Among persons with High Impact Chronic Pain (HICP), we assessed the impact of cognitive behaviorally-based self-management interventions on sustained HICP and on favorable chronic pain outcomes (mild or discontinued chronic pain). Adults with HICP (N=2331) were randomly assigned to: a remote 8-session Health Coach intervention; an 8-session self-completed on-line painTRAINER program; or to Usual Care Plus educational materials. Participants were re-assessed at 3, 6 and 12 months. At 3 months, favorable chronic pain outcomes were somewhat more common among intervention participants than controls, but rates of sustained HICP were similar across all three study groups. At 6 and 12 months, over 40% of intervention participants reported favorable chronic pain outcomes compared to about 30% of Usual Care Plus participants. At 6 and 12 months, 36-42% of intervention participants had sustained HICP, compared to 50-52% of Usual Care Plus participants. At 3 months, relative risk confidence intervals for sustained HICP for the two intervention groups (compared to Usual Care Plus) included 1.0 indicating differences within chance expectation. At 3 months, relative risks of favorable chronic pain outcomes were 1.43 for painTRAINER and 1.39 for Health Coach interventions, compared to Usual Care Plus. At 6 and 12 months, relative risks for sustained HICP were about 0.8 for painTRAINER and Health Coach participants (compared to Usual Care Plus), while relative risks of a favorable chronic pain outcome were 1.24-1.44. Among participants with HICP, self-management interventions modestly reduced rates of sustained HICP and increased favorable chronic pain outcomes.

High-impact chronic pain (HICP), defined as persistent pain that substantially limits daily activities, affects millions of adults and poses a public health challenge. Yet relatively little is known about how HICP manifests in people's daily lives. To address this gap, this study used the comprehensive Ecological Momentary Assessment of pain (cEMAp) to assess pain-related experiences four times per day over 7 days in individuals with chronic low back pain. Based on the classification using the Graded Chronic Pain Scale-Revised, we compared individuals with HICP (n = 66) with those in the next most severe pain category, bothersome chronic pain (n = 41), defined as having similar pain frequency but less frequent interference with daily activities. On each prompt, participants completed 2-hour assessments of pain intensity, interference, catastrophizing, behaviors, coping strategies, and pain characteristics. In line with prior research, both groups reported similar pain intensity levels, but the HICP group reported more frequent interference with physical, mental, and social activities. There were no group differences in daily mood or catastrophizing. Exploratory analyses suggested that many daily experiences were similar across groups, with differences observed in selected pain qualities, coping strategies, and pain behaviors. Additional analyses of response distributions showed some similarity across groups in many experiences. Overall, although individuals with HICP on average experience higher pain interference in daily life, levels of many day-to-day experiences are similar between the two groups. Data obtained with cEMAp complement traditional retrospective assessment by providing a detailed view of chronic pain in everyday life.

ABSTRACT:Remote cognitive behavioral therapy-based interventions for chronic pain (CBT-CP-based) have consistently shown modest pain benefits. With remote treatment availability accelerating and increasingly tight healthcare resources, clinical decision-makers need to understand when working with a therapist may be beneficial vs a largely self-directed online program. Using data from a large-scale 3-arm pragmatic trial, we assessed the role of patient session adherence and potential moderators of intervention pain severity effectiveness for 2 remote CBT-CP-based approaches (online program [painTRAINER] and therapist-delivered telephone or video program [health coach]) and usual medical care. Of the prespecified moderators (demographics [sex, age, race/ethnicity, rurality], social determinants of health, and clinical variables [comorbid depression and/or anxiety, multiple types of chronic pain]), the health coach program was more effective than painTRAINER at 3 months among men and for those who screened positive for depression. No other factors moderated intervention pain severity effects at 3 or 12 months. The health coach program had higher session adherence than painTRAINER (70.4% vs 47.8%). Among intervention completers, pain severity outcomes were similar between CBT-CP-based interventions (Adjusted relative risk [95% confidence interval]: 0.99 [0.85-1.16] and 0.93 [0.82-1.05] at 3 and 12 months, respectively), suggesting that both interventions may be helpful for those with a variety of demographic and clinical characteristics if adherence is achieved. Participant engagement is critical in optimizing outcomes for online programs, but these findings suggest flexibility in the specific modality for delivering remote CBT-CP based on patient preference and healthcare system capacity that may enhance scalability and patient access to care.

