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Chronic pain is prevalent among individuals with higher body weight and associated with greater impairment. As a result, weight loss is a common recommendation for pain management among those with higher body weight. Body weight is an appealing target because it is modifiable and evidence-based treatments to produce weight loss are well-established. In the last 2 decades, there has been a growing line of scientific work investigating the application of weight loss to individuals with chronic pain. This represents an important step to integrate the conceptualization of pain and body weight and there is preliminary work suggesting treatment effects are enhanced when weight loss treatment is combined with pain coping skills. However, weight loss outcomes are variable and difficult to sustain, and access to evidence-based treatment is limited. These concerns are set against the backdrop of growing public and academic concern about the weight-centric approach to health care that dominates western medicine. This is a timely moment to reconsider the conceptualization of weight and pain, and the role of weight loss in chronic pain treatment. Using osteoarthritis as an exemplar, we review the evidence for and clinical uptake of weight loss as a chronic pain management strategy and conclude with key areas for consideration to advance the scientific understanding of these comorbid conditions and how to optimize pain management for individuals of higher body weight. PERSPECTIVE: This focus article critically considers the role of weight loss in management of chronic pain among individuals of higher body. Using knee osteoarthritis as an exemplar, the evidence and clinical uptake of weight loss for pain management is reviewed. Limitations are considered to guide future research and clinical care., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

The personal, social and economic burden of chronic pain is enormous. Tremendous research efforts are being directed toward understanding, preventing, and managing chronic pain. Yet patients with chronic pain, clinicians and the public are sometimes poorly served by an evidence architecture that contains multiple structural weaknesses. These include incomplete research governance, a lack of diversity and inclusivity, inadequate stakeholder engagement, poor methodological rigour and incomplete reporting, a lack of data accessibility and transparency, and a failure to communicate findings with appropriate balance. These issues span pre-clinical research, clinical trials and systematic reviews and impact the development of clinical guidance and practice. Research misconduct and inauthentic data present a further critical risk. Combined, they increase uncertainty in this highly challenging area of study and practice, drive the provision of low value care, increase costs and impede the discovery of more effective solutions. In this focus article, we explore how we can increase trust in pain science, by examining critical challenges using contemporary examples, and describe a novel integrated conceptual framework for enhancing the trustworthiness of pain science. We end with a call for collective action to address this critical issue. PERSPECTIVE: Multiple challenges can adversely impact the trustworthiness of pain research and health research more broadly. We present ENTRUST-PE, a novel, integrated framework for more trustworthy pain research with recommendations for all stakeholders in the research ecosystem, and make a call to action to the pain research community., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Multiple large longitudinal cohorts provide opportunities to address questions about predictors of pain and pain trajectories, even when not anticipated in the design of the historical databases. This focus article uses 2 empirical examples to illustrate the processes of assessing the measurement properties of data from large cohort studies to answer questions about pain. In both examples, data were screened to select candidate variables that captured the impact of chronic pain on self-care activities, productivity, and social activities. We describe a series of steps to select candidate items and evaluate their psychometric characteristics in relation to the measurement of pain impact proposed. In the UK Biobank, a general lack of internal consistency of variables selected prevented the identification of a satisfactory measurement model, with lessons for the measurement of chronic pain impact. In the English Longitudinal Study of Ageing, a measurement model for chronic pain impact was identified, albeit limited to capturing the impact of pain on self-care and productivity but lacking coverage related to social participation. In conjunction with its Supplementary Material, this focus article aims to encourage exploration of these valuable prospectively collected data to support researchers to make explicit the relationships between items in the databases and constructs of interest in pain research and to use empirical methods to estimate the possible biases in these variables. PERSPECTIVE: This focus article outlines a theory-driven approach for fitting new measurement models to data from large cohort studies and evaluating their psychometric properties. This aims to help researchers develop an empirical understanding of the gains and limitations connected with the process of repurposing the data stored in these datasets., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Cannabidiol (CBD) attracts considerable attention for promoting good health and treating various conditions, predominantly pain, often in breach of advertising rules. Examination of available CBD products in North America and Europe demonstrates that CBD content can vary from none to much more than advertised and that potentially harmful other chemicals are often included. Serious harm