Chronic pain is common among people living with HIV (PLWH) who engage in heavy drinking and both pain and heavy drinking influence quality of life, functioning, and HIV-outcomes. The purpose of this study was to: (1) test the acceptability and feasibility of a cognitive behavioral telehealth intervention (INTV) to reduce pain and heavy drinking among PLWH, (2) evaluate methods to implement a randomized controlled efficacy trial, and (3) provide preliminary information about its potential value. Forty-eight PLWH with chronic pain who engaged in heavy drinking were recruited from HIV-health clinics and social media. Following baseline assessment, participants were randomized to INTV or treatment-as-usual control (CTL). Participants completed outcome assessments at 3- and 6-months post-baseline. Results indicated that participants experienced high levels of satisfaction and showed strong intervention engagement. Over 85

BACKGROUND:Unhealthy alcohol use represents a significant risk for morbidity and mortality among people living with HIV (PLWH), in part through its impact on HIV management. Chronic pain, a common comorbidity, exacerbates suboptimal engagement in the HIV care continuum and has reciprocal detrimental effects on alcohol outcomes. There are no integrated, accessible approaches that address these comorbid conditions among PLWH to date. This paper describes a research study protocol of an integrated telehealth intervention to reduce unhealthy drinking and chronic pain among PLWH (Motivational and Cognitive-Behavioral Management for Alcohol and Pain [INTV]). METHODS:Two-hundred and fifty PLWH with unhealthy drinking and chronic pain will be recruited nationally via online advertisement. Informed consent and baseline assessments occur remotely, followed by 15 days of ecological momentary assessment to assess alcohol use, chronic pain, functioning, and mechanisms of behavior change. Next, participants will be randomized to either the INTV or Control (CTL) condition. Individuals in both conditions will meet with a health counselor through videoconferencing following randomization, and those in the INTV condition will receive 6 additional sessions. At 3- and 6-months post-baseline, participants will complete outcome assessments. It is hypothesized that the INTV condition will result in reduced unhealthy alcohol use and pain ratings compared to the CTL condition. CONCLUSION:This protocol paper describes a randomized controlled trial which tests the efficacy of a novel, integrated telehealth approach to reduce unhealthy alcohol use and chronic pain for PLWH, two common comorbid conditions that influence the HIV treatment cascade. CLINICALTRIALS: GOV IDENTIFIER:NCT05503173.

BackgroundHazardous drinking has been associated with chronic pain in community and medical samples. The purpose of this study was to develop a novel, integrated mobile health intervention that improves pain management and reduces hazardous drinking that may be implemented in primary care settings.MethodsForty-eight participants with moderate or greater chronic pain and hazardous drinking were recruited from primary care clinics and through social media sites. Following baseline assessment, participants were randomized to a counselor-supported smartphone app intervention (INTV) or a counselor delivered treatment-as-usual control condition (CTL).ResultsResults supported the feasibility and acceptability of the smartphone app intervention. Participants found it easy to use, reported high levels of satisfaction, and showed high levels of engagement with the app. Between-group effect size estimates at follow-up showed small effects for the intervention on pain ratings. However, using clinically meaningful change thresholds of 30% and 50% improvement in pain scores, 38% and 25% respectively of those in the INTV condition showed reductions compared to 20% and 12.5% respectively in the CTL condition. Effect size estimates did not indicate intervention superiority on alcohol outcomes as participants in both conditions showed considerable reductions in drinking over the course of the study.ConclusionsResults supported the view that a mobile health intervention delivered via smartphone with electronic coaching is a feasible and acceptable method of addressing chronic pain among those who engage in hazardous drinking. Future work should test the efficacy of this approach in a fully powered trial.

