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Pain catastrophizing is understood as a negative cognitive and emotional response to pain. Researchers, advocates and patients have reported stigmatizing effects of the term in clinical settings and the media. We conducted an international study to investigate patient perspectives on the term pain catastrophizing. Open-ended electronic patient and caregiver proxy surveys were promoted internationally by collaborator stakeholders and through social media. 3,521 surveys were received from 47 countries (77.3% from the U.S.). The sample was mainly female (82.1%), with a mean age of 41.62 (SD 12.03) years; 95% reported ongoing pain and pain duration10 years (68.4%). Forty-five percent (n = 1,295) had heard of the term pain catastrophizing; 12% (n = 349) reported being described as a 'pain catastrophizer' by a clinician with associated high levels of feeling blamed, judged, and dismissed. We present qualitative thematic data analytics for responses to open-ended questions, with 32% of responses highlighting the problematic nature of the term. We present the patients' perspective on the term pain catastrophizing, its material effect on clinical experiences, and associations with negative gender stereotypes. Use of patient-centered terminology may be important for favorably shaping the social context of patients' experience of pain and pain care. PERSPECTIVE: Our international patient survey found that 45% had heard of the term pain catastrophizing, about one-third spontaneously rated the term as problematic, and 12% reported the term was applied to them with most stating this was a negative experience. Clinician education on patient-centered terminology may improve care and reduce stigma.

Objectives Self-affirmation may be a promising treatment strategy for improving clinical outcomes. This study examined the association between self-affirmation and self-reported health status among people with chronic pain. Methods In this cross-sectional study, 768 treatment seeking people (female 67.2%, mean age=50.4 years with SD of 17.1, White/Caucasian 59.9%) completed surveys using a learning healthcare system. Measures included spontaneous self-affirmation (SSA) items, PROMIS® outcome measures, and Pain Catastrophizing Scale (PCS). Multiple regressions were conducted to examine if strength-based SSA, value-based SSA, and their interaction would predict perceived health status and pain coping strategy. Sensitivity analysis was done by performing additional regressions with covariates (age, sex, race/ethnicity, and education). Lastly, exploratory analysis examined if average SSA scores would have a linear relationship with perceived health status. Results The strength x value-based SSA interaction significantly predicted the PROMIS-depression, anxiety, and social isolation T-scores (ps≤0.007), but not anger T-scores (p=0.067). Specifically, greater tendency to use both SSA styles predicted less symptoms of depression, anxiety and social isolation. This interaction remained significant when controlling for the covariates. The two SSA styles and their interaction did not significantly predict pain interference, sleep disturbance, fatigue, average pain rating and PCS scores (ps≥0.054). Exploratory analysis revealed SSA average scores did not have a significant linear relationship with perceived health status. Conclusions The current study showed self-affirmation as being associated with better psychosocial health, but not associated with physical health and pain catastrophizing among patients with chronic pain. Our findings suggested the potential benefit of incorporating strength- and value-based affirmations in pain intervention approaches.

Objective In light of the opioid epidemic, there is a need to identify factors that predict aberrant opioid behaviors including misuse and abuse. Impulsivity has been extensively studied in addiction literature, but not in the context of opioid misuse. Hence, this study aimed to identify which of the impulsivity facets (negative urgency, positive urgency, sensation seeking, lack of perseverance, and lack of premeditation) would predict current aberrant opioid-related behaviors in patients with chronic pain. Methods Data were collected through an online survey from patients with chronic pain who visited a tertiary pain clinic. Patients were predominately female (74%), middle aged (M = 55 years), and White/Caucasian (84%). Upon consent, they completed a series of surveys including UPPS-P Impulsive Behavior Scale, the Current Opioid misuse Measure, Pain Catastrophizing Scale, PROMIS-anxiety, depression, and physical function, and a 0-10 numerical pain rating scale. Ordinal regression analyses were conducted to test study hypotheses. Results Contrary to expectations, only lack of premeditation predicted higher odds of aberrant opioid-related behaviors in the past 30 days, after controlling for known covariates, and explained 26% of variance. Interestingly, lack of premeditation together with pain catastrophizing as a covariate explained 56% of the variance in aberrant opioid-related behaviors. Discussion The current study is the first to identify a potential role of lack of premeditation as an impulsivity facet predicting aberrant opioid-related behaviors among patients with chronic pain.

OBJECTIVES: Observational studies suggest emotion regulation (ER) as a potential treatment target for problematic college drinking. The primary aim of this laboratory study was to determine whether trait ER strategies would moderate the impact of negative affect induction on alcohol craving in college drinkers. METHODS: Participants were randomly assigned to a neutral (n = 74) or a negative affect induction (n = 76) and reported their craving after the affect inductions. RESULTS: Greater use of drinking to cope and less use of cognitive reappraisal predicted greater alcohol craving after the negative affect induction, but not after the neutral condition. In contrast, emotion suppression did not predict alcohol craving in either condition. CONCLUSION: Our results highlight the role of ER tendencies — particularly the benefits of cognitive reappraisal — on alcohol craving when experiencing emotional distress. Therefore, ER strategies may be an important target for college drinkers to prevent and reduce problematic drinking.