is associated with chemicals found in CBD products and reported in children, adults, and the elderly. A 2021 International Association for the Study of Pain task force examined the evidence for cannabinoids and pain but found no trials of CBD. Sixteen CBD randomized trials using pharmaceutical-supplied CBD or making preparations from such a source and with pain as an outcome have been published subsequently. The trials were conducted in 12 different pain states, using 3 oral, topical, and buccal/sublingual administration, with CBD doses between 6 and 1,600 mg, and durations of treatment between a single dose and 12 weeks. Fifteen of the 16 showed no benefit of CBD over placebo. Small clinical trials using verified CBD suggest the drug to be largely benign; while large-scale evidence of safety is lacking, there is growing evidence linking CBD to increased rates of serious adverse events and hepatotoxicity. In January 2023, the Food and Drug Administration (FDA) announced that a new regulatory pathway for CBD was needed. Consumers and health care providers should rely on evidence-based sources of information on CBD, not just advertisements. Current evidence is that CBD for pain is expensive, ineffective, and possibly harmful. PERSPECTIVE: There is no good reason for thinking that CBD relieves pain, but there are good reasons for doubting the contents of CBD products in terms of CBD content and purity., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

We previously conducted an exploration of the trustworthiness of a group of clinical trials of cognitive-behavioral therapy and exercise in spinal pain. We identified multiple concerns in 8 trials, judging them untrustworthy. In this study, we systematically explored the impact of these trials ("index trials") on results, conclusions, and recommendations of systematic reviews and clinical practice guidelines (CPGs). We conducted forward citation tracking using Google Scholar and the citationchaser tool, searched the Guidelines International Network library and National Institute of Health and Care Excellence archive to June 2022 to identify systematic reviews and CPGs. We explored how index trials impacted their findings. Where reviews presented meta-analyses, we extracted or conducted sensitivity analyses for the outcomes of pain and disability, to explore how the exclusion of index trials affected effect estimates. We developed and applied an 'Impact Index' to categorize the extent to which index studies impacted their results. We included 32 unique reviews and 10 CPGs. None directly raised concerns regarding the veracity of the trials. Across meta-analyses (55 comparisons), the removal of index trials reduced effect sizes by a median of 58% (Inter Quartlie Range (IQR) 40-74). 85% of comparisons were classified as highly, 3% as moderately, and 11% as minimally impacted. Nine out of 10 reviews conducting narrative synthesis drew positive conclusions regarding the intervention tested. Nine out of 10 CPGs made positive recommendations for the intervention(s) evaluated. This cohort of trials, with concerns regarding trustworthiness, has substantially impacted the results of systematic reviews and guideline recommendations. PERSPECTIVE: We found that a group of trials of CBT for spinal pain with concerns relating to their trustworthiness has had substantial impacts on the analyses and conclusions of systematic reviews and clinical practice guidelines. This highlights the need for a greater focus on the trustworthiness of studies in evidence appraisal. PRE-REGISTRATION: Our protocol was preregistered on the Open Science Framework: https://osf.io/m92ax/., (Copyright © 2023 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

This study investigated whether there are gender differences in attention to bodily expressions of pain and core emotions. Three experiments are reported using the attentional dot probe task. Images of men and women displaying bodily expressions, including pain, were presented. The task was used to determine whether participants' attention was drawn towards or away from target expressions. Inconsistent evidence was found for an attentional bias towards body expressions, including pain. While biases were affected by gender, patterns varied across the Experiments. Experiment 1, which had a presentation duration of 500 ms, found a relative bias towards the location of male body expressions compared to female expressions. Experiments 2 and 3 varied stimulus exposure times by including both shorter and longer duration conditions (e.g., 100 vs. 500 vs. 1250 ms). In these experiments, a bias towards pain was confirmed. Gender differences were also found, especially in the longer presentation conditions. Expressive body postures captured the attention of women for longer compared to men. These results are discussed in light of their implications for why there are gender differences in attention to pain, and what impact this has on pain behaviour. PERSPECTIVE: We show that men and women might differ in how they direct their attention towards bodily expressions, including pain. These results have relevance to understanding how carers might attend to the pain of others, as well as highlighting the wider role that social-contextual factors have in pain., (Copyright © 2021 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

