Pain can have a devastating effect on the quality of life of patients in palliative medicine. Thus far, majority of research has been centered on opioid-based pain management, with a limited empirical evidence for the use of nonopioid medications in palliative care. However, opioid and nonopioid medications such as nonsteroidal anti-inflammatory drugs have their limitations in the clinical use due to risk of adverse effects, therefore, there is a need for more research to be directed to finding an alternative approach to pain management in comfort care setting. The purpose of this article is to discuss a potential new drug that would adequately alleviate pain and enhance quality of life without significant risks of adverse effects that would limit its use. Naltrexone is a reversible competitive antagonist at μ-opioid and κ-opioid receptors, which when used at standard doses of 50 to 150 mg was initially intended for use in opioid and alcohol use disorders. However, it was discovered that its use in low doses follows alternate pharmacodynamic pathways with various effects. When used in doses of 1 to 5 mg it acts as a glial modulator with a neuroprotective effect via inhibition of microglial activation. It binds to Toll-like receptor 4 and acts as an antagonist, therefore inhibiting the downstream cellular signaling pathways that ultimately lead to pro-inflammatory cytokines, therefore reducing inflammatory response. Its other mode of action involves transient opioid receptor blockade ensuing from low-dose use which upregulates opioid signaling resulting in increased levels of endogenous opioid production, known as opioid rebound effect. Low dose naltrexone has gained popularity as an off-label treatment of several autoimmune diseases including multiple sclerosis and inflammatory bowel disease, as well as chronic pain disorders including fibromyalgia, complex regional pain syndrome, and diabetic neuropathy. Low-dose naltrexone (LDN) may also have utility in improving mood disorders and the potential to enhance the quality of life. This article will therefore propose the potential off-label use of LDN in management of nonmalignant pain in the palliative medicine setting.

OBJECTIVE: To examine how parent factors assessed at a multidisciplinary pain clinic evaluation predict child psychological and functional outcomes at four-month follow-up. After controlling for child baseline functioning, we predicted that parent distress and behavior would significantly predict child pain-related psychological and functional outcomes. METHODS: Among the 321 patients with chronic pain (ages 8-17) and their parents who presented for a multidisciplinary evaluation, 195 completed measures at baseline and at four-month follow-up via REDCap surveys. Patients completed measures of pain catastrophizing, pain-related fear and avoidance, generalized anxiety, depressive symptoms, functional disability, and somatic symptoms. Parents completed measures of pain catastrophizing, pain-related fear and avoidance, protective responses to pain, and child school functioning. Associations between parent and child distress and behavior were examined cross-sectionally at the time of the pain clinic evaluation, and longitudinally (i.e., parent at evaluation and child at follow-up). Lastly, using step-wise hierarchical regression analyses, we controlled for child baseline measures and examined the degree to which parent distress and behaviors predicted child outcomes at four-month follow-up. RESULTS: As hypothesized, parent distress and behavior was correlated with child distress and functioning at the time of evaluation with many of these associations persisting at four-month follow-up. For the regression analyses, after controlling for baseline child depressive symptoms, parent avoidance of activities (b = .24, p < .01) and parent helplessness (b = -.14, p < .10) reported at baseline significantly predicted child depressive symptoms at four-month follow-up. After controlling for baseline child pain catastrophizing, only parent pain-related fear reported at baseline (b = .15, p < .05) emerged as a significant predictor of child pain catastrophizing at four-month follow-up. Lastly after controlling for child school functioning at baseline, parent avoidance of activities (b = -.27, p < .01) and parent protective behavior (b = -.18, p < .05) reported at baseline emerged as significant predictors of child school functioning at four-month follow-up. Parent distress and behavior did not significantly predict child anxiety, pain-related fear, avoidance of activities, somatic symptoms, or functional disability at follow-up, after controlling for baseline functioning. CONCLUSIONS: Across parent factors, parent helplessness, avoidance of activities, pain-related fear, and protective behavior emerged as predictors of child outcomes four months after a multidisciplinary pain clinic evaluation. The results from this study provide initial data regarding the influence of parent emotions and behavior on child function over time. In addition, the results suggest potential targets for pain treatment interventions that go beyond the typical focus on child emotions and behaviors to include influential parent factors.