Cumulative evidence supports the association between perceived childhood neglect and adulthood psychological and physical health. To date, pathways mediating this association remain largely unknown, though other evidence suggests that negative patterns of appraisal, including injustice perception related to pain, may be shaped by prior adverse social experiences. Consequently, the current study examined perceived injustice about chronic pain as a possible factor connecting childhood neglect and pain-related outcomes, given its relevance for both adaptation to chronic pain and to prior adverse life experiences. Patients (n = 742) visiting a tertiary pain clinic completed a survey administered via the Collaborative Health Outcomes Information Registry. Path modeling analyses were used to examine perceived injustice as a mediator of the relationships between childhood neglect and affective distress and physical function, after controlling for pain intensity and pain catastrophizing. Patients endorsing childhood neglect reported higher levels of perceived injustice and worse affective distress and physical function. Further, inclusion of perceived injustice as a mediator fully accounted for the relationship between neglect and current levels of physical function, and accounted for a significant proportion of the relationship between neglect and current levels of affective distress. These preliminary findings suggest that perceived injustice appears to be a more proximal factor by which prior experiences of neglect may adversely affect adaptation to chronic pain. Given the single-item assessment of childhood neglect and cross-sectional nature of the current findings, further research may focus on replicating these findings in longitudinal studies with validated measures and examining other adverse social experiences (e.g., abuse, social disparities) that may contribute to injustice perception and poor pain-related outcomes.

Behavioral pain treatments may improve postsurgical analgesia and recovery; however, effective and scalable options are not widely available. This study tested a digital perioperative behavioral medicine intervention in orthopedic trauma surgery patients for feasibility and efficacy for reducing pain intensity, pain catastrophizing, and opioid cessation up to 3 months after surgery.A randomized controlled clinical trial was conducted at an orthopedic trauma surgery unit at a major academic hospital to compare a digital behavioral pain management intervention ("My Surgical Success" [MSS]) to a digital general health education (HE) intervention (HE; no pain management skills). The enrolled sample included 133 patients; 84 patients were randomized (MSS, n = 37; HE, n = 47) and completed study procedures. Most patients received their assigned intervention within 3 days of surgery (85%). The sample was predominantly male (61.5%), White (61.9%), and partnered (65.5%), with at least a bachelor's degree (69.0%). Outcomes were collected at 1-3 months after intervention through self-report e-surveys and electronic medical record review; an intention-to-treat analytic framework was applied. Feasibility was dually determined by the proportion of patients engaging in their assigned treatment and an application of an 80% threshold for patient-reported acceptability. We hypothesized that MSS would result in greater reductions in pain intensity and pain catastrophizing after surgery and earlier opioid cessation compared to the digital HE control group.The engagement rate with assigned interventions was 63% and exceeded commonly reported rates for fully automated Internet-based e-health interventions. Feasibility was demonstrated for the MSS engagers, with80% reporting treatment acceptability. Overall, both groups improved in the postsurgical months across all study variables. A significant interaction effect was found for treatment group over time on pain intensity, such that the MSS group evidenced greater absolute reductions in pain intensity after surgery and up to 3 months later (treatment × time fixed effects; F [215] = 5.23; P = .024). No statistically significant between-group differences were observed for time to opioid cessation or for reductions in pain catastrophizing ( F [215] = 0.20; P = .653), although the study sample notably had subclinical baseline pain catastrophizing scores (M = 14.10; 95% confidence interval, 11.70-16.49).Study findings revealed that a fully automated behavioral pain management skills intervention (MSS) may be useful for motivated orthopedic trauma surgery patients and reduce postsurgical pain up to 3 months. MSS was not associated with reduced time to opioid cessation compared to the HE control intervention.

ObjectiveIncreased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors.MethodsA sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health’s Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect–related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders.ResultsPatients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity–worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04).ConclusionsFindings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.

BACKGROUND : Randomized clinical trials (RCT) suggest a multidisciplinary approach to pain rehabilitation is superior to other active treatments in improving pain intensity, function, disability, and pain interference for patients with chronic pain, with small effect size (ds= 0.20–0.36) but its effectiveness remains unknown in real-world practice. OBJECTIVE: The current study examined the effectiveness of a multidisciplinary program to a cognitive and behavioral therapy (pain-CBT) in real-world patients with chronic back pain. METHODS: Twenty-eight patients (M𝑎𝑔𝑒= 57.6, 82.1% Female) completed a multidisciplinary program that included pain psychology and physical therapy. Eighteen patients (M𝑎𝑔𝑒= 58.9, 77.8% Female) completed a CBT-alone program. Using a learning healthcare system, the Pain Catastrophizing Scale, 0–10 Numerical Pain Rating Scale, and Patient-Reported Outcomes Measurement Information System® measures were administered before and after the programs. RESULTS: We found significant improvement in mobility and pain behavior only after a multidisciplinary program (p’s < 0.031; d= 0.69 and 0.55). We also found significant improvement in pain interference, fatigue, depression, anxiety, social role satisfaction, and pain catastrophizing after pain-CBT or multidisciplinary programs (p’s < 0.037; ds = 0.29–0.73). Pain ratings were not significantly changed by either program (p’s > 0.207). CONCLUSIONS: The effect of a multidisciplinary rehabilitation program observed in RCT would be generalizable to real-world practice.

