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Unlabelled: Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes., Perspective: This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement., (Published by Elsevier Inc.)

Physical illness and disability are common in individuals with substance use disorders, but little is known about the impact of physical disability status on substance use treatment outcomes. This study examined the main and interactive effects of physical disability payment status on substance use treatment. Participants (N = 1,013) were enrolled in one of six prior randomized clinical trials comparing contingency management (CM) to standard care; 79 (7.8%) participants reported receiving disability payments, CM improved all three primary substance use outcomes: treatment retention, percent negative samples and longest duration of abstinence. There was no significant main effect of physical disability payment status on treatment outcomes; however, a significant treatment condition by physical disability status interaction effect emerged in terms of retention in treatment and duration of abstinence achieved. Patients who were receiving physical disability payments responded particularly well to CM, and their time in treatment and durations of drug and alcohol abstinence increased even more markedly with CM than did that of their counterparts who were not receiving physical disability assistance. These findings suggest an objectively defined cohort of patients receiving substance use treatment who respond particularly well to CM., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Unlabelled: The Centrality of Pain Scale (COPS) is a recently developed patient-centered, 10-item self-report measure designed to assess how central, or dominating, in their lives individuals with chronic pain perceive pain to be. The COPS underwent initial development and validation previously; preliminary results suggested that the measure had excellent psychometric properties and that COPS scores were associated with important clinical factors. The purpose of the present study was to examine the psychometric properties of the COPS in a sample of individuals with mixed chronic pain diagnoses (N = 178) being treated at a U.S. Veterans Affairs Medical Center. Principal components analysis of COPS items revealed a single factor, and all items loaded highly. The COPS had high internal consistency (Cronbach's alpha = .902) and was significantly correlated with other measures of pain, mental health, psychological factors associated with pain, and chronic pain coping styles, suggesting convergent and divergent validity. Hierarchical linear regression analyses indicated that COPS score was independently associated with both pain severity and interference. Future research should evaluate the generalizability of the COPS in different samples, its responsiveness to treatment, and the extent to which pain centrality may be a focus of nonpharmacologic interventions for chronic pain., Perspective: We conducted psychometric testing of the COPS, a recently developed patient-centered self-report measure designed to examine how central or dominating pain is to a person's life. Study results indicated a reliable and valid measure, which was significantly associated with pain severity and interference, even after controlling for demographic and clinical factors., (Published by Elsevier Inc.)

Background/objective: Urine drug testing (UDT) may be used to help screen for prescription opioid misuse. There are little data available describing usual pain care practices for patients who have aberrant UDT results. The goal of this research was to evaluate the clinical care for patients prescribed chronic opioid therapy (COT) and have an aberrant UDT., Design: Retrospective cohort study., Setting: VA Medical Center in the Pacific Northwest., Participants: Patients with chronic pain who were prescribed COT and had a UDT result that was positive for an illicit or nonprescribed substance., Main Outcome Measures: This was an exploratory study designed to document usual care practices., Results: Participants' (n = 83) mean age was 49.5 (SD = 9.6) and 81.5 percent were male. The most common substances detected on UDT were marijuana (69 percent) or a nonprescribed opioid (25 percent); 18 percent had a UDT positive for two or more substances. Plans to modify treatment were documented in 69 percent of cases. The most common treatment change after aberrant UDT results was instituting more frequent UDTs, which occurred in 43 percent of cases. Clinicians documented plans to alter their opioid prescribing (eg, terminating opioids, requiring more frequent fills, changing opioid dose, or transitioning to another opioid) in 52 percent of cases, but implemented these changes in only 24 percent., Discussion: Current methods for optimizing treatment after obtaining aberrant UDT results should be enhanced. To improve the utility of UDT to reduce prescription opioid misuse, additional interventions and support for clinicians need to be developed and tested.

Objectives: This manuscript evaluates physician monitoring practices and incidence of cardiac side effects following initiation of methadone for treatment of chronic pain as compared to patients who began treatment for chronic pain with morphine sustained release (SR)., Design: We retrospectively reviewed medical record data on all new initiations of methadone and compared results of physician monitoring practices to patients with new initiations of morphine SR. A standardized chart tool was used to capture clinical data. Data related to health service utilization and clinical diagnoses were obtained from the VA clinical information system., Setting: A single VA Medical Center in the Pacific Northwest., Patients: Chronic pain patients prescribed methadone (n=92) or morphine (n=90) in the calendar year 2008., Results: There was no difference between patients prescribed methadone versus patients prescribed morphine SR in the likelihood of receiving an electrocardiogram (ECG) prior to initiating medication (53 percent versus 54 percent) or in the year after opioid initiation (37 percent versus 40 percent). The two groups also did not differ in rates of developing prolonged rate-corrected (QTc) intervals (>450 ms) (11 percent versus 17 percent). Seventy-two percent of all patients discontinued their long-acting opioid regimens before 90 days due to adverse effects or insufficient pain relief., Conclusion: Despite recommendations for standardized assessment and cardiac risk monitoring, few patients prescribed methadone received an ECG, and this occurred at a rate that did not differ from patients prescribed morphine SR. Patients discontinued both medications at high rates. Further research is needed to evaluate the clinical significance of QTc prolongation in patients treated with methadone.