abstract: Experiencing poor, unrefreshing sleep is a common occurrence for individuals with chronic pain. Sleep disturbance predicts not only greater pain and disability, but also heightened negative affect and reduced positive affect in individuals with chronic pain. Such fluctuations in affect have been linked with more negative and fewer positive social events. For those with chronic pain, negative social relations can exacerbate pain, whereas positive social interactions can help decrease disability. Thus, exploring the sleep‒social functioning process in chronic pain may be one way to improve daily functioning and quality of life. The current study examined positive and negative affect as two parallel mediators of the within-day relations between sleep quality and positive and negative social events in individuals with chronic pain. For 21 days, electronic daily diary reports were collected from 220 individuals with fibromyalgia, a condition characterized by widespread chronic pain. Within-person relations among reports of last night’s sleep quality, afternoon affects and pain, and evening social events were estimated via multilevel structural equation modeling. Findings showed that positive affect mediated both the sleep quality‒positive social events and sleep quality‒negative social events relations. That is, greater than usual sleep disturbance last night predicted afternoon reports of lower than usual positive affect. Low positive affect, in turn, predicted evening reports of fewer than usual positive social events and more than usual negative social events that day, controlling for the effects of afternoon pain. In addition, negative affect mediated the sleep quality‒negative social events link. That is, greater than usual sleep disturbance last night predicted afternoon reports of higher than usual negative affect, which, in turn, predicted evening reports of more than usual negative social events that day, controlling for the effects of afternoon pain. Of the three significant mediated paths, the sleep quality‒positive affect‒positive social events path was the strongest in magnitude. Thus, a night of poor sleep can have an impact on social events the next day in those with chronic pain by dysregulating affect. Further, findings highlight the key role of positive affect in the sleep‒social functioning process and potential socio-affective benefits of sleep interventions in chronic pain. / Dissertation/Thesis / Doctoral Dissertation Psychology 2019

Indiana University-Purdue University Indianapolis (IUPUI) / Hispanic patients receive disparate pain care compared to non-Hispanic White (NHW) patients. Healthcare providers’ ethnic bias may be one reason for pain disparities. This investigation sought to determine the influence of Hispanic ethnicity and ethnic bias on chronic pain management decisions. During an online experiment, 97 medical students made pain assessment and opioid treatment decisions for Hispanic and NHW virtual human patients with chronic pain. They also completed explicit and implicit measures of ethnic bias. Individual-level analyses found that 31% and 36% of participants demonstrated large effect sizes (dz>.50), indicating that patient ethnicity strongly influenced their pain assessment and opioid treatment decisions, respectively. At the group level of analysis, participants’ decisions did not differ significantly between NHW and Hispanic patients (all p values >.05). Participants did not report significant explicit ethnic bias (t[96]=1.88, p=.06; dz=.19; Hispanic mean rating=77.6[SD=18.7]; NHW mean rating=75.2[SD=19.4]) but demonstrated a small-to-moderate implicit preference for NHWs relative to Hispanics (Mean=.31[SD=.41]). Patient ethnicity and implicit ethnic bias had an interactive effect on opioid treatment decisions (F[1, 95]=5.15, p<.05, generalized eta squared =.02); however, the direction of the effect was not as hypothesized. Participants with higher implicit ethnic bias gave significantly higher opioid ratings to Hispanics relative to NHWs (p=.05), whereas participants with lower bias gave marginally higher opioid ratings to NHWs relative to Hispanics (p=.20). Participants with higher vs. lower implicit ethnic bias differed only in their treatment ratings for NHW patients, such that participants with lower bias gave significantly higher opioid ratings to NHW patients than did participants with higher bias (p<.05). This investigation found that approximately one-third of participants made significantly different chronic pain management decisions for Hispanic vs. NHW patients. Participants’ implicit ethnic bias interacted with their opioid treatment decisions but not as expected. Future investigations should measure healthcare providers’ stereotypes about Hispanic patients with pain as this may better predict their pain decisions.