Objective The 22-item PROMIS®-Rx Pain Medication Misuse item bank (Bank-22) imposes a high response burden. This study aimed to characterize the performance of the Bank-22 in a computer adaptive testing (CAT) setting based on varied stopping rules. Methods The 22 items were administered to 288 patients. We performed a CAT simulation using default stopping rules (CATPROMIS). In 5 other simulations, a “best health” response rule was added to decrease response burden. This rule stopped CAT administration when a participant selected “never” to a specified number of initial Bank-22 items (2–6 in this study, designated CATAlt2-Alt6). The Bank-22 and 7-item short form (SF-7) scores were compared to scores based on CATPROMIS, and the 5 CAT variations. Results Bank-22 scores correlated highly with the SF-7 and CATPROMIS, Alt5, Alt6 scores (r=0.87–0.95) and moderately with CATAlt2- Alt4 scores (r=0.63–0.74). In all CAT conditions, the greatest differences with Bank-22 scores were at the lower end of misuse T-scores. The smallest differences with Bank-22 and CATPROMIS scores were observed with CATAlt5 and CATAlt6. Compared to the SF-7, CATAlt5 and CATAlt6 reduced overall response burden by about 42%. Finally, the correlations between PROMIS-Rx Misuse and Anxiety T-scores remained relatively unchanged across the conditions (r=0.31–0.43, Ps < .001). Conclusions Applying a stopping rule based on number of initial “best health” responses reduced response burden for respondents with lower levels of misuse. The tradeoff was less measurement precision for those individuals, which could be an acceptable tradeoff when the chief concern is in discriminating higher levels of misuse.

Patient Reported Outcomes (PROs) are utilized in clinical registries and trials, necessitating development of benchmarks to enhance interpretability. This study aimed to 1) examine if PROMIS measures administered via computer adaptive testing (CAT) were responsive to change, and 2) highlight one method of assessing clinically significant change for youth seen in a tertiary pain clinic. Clinically significant change was achieved if patients had significantly reliable pre-to-post-changes greater than Reliable Change Index (RCI) value and reported decreased symptoms by at least one severity level (e.g., moderate to mild). Participants were 328 youth (8-17 years old) seen in a tertiary pediatric pain management clinic. Small to moderate effect sizes were noted across PROMIS measures (except Peer Relations). Reliable magnitudes of change were estimated for this sample as approximately 6 point reduction for Pain Interference and Mobility, 9 for Fatigue, and 11 for Anxiety and Depression. Depending on the measure, 10 to 24% were categorized as improved, 3 to 6% as deteriorated, and 68 to 81% were either not clinically elevated at baseline or remained unchanged at 3 months. Overall, PROMIS CAT measures demonstrated responsiveness to change over time. Estimation of clinically significant change offers preliminary yet rigorous benchmarks for evaluating treatment response and sets the stage for understanding treatment effects. Perspective This study assesses responsiveness of CAT administered PROMIS measures and highlights one methodological approach of presenting clinical significance for assessing treatment outcomes in pediatric chronic pain. These benchmarks will allow clinicians and researchers to evaluate treatment response utilizing PROs while allowing for a deeper understanding of treatment effects.

Supplemental Digital Content is Available in the Text. The CARE Scale-7 is the first validated instrument to assess self-care difficulty in both sexes and may promote individualized care planning among chronic pain patients., Objectives: Social and interpersonal factors impact the trajectory of chronic pain. We previously developed and validated a 2-factor, 7-item measure to assess interpersonal factors, including relationship guilt and worry and difficulty prioritizing self-care in chronic pain. Here, we confirm the factor structure and examine the sex invariance of the two-factor structure of the CARE Scale-7. Methods: Data were collected as part of routine clinical care at a tertiary pain clinic using the Collaborative Health Outcomes Information Registry. Patient participants (67% women) were predominantly middle-aged (M = 50.9 years, SD = 17.8), married (55.2%), and White/non-Hispanic (55.7%). Data included demographics, pain characteristics, CARE Scale-7, pain catastrophizing, and Patient-Reported Outcomes Measurement Information System psychological and physical function measures. Confirmatory factor analysis was conducted to validate the factor structure of the CARE Scale, and a stepwise approach to measurement invariances by sex examined configural, metric, and scalar invariance. Results: Internal consistency of the scale items ensured suitability for factor analyses. Confirmatory factor analysis findings revealed an overall good fit of the 2-factor model among males and females and that CARE Scale-7 is in fact sex invariant. Finally, CARE Scale-7 showed convergent validity with pain-related outcomes. Discussion: The CARE Scale is the first validated instrument to assess self-care in both sexes among patients with chronic pain. The subscale of difficulty prioritizing self-care emerged as a potentially unique factor that should be integrated in clinical assessment. CARE Scale may facilitate standardized measurement in research and clinical contexts, which may inform a comprehensive treatment focus that integrates individualized self-care planning.

