All-cause mortality among males living with and without HIV initiating long-term opioid therapy, and its association with opioid dose, opioid interruption and other factors.

BACKGROUND: While the relationship between long-term opioid therapy (LTOT) dose and overdose is well-established, LTOT's association with all-cause mortality is less understood, especially among people living with HIV (PLWH). There is also limited information regarding the association of LTOT cessation or interruption with mortality. METHODS: Among PLWH and matched uninfected male veterans in care, we identified those who initiated LTOT. Using time-updated cox regression, we examined the association between all-cause mortality, unnatural death, and overdose, and opioid use categorized as 1-20 (reference group), 21-50, 51-90, and ≥ 91 mg morphine equivalent daily dose (MEDD). RESULTS: There were 22,996 patients on LTOT, 6,578 (29 %) PLWH and 16,418 (71 %) uninfected. Among 5,222 (23 %) deaths, 12 % were unnatural deaths and 6 % overdoses. MEDD was associated with risk of all 3 outcomes; compared to patients on 1-20 mg MEDD, adjusted risk for all-cause mortality monotonically increased (Hazard Ratios (HR) [95 % CI] for 21-50 mg MEDD = 1.36 [1.21, 1.52], 51-90 mg MEDD = 2.06 [1.82, 2.35], and ≥ 91 mg MEDD = 3.03 [2.71, 3.39]). Similar results were seen in models stratified by HIV. LTOT interruption was also associated with all-cause, unnatural, and overdose mortality (HR [95 % CI] 2.30 [2.09, 2.53], 1.47 [1.13, 1.91] and 1.52 [1.04, 2.23], respectively). CONCLUSIONS: Among PLWH and uninfected patients on LTOT we observed a strong dose-response relationship with all 3 mortality outcomes. Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all-cause mortality in addition to unnatural and overdose fatalities.

Ultra-high spatial resolution selected area electron channeling patterns.

An approach for producing ultrahigh spatial resolution selected area electron channeling patterns (UHR-SACPs) using the FEI/Thermo Elstar electron column is presented. The approach uses free lens control to directly assign lens and deflector values to rock the beam about precise points on the sample surface and generate the UHR-SACPs. Modification of the lens parameters is done using a service application that is preinstalled on the microscope or using the iFast scripting interface to run a short program to assign lens and deflector currents. Using the approach outlined here, the UHR-SACPs are collected at normal instrument scanning rates and pixel densities, resulting in rapid collection times and sharp patterns with simple push button changes in instrument mode. UHR-SACPs with spatial resolutions of 300 nm with angular ranges of 20° are demonstrated, as are patterns approaching 125 nm spatial resolution with angular ranges of 4°. Such spatial resolution/angular range combinations are significantly better than any reported previously. This approach for rapidly collecting high accuracy crystallographic information greatly enhances the ability to carry out electron channeling contrast imaging (ECCI) for a broad range of materials applications.

Prevalence and correlates of depression in treatment-seeking women with vulvodynia.

This study aimed to examine rates and correlates of depression in a treatment-seeking sample of women with vulvodynia. A total of 53 women were independently diagnosed with vulvodynia and assessed with state-of-the-art measures of major depressive disorder (MDD) and depressive symptom severity as well as psychometrically established measures of pain severity, general functioning, sexual function and quality of life. Current and lifetime prevalence rates for MDD were 17% (n = 9) and 45% (n = 24), respectively. Women with current MDD reported significantly greater pain severity, and worse functioning and quality of life than women without current MDD. Among those with lifetime MDD, the majority (62.5%) reported that their first depressive episode occurred before the onset of vulvodynia. Rates of current MDD appeared to be lower than rates of MDD among other samples of treatment seeking chronic pain patients. In summary, co-morbid MDD is related to greater pain severity and worse functioning among women with vulvodynia.

Cognitive-behavioral therapy for chronic pain in the elderly.

Cognitive-behavioral therapy has become a common nonpharmacologic treatment option for individuals experiencing chronic nonmalignant pain. This article begins with an overview of the cognitive-behavioral perspective on pain and pain management. The second section discusses relevant developmental issues and suggests refinements to cognitive-behavioral therapy for the elderly, followed by a case example describing the implementation of cognitive-behavioral therapy for an elderly gentleman in an ambulatory care setting. The details of assessment, treatment conceptualization and planning, intervention, and follow-up are explored in this context. This article concludes with suggestions for future refinements in the application of this approach in the management of chronic pain in the elderly.

