Comorbid Chronic Pain and Depression: Patient Perspectives on Empathy

Clinician empathy is a well-documented component of effective patient/provider communication. Evidence surrounding the association between patient perspectives on clinician empathy and perception of pain management is currently limited, particularly among patients with chronic pain and depression. The aim of this study was to analyze patients’ perspectives on the emergent theme of empathy and describe how patients construct their experiences and expectations surrounding empathic interactions. A secondary analysis of focus group data was designed using grounded theory methodology. Veterans Affairs (VA) and University Primary Care Clinics. Respondents with chronic pain and comorbid depression (N = 18) were 27 to 84 years old (mean 54.8 years), 61% women, 22% black, and 74% white. Study participants highly valued empathy and two types of empathic interactions: empathic listening and empathic action. Patients who provided examples of empathic interactions claimed that others understood, valued, and cared for them. In contrast, patients who perceived a lack of empathy and empathic interactions felt frustrated and uncared for by others (including their physicians) physically and emotionally. Patients with chronic pain and depression claimed that empathy helped them feel understood, believed, taken seriously, and that their needs were met. In demonstrating empathy and engaging in empathic interactions with patients, providers relate better to patients, better understand their life experience, and provide patient-centered care that is meaningful for patients, providers, and the health care systems within which they interact. Future research is needed to purposefully study the effects of empathic interactions on outcomes for patients with chronic pain and comorbid depression

Trigger-Point Self-Care for Chronic Neck Pain: Pilot and Feasibility

poster abstractMassage is a non-pharmacological approach for neck pain with building evidence. Trigger points (TrPts) are thought to be associated with chronic neck pain (CNP) and can be treated with massage techniques. Due to massage’s out-of-pocket costs, TrPt self-care (TrPtSC) may serve as a cost-effective treatment that may reach broader populations. No study has examined a) feasibility of conducting TrPtSC training in a research setting, b) ability of such programs to meet stated training objectives, c) adherence to personalized TrPtSC plans, and d) TrPtSC outcomes for CNP. A pilot observational, pre- post-intervention cohort study with 1-, 4-, and 8-week follow-ups was implemented. Participants: self-identified adults with CNP and Neck Disability Index (NDI) ≥4. Measures: pre-/post-TrPtSC training objectives survey, TrPtSC daily self-report log, NDI and 11-point pain rating scale. Intervention: three-hour TrPtSC training with interactive lecture, demonstration, supervised practice, and private assessment with individualized TrPtSC plan development. Handouts and tools were provided for training and home TrPtSC. Participants documented their individualized TrPtSC plan adherence daily. Five participants (women=3; ages 22-58; White=5) enrolled in the study and two separate group training sessions occurred (n=3 & 2, respectively). By the end of the TrPtSC training, all participants agreed or strongly agreed they achieved all intended training objectives. Baseline NDI categorized all participants as mild neck pain with disability (mean NDI=10.4±2.1). Week-1 follow-up: 1 participant had no NDI change, 1 participant worsened, and 3 reported 23-50% improvement. All participants had improved NDI at week-4 and week-8 compared to baseline. Three participants reported 23-30% improvement by study’s end. Our TrPtSC group training approach met objectives and our study design is feasible for larger scale trials. Results suggest TrPtSC may improve CNP outcomes. More robust studies with greater than mild neck pain and disability participants are needed to estimate effect sizes and adequately power larger comparison trials

How Do Patients with Chronic Pain Benefit from a Peer-Supported Pain Self-Management Intervention? A Qualitative Investigation

Objective. Peer support is a novel and under-studied approach to the management of chronic pain. This study’s purpose was to uncover the elements of a peer-supported self-management intervention that are perceived by participants as essential to achieving positive changes. Design. Qualitative, semi-structured interviews. Methods. Veterans and veteran peer coaches who participated in a pilot study of peer support Improving Pain using Peer-Reinforced Self-Management Strategies (IMPPRESS, NCT01748227) took part in qualitative semi-structured interviews after completing the 4-month intervention. Questions were designed to facilitate understanding of how participants experienced the intervention. An immersion/crystallization approach was used to analyze data. Results. All 26 peer coaches and patients who completed the intervention were interviewed. Qualitative analysis revealed three elements of IMPPRESS that peer coaches and patients believed conferred benefit: 1) making interpersonal connections; 2) providing/receiving encouragement and support; and 3) facilitating the use of pain self-management strategies. Conclusions. Peer support represents a promising approach to chronic pain management that merits further study. The current study helps to identify intervention elements perceived by participants to be important in achieving positive results. Understanding how peer support may benefit patients is essential to optimize the effectiveness of peer support interventions and increase the implementation potential of peer-supported pain self-management into clinical practice

Analgesic prescribing trends in a national sample of older veterans with osteoarthritis: 2012-2017

Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre–post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis

Impact of Race and Sex on Pain Management by Medical Trainees: A Mixed Methods Pilot Study of Decision Making and Awareness of Influence