ObjectiveThe National Institutes of Health’s Patient-Reported Outcomes Measurement Information System (PROMIS)® includes an item bank for measuring misuse of prescription pain medication (PROMIS-Rx Misuse). The bank was developed and its validity evaluated in samples of community-dwelling adults and patients in addiction treatment programs. The goal of the current study was to investigate the validity of the item bank among patients with mixed-etiology chronic pain conditions.MethodA consecutive sample of 288 patients who presented for initial medical evaluations at a tertiary pain clinic completed questionnaires using the open-source Collaborative Health Outcomes Information Registry. Participants were predominantly middle-aged (M [SD] = 51.6 [15.5] years), female (62.2%), and white/non-Hispanic (51.7%). Validity was evaluated by estimating the association between PROMIS-Rx Misuse scores and scores on other measures and testing the ability of scores to distinguish among risk factor subgroups expected to have different levels of prescription pain medicine misuse (known groups analyses).ResultsOverall, score associations with other measures were as expected and scores effectively distinguished among patients with and without relevant risk factors.ConclusionThe study results supported the preliminary validity of PROMIS-Rx Misuse item bank scores for the assessment of prescription opioid misuse in patients visiting an outpatient pain clinic.

Aims Rodent studies propose potential mechanisms linking excessive drinking and pain hypersensitivity (hyperalgesia), such that stress hormones (i.e. epinephrine and cortisol) mediate induction and maintenance of alcohol withdrawal-induced hyperalgesia. The first aim of this study was to examine whether hyperalgesia would occur within 48 h after a drinking episode in healthy young adult binge drinkers. The second was to examine whether stress hormones and negative effect would be associated with binge drinking or alcohol withdrawal-associated hyperalgesia. Methods A cross-sectional experiment was conducted in five groups with naturally occurring drinking (mean age = 19.6, range 18–29 years): abstainers (n = 43, 54% female), moderate drinkers with (n = 50, 50% female) or without recent drinking (i.e. within 48 h, n = 23, 26% female) and binge drinkers with (n = 36, 58% female) or without recent drinking (n = 25, 44% female). All types of drinkers endorsed drinking about 2–3 times a month and 2–3 years of drinking history. Results Muscle pressure pain thresholds were significantly lower in the binge group with recent drinking compared to other groups, but cutaneous mechanical and heat pain thresholds were not significantly different across the five groups. Basal epinephrine levels were significantly higher in binge groups regardless of recent drinking, but cortisol and negative effect were not significantly different across the five groups. Conclusions This is the first study to show that alcohol withdrawal-associated muscle hyperalgesia may occur in healthy episodic binge drinkers with only 2–3 years of drinking history, and epinephrine may play a role in binge drinking-associated hyperalgesia.

OBJECTIVES: Social and interpersonal factors may impact chronic pain self-care and self-management; however, no integrated measure exists to assess the interplay of these factors. We developed and tested a measure designed to assess salient interpersonal factors, including relationship guilt and worry, and difficulty prioritizing self-care in chronic pain. METHODS: We tested self-report items broadly relevant to locus of care, limit-setting capacity, and worry/guilt about relationships in 3 discrete chronic pain samples (total N=1,452): (1) online sample of chronic pain clinic patients (N=729; 21 candidate CARE items, sociodemographics, and measures of psychological and physical functioning). Analytic results supported a final 7-item CARE Scale which was next tested in (2) an anonymous online sample of 578 adults with chronic pain. (3) Finally, preliminary validation of the CARE Scale was performed in a tertiary pain clinic sample (N = 145). RESULTS: Exploratory factor analysis revealed a 7-item, 2-factor solution (difficulty prioritizing self-care and guilt/worry) that accounted for a combined total of 58% of the variance. CARE Scale-7 had modest convergent validity with pain intensity, pain-related interference, and emotional distress. Extreme difficulty with both factors was reported by about one-third of the total sample, suggesting that relationship factors significantly impact pain management and self-care. DISCUSSION: Social factors are gaining attention for their influence on the trajectory of chronic pain. The CARE Scale is a brief, integrated measure that may be used to reveal specific interpersonal and personal impediments to self-care, and identify important therapeutic targets to optimize self-management behaviors.

Objective Multiple and specific types of childhood adverse events are risk factors for chronic pain conditions. Although both can covary, no study has evaluated one aspect while controlling for the other. Therefore, the current study examined whether more adverse events would be a risk factor for common chronic pain conditions and pain medication use in young adults after controlling for different adversity types such as physical, emotional, and sexual traumatic events or vice versa. Methods This cross-sectional study recruited 3,073 undergraduates (72% female, mean age = 18.8 years, SD = 1.4 years) who completed the survey for current health status and early life traumatic events. Results More adverse events were associated with a 1.2-1.3-fold increase in the odds of any chronic pain, chronic back pain, headache, and dysmenorrhea with adjusting for adversity types, but they were not associated with the risk of comorbid pain conditions and use of pain medications. In contrast, specific adversity types were unrelated to chronic pain conditions when controlling for the number of adverse events. Conclusions Cumulative childhood adverse events may be a more relevant risk factor for chronic pain conditions than the experience of a specific type of adverse event. Clinicians and researchers need to evaluate cumulative childhood adversity when assessing its link to chronic pain.

