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Study Objectives: Chronic noncancer pain (CP) commonly co-occurs with obstructive sleep apnea (OSA) and may contribute to greater symptom burden. The study aims were to (1) characterize CP among veterans with OSA and (2) examine differences in sleepiness (Epworth Sleepiness Scale), insomnia symptoms (Insomnia Severity Index), and quality of life (Short Form Health Survey-20) in veterans with OSA with or without pre-existing CP., Methods: An observational, cross-sectional, study of 111 veterans with newly diagnosed, untreated OSA was conducted. Descriptive statistics characterized the sample and comorbid CP outcomes. Regression analyses were performed to investigate associations between self-reported CP and sleep-related symptoms or quality of life while controlling for potential confounders., Results: CP was reported by 69.5% (95% confidence interval: 61.8%, 76.2%) of participants. Having CP was associated with increased Epworth Sleepiness Scale (12.7 ± 5.5 vs 10.2 ± 5.2; P = .021) and Insomnia Severity Index scores (18.1 ± 6.2 vs 13.7 ± 7.4; P = .002), and worse quality of life across all Short Form Health Survey-20 domains., Conclusions: There is a high prevalence of CP among veterans with OSA and symptom burden is higher in patients with OSA and CP. Future investigations should address symptom response and burden to OSA treatment in comorbid OSA and CP to guide outcome expectancies and residual OSA symptom treatment plans., Citation: Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med . 2023;19(6):1121-1132., (© 2023 American Academy of Sleep Medicine.)

Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management., Competing Interests: Conflicts of interest The authors do not have any conflicts of interest to disclose., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Chronic noncancer pain (CNCP) in military and veteran populations mirrors the experience of chronic pain in America; however, these two populations have unique characteristics and comorbid conditions such as traumatic brain injuries, postconcussive syndrome, posttraumatic stress disorder, and behavioral health disorders that complicate the diagnosis and treatment of chronic pain. Military members and veterans may also be stigmatized about their conditions and experience problems with integration back into healthy lifestyles and society as a whole following deployments and after military service. The military and veteran health care systems have made chronic pain a priority and have made substantial strides in addressing this condition through advances in practice, education, research, and health policy. Despite this progress, significant challenges remain in responding to the wide-spread problem of chronic pain. The purpose of this article is to: (a) examine the state of CNCP in military and veteran populations; (b) discuss progress made in pain practice, education, research, and health policy; and (c) examine research, evidence-based practice guidelines, and expert consensus reports that are foundational to advancing pain care and improving health for military service members and veterans with CNCP. In addition, recommendations are proposed to address this widespread health problem through the expanded use of advanced practice registered nurses, the implementation of models of care, and use of national resources to educate health care providers, support practice, and promote effective pain care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To recruit healthy full- and preterm infants into genetic research and determine the effectiveness of a noninvasive DNA sampling technique for comparing epigenetic modifications. Background: Noxious stimuli during a vulnerable period of infant neuronal plasticity may trigger long-term epigenetic changes affecting neurodevelopment, pain modulation, and reactivity. Recognizing epigenetic pain findings is problematic because parents are reluctant to enroll newborns into genetic research. Methods: Design: Within-subject change over time candidate-gene DNA methylation association study. Setting/sample: Urban teaching hospital’s neonatal intensive care unit and newborn nursery. Convenience sample of healthy full- (>37 weeks, n = 6) and preterm (<37 weeks, n = 6) infants. Procedure: Parents participated in a genetic presentation prior to informed consent. Infant buccal saliva was collected after admission to the unit and prior to discharge. Analysis: The methylation pattern at the 5′ end of µ-opioid receptor gene (OPRM1) was examined. DNA was treated with bisulfite to convert all cytosines to uracil residues, leaving methylated cytosines unchanged. Sequencing of untreated and bisulfite-converted DNA was carried out. The sequences of unconverted and bisulfite-converted DNA were aligned with ClustalW, fidelity of the polymerase chain reaction and the sequencing reaction evaluated, and the methylation pattern identified. Results: Recruitment and assessment of a noninvasive DNA sampling technique for comparing epigenetic modifications were successful; however, infant stress did not produce a change in OPRM1 methylation expression. Relevance: This study established the feasibility of recruiting healthy full-term infants into genetic research and the effectiveness of noninvasive DNA sampling for comparing epigenetic modification in infants. [ABSTRACT FROM AUTHOR]

Objective. To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids. Methods. An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations. Results. Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment. Conclusions. Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain. [ABSTRACT FROM AUTHOR]

