Steven A. King, MD, MS

Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been 

 both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.

On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”

This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.

These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.

A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.

 the effects of race and ethnicity on the care individuals received for chronic pain.

 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.

Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have 

 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.

Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that 

 patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.

 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.

In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry 

Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of 

, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.

The extent to which race, socioeconomic status, and 

 contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of 

It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.

The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.

is in private practice in Philadelphia, Pennsylvania.

2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. 

Health, Disease, and Illness: Concepts in Medicine

Racial and ethnic disparities in the treatment of chronic pain

4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. 

5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. 

6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. 

Access to care for chronic pain: racial and ethnic differences

7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. 

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. 

Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004

9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. 

10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “

We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

Articles

Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.

Race, Ethnicity, and Chronic Pain

The association between smoking cigarettes and the risk of developing serious and potentially fatal health problems (most notably cardiovascular diseases, pulmonary diseases, and cancer), has long been accepted fact. However, an additional health problem that may also be associated with smoking has often been overlooked: pain.

Two recent papers indicate a strong association between smoking and pain.

 Among the review’s important findings is that those who suffer from chronic pain are substantially more likely to smoke than are those who do not suffer from chronic pain. Although smoking rates continue to decline in the latter group, this does not appear to be occurring in those with pain.

Cigarette smoking has been cited as a risk factor for a wide variety of painful conditions, including back pain, 

, and diabetic peripheral neuropathy. Smoking appears to be associated with both the development and severity of pain.

The second paper specifically studied the most likely locations of pain among individuals who smoke. The 

 examined data from a 2003 to 2004 National Health and Nutrition Examination Survey, which contained data from comprehensive bodily pain questionnaires in addition to questions on other health issues, including tobacco use.

 The study compared 1054 participants who smoked tobacco with 1316 participants who did not.

Those who smoked were found to be more likely to suffer chronic pain. Although the likelihood of pain was increased throughout the body, the study found that spine pain, and especially low back pain, had the strongest association with smoking. The second strongest association was between 

 and smoking. Smoking was also associated with both trunk pain, which included the chest and abdomen, and limb pain. (All statistical associations were drawn from Smuck et al.

This is an interesting and perhaps an unexpected finding. Because of the association between smoking and cardiovascular and cerebrovascular problems, it is easy to see why headaches would be fairly common among individuals who smoke. However, it might be reasonably expected that pain in the trunk and 

 would be more common than pain in the spine. The authors suggest that vascular factors may play a greater role in back pain than is often thought.

, which are becoming more popular, are any less associated with pain than traditional cigarettes remains an unanswered question.

From personal experience treating patients with chronic pain who also smoke, I know that helping them with smoking cessation attempts can be challenging. Although most patients are often well aware of the risks associated with smoking, their pain and its impact on their lives may make it more difficult for them to quit. Their pain may make them feel restricted, and their ability to participate in previously enjoyable activities is limited. Smoking is among the few such activities in which they can still indulge. They may also feel that smoking helps them cope with the pain.

 may have some analgesic effects, but abstaining from smoking may 

 individuals to suffer hyperalgesia, a lowering of the pain threshold.

 Thus, those who smoke may receive temporary relief from tobacco use, and their pain may get worse when they try to stop.

Additionally, depression and anxiety are frequent 

 among those with chronic pain, and their presence can also contribute to the challenge of getting patients to stop smoking.

Ultimately, all evidence points to the importance of convincing patients with chronic pain who also smoke that tobacco is not helpful. Indeed, tobacco may be significantly exacerbating their pain and adding to their misery.

The multitude of challenges can understandably make it difficult to persuade patients with chronic pain to stop using tobacco. Unfortunately, only a 

 of studies have sought to investigate the best treatments for attaining this goal.

Although no single optimal treatment has yet been identified, it appears that while nicotine replacement therapy can be useful, the 

 that are most successful are those that address both the pain and the smoking using psychotherapeutic interventions.

 In this way, treating tobacco use disorder and comorbid chronic pain is similar to the treatment of pain and iatrogenic opioid use disorder, where both problems must be managed together to be successful in treating either.