OBJECTIVES:Assess cost-effectiveness from the health plan perspective comparing 2 remote cognitive-behavioral-therapy-for-chronic-pain-based interventions (1) pain TRAINER online program and (2) health coach-led telehealth program relative to usual care (UC) and each other. METHODS:Cost-effectiveness analysis includes N = 1725 individuals with high-impact chronic pain from 3 Kaiser Permanente sites of RESOLVE randomized clinical trial. Costs were calculated for all healthcare and pain-related services. Clinical outcomes at 1-year included: quality-adjusted life-years (QALY) and minimal clinically important difference (MCID) in pain severity score (≥30% improvement). RESULTS:Both cognitive-behavioral-therapy-for-chronic-pain-based interventions had significantly higher QALYs (painTRAINER: Adj Diff. = 0.035, P < .001; health coach: Adj Diff. = 0.041, P < .001) and proportion achieving MCID (painTRAINER: Adj Diff. = 14.1%, P < .001; health coach: Adj Diff. = 12.2%, P < .001) than UC. painTRAINER was dominant relative to UC (ie, less expensive and more effective) for both QALYs and MCIDs. The incremental cost-effectiveness ratio for health coach vs UC was $19 009 per QALY and $6267 per MCID. The incremental cost-effectiveness ratio for health coach vs painTRAINER was $244 446 per QALY. Net benefit regression identified painTRAINER as the cost-effective choice across all willingness-to-pay levels. Sensitivity analyses, excluding overly influential outliers, demonstrated consistent results, and that health coach vs painTRAINER was cost-effective above willingness-to-pay of $120 000 per QALY. CONCLUSION:Analyses showed that both the painTRAINER and health coach programs are highly cost-effective relative to UC. Compared with each other, painTRAINER is more cost-effective than the health coach program.

Our study aims to establish PROMIS Pain Interference score (PI) ranges that clinicians and persons living with chronic pain (PLwCP) associate with none, mild, moderate, and high impact chronic pain. We employed the PRO-Bookmarking technique to identify threshold scores that delineate different levels of chronic pain impact. PROMIS-PI score vignettes or "score stories" were developed to communicate the experience of living with different levels of pain interference. A panel of 10 PLwCP and another of 5 pain clinicians identified pairs of score vignettes they judged to represent the threshold between two levels of pain impact (e.g., ''moderate impact" and ''high impact"). We defined threshold scores as the mean score of the adjacent vignettes. We applied the obtained threshold scores to the distribution of PROMIS-PI scores in a sample of persons (n = 31,090) seen in a tertiary pain clinic. In another sample, we compared the Bookmarking and the revised Graded Chronic Pain Scale (GCPS-R) classifications. Patients and clinicians were in consensus on threshold scores for "no impact" to "mild impact" and "moderate impact" to "high impact," scores of 47 and 69, respectively. However, for the threshold for "mild impact to "moderate impact," the value was 65 for patients and 60 for clinicians. The comparison of classifications in the secondary sample revealed differences, especially for the 3rd level, high impact. The GCPS-R classified 58.2% as having high impact chronic pain; the Bookmarking thresholds classified 23.8% as such. The PRO-Bookmarking approach effectively delineated thresholds for classifying levels of chronic pain impact using PROMIS-PI scores. This method incorporates the perspectives of PLwCP and allows for post-hoc application to diverse patient samples.