Objective. The Defense and Veterans Pain Rating Scale (DVPRS 2.0) is a pain assessment tool that utilizes a numerical rating scale enhanced by functional word descriptors, color coding, and pictorial facial expressions matched to pain levels. Four supplemental questions measure how much pain interferes with usual activity and sleep, and affects mood and contributes to stress. Methods. Psychometric testing was performed on a revised DVPRS 2.0 using data from 307 active duty service members and Veterans experiencing acute or chronic pain. A new set of facial representations designating pain levels was tested. Results. Results demonstrated acceptable internal consistency reliability (Cronbach's alpha = 0.871) and test-retest reliability (r = 0.637 to r = 0.774) for the five items. Excellent interrater agreement was established for correctly ordering faces depicting pain levels and aligning them on the pain intensity scale (Kendall's coefficient of concordance, = 5 0.95 and 0.959, respectively). Construct validity was supported by an exploratory principal component factor analysis and known groups validity testing. Most participants, 70.9%, felt that the DVPRS was superior to other pain rating scales. Consclusion. The DVPRS 2.0 is a reliable and valid instrument that provides standard language and metrics to communicate pain and related outcomes. [ABSTRACT FROM AUTHOR]

Objective. Examine response patterns to low-dose intravenous ( IV) ketamine continuous infusions on multiple pain outcomes, and demonstrate effectiveness, safety, and tolerability of ketamine administration on general wards. Design. Retrospective case series of consecutive patients given low-dose IV ketamine continuous infusions. Setting. Walter Reed Army Medical Center, Washington, DC. Patients. Nineteen eligible inpatients with neuropathic pain from major limb injuries sustained in combat with inadequate pain control from multimodal analgesia. Interventions. A 3-day IV infusion of ketamine at doses ≤120 μg/kg/h. Outcome Measures. Daily present ( PPI), average ( API), and worst ( WPI) pain intensity (0-10), global pain relief ( GPR) (1 'no relief' to 5 'complete relief'), daily assessments of adverse events, and daily opioid requirements measured during therapy. Results. A significant reduction in PPI ( P < 0.001) and improvement in GPR ( P = 0.031) was noted over time. Higher baseline WPI (≥7; N = 14) was associated with a significant decrease in WPI ( P = 0.0388), but lower baseline WPI (N = 5) was not. Significant mean percent decreases in PPI with higher baseline PPI (N = 8; P = 0.0078) and WPI with no phantom limb pain ( PLP) (N = 10; P = 0.0436) were observed. Mean percent increase in overall GPR was better for those reporting GPR scores ≤3 (N = 13) in the first 24 hours of therapy ( P = 0.0153). While not significant, mean opioid requirement ( IV morphine equivalents) decreased from 129.9 mgs ± 137.3 on day 1 to 112.14 ± 86.3 24 hours after therapy. Conclusions. Low-dose ketamine infusions for complex combat injury pain were safe and effective, and demonstrated response patterns over time and by baseline pain score stratification and presence or absence of PLP. [ABSTRACT FROM AUTHOR]

The authors performed an electronic search of websites that address psychosocial issues in pain management identified over 5 million sites. A search limited to pychosocial issues in pain produced nearly 400,000. Nine scientific, professional and consumer-oriented websites were selected for review of social support information and opportunities using criteria focusing on patient information, referrals for counseling services and community-based assistance programs, sell-help groups, specific pain syndromes, and readability and interpretability of consumer-oriented content. The internet can empower patients to self-manage their pain and seek out effective social support venues for improving their lives. [ABSTRACT FROM AUTHOR]

The article focuses on the research on pain and neuropathy conducted among cancer survivors. It is emphasized that chronic pain syndromes and neuropathies felt by disease-free-cancer survivors came from an injury to peripheral nerves from surgical trauma, neurotoxicity of chemotherapeutic agents, and radiation-induced damage to nerves. The surgery-related pain and neuropathy includes mastectomy, thoracotomy, and head and neck cancer.

Opioid analgesics are commonly administered to hospitalized patients to treat acute pain, but these drugs put patients at risk for serious adverse events, such as unintended advancing sedation, respiratory depression, and death. Nurses play an important role in keeping patients safe by making clinical decisions about the frequency and intensity with which patients receivings and epidural opioids should be monitored. To make sound clinical judgments, nurses must be aware of the factors that place patients at elevated risk for adverse opioid-related effects and know how to screen and assess patients for these risks. The authors review the literature on unintended advancing sedation and respiratory depression associated with opioid administration and present evidence-based recommendations for clinical decision making and patient monitoring, using both nursing assessments and electronic technologies. [ABSTRACT FROM AUTHOR]

Acute pain, which is usually sudden in onset and time limited, serves a biological protective function, warning the body of impending danger. However, while acute pain often resolves over time with normal healing, unrelieved acute pain can disrupt activities of daily living and transition to chronic pain. This article describes the effects of unrelieved acute pain on patients and clinical outcomes. The authors call on nurses to assess and manage acute pain in accordance with evidence-based guidelines, expert consensus reports, and position statements from professional nursing organizations in order to minimize the likelihood of its becoming chronic. [ABSTRACT FROM AUTHOR]