Of course, this raises the important issue of who treats pain and how it is treated. (For more information on psychiatry and pain, see 

Psychiatric TimesTM November 2020 Special Report

For the most part, the management of chronic pain has been under the aegis of anesthesiology, followed by physiatry and neurology, with psychiatry far down the list. However, the order of these specialties would be reversed if we asked which is best able to aid in smoking cessation. One doubts that there are many anesthesiologists, physiatrists, or neurologists who have expertise in treating patients with nicotine addiction.

As a result, it is difficult for patients with chronic pain who smoke to find health care professionals qualified to treat both issues. If it appears to patients that smoking and pain are 2 separate problems that require different medical specialties to treat them, it may make it more difficult to convince them that the issues are actually entangled. Nonetheless, the evidence suggests that managing 1 issue may aid in managing the other.

This article was posted ahead of print on November 11, 2020, and has since been updated. -Ed

Pain, nicotine, and tobacco smoking: current state of the science

2. Smuck M, Schneider BJ, Ehsanian R, et al. 

Smoking is associated with pain in all body regions, with greatest influence on spinal pain

Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers

Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers

Anxiety and depression in bidirectional relations between pain and smoking: implications for smoking cessation

A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions

7. Hooten WM, LaRowe LR, Ditre JW, et al. 

Effects of a brief pain and smoking cessation intervention in adults with chronic pain: a randomized controlled trial

Two recent papers look at the subtle and surprising links between smoking and pain in different parts of the body. 

Pain and Smoking: Is There an Association?

If you were to poll physicians and ask which specialty usually takes the lead in the management of chronic pain, no doubt an overwhelming majority would say anesthesiology, with a smaller number saying neurology and physiatry. However, probably few would say psychiatry.

It is odd considering the recent revision of the 

 by the International Association for the Study of Pain, the leading worldwide organization for medical professionals involved in the field of pain: “Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors.”

 This appears to be almost precisely with what psychiatry deals.

Sleep Disturbances as a Sequalae of Chronic Pain

Exploring the Relationship Between Posttraumatic Stress and Chronic Pain

We already know that there is a high degree of comorbidity between 

 with chronic pain and, although it is commonly thought that the mental disorders are always secondary to the pain, research has shown that pain is a common presenting symptom of these disorders.

The papers in this Special Report discuss 2 other problems that frequently occur in those with chronic pain: 

 (PTSD). We have known about the relationship between sleep disorders and chronic pain for years; however, the relationship between pain and PTSD is a more recent finding.

As with depressive and anxiety disorders, it is usually thought that if a sleep disorder is present in a person with chronic pain, the sleep issue is always secondary to the pain. However, this oversimplifies the relationship. The interaction between pain and sleep disorders is often a 2-way street, with each exacerbating the other. Both the pain and the sleep disorder need to be addressed.

Of course, the presence of any type of pain can impair sleep. Patients with peripheral diabetic neuropathic pain often report worse pain in their lower extremities during the night when they are trying to sleep. Those who suffer from complex regional pain syndrome in their lower extremities may complain that it is it painful to have sheets touch their skin due to allodynia, in which stimuli that do not usually cause pain do so. Patients with back pain often report problems with sleep due to pain although, curiously, laying down is the position they usually find most comfortable. In fact, if the pain is worse lying down, it is considered a red flag indicative of serious underlying pathology.

Similarly, disruption in normal sleep cycles can cause pain. More than 45 years ago, research found disruptive sleep in some healthy individuals precipitated the symptoms of fibromyalgia and resulted in widespread pain.

There are few studies on the treatment of comorbid pain and sleep disorders. Although both are commonly treated with medications, there is limited research on using pharmacologic agents when both problems are present. Most of the studies have looked at pregabalin in patients with fibromyalgia.

Opioids and benzodiazepines, medications that are frequently prescribed for patients with chronic pain, may actually exacerbate pain because they can cause hyperalgesia (eg, lower pain threshold). These agents can also exacerbate sleep disorders because of their disruption of normal sleep architecture. Sadly, many lay people and medical professionals mistakenly believe that the sedative side effects of these medications mean they will be beneficial for sleep.

There is much less research on chronic pain and PTSD, although there has been a growing interest in the past few years. 