Individuals with greater borderline personality features may be vulnerable to chronic pain. Because pain is an unpleasant sensory and emotional experience, affect dysregulation as the core personality feature may be linked to pain hypersensitivity. Studies have found that greater borderline features are associated with increased intensity in clinical and experimental pain, and that depression mediates this increase. The current study further examined the association between borderline features and heat pain sensitivity, the contribution of affect dysregulation and the other borderline personality factors (identity problems, negative relationships, self-harming/impulsivity) to the association, and depression as a mediator. Additionally, we examined whether blunted sympathetic responses mediate the association between borderline features and temporal summation of second pain (TSSP). Thermal pain threshold, thermal TSSP and aftersensations pain were assessed in 79 healthy individuals with varying degrees of borderline features. TSSP is a proxy measure for central sensitization and refers to the gradual increase in pain to repeated nociceptive stimuli. A regression analysis showed that greater borderline features predicted greater TSSP (β = .22, p = .050, R2 = .05). Borderline features were unrelated to pain threshold and TSSP decay. A stepwise regression showed greater TSSP in individuals with greater borderline features was accounted for by the negative relationships factor rather than the affect dysregulation factor. The results of mediational analyses showed depression and blunted sympathetic skin conductance responses mediated the positive association between TSSP and borderline features.

Location-based geosocial networking smartphone applications (GSN apps) have become a popular way to meet romantic and casual sex partners. Although first used primarily by men who have sex with men (MSM), GSN apps are now commonly used in the population at large, particularly among emerging adults. Although, these apps may potentially contribute to increases in STI/HIV incidence, previous research linking GSN app use to sexual risk behavior has been mixed, with some suggesting app users report greater sexual risk behavior and others suggesting less. The present paper details findings of two studies with independent samples of emerging adults. The first, a pilot study, examined GSN app use among young MSM (n = 64) to identify possible within-group factors relating dating app use to sexual risk behavior. Results indicated that the time app users spent talking to each other through the app before meeting in person (time before meeting) was related to engagement in sexual risk behavior. Those who talked less before meeting in person engaged in more sexual risk behaviors than those who spent more time talking before meeting in person. The second study sought to expand upon this finding in a more representative sample of GSN app users (n = 129) and compared sexual risk behavior and impulsivity to non-users (n = 88). There were no differences in sexual risk behavior between GSN app users and non-users. However, when examining app users by time before meeting, those with a shorter time before meeting were more impulsive and more likely to report sexual risk behavior. These findings highlight the importance of understanding GSN app use in the spread of STIs/HIV among emerging adults.

Background Emotional approach coping (EAC) is a potentially adaptive emotion-focused coping style that involves understanding or processing one's emotions and expressing them appropriately. Although EAC has been studied in various populations, little is known about this construct among people with chronic pain, including potential mediators such as negative affect, which might link EAC to pain-related variables, and moderators of these relationships. Methods Participants (N = 670; 76% women; 30% older adults-age 60 or over) with chronic pain completed online the Emotional Approach Coping Scale and measures of pain severity, pain interference and negative affect. Analyses correlated EAC to pain severity and interference and tested whether gender and age group (older adults versus young/middle-age adults) moderated the mediated relationships of EAC with pain-related variables through negative affect. Results Findings reveal that higher EAC was associated with lower pain intensity through lower negative affect in the young/middle-age portion of the sample, but not older adults. Also, higher EAC was associated with lower pain interference through lower negative affect among women in the sample, but not men. The associations of EAC to pain intensity and interference are small in magnitude, however, and should be considered preliminary. Conclusion EAC is associated with lower pain intensity in young/middle-age adults and lower pain interference in women, and lower negative affect mediates these relationships. These results suggest the potential value of assessing and bolstering emotional approach coping processes in some people with chronic pain.

Objectives Post-traumatic stress disorder (PTSD) commonly co-occurs with chronic pain. Although PTSD symptoms are associated with negative health outcomes in patients with chronic pain, PTSD is typically under-detected and under-treated in outpatient pain settings. There is a need for rapid, brief screening tools to identify those at greatest risk for severe PTSD symptoms. To achieve that goal, our aim was to use item response theory (IRT) to identify the most informative PTSD symptoms characterizing severe PTSD in patients with chronic pain. Methods Fifty-six patients (71% female, 61% White) with mixed etiology chronic pain completed the PTSD Checklist-Civilian Version (PCL-C) as part of their appointment with a pain psychologist at a tertiary outpatient pain clinic. We used an IRT approach to evaluate each item's discriminant (a) and severity (b) parameters. Results Findings revealed that "feeling upset at reminders" (a = 3.67, b = 2.44) and "avoid thinking or talking about it" (a = 3.61, b = 2.17) as being highly discriminant for severe PTSD. Conclusions We identified 2 candidate items for a brief PTSD screener as they were associated with severe PTSD symptoms. These 2 items may provide clinical utility in outpatient pain treatment settings to identify those suffering from severe PTSD, enabling physicians to refer them to trauma-specific evaluation or therapy. Future research is needed to further validate and confirm these candidate PTSD items in a larger clinic sample. Lay summary The current study used the IRT approach to identify candidate items for a brief screener for severe PTSD. We examined 17 items of the PCL-C, and identified 2 items that were highly discriminant for severe PTSD. The 2 items were "feeling upset at reminders" and "avoid thinking or talking about it." These 2 items may provide clinical utility, since they may enable physicians to screen and make a referral for further assessment or treatment for PTSD.