Importance:Cognitive behavioral therapy (CBT) skills training interventions are recommended first-line nonpharmacologic treatment for chronic pain, yet they are not widely accessible. Objective:To examine effectiveness of remote, scalable CBT-based chronic pain (CBT-CP) treatments (telehealth and self-completed online) for individuals with high-impact chronic pain, compared with usual care. Design, Setting, and Participants:This comparative effectiveness, 3-group, phase 3 randomized clinical trial enrolled 2331 eligible patients with high-impact chronic musculoskeletal pain from 4 geographically diverse health care systems in the US from January 2021 through February 2023. Follow-up concluded in April 2024. Interventions:Participants were randomized 1:1:1 to 1 of 2 remote, 8-session, CBT-based skills training treatments: health coach-led via telephone/videoconferencing (health coach; n = 778) or online self-completed program (painTRAINER; n = 776); or to usual care plus a resource guide (n = 777). Main Outcomes and Measures:The primary outcome was attaining or exceeding the minimal clinically important difference (MCID) in pain severity score (≥30% decrease; score range, 0-10) on the 11-item Brief Pain Inventory-Short Form from baseline to 3 months; 6 and 12 months from baseline were secondary time points. Secondary outcomes at 3, 6, and 12 months included pain intensity, pain-related interference, PROMIS (Patient-Reported Outcomes Measurement Information System) social role and physical functioning; and patient global impression of change. Results:Among 2331 eligible randomized individuals (mean age, 58.8 [SD, 14.3] years; 1712 [74%] women; 1030 [44%] rural/medically underserved), 2210 (94.8%) completed the trial. At 3 months, the adjusted percentage of participants achieving 30% or greater decrease in pain severity score was 32.0 (95% CI, 29.3-35.0) in the health coach group, 26.6 (95% CI, 23.4-30.2) in the painTRAINER group, and 20.8 (95% CI, 18.0-24.0) in the usual care group. Both intervention groups were significantly more likely to attain an MCID in pain severity compared with control (health coach vs usual care: relative risk [RR], 1.54 [95% CI, 1.30-1.82]; painTRAINER vs usual care: RR, 1.28 [95% CI, 1.06-1.55]), and the health coach program was more effective than the online self-completed painTRAINER program (health coach vs painTRAINER: RR, 1.20 [95% CI, 1.03-1.40]). Statistically significant benefits were observed for both intervention groups vs usual care at 6 and 12 months after randomization for the pain severity outcomes and for other secondary pain and functioning outcomes. Conclusions and Relevance:Remote, scalable CBT-CP treatments (delivered either via telehealth or self-completed modules online) resulted in modest improvements in pain and related functional/quality-of-life outcomes compared with usual care among individuals with high-impact chronic pain. These lower-resource CBT-CP treatments could improve availability of evidence-based nonpharmacologic pain treatments within health care systems. Trial Registration:ClinicalTrials.gov Identifier: NCT04523714.