A limiting factor of the data is that much of the research involves veterans. Due to the nature of our recent wars, many veterans suffer from painful injuries caused by explosions. They frequently suffer from traumatic brain injuries (TBI) of varying severity. In fact, both pain and sleep disorders have both been associated with TBI.

 Of course, few civilians who suffer PTSD have similar experiences, so the role TBI may play in the development of comorbid PTSD and chronic pain remains to be determined. 

In addition, research has shown that PTSD may not only be associated with both pain and sleep disorders, but also play a role in acute pain becoming chronic pain.

Since we have yet to identify a markedly efficacious treatment for PTSD, adding chronic pain as a factor further complicates care decisions. Furthermore, although there has been much speculation as to which factors predispose people to develop PTSD and chronic pain separately, we still have no final answer, and we have limited ability to predict who is at increased likelihood for developing both.

For all 3 problems—PTSD, sleep disorders, and chronic pain—psychologically based therapies appear to be among the most promising treatments. They also do not carry the same risks of exacerbating another condition as do medications.

Since psychiatrists often treat PTSD and even sleep, there is little doubt they will see patients with comorbid chronic pain. Unless psychiatrists also are knowledgeable about pain and its management, we will not be able to provide optimal care for our patients.

 is in private practice in Philadelphia.

This article was originally posted on October 21, 2020, and has since been updated. Scroll down for the 

 of the full print issue in which it appeared. -Ed

The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.

2. Moldofsky H, Scarisbrick P, England R, et al. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and health subjects. 

3. Husak AK, Bair MJ. Chronic pain and sleep disturbances: a pragmatic review of their relationships, comorbidities, and treatments. 

4. Lavigne G, Khoury S, Chauny JM, et al. Pain and sleep in post-concussion/mild traumatic brain injury. 

5. Burns JW, Janssen, Lillis T, et al. The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. 

Pain may not often be considered within the realm of psychiatry; however, chronic pain's relationships with sleep disorders and PTSD make it an issue psychiatrists can—and should—address.  

Psychiatry’s Role in the Management of Chronic Pain

Fears about the overprescription of opioid analgesics and the opioid epidemic have resulted in initiatives for physicians to prescribe these medications more judiciously. However, new concerns about patients needlessly suffering untreated or undertreated pain have been raised.

Unfortunately, many lay people and even many health care providers still believe that opioids are the optimal treatment for all forms of pain and that there are no good alternatives. Studies, however, have shown that nonopioid pharmacologic therapies and nonpharmacologic therapies can be as effective and, in many cases, even more effective than opioids.

and meta-analysis of mind-body therapies (MBTs) for patients whose pain is being treated with opioids highlights how useful these modalities can be and the importance of considering them when caring for patients suffering with pain.

The review included 60 studies with 6404 participants. A variety of MBTs were employed, including meditation, hypnosis, relaxation, guide imagery, therapeutic suggestion, and cognitive-behavioral therapy (CBT) depending on the individual studies. The types of pain varied from procedural pain to burn pain to cancer-related pain to chronic pain. The impact of various MBTs on the pain and on the use of opioids were examined.

The findings indicated that meditation, hypnosis, therapeutic suggestion, and CBT were most likely among the MBTs to provide the greatest pain relief with moderate to large improvements. Meditation, hypnosis, and CBT appeared to have the greatest impact on opioid use. The researchers noted that the lack of evidence for the impact of the other MBTs may reflect that there were fewer studies rather than evidence that those MBTs are less likely to have an effect on either the pain or opioid use.

There were also indications that MBTs may provide some benefit for opioid craving and misuse, another reason why their use should be considered for patients on opioids for whom it is believed these medications should be discontinued.

There were differences between the types of pain for which the individual MBTs were studied. Studies that looked at meditation-based therapies primarily focused on chronic noncancer pain while most hypnosis, relaxation, and imagery studies focused on acute, procedural, or cancer-related pain. Whether this provides any guidance as to which type of therapy would be most beneficial for which type of pain is open to question and warrants further study.