Military combat can result in the need for comprehensive care related to both physical and psychological trauma, most commonly chronic pain and post-traumatic stress disorder (PTSD). These conditions tend to co-occur and result in high levels of distress and interference in everyday life. Thus, it is imperative to develop effective, time-efficient treatments for these conditions before they become chronic and resistant to change. We developed and pilot-tested the Pain and Trauma Intensive Outpatient Treatment (PATRIOT) Program, a brief, intensive (3 weeks, six sessions) integrated chronic pain and PTSD treatment. An overview and session-by-session outline of the PATRIOT Program is provided, followed by results from the first pilot evaluation of the PATRIOT Program’s feasibility, acceptability, and preliminary efficacy in a sample of eight participating Veterans with comorbid chronic pain and PTSD. There were no treatment dropouts. At post-treatment, there were significant reductions in PTSD symptoms based on the Clinician-Administered Assessment of PTSD (CAPS). Pain and catastrophic thinking also decreased from pre- to post-treatment. With continued investigations and support, the PATRIOT Program may offer a brief, cost-effective, and more easily accessible treatment option for individuals who could benefit from learning skills to manage pain and PTSD more effectively.

PURPOSE:Low-dose naltrexone (LDN) is commonly used to control pain and other symptoms, especially in patients with autoimmune diseases, but with limited evidence. This study tests the efficacy of LDN in reducing chronic pain in patients with osteoarthritis (OA) and inflammatory arthritis (IA), where existing approaches often fail to adequately control pain. METHODS:In this randomized, double-blind, placebo-controlled, crossover clinical trial, each patient received 4.5 mg LDN for 8 weeks and placebo for 8 weeks. Outcome measures were patient reported, using validated questionnaires. The primary outcome was differences in pain interference during the LDN and placebo periods, using the Brief Pain Inventory (scale, 0-70). Secondary outcomes included changes in mean pain severity, fatigue, depression, and multiple domains of health-related quality of life. The painDETECT questionnaire classified pain as nociceptive, neuropathic, or mixed. Data were analyzed using mixed-effects models. FINDINGS:Seventeen patients with OA and 6 with IA completed the pilot study. Most patients described their pain as nociceptive (n = 9) or mixed (n = 8) rather than neuropathic (n = 3). There was no difference in change in pain interference after treatment with LDN (mean [SD], -23 [19.4]) versus placebo (mean [SD], -22 [19.2]; P = 0.90). No significant differences were seen in pain severity, fatigue, depression, or health-related quality of life. IMPLICATIONS:In this small pilot study, findings do not support LDN being efficacious in reducing nociceptive pain due to arthritis. Too few patients were enrolled to rule out modest benefit or to assess inflammatory or neuropathic pain. CLINICALTRIALS:gov identifier: NCT03008590.

Abstract Chronic pain is influenced by the interaction of biological and psychological processes. In addition, emotional disorders are highly prevalent in chronic pain patients and are thought to share common neurobiological pathways with pain. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) may have the potential to address these shared vulnerabilities and produce long-lasting change. This chapter outlines the evidence for adapting the UP to treat patients with chronic pain and comorbid emotional disorders. Although no studies to date have empirically tested the use of the UP for chronic pain, accumulating research evidence provides support for the UP’s individual treatment components. The chapter also describe a case study demonstrating how to deliver the UP with a chronic pain patient. Limitations of the UP for chronic pain and recommended adaptations are described.

BACKGROUND:Pain is a common and often debilitating symptom in persons with multiple sclerosis (MS). Besides interfering with daily functioning, pain in MS is associated with higher levels of depression and anxiety. Although cognitive behavioral therapy (CBT) for pain has been found to be an effective treatment in other populations, there has been a dearth of research in persons with MS.METHODS:Persons with MS with at least moderate pain severity (N = 20) were randomly assigned to one of two groups: CBT plus standard care or MS-related education plus standard care, each of which met for 12 sessions. Changes in pain severity, pain interference, and depressive symptom severity from baseline to 15-week follow-up were assessed using a 2×2 factorial design. Participants also rated their satisfaction with their treatment and accomplishment of personally meaningful behavioral goals.RESULTS:Both treatment groups rated their treatment satisfaction as very high and their behavioral goals as largely met, although only the CBT plus standard care group's mean goal accomplishment ratings represented significant improvement. Although there were no significant differences between groups after treatment on the three primary outcomes, there was an overall improvement over time for pain severity, pain interference, and depressive symptom severity.CONCLUSIONS:Cognitive behavioral therapy or education-based programs may be helpful adjunctive treatments for persons with MS experiencing pain.