We are able to recognize others' experience of pain from their facial expressions. However, little is known about what makes the recognition of pain possible and whether it is similar or different from core emotions. This study investigated the mechanisms underpinning the recognition of pain expressions, in terms of spatial frequency (SF) information analysis, and compared pain with 2 core emotions (ie, fear and happiness). Two experiments using a backward masking paradigm were conducted to examine the time course of low- and high-SF information processing, by manipulating the presentation duration of face stimuli and target-mask onset asynchrony. Overall, we found a temporal advantage of low-SF over high-SF information for expression recognition, including pain. This asynchrony between low- and high-SF happened at a very early stage of information extraction, which indicates that the decoding of low-SF expression information is not only faster but possibly occurs before the processing of high-SF information. Interestingly, the recognition of pain was also found to be slower and more difficult than core emotions. It is suggested that more complex decoding process may be involved in the successful recognition of pain from facial expressions, possibly due to the multidimensional nature of pain experiences. PERSPECTIVE: Two studies explore the perceptual and temporal properties of the decoding of pain facial expressions. At very early stages of attention, the recognition of pain was found to be more difficult than fear and happiness. It suggests that pain is a complex expression, and requires additional time to detect and process., (Copyright © 2020 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

The rapid growth of mobile health (mHealth) devices holds substantial potential for improving care and care outcomes in all patient populations, including older adults with pain. However, existing research reflects a substantial gap in knowledge about how to design, evaluate, and disseminate devices to optimally address the many challenges associated with managing pain in older persons. Given these knowledge gaps, we sought to develop a set of practice-based research priorities to facilitate innovation in this field. We employed the Cornell Research-Practice Consensus Workshop Model, an evidence-based approach to generating research priorities. Sixty participants attended the conference, where stakeholder groups included older adults with pain and their caregivers, behavioral and social scientists, healthcare providers, pain experts, and specialists in mHealth and health policy. Participants generated 13 recommendations classified into 2 categories: 1) implications for designing research on mHealth among older adults (eg, conduct research on ways to enhance accessibility of mHealth tools among diverse groups of older adults with pain, expand research on mHealth sensing applications), and 2) implementation of mHealth technology into practice and associated regulatory issues (eg, promote research on ways to initiate/sustain patient behavior change, expand research on mHealth cybersecurity and privacy issues). PERSPECTIVE: This report highlights a set of research priorities in the area of mHealth and later-life pain derived from the joint perspectives of researchers and key stakeholder groups. Addressing these priorities could help to improve the quality of care delivered to older adults with pain., (Copyright © 2018 the American Pain Society. Published by Elsevier Inc. All rights reserved.)

Pain is thought to capture our attention. A consequence is that our performance on other tasks may suffer. Research has supported this, showing that pain disrupts our ability to perform various attention tasks. However, the specific nature of the effect of pain on attention is inconsistent, possibly due to different studies investigating different types of pain. Few studies seek to replicate basic findings. In this study, we conceptually replicated and extended the headache study by Moore, Keogh, and Eccleston in 2013, by including 2 additional attention tasks, a broader sample, and measures of affect and pain cognition. Participants performed 5 complex attention tasks and a choice reaction time task with and without a naturally-occurring headache. Headache slowed reaction times to 4 of the 5 complex tasks, and this could be attributed to a slower basic processing speed measured using the choice reaction time task. Our findings differ from those of Moore et al in their headache study, suggesting that the effect of pain on attention is dynamic, even within a given type of pain. Whereas there is growing evidence that pain does disrupt attention, we cannot yet predict the specific nature of disruption in any given case., Perspective: We extended a study investigating the effect of headache on attention. Although both studies showed attentional disruption, the specific effects differed. Research must establish when and why the effect of pain on attention varies before we will be able to develop interventions to reduce attentional disruption from pain., (Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Negative interpretation bias, the tendency to appraise ambiguous situations in a negative or threatening way, has been suggested to be important for the development of adult chronic pain. To our knowledge, this is the first study to examine the role of a negative interpretation bias in adolescent pain. We first developed and piloted a novel task that measures the tendency for adolescents to interpret ambiguous situations as indicative of pain and bodily threat. Using this task in a separate community sample of adolescents (N = 115), we then found that adolescents who catastrophize about pain, as well as those who reported more pain issues in the preceding 3 months, were more likely to endorse negative interpretations, and less likely to endorse benign interpretations, of ambiguous situations. This interpretation pattern was not, however, specific for situations regarding pain and bodily threat, but generalized across social situations as well. We also found that a negative interpretation bias, specifically in ambiguous situations that could indicate pain and bodily threat, mediated the association between pain catastrophizing and recent pain experiences. Findings may support one potential cognitive mechanism explaining why adolescents who catastrophize about pain often report more pain., Perspective: This article presents a new