It is worth noting that there is a great deal of overlap between many of the MBTs and what might be considered meditation by some could be considered relaxation or even hypnosis by others, so there is often a lack of clear demarcation between them. MBTs are not a magic bullet for the management of pain. They showed a moderate but statistically significant effect on the pain and resulted in a small but statistically significant reduction in opioid use.

In addition to these apparent benefits, MBTs also have one very significant advantage over many of the other treatments for pain: they are essentially free of adverse events. If they are tried and do not provide any benefit, the patient will be no worse off. As with all the other interventions to manage pain, no one can guarantee that MBTs will provide improvement but one can be as close as possible to certainty that they will not have any negative impact on those being treated with them. If the opioid epidemic has taught us anything it is that therapies initiated to help patients can end up having a destructive effect.

There is one very real limitation in the introduction of the MBTs as major treatments for pain. For the most part, in academic centers and hospitals, pain management is primarily considered to be a subspecialty of a single medical specialty—anesthesiology. The only significant exception to this is headache management, which is usually considered to be a part of neurology.

The reality is that few anesthesiologists and neurologists, even those who specialize in pain management, receive much, if any, training in the use of MBTs, nor do most primary care physicians upon whom the management of pain often falls. Thus, most patients with pain are unlikely to come into contact with caregivers who are knowledgeable about MBTs, much less know how to utilize them.

Obviously, the physicians most likely to be trained in the use of MBTs are psychiatrists, and this is one of many reasons why psychiatrists should be more involved in the care for patients with all forms of pain and not just those patients with diagnosable mental disorders.

There is a need for more and better studies on MBTs for pain. However, this can be said of all the other treatments for it. Let us recall that millions of patients have been prescribed opioids for the management of chronic pain although there are virtually no studies demonstrating their efficacy.

1. Garland EL, Brintz CEE, Hanley AW, et al. 

Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis

This article was originally posted on February 20, 2020, and has since been updated. -Ed

For the millions of patients whose pain is being treated with opioids, mind-body interventions are proving to be important considerations to ease suffering.

Mind-Body Therapies for the Management of Pain: How Effective Are They?

Pain is a subjective complaint for which health care professionals largely depend upon self-report by patients. However, we face a special challenge in determining whether pain is present, its severity if it is, and how it is responding to treatment in patients who are cognitively impaired. A recent review of the problem of pain among patients who suffer 

 identifies many of these issues and current recommendations for addressing them.


	Dementia largely occurs among older patients who, while not inevitably experiencing 

, are more likely than younger patients to suffer from many disorders that can cause pain, such as arthritis, cancer, 

, and shingles. Furthermore, some disorders such as 

 and stroke can cause both severe pain and dementia.

Although there has long been a widely propagated myth that as people age they are less likely to experience pain, there is little to support this view. Studies have indicated that as many as 60% to 80% of residents of nursing homes with dementia and over 50% of those in the community with it experience pain.


	The greatest challenge to health care providers is determining whether patients with dementia are experiencing pain. Although patients with mild to moderate dementia may still be able to respond appropriately when asked if they are experiencing pain, those with more severe dementia are probably unable to gauge how much pain they feel, so asking them this question is unlikely to provide much information nor will the commonly used instruments to measure pain such as numerical rating scales.

Thus, it falls on healthcare providers to find alternative methods for identifying pain in those who can’t respond. Determining whether pain is present primarily consists of observing patients. Of greatest use in determining pain in patients who can’t self-report are observations of:
	• Facial responses
	• Vocalization
	• Body movement or body posture

Although there have been multiple instruments (the review identified 19) that have incorporated these observable behaviors, the review considered them to be of poor or unproven reliability, to lack evidence of validity, and none had been tested for sensitivity to change. Thus, it is impossible to determine which one of these scales is be more reliable or valid than the others.

It is worth noting that two observational measures that may be useful for cognitively intact patients-improvement in levels of functioning and reduction in the use of analgesic medications-may be of limited use for patients with dementia whose functioning is already significantly limited by the cognitive impairment and who have little control of what medications they take and when they take them.


	Even when pain is identified in patients with dementia, there are still multiple challenges with regard to treatment. Although analgesic medications may be beneficial, as with all geriatric patients, cormorbid conditions and reduced renal and hepatic function can make it difficult to find the optimal balance between pain relief while avoiding adverse effects. Furthermore, because of limitations in self report patients with dementia and pain may be unable to report those adverse effects when they do occur.