Cognitive behavioral therapy (CBT) skills training interventions are recommended first-line nonpharmacologic treatment for chronic pain, yet they are not widely accessible. To examine effectiveness of remote, scalable CBT-based chronic pain (CBT-CP) treatments (telehealth and self-completed online) for individuals with high-impact chronic pain, compared with usual care. This comparative effectiveness, 3-group, phase 3 randomized clinical trial enrolled 2331 eligible patients with high-impact chronic musculoskeletal pain from 4 geographically diverse health care systems in the US from January 2021 through February 2023. Follow-up concluded in April 2024. Participants were randomized 1:1:1 to 1 of 2 remote, 8-session, CBT-based skills training treatments: health coach–led via telephone/videoconferencing (health coach; n = 778) or online self-completed program (painTRAINER; n = 776); or to usual care plus a resource guide (n = 777). The primary outcome was attaining or exceeding the minimal clinically important difference (MCID) in pain severity score (≥30% decrease; score range, 0-10) on the 11-item Brief Pain Inventory–Short Form from baseline to 3 months; 6 and 12 months from baseline were secondary time points. Secondary outcomes at 3, 6, and 12 months included pain intensity, pain-related interference, PROMIS (Patient-Reported Outcomes Measurement Information System) social role and physical functioning; and patient global impression of change. Among 2331 eligible randomized individuals (mean age, 58.8 [SD, 14.3] years; 1712 [74%] women; 1030 [44%] rural/medically underserved), 2210 (94.8%) completed the trial. At 3 months, the adjusted percentage of participants achieving 30% or greater decrease in pain severity score was 32.0 (95% CI, 29.3-35.0) in the health coach group, 26.6 (95% CI, 23.4-30.2) in the painTRAINER group, and 20.8 (95% CI, 18.0-24.0) in the usual care group. Both intervention groups were significantly more likely to attain an MCID in pain severity compared with control (health coach vs usual care: relative risk [RR], 1.54 [95% CI, 1.30-1.82]; painTRAINER vs usual care: RR, 1.28 [95% CI, 1.06-1.55]), and the health coach program was more effective than the online self-completed painTRAINER program (health coach vs painTRAINER: RR, 1.20 [95% CI, 1.03-1.40]). Statistically significant benefits were observed for both intervention groups vs usual care at 6 and 12 months after randomization for the pain severity outcomes and for other secondary pain and functioning outcomes. Remote, scalable CBT-CP treatments (delivered either via telehealth or self-completed modules online) resulted in modest improvements in pain and related functional/quality-of-life outcomes compared with usual care among individuals with high-impact chronic pain. These lower-resource CBT-CP treatments could improve availability of evidence-based nonpharmacologic pain treatments within health care systems. ClinicalTrials.gov Identifier: NCT04523714

The global burden of Common Mental Disorders (CMDs), including depressive, anxiety and substance use disorders, is substantial. Since increased treatment has not reduced CMD prevalence, prevention is a logical approach to reduce CMD burden. However, CMD prevention as currently delivered has not reduced prevalence. Seven conditions need to be met to maximize the long-term effectiveness of CMD prevention: 1. Target young persons early in life and families. 2. Modify major CMD risk and protective factors. 3. Embed in social institutions and culture. 4. Implement via synergistic programs of proven effectiveness in multiple community settings (pre-school and kindergarten, elementary and secondary schools, child and health care, social welfare/family support). 5. Secure long-term funding with permanent, structural integration into community organizations. 6. Address socio-economic disadvantage and attendant risk factors. 7. Use the power of policy. We consider how these conditions might be achieved in large populations. A dilemma is that compelling evidence regarding the benefits of CMD prevention may be needed to motivate large, long-term investments, but until society has made and sustained these investments for 10 to 20 years, full benefits of CMD prevention may not be realized. Therefore, we propose regional implementation and evaluation focused initially on proximal benefits for child development. Developmental determinants important to educators, parents and other stakeholders should be evaluated initially to establish short-term pay-offs for educational and behavioral outcomes. Long-term CMD prevention initiatives may not only prevent CMDs, but also develop resourceful, resilient, and well-educated children and adults.

In response to the overuse of prescription opioid analgesics, clinical practice guidelines encourage opioid deprescribing (ie, dose reduction or cessation) in patients with chronic noncancer pain. Therefore, this study evaluated and compared international clinical guideline recommendations on opioid deprescribing in patients with chronic noncancer pain. We searched PubMed, EMBASE, PEDro, National Institute for Health and Care Excellence (United Kingdom), and MAGICapp databases from inception to June 4, 2021, with no language or publication restrictions. In addition, we searched the National Guideline Clearinghouse and International Guideline Network databases from inception to December 2018. Two independent reviewers conducted the initial title and abstract screening. After discrepancies were resolved through discussion, 2 independent reviewers conducted the full-text screening of each potentially eligible reference. Four independent reviewers completed the prepiloted, standardized data extraction forms of each included guideline. Extracted information included bibliographical details; strength of recommendations; and the outcomes, such as when and how to deprescribe, managing withdrawal symptoms, additional support, outcome monitoring, and deprescribing with coprescription of sedatives. A narrative synthesis was used to present the results. This study found that clinical practice guidelines agree on when and how to deprescribe opioid analgesics but lack advice on managing a patient's withdrawal symptoms, outcome monitoring, and deprescribing with coprescription of sedatives. Quality assessment of the guidelines suggests that greater discussion on implementation and dissemination is needed.