People with chronic pain and comorbid posttraumatic stress disorder (PTSD) report more severe pain and poorer quality of life than those with chronic pain alone. This study evaluated the extent to which associations between PTSD and chronic pain interference and severity are mediated by pain-related coping strategies and depressive symptoms. Veterans with chronic pain were divided into 2 groups, those with (n=65) and those without (n=136) concurrent PTSD. All participants completed measures of pain severity, interference, emotional functioning, and coping strategies. Those with current PTSD reported significantly greater pain severity and pain interference, had more symptoms of depression, and were more likely to meet diagnostic criteria for a current alcohol or substance use disorder (all p-values <.01). Participants with PTSD reported more use of several coping strategies, including guarding, resting, relaxation, exercise/stretching, and coping self-statements. Illness-focused pain coping (i.e., guarding, resting, and asking for assistance) and depressive symptoms jointly mediated the relationship between PTSD and both pain interference (total indirect effect=0.194, p<.001) and pain severity (total indirect effect=0.153, p=.004). Illness-focused pain coping also evidenced specific mediating effects, independent of depression. In summary, specific pain coping strategies and depressive symptoms partially mediated the relationship between PTSD and both pain interference and severity. Future research should examine whether changes in types of coping strategies after targeted treatments predict improvements in pain-related function for chronic pain patients with concurrent PTSD., (Published by Elsevier B.V.)

Background: History of substance use disorder (SUD) is associated with risk for prescription opioid misuse in chronic pain patients; however, little data are available regarding risk for prescription opioid misuse within the subgroup of patients with SUD histories., Methods: Participants with chronic pain, histories of SUD, and current opioid prescriptions were recruited from a single VA Medical Center. Participants (n=80) completed measures of risk for prescription opioid misuse, pain severity, pain-related interference, pain catastrophizing, attitudes about managing pain, emotional functioning, and substance abuse., Results: Participants were divided into three groups based on risk for prescription opioid misuse, as assessed by the Pain Medication Questionnaire (PMQ). Participants in the High-PMQ group reported more pain severity, interference, catastrophizing, depressive symptoms, and lowest self-efficacy for managing pain, relative to the Low-PMQ group; the High-PMQ group and Moderate-PMQ group differed on measures of pain severity, catastrophizing, and psychiatric symptoms (all p-values <0.05). The High-PMQ group had the highest rates of current SUD (32% versus 20% and 0, p=0.009). A regression analysis evaluated factors associated with PMQ scores: pain catastrophizing was the only variable significantly associated with risk for prescription opioid misuse., Conclusions: Among patients with SUD histories, those with higher risk for prescription opioid misuse reported more pain and impairment, symptoms of depression, and were more likely to have current SUD, relative to patients with lower risk for prescription opioid misuse. In adjusted analyses, pain catastrophizing was significantly associated with risk for prescription opioid misuse, but current SUD status was not a significant predictor., (Published by Elsevier Ireland Ltd.)

The role of serotonin in contributing to viral clearance has not been investigated in patients with chronic hepatitis C (HCV). In this prospective study we collected blood samples from 39 patients prior to and during antiviral therapy. Participants completed mood rating scales to monitor psychiatric symptoms, and serum serotonin and tryptophan levels were measured. Significant differences in serotonin levels were found between patients who achieved sustained viral responses (SVRs) and those who did not. Regression analysis revealed that serotonin was the only variable with a statistically significant relationship with antiviral therapy outcomes, even after controlling for other variables known to be associated with outcomes. Baseline serum serotonin levels, in combination with other variables such as degree of liver fibrosis, may be clinically useful for identifying patients in whom HCV can be cleared by antiviral therapy. Additional clinical predictors that could forecast treatment success are needed so that interventions to improve SVR rates, and reduce side effects, can be developed.

Background: Interferon-alpha-(IFN-alpha) induced depression presents a challenge when treating patients with the hepatitis C virus (HCV). Depression occurs in approximately one-third of patients during antiviral therapy and can lead to reduction in treatment dosage or discontinuation of treatment, thus reducing the likelihood of clearing HCV infection. This study examined the efficacy of paroxetine in preventing the development of depression during antiviral therapy., Methods: In a double-blind, placebo-controlled study, 33 patients with HCV were randomly assigned to paroxetine or placebo prior to antiviral therapy. Patients were evaluated for psychiatric symptoms prior, during, and six months after antiviral therapy., Results: The rate of IFN-alpha-induced depression for the entire sample was 33.3%. The prophylactic use of paroxetine did not decrease the likelihood of IFN-alpha-induced depression (35.7% in the paroxetine group vs. 31.6% in the placebo group). However, in 10 of 11 patients who developed IFN-alpha-induced depression and entered the rescue arm of the study, open-label treatment with paroxetine helped reduce symptoms of depression. Group assignment did not appear to impact antiviral therapy completion rates, as a similar proportion of patients from each group completed treatment., Limitations: The antiviral treatment was changed during the trial and aspects of the sample limit the generalizability of the results., Conclusion: A prophylactic approach to interferon-alpha-induced depression may not be indicated in patients with HCV infection.