	Recommendations with regard to pharmacologic management of pain among those with dementia follow. It should be noted, however, that these recommendations are based primarily on those for geriatric patients in general as there is little research on their efficacy specifically for patients with dementia:
	1. Acetaminophen is considered the first-line medication although there is limited research beyond 3 months of use (ie, that would be considered being used for chronic pain)
	2. Because of their potential adverse effects the use of 

 should be avoided.
	3. Opioids may be effective in managing pain although it is still an open question whether their benefits outweigh their potential adverse effects. One issue that the review doesn’t address is how much whatever benefits ascribed to opioids for patients with dementia may be due to their sedating effects. Considering that measurement of their efficacy would be primarily based on observation of the patients, sedation might be confused with patients actually experiencing a reduction in pain.
	4. Other medications commonly used for the management of chronic pain, most notably the 

serotonin-norepinephrine reuptake inhibitors

, may be effective but they can have adverse effects that might exacerbate other medical problems. Moreover, similar to the opioids, can have sedative effects that might be mistaken as providing analgesia.
	5. Another issue not mentioned by the review is that of scheduling of medications. For patients in nursing homes, analgesic medications are often prescribed on a prn basis which means that patients with dementia who are unable to report they are having pain are unlikely to receive them. During my career, I have often observed that cognitively impaired patients who are prescribed prn sedative medications for agitation and prn medications for pain will receive the former because agitation is easily observable but won’t receive the latter because pain is not.


	As with the treatment of chronic pain for patients of any age, nonpharmacologic treatments should be considered and may be effective. They have the added benefits of essentially being free of adverse effects so therefore, unlike medications, are unlikely to exacerbate any other medical problems. However, as with pharmacologic therapies, there is limited research on these treatments for this patient cohort and the recommendations are primarily based on those for geriatric patients without dementia.

The most promising nonpharmacologic treatments for these patients are: exercise and/or movement therapies, massage and/or human touch, heat and relaxation therapies, human interaction and presence. Unfortunately, other interventions that may be effective for the management of chronic pain in cognitively intact patients, most notably psychologically based therapies such as cognitive-behavioral therapies, are of markedly limited use for patients with dementia. Other therapies that do not require direct involvement of the patient such as music therapy may be more effective.

Many of the treatments for chronic pain provided by physical and occupational therapists are focused on educating patients by teaching them alternative methods to manage their pain and how to perform tasks using different body mechanics. Obviously, learning new material would be difficult for many patients with dementia.


	Health care providers must rely on observation of patients with dementia to determine if they are experiencing pain. Agitation on the part of these patients may be a reflection of pain. Health care providers should be especially observant for indications of pain among patients who are suffering from disorders that frequently cause pain such as rheumatologic disorders, Parkinson disease, diabetes.

Therapies to manage the pain must always be weigh potential benefits against potential adverse effects. Even though we have known about the difficulties of managing pain in patients with dementia for almost 30 years, we still have made relatively little progress on how best to evaluate their pain and how to treat it.

1. Achterberg W, Lautenbacher S, Husebo B, et al. 

. 2020;5:1-8.
	2. Sengstaken EA, King SA. 

The problems of pain and its detection among nursing home residents

How do you determine whether pain is present and its severity as well as how it responds to treatment in patients who are cognitively impaired? Some answers to these questions.

Pain and Dementia

Slideshows

How can clinicians determine the presence of pain in cognitively impaired patients? And how do you know the medication is working if your patient can’t tell you?

Identifying and Managing Pain in Cognitively Impaired Patients

When physicians prescribe medications, usually the only thing we need to consider is how the drugs will affect the person for whom we are prescribing. We make choices based on the problems for which they are being prescribed and the risks and benefits based on the overall health of the patients. We rarely have to give much consideration to what, if any, impact the medications may have on the medical status of the patients’ families.

However, three new studies highlight how important it is that when physicians prescribe opioids there can be significant and even potentially fatal consequences for the family members of those for whom they are being prescribed.