Vulvodynia: an introduction and critical review of a chronic pain condition.

Vulvodynia, or chronic vulvar discomfort, has become an increasingly recognized complaint in the medical literature. However, classification, assessment, and treatment for vulvodynia have not been universally established. There is a serious need for greater understanding of this disorder since evidence suggests, although not life-threatening, vulvodynia appears to have a significant impact on quality of life. This article reviews the medical and psychological literature on vulvodynia published since 1983, the first year vulvodynia was recognized as a diagnosis in the medical literature. The purpose of this article is to provide a review of the literature on diagnostic issues, treatment options, and psychosocial sequelae with the aim of highlighting areas in need of future research. Finally, suggestions are made for considering vulvodynia from a multidimensional, chronic pain perspective.

HIV/AIDS-related pain as a chronic pain condition: implications of a biopsychosocial model for comprehensive assessment and effective management.

This paper reviews the current literature focusing on pain in HIV/AIDS, including prevalence, pathophysiology, substance abuse, treatment issues, and psychosocial contributions. In light of the high prevalence of pain among individuals with HIV/AIDS, attention is paid to the negative psychosocial impacts of pain in this population and to psychosocial barriers to optimal HIV/AIDS-related pain treatment. The paper conceptualizes HIV/AIDS pain as chronic pain. Subsequently, a biopsychosocial model of chronic pain assessment and treatment is applied. A multidimensional framework is presented for appropriate assessment and treatment of HIV/AIDS patients with pain, and specific recommendations and guidelines are offered for assessment and multimodal treatment of HIV/AIDS-related pain informed by the model.

Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ).

This manuscript describes the development and initial validation of a self-report questionnaire designed to assess an individual's readiness to adopt a self-management approach to their chronic pain condition. Theory and preliminary empirical work informed the development of a pool of items that were administered to a sample of individuals reporting chronic pain. Analyses of the data support a four factor measure that is consistent with the transtheoretical model of change and associated stages of change model. Each of the four factors, precontemplation, contemplation, action, and maintenance, was found to be internally consistent and stable over time. There was also substantial support for each factor's discriminant and criterion-related validity.

Patterns of pain-relevant social interactions.

Pasts studied have focused on the individual effects of Solicitous, Distracting, and Negative spousal responses to pain on patient's pain behavior and pain severity. Because spouses may emit any combination of these responses, this research examined the conjoint effects of marital satisfaction and these perceived spousal responses by using WISE "step-down" procedure as described by Kenny and Judd (1983. Ninety-six married male chronic-pain patients completed the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Locke Wallace marital Adjustment Scale, and Pain Behavior Check List (PBCL). Final step-down models included significant 2-way and 3-way interactions on the PBCL measures of Distorted Ambulation and Seeking Help, significant main effects for Affective Distress, and a 4-way interaction on the WHYMPI Pain Severity scale. These trimmed models accounted for 23%: to 33% of the variance in the criterion measures. These results show that higher order interactions make unique contributions to the variance and should be examined along with main effects.

Effects of self-efficacy and perceived social support on recovery-related behaviors after coronary artery bypass graft surgery.

This study investigated the extent to which measures of perceived internal and external resources, operationalized as self-efficacy and social support respectively, contribute to the prediction of participation in important recovery behaviors following coronary artery bypass graft surgery. Self-efficacy ratings obtained preoperatively related to the ability to rest and tolerate pain without the use of medications contributed significantly to the prediction of pain and sleep medication use postoperatively, after controlling for important demographic, medical, and surgical variables. Patients' reports of staff and significant-other interactions regarding adherence to cued productive coughing and ambulation accountedfor significant proportions of the variance in these recovery behaviors. Results support models of recovery from surgery that emphasize the important roles of self-efficacy and social interaction.

Anger expression and chronic pain.

Intensity of angry feelings and styles of expressing anger were examined for their relationship to measures of the chronic pain experience. Subjects were 142 chronic pain patients. Multiple regression analyses revealed that a style of inhibiting the expression of angry feelings was the strongest predictor of reports of pain intensity and pain behavior among a group of variables including demographics, pain history, depression, anger intensity, and other styles of anger expression. In a similar manner anger intensity contributed significantly to predictions of perceived pain interference and activity level. More conservative hierarchical regression analyses supported these findings. Results are consistent with explanatory models of pain and disability that hypothesize an etiologic role of a pervasive inability to express intense negative emotions, particularly anger.