Background Cognitive behavioral therapy for chronic pain (CBT-CP) is an effective but underused treatment for high-impact chronic pain. Increased access to CBT-CP services for pain is of critical public health importance, particularly for rural and medically underserved populations who have limited access due to these services being concentrated in urban and high income areas. Making CBT-CP widely available and more affordable could reduce barriers to CBT-CP use. Methods As part of the National Institutes of Health Helping to End Addiction Long-term® (NIH HEAL) initiative, we designed and implemented a comparative effectiveness, 3-arm randomized control trial comparing remotely delivered telephonic/video and online CBT-CP-based services to usual care for patients with high-impact chronic pain. The RESOLVE trial is being conducted in 4 large integrated healthcare systems located in Minnesota, Georgia, Oregon, and Washington state and includes demographically diverse populations residing in urban and rural areas. The trial compares (1) an 8-session, one-on-one, professionally delivered telephonic/video CBT-CP program; and (2) a previously developed and tested 8-session online CBT-CP-based program (painTRAINER) to (3) usual care augmented by a written guide for chronic pain management. Participants are followed for 1 year post-allocation and are assessed at baseline, and 3, 6, and 12 months post-allocation. The primary outcome is minimal clinically important difference (MCID; ≥ 30% reduction) in pain severity (composite of pain intensity and pain-related interference) assessed by a modified 11-item version of the Brief Pain Inventory-Short Form at 3 months. Secondary outcomes include pain severity, pain intensity, and pain-related interference scores, quality of life measures, and patient global impression of change at 3, 6, and 12 months. Cost-effectiveness is assessed by incremental cost per additional patient with MCID in primary outcome and by cost per quality-adjusted life year achieved. Outcome assessment is blinded to group assignment. Discussion This large-scale trial provides a unique opportunity to rigorously evaluate and compare the clinical and cost-effectiveness of 2 relatively low-cost and scalable modalities for providing CBT-CP-based treatments to persons with high-impact chronic pain, including those residing in rural and other medically underserved areas with limited access to these services. Trial registration ClinicalTrials.gov NCT04523714. This trial was registered on 24 August 2020.

Objective The Graded Chronic Pain Scale (GCPS) is frequently used in pain research and treatment to classify mild, bothersome, and high impact chronic pain. This study’s objective was to validate the revised version of the GCPS (GCPS-R) in a US Veterans Affairs (VA) healthcare sample to support its use in this high-risk population. Methods Data were collected from Veterans (n = 794) via self-report (GCPS-R and relevant health questionnaires) and electronic health record extraction (demographics and opioid prescriptions). Logistic regression, adjusting for age and gender, was used to test for differences in health indicators by pain grade. Adjusted odds ratio (AOR) with 95% confidence intervals (CIs) were reported with CIs not including an AOR of 1 indicating that the difference exceeded chance. Results In this population, the prevalence of chronic pain (pain present most or every day, prior 3 months) was 49.3%: 7.1% with mild chronic pain (mild pain intensity and lower interference with activities); 23.3% bothersome chronic pain (moderate to severe pain intensity with lower interference); and 21.1% high impact chronic pain (higher interference). Results of this study mirrored findings in the non-VA validation study; differences between bothersome and high impact were consistent for activity limitations and present but not fully consistent for psychological variables. Those with bothersome chronic pain or high impact chronic pain were more likely to receive long-term opioid therapy compared to those with no/mild chronic pain. Conclusions Findings highlight categorical differences captured with the GCPS-R, and convergent validity supports use of the GCPS-R in US Veterans.

Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (ie, chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past 2 decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic noncancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomena. PERSPECTIVE: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against 8 surveillance attributes.

Background Osteoarthritis-related insomnia is the most common form of comorbid insomnia among older Americans. A randomized clinical trial found that six sessions of telephone-delivered cognitive behavioral therapy for insomnia (CBT-I) improved sleep outcomes in this population. Using these data, we evaluated the incremental cost-effectiveness of CBT-I from a healthcare sector perspective. Methods The study was based on 325 community-dwelling older adults with insomnia and osteoarthritis pain enrolled with Kaiser Permanente of Washington State. We measured quality-adjusted life years (QALYs) using the EuroQol 5-dimension scale. Arthritis-specific quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Insomnia-specific quality of life was measured using the Insomnia Severity Index (ISI) and nights without clinical insomnia (i.e., "insomnia-free nights"). Total healthcare costs included intervention and healthcare utilization costs. Results Over the 12 months after randomization, CBT-I improved ISI and WOMAC by -2.6 points (95% CI: -2.9 to -2.4) and -2.6 points (95% CI: -3.4 to -1.8), respectively. The ISI improvement translated into 89 additional insomnia-free nights (95% CI: 79 to 98) over the 12 months. CBT-I did not significantly reduce total healthcare costs (-$1072 [95% CI: -$1968 to $92]). Improvements in condition-specific measures were not reflected in QALYs gained (-0.01 [95% CI: -0.01 to 0.01]); at a willingness-to-pay of $150,000 per QALY, CBT-I resulted in a positive net monetary benefit of $369 with substantial uncertainty (95% CI: -$1737 to $2270). Conclusion CBT-I improved sleep and arthritis function without increasing costs. These findings support the consideration of telephone CBT-I for treating insomnia among older adults with comorbid OA. Our findings also suggest potential limitations of the general quality of life measures in assessing interventions designed to improve sleep and arthritis outcomes.

Purpose of this study was to examine the discriminative properties of the 3-item Pain (P), Enjoyment (E), and General activity (G) (PEG) questionnaire for grading impact of nondental orofacial pain. Two hundred eighty-six consecutive patients with orofacial pain of nondental origin filled out the PEG questionnaire and Graded Chronic Pain Scale (GCPS, version 2), Correlation between the PEG and GCPS scores, internal consistency of the PEG, and differences between groups were examined statistically (level of significance: P <= 0.05). The mean (+/- SD) age of the 213 patients (158 female) who were included in the analysis was 43.1 (+/- 16.7) years. Of the sample, 48.8% (n = 104) had some degree of orofacial pain-related disability (mean overall characteristic pain intensity: 51.2 +/- 23.2, average overall PEG score: 4.3 +/- 2.7, and average PHQ-9 score: 8.2 +/- 6.5). No significant differences were found between the sexes for any score. The number of disability points (GCPS) and overall PEG score showed a strong and positive correlation (Spearman rho = 0.77, P < 0.001). The internal consistency of the PEG questionnaire was high (Cronbach alpha = 0.86). Assuming 3 different levels of orofacial pain-related disability (mild, moderate, and severe), we obtained overall accuracy of 69.01%, with high specificity for mild and severe cases. The 3 PEG groups (mild, moderate, or severe) differed from each other significantly regarding their clinical grading according to the GCPS (Kruskal-Wallis, P < 0.001). Analysis of the receiver operating characteristic curve showed that a single cutoff value of 3.8 points in the PEG score yields adequate validity (sensitivity = 0.91 and specificity = 0.78). The proposed 2 cutoff points (upper = 7 and lower = 4) yield low sensitivity for the upper threshold. The 3-item PEG questionnaire is suitable for grading impact of nondental orofacial pain.