Objective Previous research suggests female and black patients receive less optimal treatment for their chronic pain compared with male and white patients. Provider-related factors are hypothesized to contribute to unequal treatment, but these factors have not been examined extensively. This mixed methods investigation examined the influence of patients' demographic characteristics on providers' treatment decisions and providers' awareness of these influences on their treatment decisions. Methods Twenty medical trainees made treatment decisions (opioid, antidepressant, physical therapy) for 16 virtual patients with chronic low back pain; patient sex and race were manipulated across patients. Participants then indicated from a provided list the factors that influenced their treatment decisions, including patient demographics. Finally, individual interviews were conducted to discuss the role of patient demographics on providers' clinical decisions. Results Individual regression analyses indicated that 30% of participants were reliably influenced by patient sex and 15% by patient race when making their decisions (P < 0.05 or P < 0.10). Group analyses indicated that white patients received higher antidepressant recommendations, on average, than black patients (P < 0.05). Half of the medical trainees demonstrated awareness of the influence of demographic characteristics on their decision making. Participants, regardless of whether they were influenced by patients' demographics, discussed themes related to patient sex and race; however, participants' discussion of patient demographics in the interviews did not always align with their online study results. Conclusions These findings suggest there is a considerable variability in the extent to which medical trainees are influenced by patient demographics and their awareness of these decision making influences

A Brief Peer Support Intervention for Veterans with Chronic Musculoskeletal Pain: A Pilot Study of Feasibility and Effectiveness

Objective The aim of this study was to pilot test a peer support intervention, involving peer delivery of pain self-management strategies, for veterans with chronic musculoskeletal pain. Design Pretest/posttest with 4-month intervention period. Methods Ten peer coaches were each assigned 2 patients (N = 20 patients). All had chronic musculoskeletal pain. Guided by a study manual, peer coach–patient pairs were instructed to talk biweekly for 4 months. Pain was the primary outcome and was assessed with the PEG, a three-item version of the Brief Pain Inventory, and the PROMIS Pain Interference Questionnaire. Several secondary outcomes were also assessed. To assess change in outcomes, a linear mixed model with a random effect for peer coaches was applied. Results Nine peer coaches and 17 patients completed the study. All were male veterans. Patients' pain improved at 4 months compared with baseline but did not reach statistical significance (PEG: P = 0.33, ICC [intra-class correlation] = 0.28, Cohen's d = −0.25; PROMIS: P = 0.17, d = −0.35). Of secondary outcomes, self-efficacy (P = 0.16, ICC = 0.56, d = 0.60) and pain centrality (P = 0.06, ICC = 0.32, d = −0.62) showed greatest improvement, with moderate effect sizes. Conclusions This study suggests that peers can effectively deliver pain self-management strategies to other veterans with pain. Although this was a pilot study with a relatively short intervention period, patients improved on several outcomes

Balancing patient-centered and safe pain care for non-surgical inpatients: clinical and managerial perspectives

Background: Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are ensuring that care is patient-centered, meaning that it is respectful of patients’ values, preferences, and experiences. However, little is known about delivering care in cases where these goals may not align. For example, hospitals and clinicians are facing the daunting challenge of balancing safe and patient-centered pain care for nonsurgical patients, due to lack of comprehensive care guidelines and complexity of this patient population. Methods: To gather clinical and managerial perspectives on the importance, feasibility, and strategies used to balance patient-centered care (PCC) and safe pain care for nonsurgical inpatients, we conducted in-depth, semi-structured interviews with hospitalists (n=10), registered nurses (n=10), and health care managers (n=10) from one healthcare system in the Midwestern United States. We systematically examined transcribed interviews and identified major themes using a thematic analysis approach. Results: Participants acknowledged the importance of balancing PCC and safe pain care. They envisioned this balance as a continuum, with certain patients for whom it is easier (e.g., opioid-naïve patient with a fracture), versus more difficult (e.g., patient with opioid use disorder). Participants also reported several strategies they use to balance PCC and safe pain care, including offering alternatives to opioids, setting realistic pain goals and expectations, and using a team approach. Conclusions: Clinicians and health care managers use various strategies to balance PCC and safe pain care for nonsurgical patients. Future studies should examine the effectiveness of these strategies on patient outcomes

A Qualitative Examination of Pain Centrality Among Veterans of Iraq and Afghanistan Conflicts

Objective. Centrality of pain refers to the degree to which a patient views chronic pain as integral to his or her life or identity. The purpose of this study was to gain a richer understanding of pain centrality from the perspective of patients who live with chronic pain. Methods. Face-to-face interviews were conducted with 26 Veterans with chronic and disabling musculoskeletal pain after completing a stepped care intervention within a randomized controlled trial. Qualitative data were analyzed using an immersion/crystallization approach. We evaluated the role centrality plays in Veterans’ lives and examined whether and how their narratives differ when centrality either significantly decreases or increases after participation in a stepped care intervention for chronic pain. Results. Our data identified three emergent themes that characterized pain centrality: 1) control, 2) acceptance, and 3) preoccupation. We identified five characteristics that distinguished patients’ changes in centrality from baseline: 1) biopsychosocial viewpoint, 2) activity level, 3) pain communication, 4) participation in managing own pain, and 5) social support. Conclusions. This study highlights centrality of pain as an important construct to consider within the overall patient experience of chronic pain