Importance Chronic low back pain (CLBP), the most prevalent chronic pain condition, imparts substantial disability and discomfort. Cognitive behavioral therapy (CBT) reduces the effect of CLBP, but access is limited. Objective To determine whether a single class in evidence-based pain management skills (empowered relief) is noninferior to 8-session CBT and superior to health education at 3 months after treatment for improving pain catastrophizing, pain intensity, pain interference, and other secondary outcomes. Design, Setting, and Participants This 3-arm randomized clinical trial collected data from May 24, 2017, to March 3, 2020. Participants included individuals in the community with self-reported CLBP for 6 months or more and an average pain intensity of at least 4 (range, 0-10, with 10 indicating worst pain imaginable). Data were analyzed using intention-to-treat and per-protocol approaches. Interventions Participants were randomized to (1) empowered relief, (2) health education (matched to empowered relief for duration and format), or (3) 8-session CBT. Self-reported data were collected at baseline, before treatment, and at posttreatment months 1, 2, and 3. Main Outcomes and Measures Group differences in Pain Catastrophizing Scale scores and secondary outcomes at month 3 after treatment. Pain intensity and pain interference were priority secondary outcomes. Results A total of 263 participants were included in the analysis (131 women [49.8%], 130 men [49.4%], and 2 other [0.8%]; mean [SD] age, 47.9 [13.8] years) and were randomized into 3 groups: empowered relief (n = 87), CBT (n = 88), and health education (n = 88). Empowered relief was noninferior to CBT for pain catastrophizing scores at 3 months (difference from CBT, 1.39 [97.5% CI, -∞ to 4.24]). Empowered relief and CBT were superior to health education for pain catastrophizing scores (empowered relief difference from health education, -5.90 [95% CI, -8.78 to -3.01; P

Objective Childhood adversity is a vulnerability factor for chronic pain. However, the underlying pain mechanisms influenced by childhood adversity remain unknown. The aim of the current study was to evaluate the impact of childhood adversity on dynamic pain sensitivity in young adults. Methods After screening for childhood adverse events and health status, healthy individuals reporting low (below median; n = 75) or high levels of adversity (the top 5%; n = 51) were invited for pain testing. Both groups underwent heat pain threshold and temporal summation of second pain (TSSP) testing after reporting depressive symptoms. TSSP refers to a progressive increase in pain intensity with repetition of identical noxious stimuli and is attributed to central sensitization. Changes in pain ratings over time (slope) were computed for TSSP sensitization and decay of subsequent aftersensations. Results The high-adversity group showed greater TSSP sensitization (meanslope, 0.75; SDpositive slope, 1.78), and a trend toward a slower decay (meanslope, -11.9; SD, 3.4), whereas the low-adversity group showed minimal sensitization (meanslope, 0.07; SDnear-zero slope, 1.77), F(1,123) = 5.84, p = .017 and faster decay (meanslope, -13.1; SD, 3.4), F(1,123) = 3.79, p = .054. This group difference remained significant even after adjusting for adult depressive symptoms (p = .033). No group difference was found in heat pain threshold (p = .85). Lastly, the high-adversity group showed blunted cardiac and skin conductance responses. Conclusions These findings suggest that enhancement of central sensitization may provide a mechanism underlying the pain hypersensitivity and chronicity linked to childhood adversity.

Objective This study investigated whether childhood adversity would be associated with hypersensitivity on two measures of central pain facilitation: area of secondary allodynia and temporal summation of second pain (TSSP), and whether pain facilitation would be explained by adult posttraumatic stress disorder (PTSD) symptoms. Method Participants endorsing high (n = 31) and low (n = 31) childhood adversity underwent capsaicin-induced secondary allodynia and TSSP testing. The tests were conducted a week apart with test order counterbalanced. Results Larger areas of secondary allodynia were observed in the high adversity group compared with the low adversity group (F(1,60) = 4.81, p = .032). This group difference was largely (62%) explained by greater PTSD symptoms in the high adversity group. Although no overall difference was found in TSSP slopes (p = .886), this was attributed to an order by group interaction (F(1,58) = 5.07, p = .028) and low power. Subsequent analyses revealed positive TSSP slopes in the high adversity group when TSSP testing was performed first, and this order effect was associated with blunted sympathetic responses to TSSP on the first visit. The two facilitation measures were unrelated (p = .631). Conclusions Larger areas of secondary allodynia were observed in the high adversity group, which was explained largely by PTSD symptoms. This suggests that adversity-related changes in pain facilitation may underlie the association between childhood adversity and generalized widespread pain. Although TSSP was affected by previous testing, adversity-related pain facilitation was observed when TSSP testing occurred first. Finally, adversity was not associated with a consistent pattern of hypersensitivity across the two measures of central pain facilitation.

