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Nikulina V.,Queens College, City University of New York | Guarino H.,National Development and Research Institutes Inc | Acosta M.C.,National Development and Research Institutes Inc | Marsch L.A.,Dartmouth Center for Technology and Behavioral Health | And 6 more authors.
Pain | Year: 2016

During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training. © 2016 International Association for the Study of Pain. Source

Dhingra L.,MJHS Institute for Innovation in Palliative Care | Perlman D.C.,Rothschild | Perlman D.C.,First Avenue Partners | Perlman D.C.,New York University | And 10 more authors.
Drug and Alcohol Dependence | Year: 2015

Background: Little is known about the experience of chronic pain and the occurrence of illicit drug use behaviors in the population enrolled in methadone maintenance treatment (MMT) programs. Methods: This is a secondary analysis of longitudinal data from two MMT samples enrolled in a randomized controlled trial of hepatitis care coordination. Patients completed pain, illicit drug use, and other questionnaires at baseline and 3, 9, and 12 months later. Associations were sought over time between the presence or absence of clinically significant pain (average daily pain ≥4 or mean pain interference ≥4 during the past week) and current illicit drug use (i.e., non-therapeutic opioid, cocaine or amphetamine use identified from self-report or urine drug screening). Results: Of 404 patients providing complete data, within-patient variability in pain and illicit drug use was high across the four assessment periods. While 263 denied pain at baseline, 118 (44.9%) later experienced clinically significant pain during ≥1 follow-up assessments. Of 180 patients (44.6%) without evidence of illicit drug use at baseline, only 109 (27.0%) had similar negative drug use at all follow-up assessments. Across four assessment periods, there was no significant association between pain group status and current illicit drug use. Conclusions: This one-year longitudinal analysis did not identify a significant association between pain and illicit drug use in MMT populations. This finding conflicts with some earlier investigations and underscores the need for additional studies to clarify the complex association between pain and substance use disorders in patients in MMT program settings. © 2015 Elsevier Ireland Ltd. Source

Breuer B.,MJHS Institute for Innovation in Palliative Care | Chang V.T.,Section of Hematology Oncology | Chang V.T.,The New School | Von Roenn J.H.,Northwestern University | And 7 more authors.
Oncologist | Year: 2015

Background. Cancer pain is usually managed by oncologists, occasionallywith input fromspecialists in hospice and palliative medicine (PLM) or pain medicine (PMD). We evaluated the knowledge of cancer painmanagement in these three specialty groups. Methods. Eight vignettes depicting challenging scenarios of patients with poorly controlled pain were developed; each had five or six treatment choices. Respondents indicated choices likely tobesafeandefficacious as“true”andchoices likely tobe unsafe or inefficacious as “false.” Two questionnaires were created, each with four vignettes. Three anonymous mailings targeted geographically representative U.S. samples of 570 oncologists, 266PMD specialists, and 280 PLM specialists, each randomly assigned one version of the questionnaire. Vignette scores were normalized to a 0–100 numeric rating scale (NRS); a score of50 indicates that the number ofcorrect choices equals the number of incorrect choices (consistent with guessing). Results. Overall response ratewas 49% (oncologists, 39%; PMD specialists, 48%; and PLM specialists, 70%). Average vignette score ranges were 53.2–66.5, 45.6–65.6, and 50.8–72.0 for oncologists,PMDspecialists, andPLMspecialists, respectively. Oncologists scored lower than PLM specialists on both questionnaires and lower than PMD specialists on one. On a 0–10 NRS, oncologists rated their ability to manage pain highly (median 7, with an interquartile range [IQR] of 5–8). Lower ratings wereassigned to pain-related training in medical school (median 3, withan IQRof2–5) and residency/fellowship (median 5, with an IQR of 4–7). Oncologists older than 46–47 years rated their training lower than younger oncologists. Conclusion. These data suggest that oncologists and other medical specialists who manage cancer pain have knowledge deficiencies in cancer pain management. These gaps help clarify the need for pain management education. © AlphaMed Press 2015. Source

Dhingra L.,MJHS Institute for Innovation in Palliative Care | Ahmed E.,MJHS Institute for Innovation in Palliative Care | Ahmed E.,St. Johns University | Shin J.,California Pacific Medical Center | And 2 more authors.
Pain Medicine (United States) | Year: 2015

Objective: Cognitive effects and sedation (CES) are prevalent in chronic nonmalignant pain populations receiving long-term opioid therapy and are among the most common reasons patients discontinue opioid use. In this narrative review, we describe the phenomenology, epidemiology, mechanisms, assessment, and management of opioid-related CES. Design: We reviewed the empirical and theoretical literature on CES in opioid-treated populations with chronic pain. Data on long-term opioid therapy (≥3 months in duration) in chronic nonmalignant pain patients were sought. Results: The phenomenology of CES includes: inattention, concentration difficulties, memory deficits, psychomotor dysfunction, perceptual distortions, and executive dysfunction and somnolence, sleep disorders, and lethargy. Deficits may be caused by unrelieved pain or opioid therapy alone, or from a combination of these and other factors. Mechanisms include central nervous system effects, for example, direct toxic effects on neurons resulting in decreased consciousness; direct effects on processing and reaction resulting in cognitive or psychomotor impairment, and inhibitory effects on cholinergic activity. Pharmacological management approaches may include opioid dose reduction and rotation or psychostimulant use. Nonpharmacological approaches may include cognitive-behavioral therapy, mindfulness-based stress reduction, acupuncture, exercise, and yoga. Conclusions: The most prevalent CES include: memory deficits (73-81%), sleep disturbance (35-57%), and fatigue (10%). At its most severe, extreme cognitive dysfunction can result in frank delirium and decreased alertness can result in coma. Emotional distress, sleep disorders, and other comorbidities and treatments can worsen CES, particularly among the elderly. Conclusions about the neuropsychological domains affected by opioids are limited due to the heterogeneity of studies and methodological issues. © 2015 American Academy of Pain Medicine. Source

Woods A.J.,University of Florida | Antal A.,University Hospital Freiburg | Bikson M.,City College of New York | Boggio P.S.,Mackenzie Presbyterian University | And 18 more authors.
Clinical Neurophysiology | Year: 2016

Transcranial electrical stimulation (tES), including transcranial direct and alternating current stimulation (tDCS, tACS) are non-invasive brain stimulation techniques increasingly used for modulation of central nervous system excitability in humans. Here we address methodological issues required for tES application. This review covers technical aspects of tES, as well as applications like exploration of brain physiology, modelling approaches, tES in cognitive neurosciences, and interventional approaches. It aims to help the reader to appropriately design and conduct studies involving these brain stimulation techniques, understand limitations and avoid shortcomings, which might hamper the scientific rigor and potential applications in the clinical domain. © 2015 International Federation of Clinical Neurophysiology. Source

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