Role of behavioral and psychological factors in mental stress-induced silent left ventricular dysfunction in coronary artery disease.

OBJECTIVES: We examined the relationship of the psychological profile to left ventricular dysfunction induced during mental stress. BACKGROUND: The contribution of psychological factors to mental stress-provoked silent myocardial ischemia has not been explored. METHODS: Thirty patients with chronic stable coronary artery disease and a reversible defect on stress thallium-201 imaging completed a psychological assessment by questionnaire and Structured Interview, serially administered mental stress and brief walking exercise. Blood pressure, electrocardiogram (ECG) and left ventricular indexes were obtained by ambulatory serial radionuclide ventriculography. Silent ventricular dysfunction was defined by a decrease > or = 0.05 in ejection fraction or > or = 1 mm in ST segment on the ECG in the absence of symptoms. RESULTS: Of the 30 patients, 15 (Group I) had evidence of silent left ventricular dysfunction during mental arithmetic. The other 15 (Group II) showed no change. In addition, 18 of 30 patients had this dysfunction during the Structured Interview. Both ischemic and nonischemic groups developed comparable and significant increases in heart rate and blood pressure. Group I patients were distinguished by higher scores on measures of aggressive responding (p < 0.001), trait anger (p < 0.0001), hostile affect (p < 0.003) and an index of behavioral reactivity (p < 0.003) and a lower score on anger control (p < 0.001). No other variables, including historical and clinical indexes, discriminated between the two groups. CONCLUSIONS: Patients with coronary artery disease and mental stress-provoked silent ventricular dysfunction were distinguished by a psychological profile consistent with emotional reactivity to social interaction and mental provocation, with anger as the predominant affective state. Patients with such a profile may be at risk of frequent silent left ventricular dysfunction.

Chronic pain: intrusion and accommodation.

Cognitive-behavioral and self-management perspectives on chronic pain emphasize the central role that patient's appraisals of their pain problems may have in determining aspects of the pain experience. This paper reports the development of a self-report instrument measuring two aspects of patients' appraisals of their pain and its impact on their lives. Two reliable and meaningful scales were derived via factor analysis, and a second sample was submitted to confirmatory factor analysis. Further analyses offered support for the internal consistency and stability of the scales. Pain Intrusion is related to greater depressive symptom severity and pain behaviors reflecting affective distress. Pain Accommodation is related to self-reports of greater self-control, viewing oneself as a problem-solver, fewer depressive symptoms, and fewer pain behaviors reflecting affective distress. This report introduces these constructs and the Chronic Pain Intrusion and Accommodation Scales that measure them, and discusses their theoretical and clinical relevance.

Pain-relevant support as a buffer from depression among chronic pain patients low in instrumental activity.

OBJECTIVE: This study examined the hypothesis that among chronic pain patients lacking participation in activities, perceived pain-relevant spousal support would act to compensate for a low level of social reinforcement and provide a buffer against depression. DESIGN: Hierarchical regression analyses were conducted to examine the relative and cumulative effects of support and activity, and their interactions, in the prediction of depression severity. SETTING: The study setting was a training and research oriented Veterans Administration Medical Center. PATIENTS: Participants were 105 married, male chronic pain patients evaluated for a comprehensive pain management program. MAIN OUTCOME MEASURE: Depression severity was measured by the Beck Depression Inventory. RESULTS: Three categories of activity, and perceived interference of pain accounted for significant proportions of the variance in depression severity scores beyond that accounted for by age and pain severity. Support was not predictive of depression. Interactions between interference and support, and between two of the specific activities and support added significantly to the prediction of depression. CONCLUSIONS: Results are consistent with a buffering model of social support in which perceived spousal support among chronic pain patients appears to moderate the potentially deleterious effects of a low level of activity.

The Pain Behavior Check List (PBCL): factor structure and psychometric properties.