adolescent measure of interpretation bias. We found that the tendency to interpret ambiguous situations as indicative of pain and bodily threat may be one potential cognitive mechanism explaining why adolescents who catastrophize about pain report more pain, thus indicating a potential novel intervention target., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Daily life is characterized by the need to stop, start, repeat, and switch between multiple tasks. Here, we experimentally investigate the effects of pain, and its anticipation, in a multitask environment. Using a task-switching paradigm, participants repeated and switched between 3 tasks, of which 1 predicted the possible occurrence of pain. Half of the participants received low intensity pain (N = 30), and half high intensity pain (N = 30). Results showed that pain interferes with the performance of a simultaneous task, independent of the pain intensity. Furthermore, pain interferes with the performance on a subsequent task. These effects are stronger with high intensity pain than with low intensity pain. Finally, and of particular importance in this study, interference of pain on a subsequent task was larger when participants switched to another task than when participants repeated the same task., Perspective: This article is concerned with the interruptive effect of pain on people's task performance by using an adapted task-switching paradigm. This adapted paradigm may offer unique possibilities to investigate how pain interferes with task performance while people repeat and switch between multiple tasks in a multitask environment., (Copyright © 2012 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: This study is a pilot and feasibility study that compares 2 training experiences to improve appropriate opioid prescribing for chronic pain. Both training conditions included education in relation to opioid guidelines. Following education, 1 condition included training aimed at improving psychological flexibility and the other included training in practical knowledge and skills related to pain management. Eighty-one general practitioners (GPs) took part in the study, each having been randomly assigned to 1 of the training conditions. It proved easy to recruit GPs to the training. Overall, GPs demonstrated increased knowledge of opioid prescribing for chronic pain and decreases in concerns related to prescribing following training. However, there were no changes observed in reported prescribing practices or in secondary measures of well-being. There were also no significant differences between the training conditions, other than a greater increase in intention to use prescribing guidelines in the psychological flexibility condition. Feasibility and acceptability of the training methods were generally rated high. The psychological flexibility condition was rated higher than the comparison condition in terms of interest and satisfaction. Finally, processes of psychological flexibility before and after training significantly correlated with measures of GP well-being, providing partial support for the relevance of these processes as a focus in GP training., Perspective: A training intervention for GPs including education on opioid guidelines for chronic pain and psychological flexibility training increased knowledge of prescribing and reduced concerns but did not change prescribing behavior or well-being. The training was highly acceptable to GPs but may have been too short to produce other effects., (Copyright © 2012 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: A number of adolescents with chronic pain have clinically significant disability across physical, social, and academic activities, and pain severity only explains a portion of the variance in functioning. Thus, it is important to identify therapeutic options to improve adolescents' functioning. In contrast to studies with adults with chronic pain, research in pediatric pain has not consistently found anxiety to be a good predictor of pain-related disability. The present study evaluated pain, anxiety, and functioning in 222 adolescents with chronic pain. Results indicated that pain was consistently and linearly related to disability across measures of physical and social functioning, school attendance, and physician visits. The relation between anxiety and functioning was complex; increased anxiety was related to poorer physical and social functioning and was related to fewer physician visits, although it was not associated with school attendance. Additional analyses revealed that anxiety serves to moderate the relation between pain and functioning. Specifically, at high anxiety, pain was not related to functioning, but at low anxiety, pain consistently predicted disability. In other words, highly anxious adolescents were functioning poorly regardless of the level of pain. The moderating role of anxiety highlights a number of research and clinical possibilities to explore with adolescents with chronic pain-related disability., Perspective: Data suggest that high anxiety is associated with poor functioning irrespective of pain intensity. At low anxiety, higher pain predicted greater disability. Anxiety is important to assess when investigating potential reasons for pain-related disability., (Copyright © 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: A number of negative affect-related constructs are important in pain. Some are general, such as anxiety, depression and negative affectivity, whereas others are more specifically pain-related (eg, fear of pain, pain anxiety, and pain catastrophizing). In addition, some more specific fear-related constructs, such as anxiety sensitivity, illness/injury sensitivity, and fear of negative evaluation have emerged as important to pain. Although these various constructs are considered conceptually separate, there is likely to be overlap between them. Since the extent of this overlap