OBJECTIVEPosttraumatic stress disorder (PTSD) and fibromyalgia syndrome (FMS) are two commonly co-occurring conditions among women veterans. Each contributes to functional impairment that is compounded in those with both diagnoses. This emphasizes the need for integrated evidence-based treatments aimed at reducing symptoms of both. This pilot study examined feasibility and preliminary effectiveness of an integrated treatment combining elements of cognitive behavioral therapy for chronic pain and cognitive processing therapy in a small sample of women veterans with PTSD and FMS.METHODParticipants completed 12 sessions of an integrated treatment for PTSD and FMS, and symptoms of PTSD, FMS, and depression were evaluated using the PTSD Checklist-Civilian (PCL-C), Fibromyalgia Impact Questionnaire-Revised (FIQR), and Patient Health Questionnaire-9 (PHQ-9), respectively. Data were analyzed by identification of trends in scores due to small sample size.RESULTSFive of 11 eligible veterans completed all 12 sessions of the treatment. The mean pretreatment score on the FIQR was 82.81, and the mean pretreatment PCL-C score was 72.5. At posttreatment, the mean FIQR score decreased to 68.9 and the PCL-C score decreased to 60.8. The average reduction on PHQ-9 scores was 11 points, and all participants reported high satisfaction with treatment.CONCLUSIONSPreliminary results suggest that integrated treatment of PTSD and FMS symptoms may help to improve chronic pain, PTSD, and depressive symptoms in women veterans with PTSD, in light of several identified limitations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Chronic pain and heavy drinking are common comorbid conditions among people living with HIV/AIDS (PLWHA). An integrated approach to address these co-occurring conditions in a manner that facilitates treatment utilization would represent an important advance in HIV-care. This study examined the acceptability and feasibility of a tailored, videoconferencing intervention to reduce chronic pain and heavy drinking among PLWHA. Participants in HIV-care (n = 8) completed baseline assessments and an in-person intervention session followed by 6 videoconferencing sessions. Acceptability and feasibility were assessed with patient satisfaction ratings and interview responses 8 weeks following baseline along with videoconferencing use during the intervention period. Treatment satisfaction and comprehensibility ratings were high and supported by interview responses indicating the value of the intervention content, treatment alliance, and format. All participants successfully enabled videoconferencing on their own smartphones and completed a median number of 4.5 (out of 6) video-sessions. Changes in heavy drinking and pain provided additional support for the potential utility of this approach. Results suggest that this videoconferencing intervention is an acceptable and feasible method of addressing chronic pain and heavy drinking among PLWHA. Findings provide the basis for future work to examine the efficacy of this approach in a Stage 1b trial.