The current study examined pain and neurogenic inflammation responses to topical capsaicin during the interictal period (between headache) and their relationship with plasma oxytocin in individuals with migraine.Individuals with migraine can experience generalized (extracephalic) hyperalgesia, which can persist even between headache attacks. Elevated levels of plasma and cerebrospinal fluid oxytocin have been observed during migraine attacks, oxytocin levels being positively associated with the intensity of migraine symptoms. However, whether oxytocin plays a role in the mechanisms of generalized pain sensitization and neurogenic inflammation during the interictal period has not been studied yet. Understanding migraineurs' interictal pain phenotype and endogenous oxytocin might help identify individuals who would benefit from intranasal oxytocin treatment.Thirty-two subjects with migraine and 26 healthy controls underwent pain testing. The current study compared capsaicin-induced pain, central sensitization (areas of secondary mechanical allodynia and hyperalgesia), and neurogenic inflammation (capsaicin-induced flare) responses on the nondominant volar forearm between migraineurs and healthy controls. Additionally, we studied plasma oxytocin levels and their relationship to migraine symptoms, experimental pain and affect.The results indicated a significant group effect (P = .019): Migraineurs reported greater capsaicin-induced pain unpleasantness (M = 1.2, SD = 1.4) on a 0-10 scale and showed larger areas of flare (LnM = 2.8, SD = 0.4) than healthy controls (M = 0.5, SD = 0.8; LnM = 2.6, SD = 0.4; ps .032). In a subgroup analysis, enhanced capsaicin-induced pain unpleasantness was found in the chronic (P = .007), but not the episodic (Ps .200), migraineurs. The oxytocin levels were elevated in migraineurs and accounted for 18% of the group difference in capsaicin-induced pain unpleasantness. Within migraineurs, interictal oxytocin levels were negatively associated with psychological distress (Ps .030). However, during the interictal period, pain sensitivity in extracephalic regions and plasma oxytocin levels were unrelated to migraine symptom parameters (Ps .074). Lastly, the results found no group difference in areas of secondary mechanical allodynia and hyperalgesia (Ps.298).The current study revealed that individuals with migraine exhibit enhanced extracephalic capsaicin-induced pain unpleasantness and flare responses during interictal periods. In addition, migraineurs, especially those with chronic migraine, had slightly elevated interictal oxytocin levels compared to controls, which was associated with their affective component of experimental pain. Therefore, treatment targeting affective pain during the interictal period may help to reduce generalized pain in migraine. Furthermore, endogenous increases in oxytocin may be a compensatory mechanism that may help decrease affective distress in migraineurs. The therapeutic effects of intranasal oxytocin may benefit migraineurs by reducing their affective distress.

The widespread misuse and abuse of prescribed opioid pain relievers amongst chronic pain patients is a central contributor to the opioid epidemic. The current study aimed to identify potential risk factors and treatment targets that may reduce and prevent opioid misuse. The NIH's Patient Reported Outcomes Measurement Information System (PROMIS)-Abuse of Prescription Medication item bank (Rx-Abuse) was validated in both community and clinical samples to assess self-reported severity of medication abuse. The Rx-Abuse item bank was included in Stanford University's Collaborative Health Outcomes Information Registry (CHOIR), an open-source healthcare system to monitor chronic pain patients’ health status as part of clinical care, quality improvement, and research. We compared physical, mental and social health status factors of patients taking and not taking opioid medications and examined which of these factors best associated with prescription abuse. We hypothesized that negative affect would predict more opioid misuse in view of its crucial role in managing chronic pain and substance use. A sample of 1193 (age=50.72±14.97; 64.04% female, mean pain=5.24±2.47) patients with a mix of chronic pain disorders presenting for medical evaluations at a tertiary pain clinic completed the CHOIR survey. Participants endorsing current use of prescribed opioid medication (n=692, 58.01%) also completed the Rx-Abuse assessment. Results indicated that patients currently taking opioid medications reported significantly greater symptomatology and impairment across almost all PROMIS and pain severity measures compared to non-opioid taking patients. A data-driven stepwise hierarchical regression analysis (n=589) confirmed that a composite score of negative affect comprising anxiety, anger and depression, was the most significant predictor (β=0.36, p

This study investigated the diagnostic and clinical utility of the parent-rated Screen for Child Anxiety Related Emotional Disorders (SCARED-P) for detecting youth anxiety disorders. Youth ages 6 to 12 years, 11 months were recruited from 9 outpatient mental health clinics (N = 707). Consensus diagnoses were based on semistructured interviews (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with youth and caregivers; 31% were diagnosed with at least one anxiety disorder. Caregivers completed the SCARED-P to describe youth anxiety levels. SCARED-P scores were not considered during the consensus diagnoses. Areas under the curve (AUCs) from receiver operating characteristic analyses and diagnostic likelihood ratios (DLRs) quantified performance of the SCARED-P total score and subscale scores (generalized anxiety disorder and separation anxiety disorder). SCARED-P total scores had variable efficiency (AUCs = .69-.88), and Generalized Anxiety Disorder and Separation Anxiety subscale scores were excellent (AUCs = .86-.89) for identifying specific anxiety disorders. Optimal subscale cutoff scores were computed to help rule in (DLRs = 2.7-5.4) or rule out (DLRs1.0) anxiety disorders among youth. Results suggest that the Generalized Anxiety Disorder and Separation Anxiety SCARED-P subscales accurately identify their respective matched diagnoses. DLRs may aid clinicians in screening for youth anxiety disorders and improve accuracy of diagnosis.