The first study examined opioid overdoses among family members of people prescribed opioids using data supplied by a commercial insurance provider that provided information on both the patients and family members.

 The findings indicate that although opioid overdoses by the family members of those prescribed opioids were relatively infrequent, they occurred at almost three times the rate as for members of families where no one was prescribed an opioid. Furthermore, the risk of family member overdoses correlated with the dosage of the prescribed opioids. The risk of overdoses was present across all age groups from children to adults and prescription of long acting/extended release opioids and fentanyl patches increased the risk for overdoses.

Certainly one might expect that the availability of opioids in a household would increase the risk of someone other than the patient taking the medications and overdosing. The authors note that the overdoses in children are quite probably accidental while those in adolescents and adults are more likely to be the result of intentionally taking the opioids. However, in either case they acknowledge that health care professionals need to make patients aware that they need to closely monitor the opioids prescribed for them and do their best to prevent family members using them to prevent misuse and potentially life threatening overdoses from occurring.

A second study examined the association between opioids prescribed for parents and the risk of suicide attempts by their children aged 10 to 19 years.

 It, too, found that while suicide attempts by children of parents who were prescribed opioids were relatively rare, they occurred at more than two times the rate for children whose parents were not prescribed opioids.

The authors of the study noted that other factors such histories of substance use disorder, depression, or suicide attempts by the parents or substance use disorder or depression in the children who overdosed did not fully explain the results.

It is also worth noting that the study found that the greatest risk for suicide attempts among children were those where one or both parents were taking a prescribed opioid and a medication for insomnia, either a benzodiazepine or a “Z drug,” although over two times as many were using a benzodiazepine rather than a Z drug.

The researchers did not have an explanation for their results apart from the potential accessibility of medications with which children can attempt suicide in their home but do recommend that when physicians prescribe opioids for parents, they make them aware of the issue and tell them and their children’s health care providers to watch for behaviors that might indicate suicide is being considered.

Finally, a third study looked at opioid and benzodiazepine prescriptions for family members of people whose prescriptions for these medications had been discontinued. The authors identified patients who had filled prescriptions for opioids or benzodiazepines for a 30 day or more supply during the 10 year period between 2007 and 2016. Based on the total number of prescriptions filled during the period, the 10% of patients who filled the most prescriptions were identified as “high-volume users” and those who were in the bottom 50% with regard to the least number filled were “low-volume users.”

When opioid prescriptions were discontinued among high-volume users, 0.2% of family members filled a prescription for an opioid within 2 days and 0.5% within 14 days. The same results were found among high-volume benzodiazepine users with regard to filling a prescription for a benzodiazepine during those periods.

Among low-volume users, only .06% of family members of opioid or benzodiazepines users whose prescriptions were discontinued filled prescriptions for the respective medications within 2 days after discontinuation while 0.4% of family members of low-volume opioid users and 0.3% of benzodiazepine users filled prescriptions for the medications within 14 days after discontinuation.

Although the authors appreciated that the percentages of family members filling prescriptions after discontinuations was quite small, they noted that their findings did raise the concern that family members might have sought prescriptions for opioids or benzodiazepines in order to continue to provide the medications to those whose prescriptions have been discontinued. Another possible explanation is that the patients originally prescribed the medications were either willingly or unwillingly sharing them with family members and when the prescriptions were discontinued, the family members had to seek their own prescriptions in order to continue their use.

Certainly considering the large numbers of patients in the US who have opioid prescriptions for chronic pain and in light of current recommendations that in most of these cases opioids are not appropriate, doctors may feel they are under increased pressure to stop prescribing these medications.

 It is possible that family members subsequent seeking of opioid prescriptions may be a growing problem and something clinicians need to be aware of.

The last two studies highlight concerns physicians should have about the over prescription of benzodiazepines, a topic that has unfortunately taken a backseat to the opioid epidemic. Another new study notes the important role that both benzodiazepines and opioids can play in mortality and ongoing opioid use following noncardiac surgery.

 The study examined the use of opioids and benzodiazepines during the 6 months prior to surgery and found that patients who had been prescribed both medications had a greater 30 day mortality rate and long-term risk of mortality.