The construct of "pain behaviors" as observable and measurable manifestations of pain occupies a central role in Fordyce's operant model of pain. The present study was designed to evaluate the multidimensional nature of the construct and to explore the psychometric properties of a newly developed self-report instrument called the Pain Behavior Check List (PBCL). Subjects were 126 chronic pain patients who completed an initial version of the PBCL and other standardized questionnaires as part of their evaluation by the West Haven VAMC. Factor analysis identified four factors labeled Distorted Ambulation, Affective Distress, Facial/Audible Expressions, and Seeking Help. Substantial reliability and stability estimates for the total PBCL and the subscales support the potential clinical and theoretical utility of the instrument.

Development of a sleep diary for chronic pain patients.

The present study examined the psychometric properties of the Daily Sleep Diary (DSD), an instrument developed for monitoring sleep among chronic pain patients. As part of a comprehensive evaluation, 46 chronic pain patients completed the DSD each morning. Items assessed the number of hours slept, length of sleep onset, frequency of awakenings during the night that resulted in trouble falling back to sleep, early morning awakening, quality of sleep, lack of restfulness, and the previous night's sleep compared to usual sleep. Reliability coefficients were significant. The sleep diary items significantly correlated with other retrospective measures of sleep. Duration of pain complaint was related to delayed sleep onset and lower quality of sleep. Pain severity was related to fewer hours slept and delayed sleep onset. The DSD items correlated with measures of both depression and anxiety. The results emphasize the importance of including sleep in both assessment and treatment of chronic pain patients.

The role of marital interaction in chronic pain and depressive symptom severity.

Several investigators have noted the moderating role of the spouse in determining the severity and disability associated with the experience of chronic pain. In this study, pain-contingent responses from spouses, but not global marital satisfaction, accounted for a significant proportion of the variance in reported pain severity. Global marital satisfaction predicted depressive symptom severity. The interaction between global marital satisfaction and the reported frequency of punishing responses to pain behavior added significantly to the prediction of depressive symptoms. Similarly, the interaction between marital satisfaction and degree of spouse solicitousness significantly predicted pain severity. These results are consistent with evolving literatures on the important relationship between marital distress, aversive communication and depression on the one hand, and the potentially deleterious role of the solicitous spouse in the maintenance of chronic pain on the other.

Defensive coping and blood pressure reactivity in medical patients.

Two defensive coping styles, denial of illness and repressive coping, were studied in two groups of medical patients whose blood pressure (BP) was measured during a stress interview. Denial of illness was measured using the Levine Denial of Illness Scale (LDIS), and repressive coping was measured using a combination of the Marlowe-Crowne (MC) Social Desirability Scale and the SCL-90R anxiety subscale (ANX). Consistent with our prior research indicating that LDIS was associated with adaptive outcomes in the short run, high deniers manifested reduced systolic BP reactivity compared to low deniers. Although not related to repressive coping, systolic BP reactivity was correlated positively with MC and ANX separately. The results demonstrate that LDIS and MC measure different types of defensive coping. Current theories of the MC scale suggest two possible interpretations of the MC findings, one that focuses on avoidant coping and the second on attentional coping in high MC scorers.

Using the biopsychosocial model to predict nocturnal penile rigidity in men with erectile dysfunction.

The purpose of this study was to examine the relative contributions of sets of descriptive, organic, and psychosocial variables to a prediction of nocturnal penile rigidity among a group of men presenting with significant erectile dysfunction. Seventy veterans referred for evaluation of their erectile dysfunction completed several standardized questionnaires and two nights of nocturnal penile rigidity monitoring (NPRM) using the snap gauge technique. Results suggest that each set of variables uniquely contributes to a prediction of NPRM. Findings support the view that a biopsychosocial approach should be used in the evaluation and treatment of erectile dysfunction.

Cynical Mistrust and the search for self-worth.

Cynical Mistrust was examined among 64 medical and surgical patients, 23 of whom were selected for a history of CHD and 41 for an absence of such a history. Cynical Mistrust was found to differentiate subjects with a positive history from those without such a history. As hypothesized, persons scoring high in Cynical Mistrust also scored high in Self-Worth by Social Comparison, Playing Hardball with Others and Self-Criticism. Surprisingly, high scorers in Cynical Mistrust among subjects with a coronary history also scored high in Dependency on others for validation that they were deserving of being loved. We suggest that the pathogenicity of Cynical Mistrust for CHD may be potentiated by the presence of certain other dispositions. Further investigation of dependency on others in particular appears to be worthwhile in order to determine whether consideration of this disposition can improve the identification of risk for CHD.