As the need for appropriate assessment and treatment of veterans with chronic pain continues to grow, it is important to ensure that the instruments we use to complete these assessments, such as the Coping Strategies Questionnaire-Revised (CSQ-R), are validated on this population. The purpose of the present study was to confirm the factor structure of the CSQ-R in veterans. Secondary analyses examined associations between various pain coping strategies and measures of mood and health functioning. Participants consisted of 281 veterans who were referred to and evaluated by a Psychology Pain Management Program in a northeastern Department of Veterans Affairs health care facility. Participants completed self-report questionnaires including the CSQ-R and measures of disability, mood, and health. Confirmatory factor analysis (CFA) compared the 6-factor solution to models identified in other studies. The CFA indicated that the 6-factor solution of the CSQ-R proposed by Riley and Robinson (1997) is valid and has the best fit of all models tested when used with veterans. The results of the secondary correlational analyses were consistent with previous research indicating that coping self-statements and ignoring pain are adaptive pain coping strategies. Our findings support the psychometric soundness of the 6-factor CSQ-R when used with veterans with chronic pain. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objectives: In order to maximize the therapeutic benefits of cognitive-behavioral therapy (CBT) for chronic pain, individuals need to be motivated to adopt a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was developed to measure patients’ readiness to adopt a self-management approach to chronic pain. The present study examined whether pretreatment and posttreatment PSOCQ change scores among chronic low back pain patients could predict 6- and 12-month follow-up outcomes, and the stability of posttreatment PSOCQ scores during follow-up. Methods: Participants were recruited from a VA primary care clinic. Data from 60 participants assigned to either regular CBT or a modified CBT (ie, PRIME CBT) condition were analyzed in the present study. Self-report measures including PSOCQ, pain severity, disability, and depressive symptom severity were administered at pretreatment, 10 weeks posttreatment, 6-month and follow-up assessments. Results: Multiple regression analyses showed that pretreatment and posttreatment changes in the Action/Maintenance scores significantly predicted pain severity at 6 months, and changes in the Precontemplation scores significantly predicted disability at 6 months. None of the PSOCQ change scores significantly predicted depressive symptom severity. Posttreatment Precontemplation and Action/Maintenance scores were quite stable, even at 12-month follow-up. Conclusions: Changes in patients’ attitudes toward adopting a pain self-management approach may serve as one of the therapeutic mechanisms and predict long-term function. This study also revealed that changed attitudes toward chronic pain self-management remain quite stable over time. Adoption of beliefs consistent with chronic pain self-management during treatment may promote sustained benefits.

PURPOSE OF REVIEW:Post-traumatic stress disorder (PTSD) and chronic pain often co-occur. Understanding the shared mechanisms, signs to identify PTSD, and treatment options is integral in allowing providers to better serve their patients.RECENT FINDINGS:Individuals with comorbid PTSD and chronic pain report greater PTSD symptoms, pain, anxiety, depression, disability, and opioid use than those with only one of these conditions. There are several empirically supported therapies for chronic pain, and for PTSD, as well as pilot data for a treatment of comorbid pain and PTSD. The purpose of this paper is to review and synthesize current literature investigating the interaction between chronic pain and PTSD, and provide treatment recommendations for providers treating patients with chronic pain and PTSD.

OBJECTIVES In order to maximize the therapeutic benefits of cognitive-behavioral therapy (CBT) for chronic pain, individuals need to be motivated to adopt a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was developed to measure patients' readiness to adopt a self-management approach to chronic pain. The present study examined whether pretreatment and posttreatment PSOCQ change scores among chronic low back pain patients could predict 6- and 12-month follow-up outcomes, and the stability of posttreatment PSOCQ scores during follow-up. METHODS Participants were recruited from a VA primary care clinic. Data from 60 participants assigned to either regular CBT or a modified CBT (ie, PRIME CBT) condition were analyzed in the present study. Self-report measures including PSOCQ, pain severity, disability, and depressive symptom severity were administered at pretreatment, 10 weeks posttreatment, 6-month and follow-up assessments. RESULTS Multiple regression analyses showed that pretreatment and posttreatment changes in the Action/Maintenance scores significantly predicted pain severity at 6 months, and changes in the Precontemplation scores significantly predicted disability at 6 months. None of the PSOCQ change scores significantly predicted depressive symptom severity. Posttreatment Precontemplation and Action/Maintenance scores were quite stable, even at 12-month follow-up. CONCLUSIONS Changes in patients' attitudes toward adopting a pain self-management approach may serve as one of the therapeutic mechanisms and predict long-term function. This study also revealed that changed attitudes toward chronic pain self-management remain quite stable over time. Adoption of beliefs consistent with chronic pain self-management during treatment may promote sustained benefits.