High impact chronic pain (HICP) is a recently proposed concept for treatment stratifying patients with chronic pain and monitoring their progress. The goal is to reduce the impact of chronic pain on the individual, their family, and society. The US National Pain Strategy defined HICP as the chronic pain associated with substantial restrictions on participation in work, social, and self-care activities for at least 6 months. To understand the meaning and characteristics of HICP from the younger (<65 years old) and older adults (≥65 years old) with chronic pain, our study examined patients' perceived pain impact between the two age groups. We also characterize the degree of pain impact, assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI), between adults and older adults with HICP. We recruited patients at a tertiary pain clinic. The survey included open-ended questions about pain impact, the Graded Chronic Pain Scale-Revised to identify patients' meeting criteria for HICP, and the Patient-Reported Outcomes Measurement Information System (PROMIS®) 8-item PI short form (v.8a). A total of 55 younger adults (65.5% women, 72.7% HICP, mean age = 55.0 with SD of 16.2) and 28 older adults (53.6% women, 64.3% HICP, mean age = 72.6 with SD of 5.4) with chronic pain participated in this study. In response to an open-ended question in which participants were asked to list out the areas of major impact pain, those with HICP in the younger group most commonly listed work, social activity, and basic physical activity (e.g., walking and standing); for those in the older group, basic physical activity, instrumental activity of daily living (e.g., housework, grocery shopping), and participating in social or fun activity for older adults with HICP were the most common. A 2 × 2 ANOVA was conducted using age (younger adults vs. older adults) and HICP classification (HICP vs. No HICP). A statistically significant difference was found in the PROMIS-PI T-scores by HICP status (HICP: M = 58.4, SD = 6.3; No HICP: M = 67.8, SD = 6.3), but not by age groups with HICP. In conclusion, perceived pain impacts were qualitatively, but not quantitatively different between younger and older adults with HICP. We discuss limitations and offer recommendations for future research.

OBJECTIVE:The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation.METHODS:Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures.RESULTS:The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures.CONCLUSIONS:Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

INTRODUCTION:Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns.METHODS:This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy.RESULTS:Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity.CONCLUSIONS:Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.

Abstract Introduction We examined the relationship between treatment process measures and 12-month insomnia outcomes from a large clinical trial of telephone-delivered CBT-I. Methods A statewide sample of 327 Kaiser Permanente Washington members aged 60+ with OA, Insomnia Severity Index (ISI) scores of 11+ and Brief Pain Inventory scores of 9+ were randomized to six sessions of individual telephone-delivered cognitive-behavior therapy for insomnia (CBT-I) vs. education-only control. Participants rated their perceptions of treatment credibility and perceived effectiveness on a 7-point Likert scale after session 1 and at 2-month post-test. They also completed the Sleep Hygiene Index (SHI), the 8-item Sleep Problem Acceptance Questionnaire (SPAQ), and the 8-item Chronic Pain Acceptance Questionnaire (CPAQ) at baseline, post-treatment, and 12 months. Insomnia outcome was measured using the ISI. Results Participants (mean age=70.2 years [SD=6.81], 74.6% female, 87.8% with sleep problems for over 1 year) were randomized to the two treatment arms. Regression analyses controlling for baseline age, opioid use, depression, pain, and ISI showed that lower 12-month ISI scores were associated with CBT-I group membership and lower baseline ISI (both p Conclusion People with less severe baseline insomnia levels who received telephone-delivered CBT-I were more likely to have lower 12-month ISI scores. Participant perceptions of treatment credibility and effectiveness, and engagement in life activities despite pain and sleep symptoms were also associated with long-term improvements in insomnia, but willingness to experience sleep and pain symptoms were not contributing factors. Support (if any) This work was supported by PHS grant 5R01AG053221.