Objective. Stressful life events are associated with increased pain severity and chronicity. However, the mechanism underlying this association remains disputed. Recent animal studies suggest that chronic stress increases pain sensitivity and persistence by enhancing peripheral and central sensitization mechanisms. To test this hypothesis in humans, the authors examined whether sensitization is enhanced in healthy women reporting more stressful life events using the topical capsaicin test. Methods. Thirty-two healthy young women reporting varying levels of stressful life events were invited for laboratory pain testing. Capsaicin was applied topically to the volar forearm. Measurements included capsaicin-induced spontaneous pain and area of secondary hyperalgesia in the region surrounding capsaicin application. Physiological (heart rate and skin conductance) and self-reported affective (emotional valence and arousal) states were also measured. Results. The results indicate that more stressful life events predicted a linear increase in the area of secondary hyperalgesia (β = 0.40, p = 0.023, R 2 = 0.16), but not the intensity of secondary hyperalgesia nor capsaicin-induced spontaneous pain. These findings suggest that life stressors may be associated with heightened central sensitization manifested by an increased area of secondary hyperalgesia. Additionally, life stressors were related to greater sympathetic cardiac, but not to affective responses to capsaicin-induced pain. Conclusion. This study shows that women reporting more stressful life events show a larger area of secondary mechanical hyperalgesia. These preliminary findings suggest that life stressors may facilitate pain processing by enhancing central sensitization.

The purpose of the study was to compare diagnostic accuracy of five posttraumatic stress disorder (PTSD) measures in a large outpatient sample of youths 11-18 years of age. Index tests included a parent report (a rationally derived scale from the Child Behavioral Checklist), a teacher report (the Teacher Report Form), and three youth reports-a PTSD scale from the Youth Self Report (YSR), Child PTSD Symptom Scale, and Child and Adolescent Trauma Survey. Interviews with the youth and caregiver using Schedule for Affective Disorders and Schizophrenia for School-Age Children generated criterion diagnoses of PTSD. Diagnoses were blind to scores on the index tests. Based on consensus diagnoses (N = 458), 10% of youth had PTSD. Area under the curve (AUC) from receiver operating characteristic analyses and multilevel likelihood ratios evaluated test performance. All youth reports (AUCs .67-.73) outperformed the teacher report (AUCs .42-.48) at identifying PTSD. The YSR outperformed the caregiver reports (AUCs .57-.58). Combining tests did not improve prediction of PTSD. The YSR predicted PTSD even after controlling for a self-reported traumatic event, but checklist ratings of traumatic events had no incremental value after controlling for YSR scores. When a youth endorsed few symptoms, the likelihood of the youth having PTSD was low. Very high scores on the YSR were associated with a moderate increase in the likelihood of PTSD diagnosis. The YSR appeared to be a useful diagnostic aid for youth PTSD and could facilitate differential diagnosis of youth PTSD in outpatient settings.

OBJECTIVE This study investigated the effects of written emotional disclosure on a model of chronic pain in healthy women with and without trauma history. METHOD Participants were prescreened for their trauma history (N = 78) and randomized to a disclosure or a control writing condition. Pain testing occurred either 1 day or 1 month after disclosure. Capsaicin was applied to the forearm to evoke spontaneous burning pain at the application site and mechanical secondary hyperalgesia in the surrounding untreated skin. RESULTS As hypothesized, the effect of disclosure on the area and intensity of secondary hyperalgesia depended on trauma history and time of testing (F(1,69) ≥ 7.37, p = .008). Disclosure increased secondary hyperalgesia in participants with trauma history compared with those without trauma when testing occurred 1 day after writing (F(1,69) ≥ 5.27, p ≤ .025), whereas the opposite pattern was observed 1 month later (F(1,69) ≥ 4.88, p ≤ .031). Of the participants with trauma history in the disclosure condition, secondary hyperalgesia was reduced at 1 month compared with 1 day after writing (p = .001). Moreover, greater use of positive emotional words predicted reduced secondary hyperalgesia at 1 month (β = -0.71, p = .022). In contrast, disclosure had no effect on spontaneous pain. CONCLUSIONS Disclosure modulates secondary hyperalgesia observed in women with trauma history, producing a short-term enhancement and a long-term reduction. This suggests that disclosure has a long-term protective effect that reduces sensitization of pain, which may explain the therapeutic effects of disclosure in patients with chronic pain.