Chronic pain and heavy drinking commonly co-occur and can influence the course of HIV. There have been no interventions designed to address both of these conditions among people living with HIV (PLWH), and none that have used telehealth methods. The purpose of this study was to better understand pain symptoms, patterns of alcohol use, treatment experiences, and technology use among PLWH in order to tailor a telehealth intervention that addresses these conditions. Ten participants with moderate or greater chronic pain and heavy drinking were recruited from a cohort of patients engaged in HIV-care (Boston Alcohol Research Collaborative on HIV/AIDS Cohort) and from an integrated HIV/primary care clinic at a large urban hospital. One-on-one interviews were conducted with participants to understand experiences and treatment of HIV, chronic pain, and alcohol use. Participants’ perceptions of the influence of alcohol on HIV and chronic pain were explored as was motivation to change drinking. Technology use and treatment preferences were examined in the final section of the interview. Interviews were recorded, transcribed and uploaded into NVivo® v12 software for analysis. A codebook was developed based on interviews followed by thematic analysis in which specific meanings were assigned to codes. Interviews were supplemented with Likert-response items to evaluate components of the proposed intervention. A number of themes were identified that had implications for intervention tailoring including: resilience in coping with HIV; autonomy in health care decision-making; coping with pain, stress, and emotion; understanding treatment rationale; depression and social withdrawal; motives to drink and refrain from drinking; technology use and capacity; and preference for intervention structure and style. Ratings of intervention components indicated that participants viewed each of the proposed intervention content areas as “helpful” to “very helpful”. Videoconferencing was viewed as an acceptable modality for intervention delivery. Results helped specify treatment targets and provided information about how to enhance intervention delivery. The interviews supported the view that videoconferencing is an acceptable telehealth method of addressing chronic pain and heavy drinking among PLWH.

Individuals in pain display a wide range of behaviors that serve to communicate their experience with others. Though these behaviors may develop as adaptive ways to cope with pain (e.g. guarding to prevent increased pain), they often persist beyond their utility. Indeed, studies have shown that pain behaviors are related to increased disability and are often the target of psychosocial interventions for chronic pain. However, pain behavior is not a unidimensional construct. Rather, it is comprised of various types of behavior (e.g. guarding, verbal expressions, and facial expressions). It remains unclear which types of pain behaviors are related to increased disability. The goal of this study was to examine which types of pain behavior are predictive of pain-related disability. As part of their participation in a psychology pain management program at a northeastern Department of Veteran's Affairs healthcare facility, 167 veterans completed a battery of self-report questionnaires including the McGill Pain Inventory (MPI), Pain Behavior Check List (PBCL) and the Roland and Morris Disability Scale. A stepwise multiple regression controlling for pain severity (MPI) and age was conducted to evaluate which pain behaviors predicted disability. Results indicated that, after controlling for age and pain severity, Distorted Ambulation (b=.50, t(166)=7.59, p<.01) and Affective Distress(b=.16, t(166)=2.32, p=.02) significantly predicted disability scores and accounted for an additional 27.5% and 2.0% of the variance in disability, respectively. Seeking Help and Facial/Audible Expressions, however, did not account for additional variance in and thus were excluded from the model. These findings suggest that different types of pain behavior are more or less predictive of pain-related disability. Psychosocial interventions aimed at reducing or extinguishing pain behaviors may choose to target those behaviors more closely related to disability (e.g., limping, guarding, grimacing) in order to best improve overall physical function.