is unknown, the aim of the current study was to investigate these constructs in 1 sample in order to identify their common and unique features. Frequently used psychological measures were completed by 508 pain-free participants. Principal components analysis resulted in the extraction of three components: 1) General distress; 2) Fear of pain from injury/insult; and 3) Cognitive intrusion of pain. The results presented here suggest that there is indeed commonality between constructs, which may be due to either an overlap between items within measures or to close conceptual relatedness. The implications of these core dimensions are discussed with reference to future research and theory., Perspective: This article explores the relationships between various negative-affect pain-related measures and discusses the results from a principal components analysis. The findings show that some questionnaires may measure the same latent construct. A measure could be developed to measure these 3 core components more concisely for both clinical and research purposes., (Copyright (c) 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 26 professionals from academia, governmental agencies, and the pharmaceutical industry participated in a 2-stage Delphi poll and a consensus meeting that identified core outcome domains and measures that should be considered in clinical trials of treatments for acute and chronic pain in children and adolescents. Consensus was refined by consultation with the international pediatric pain community through announcement of our recommendations on the Pediatric Pain List and inviting and incorporating comments from external sources. There was consensus that investigators conducting pediatric acute pain clinical trials should consider assessing outcomes in pain intensity; global judgment of satisfaction with treatment; symptoms and adverse events; physical recovery; emotional response; and economic factors. There was also agreement that investigators conducting pediatric clinical trials in chronic and recurrent pain should consider assessing outcomes in pain intensity; physical functioning; emotional functioning; role functioning; symptoms and adverse events; global judgment of satisfaction with treatment; sleep; and economic factors. Specific measures or measurement strategies were recommended for different age groups for each domain., Perspective: Based on systematic review and consensus of experts, core domains and measures for clinical trials to treat pain in children and adolescents were defined. This will assist in comparison and pooling of data and promote evidence-based treatment, encourage complete reporting of outcomes, simplify the review of proposals and manuscripts, and facilitate clinicians making informed decisions regarding treatment.

Unlabelled: This report describes a study of how patients view their pain medications. Two hundred and twenty patients with chronic pain completed a set of 78 items regarding beliefs and concerns about pain medication, a brief measure of medication use, and measures of depression and disability. Item and scale analyses resulted in a 47-item measure, the Pain Medication Attitude Questionnaire (PMAQ), that assesses 7 areas of patient concern: addiction, perceived need, unfavorable scrutiny by others, adverse side effects, tolerance, mistrust in the prescribing doctor, and withdrawal. These seven scales had excellent internal consistency and predictable relations with the measures of medication use, depression, and disability supporting their validity. Correlation analyses highlighted relatively strong associations between concerns about medication and measures of emotional distress and disability, suggesting that these concerns may add significantly to the burden of chronic pain. We suggest that concerns about medication use warrant further study and may deserve clinical attention., Perspective: All medication use by chronic pain sufferers is essentially a pattern of patient behavior over time. As such, it appears to be multiply-determined, by beliefs, emotions, bodily sensations, and the social, cultural, and personal learning history that give these experiences their meaning and functions.

Unlabelled: We report 2 experiments investigating hypervigilance to pain signals in healthy individuals. In order to allow a detailed analysis, we decomposed attention in 3 different processes: 1) initial shifting, 2) engagement, and 3) disengagement. We used a spatial cueing paradigm in which the location of targets is validly or invalidly predicted by spatial cues. In the first experiment, cues were differentially conditioned to create pain signals, allowing the investigation of engagement and disengagement of attention. Because this procedure does not allow an adequate isolation of the shift component, we introduced a new adaptation of the spatial cueing paradigm in the second experiment, in which targets instead of cues were differentially conditioned. We replicated previous findings, showing enhanced engagement to and retarded disengagement from pain signals compared to control signals. In addition, we demonstrated that participants were still hypervigilant to pain signals after extinction. We were not able to demonstrate speeded shifting to pain signals. Instead we found a generally faster detection of pain signals compared to control signals. We conclude that hypervilance to pain signals does not emerge as rapid initial shifting to the pain signal but rather as enhanced processing once it is detected. Theoretical and clinical implications of these findings are discussed., Perspective: We investigated the fundamental processes associated with hypervigilance to pain. Our findings suggest that treatment approaches using attention techniques should not focus on preventing patients to shift their attention to the pain but rather on diminishing the threat value and learning to disengage from their pain.