (PCPs) treat a high proportion of chronic pain patients but often lack training about how to assess and address issues associated with prescribing opioids when they are an appropriate component of therapy. The result may be that they may avoid treating these patients, which can lead to an undertreatment of pain. The objective of this study was to identify which skills and competencies are most critical for PCPs in order to effectively manage opioid risk in patients treated for chronic pain. METHODS: We conducted 1-hour interviews with 16 nationally known experts in primary care, pain management, and addiction. Eight were trained as PCPs, and 8 were trained as specialists. Their responses were collated and then presented online to the participants for independent sorting and rating. These data were analyzed using an online concept mapping program, which offers an innovative method of summarizing and prioritizing qualitative data. RESULTS: Based on this analysis, items were organized into 10 clusters representing the most critical categories of skills (the "best fit" for these data). The cluster that received the highest average statement rating was "How to Manage Pain Patients With Comorbid Conditions." Follow-up analyses indicated that specialists rated this cluster, and 5 others, significantly higher than the PCPs, suggesting that the specialists perceive these competencies as more important in opioid risk management. DISCUSSION: Using a relatively small sample and cost-effective technique (ie, concept mapping), key PCP competencies can be identified for potential inclusion in continuing education and training in opioid risk management.

Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them.

OBJECTIVE: There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits. DESIGN: Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them. RESULTS: Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life. CONCLUSION: Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

Health care provider perceptions of pain treatment in Hispanic patients.

Despite increasing numbers of Hispanic patients in the United States, this group continues to face disparities in access and quality of pain treatment. Although previous surveys have examined treatment disparities experienced by minority patients, none have provided a provider-centric perspective on issues and concerns surrounding pain relief among pain patients of Hispanic/Latino origin. The goal of this study was to assess the relationship between provider characteristics (ie, Spanish fluency, Hispanic caseload size, and experience with Hispanic pain patients) and their perceptions of pain treatment in these patients. One hundred eighty-seven health professionals completed an online survey. The major findings indicated that: (1) less than 20% of health professionals treating Hispanic pain patients reported Spanish proficiency at an advanced level; (2) surveyed health professionals were involved treating a significant proportion of Hispanic patients in their caseloads, but reported a lack of cultural competence training; (3) Spanish fluency and experience with Hispanic pain patients exerts a strong effect on the use of established pain treatment practices; (4) providers with greater Spanish fluency report a significantly greater effect of patients' cultural beliefs and attitudes on treatment; and (5) providers did not regard cultural or language barriers as significantly impacting opioid prescribing or patient compliance.

painACTION-back pain: a self-management website for people with chronic back pain.

OBJECTIVE: To determine whether an interactive self-management Website for people with chronic back pain would significantly improve emotional management, coping, self-efficacy to manage pain, pain levels, and physical functioning compared with standard text-based materials. DESIGN: The study utilized a pretest-posttest randomized controlled design comparing Website (painACTION-Back Pain) and control (text-based material) conditions at baseline and at 1-, 3, and 6-month follow-ups. PARTICIPANTS: Two hundred and nine people with chronic back pain were recruited through dissemination of study information online and at a pain treatment clinic. The 6-month follow-up rates for the Website and control groups were 73% and 84%, respectively. MEASUREMENTS: Measures were based on the recommendations of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials and included measures of pain intensity, physical functioning, emotional functioning, coping, self-efficacy, fear-avoidance, perceived improvement with treatment, self-efficacy, and catastrophizing. RESULTS: Compared with controls, painACTION-Back Pain participants reported significantly: 1) lower stress; 2) increased coping self-statements; and 3) greater use of social support. Comparisons between groups suggested clinically significant differences in current pain intensity, depression, anxiety, stress, and global ratings of improvement. Among participants recruited online, those using the Website reported significantly: 1) lower "worst" pain; 2) lower "average" pain; and 3) increased coping self-statements, compared with controls. Participants recruited through the pain clinic evidenced no such differences. CONCLUSIONS: An online self-management program for people with chronic back pain can lead to improvements in stress, coping, and social support, and produce clinically significant differences in pain, depression, anxiety, and global rates of improvement.