This pilot study assessed the effects of cardiopulmonary exercise testing and cardiorespiratory fitness on plasma neuropeptide Y (NPY), allopregnanolone and pregnanolone (ALLO), cortisol, and dehydroepiandrosterone (DHEA), and their association with pain sensitivity. Medication-free trauma-exposed participants were either healthy (n = 7) or experiencing comorbid chronic pain/posttraumatic stress disorder (PTSD) (n = 5). Peak oxygen consumption (VO2) during exercise testing was used to characterize cardiorespiratory fitness. Peak VO2 correlated with baseline and peak NPY levels (r = 0.66, p < 0.05 and r = 0.69, p < 0.05, respectively), as well as exercise-induced changes in ALLO (r = 0.89, p < 0.001) and peak ALLO levels (r = 0.71, p < 0.01). NPY levels at the peak of exercise correlated with pain threshold 30 min after exercise (r = 0.65, p < 0.05), while exercise-induced increases in ALLO correlated with pain tolerance 30 min after exercise (r = 0.64, p < 0.05). In contrast, exercise-induced changes in cortisol and DHEA levels were inversely correlated with pain tolerance after exercise (r = -0.69, p < 0.05 and r = -0.58, p < 0.05, respectively). These data suggest that cardiorespiratory fitness is associated with higher plasma NPY levels and increased ALLO responses to exercise, which in turn relate to pain sensitivity. Future work will examine whether progressive exercise training increases cardiorespiratory fitness in association with increases in NPY and ALLO and reductions in pain sensitivity in chronic pain patients with PTSD.

Accumulating evidence supports the concurrent association between parent distress and behavior and child functioning in the context of chronic pain, with existing longitudinal studies limited to a pediatric surgical context that identify parent catastrophizing as influential. In this study, we examined how parent factors assessed at a multidisciplinary pediatric pain clinic evaluation affect child psychological and functional outcomes over time. A cohort of 195 patients with chronic pain (ages 8-17 years) and their parents who presented for a multidisciplinary evaluation completed measures at baseline and at 4-month follow-up. Patients completed measures of pain catastrophizing, pain-related fear and avoidance, generalized anxiety, depressive symptoms, and functional disability. Parents completed measures of pain catastrophizing, pain-related fear and avoidance, and protective responses to child pain. Parent-reported child school functioning was also collected. Parent distress and behavior was concurrently associated with child distress and functioning at evaluation. After controlling for baseline child functioning, baseline parent avoidance and protective behavior emerged as significant predictors of child functioning at 4-month follow-up. Parent distress and behavior influence child distress and functioning over time and these findings identify key parent domains to target in the context of a child's pain treatment.Perspective: Parent behavior, specifically avoidance and protective responses, influence child distress and functioning over time. Child pain treatment interventions should include influential parent factors to ensure successful outcomes. (C) 2016 by the American Pain Society

Chronic pain and posttraumatic stress disorder (PTSD) are disabling conditions that affect biological, psychological, and social domains of functioning. Clinical research demonstrates that patients who are affected by chronic pain and PTSD in combination experience greater pain, affective distress, and disability than patients with either condition alone. Additional research is needed to delineate the interrelated pathophysiology of chronic pain and PTSD, with the goal of facilitating more effective therapies to treat both conditions more effectively; current treatment strategies for chronic pain associated with PTSD have limited efficacy and place a heavy burden on patients, who must visit various specialists to manage these conditions separately. This article focuses on neurobiological factors that may contribute to the coprevalence and synergistic interactions of chronic pain and PTSD. First, we outline how circuits that mediate emotional distress and physiological threat, including pain, converge. Secondly, we discuss specific neurobiological mediators and modulators of these circuits that may contribute to chronic pain and PTSD symptoms. For example, neuropeptide Y, and the neuroactive steroids allopregnanolone and pregnanolone (together termed ALLO) have antistress and antinociceptive properties. Reduced levels of neuropeptide Y and ALLO have been implicated in the pathophysiology of both chronic pain and PTSD. The potential contribution of opioid and cannabinoid system factors also will be discussed. Finally, we address potential novel methods to restore the normal function of these systems. Such novel perspectives regarding disease and disease management are vital to the pursuit of relief for the many individuals who struggle with these disabling conditions.