Indiana University-Purdue University Indianapolis (IUPUI) / Chronic pain is a common and costly health condition for children. Previous studies have documented racial and gender disparities in pain care for adults, with women and racial minorities receiving poorer pain assessment and treatment. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient demographic groups. Little is known about racial and gender disparities in children with chronic pain, or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as ‘providers’), Virtual Human (VH) methodology and a pain-related version of the Implicit Association Test (IAT) were used to assess the effects of patient race/gender and provider implicit racial/gender attitudes on providers’ pain assessment and treatment decisions for children with chronic pain. Findings indicated that, in the context of abdominal pain, providers rated Black patients as more distressed (mean difference [MD]=2.33, p<.01, SE=.71, 95% CI=.92, 3.73) and as experiencing more pain-related interference in daily activities (MD=3.14, p<.01, SE=.76, 95% CI=1.63, 4.64) compared to White patients. Providers were also more likely to recommended opioids for Black patients’ pain compared to White patients (MD=2.41, p<.01, SE=.58, 95% CI=1.05, 3.76). Female patients were also perceived to be more distressed by their pain (MD=2.14, p<.01, SE=.79, 95% CI=.58, 3.70), however they there were no differences in treatment recommendations based on patient gender (all ps>.05). The sample reported implicit attitudes that men and Black Americans were more pain-tolerant than their demographic counterparts; however, pain assessment and treatment decisions were not related to these implicit attitudes. This study represents a critical step in research on pain-related disparities in pediatric pain. Future studies are needed to further elucidate specific paths through which the pain experience and consequent treatment differ across racial and gender groups.

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Bakgrund: Fysisk aktivitet främjar hälsa generellt men kan upplevas svårt att få till förpersoner med långvarig smärta. Många utövar fysisk aktivitet trots smärta vilket även kan gesymptomlindring. Enkäten “Självskattade orsaksnätverk för fysisk aktivitet” undersökerunderlättande faktorer för fysisk aktivitet hos personer med långvarig smärta. Enkätensvaliditet är dock inte utforskad ännu. Syfte: För att utveckla enkäten undersöktes ytvaliditet, trovärdighet samt deltagarnas nöjdhet.Dessutom jämfördes resultaten för olika subgrupper hos personer med långvarig smärta. Metod: För att rekrytera deltagare publicerades enkäten i flertalet Facebook-grupper förpersoner med långvarig smärta. Det formulerades nio validitetsfrågor, inspirerat av andrapsykometriskt testade frågeformulär samt eget framtagna för att svara på frågeställningarna.Frågorna utvärderades genom en skattningsskala 0-10 samt ett fritextsvar. Data analyseradesmed deskriptiv statistik samt Mann Whiney U-Test. Resultat: Det inkluderades 48 personer. Genomförbarhet och frågan, om resultatetrepresenterar vardagslivet, skattades 6 till 7 i median. Smärtvariation, hindrande faktorer ochpsykiska faktorer saknades i enkäten enligt deltagarna. Det fanns inga signifikanta skillnaderi skattningen av enkätens egenskaper, varken vid jämförelser hos personer med låg respektivehög genomsnittssmärta eller hos personer som uppfyller respektive inte uppfyllerrekommendationer för fysiska aktivitet. Konklusion: Deltagarnas uppfattning om enkätens tydlighet, genomförbarhet samt relevansvar genomgående ganska bra. Ingen skillnad upptäcktes vid gruppjämförelser. För framtidastudier rekommenderas utvärdering av enkäten hos andra populationer samt vidare test avvaliditet och reliabilitet. / Background: Physical activity promotes health in general, but can be difficult to achieve forpeople with chronic pain. Many people are physically active despite pain. However, physicalactivity can also provide symptom relief. The questionnaire " Självskattade orsaksnätverk förfysisk aktivitet'' investigates facilitating factors for physical activity in people with chronicpain and its validity has not yet been explored. Aim: To develop the questionnaire, face validity, credibility and the participants' satisfactionwere investigated. In addition, the results were compared for different subgroups of peoplewith chronic pain. Method: To recruit participants, the questionnaire was published in several Facebook groupsfor people with chronic pain. Nine validity questions were formulated, including questionsinspired by previous psychometrically tested questionnaires as well as self-developedquestions. These were evaluated using a 0-10 rating scale and a free text answer. Data wereanalysed with descriptive statistics and Mann Whitney U-test. Results: 48 participants were included. Feasibility and the question whether the resultrepresents everyday life was rated 6 till 7 as median. Pain variation, complicating factors andpsychological factors were missing in the questionnaire according to the participants. Therewere no significant differences between people with low or high average pain or those whodid and did not meet recommendations for physical activity. Conclusion: The participants' perception of the questionnaire's clarity, feasibility andrelevance was consistently quite good. No significant differences were found in groupcomparisons. For future studies, evaluation of the questionnaire in other populations andfurther tests of validity and reliability are recommended.

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No description available.

Bakgrund: Långvarig smärta innebär stort lidande för individen. Multimodal rehabilitering har positiv påverkan på långvarig smärta, men det är ej känt vilken multimodal rehabilitering som är effektivast. Ökad kunskap om vilka delar i smärtrehabilitering som gör nytta är viktigt för att kunna optimera vården. Syfte: Syftet med studien var att undersöka kroppsmedvetenhet, tilltro till egen förmåga att vara fysiskt aktiv och självskattad fysisk aktivitetsnivå för personer med långvarig smärta samt att undersöka om dessa variabler förändrades av multimodal smärtrehabilitering. Syftet var även att undersöka korrelationen mellan kroppsmedvetenhet och tilltro till egen förmåga att vara fysiskt aktiv. Metod: Studien hade en deskriptiv, korrelerande kvasiexperimentell design. Patienter med långvarig smärta som vårdades inneliggande för ett 4 veckors långt multimodal smärtrehabiliteringsprogram besvarade direkt före och efter rehabiliteringen frågeformulären Multidimensional Assessment of Interoception Awareness (MAIA) och Exercise Self-efficacy Scale (S-ESES) samt Socialstyrelsens indikatorfrågor för fysisk aktivitet. Resultat: Tjugofem personer deltog i studien. Interventionen ökade vissa dimensioner av kroppsmedvetenhet samt tilltron till egen förmåga att vara fysiskt aktiv. Den självskattade fysiska aktivitetsnivån var låg och ökade ej efter interventionen. Korrelationen mellan MAIA och S-ESES var statistiskt signifikant efter interventionen. Konklusion: Multimodal smärtrehabilitering kan öka kroppsmedvetenhet och tilltro till egen förmåga att vara fysiskt aktiv för personer med långvarig smärta. / Background: Chronic pain implies a big suffering for individuals. Multimodal rehabilitation has a positive impact on chronic pain, but it is unknown which rehabilitation that is the most effective. Increased knowledge of which parts in pain rehabilitation that are effective is important to be able to optimize the care of these individuals. Purpose: The purpose of this study was to investigate interoception, exercise self-efficacy and level of self-assessed physical activity in people suffering from chronic pain and explore if these variables are changed by multimodal pain rehabilitation. The purpose was also to investigate the correlation between interoception and execise self-efficay. Method: The study had a descriptive, correlating experimental within-group design. Patients with chronic pain that were enrolled for inpatient care 4 weeks of multimodal pain rehabilitation answered the questionnaires Multidimensional Assessment of Interoception Awareness (MAIA) and swedish version of Exercise Self-Efficacy Scale (S-ESES) and the Swedish social welfare boards indicator questions of level of physical activity before and after the intervention. Results: Twenty five persons participated in the study. The intervention increased some dimensions of interoception and the exercise self-efficacy. The self-assessed level of physical activity was low and did not increase. The correlation between MAIA and S-ESES was strengthened by the intervention. Conclusion: Multimodal pain rehabilitation can for people with chronic pain increase interoception and exercise self-efficacy.