Use of opioids, benzodiazepines, or both prior to surgery all were associated with persistent opioid use following it. 43% of preoperative opioid users and 23% of benzodiazepine users were persistent opioid users while 65% of those who used both medications became persistent users of opioids. This was in contrast to only 12% of patients who took neither opioids nor benzodiazepines preoperatively who became persistent opioid users.

Despite the fact that there has been little literature to support the co-prescription of opioids and benzodiazepine and much to recommend against it, it still continues to occur not infrequently. How hard it has been to change the habits of doctors who are doing the coprescribing is demonstrated by another new study.

This study examined the impact of the 2016 Centers for Disease Control and Prevention guideline on the use of opioids for chronic pain, which strongly advised against the co-prescription of these with benzodiazepines. A small but statistically significant decrease in the rates of co-prescription was seen in the two years following the release of the guideline among patients using opioids for extended periods. However, there was no change in what the researchers described as “intensity of co-prescription” measured by the number of days both medications were prescribed concurrently. Curiously, although the study found that there was a reduction in co-prescription for patients with Medicare Advantage no reduction was seen among patients with commercial insurance.

One other interesting finding of the study was that in most cases the same physician prescribed both the opioids and benzodiazepines, which suggests that the problem was not due to lack of coordination between physicians where different ones were prescribing each medication.

None of the findings of any of these studies indicate that physicians should cease to prescribe either opioids or benzodiazepines to patients who truly require them. They do, however, highlight the many issues associated with their use that they may not need to consider when prescribing other medications but do with these two classes.

Dr King is in private practice in Philadelphia.

1. Khan NF, Bateman BT, Landon JE, et al. Association of opioid overdose with opioid prescriptions to family members. 

2. Brent DA, Kur K, Gibbons Rd. Association between parental medical claims for opioid prescriptions and risk of suicide attempt by their children.

3. Barnett ML, Hick TR, Jena AB. Prescription patterns of family members after discontinued opioid or benzodiazepine therapy of users. 

4. Sigurdsson MI, Helgadottir S, Long TE, et al. Association between preoperative opioid and benzodiazepine prescription patterns and mortality after noncardiac surgery.

5. Jeffery M, Hooten WM, Jena AB, et al. Rates of physician coprescribing of opioids and benzodiazepines after the release of the Centers for Disease Control and Prevention Guidelines in 2016. 

Three studies highlight how important it is that when physicians prescribe opioids there can be significant and even potentially fatal consequences for the family members of those for whom they are being prescribed.

When Medications Affect More Than the Patient: Opioids and Family Members

The association between psychiatric disorders, most notably depression and anxiety, and pain is well established. However, mental health professionals, and especially psychiatrists, are still often excluded from treating patients with pain as many of our non-psychiatrist physician colleagues still often believe that there is little for them to do in the care of patients with pain unless it is clearly secondary to a psychiatric disorder. The results of two new studies highlight the importance of addressing mental health problems in patients with pain.

The first study examined the effects of MDD on the outcomes for 260 patients who underwent total knee arthroplasty (TKA).

 Patients completed baseline measures before the surgery that included the Patient Health Questionnaire to evaluate the presence of MDD and others to evaluate pain, level of functioning, and overall quality of life. The testing was repeated at a year following the surgery.

The patients were divided into four groups:

 Those who didn’t suffer from MDD either at baseline or follow-up

 Those who suffered MDD at baseline but not at follow-up

 Those who didn’t suffer MDD at baseline but did at follow-up

 Those who suffered MDD both at baseline and follow-up

At baseline there were no significant differences between the groups with regard to knee function. However, there were significant differences between them at one-year follow-up. Patient with MDD at both baseline and follow-up were found to have significantly less net improvement than patients in the other three groups. Patients who did not have MDD at baseline but did at follow-up also had less improvement than patients who never had MDD or those with MDD that had resolved by follow-up. Patients in the latter two groups had similar levels of improvement.

Visser and colleagues conclude that patients with MDD can still benefit from TKA. They emphasize that the presence of the psychiatric disorder is not a contraindication to the surgery, but it is important to at least begin to treat symptoms before patients undergo TKA. Moreover, it is important to monitor the mental health of patients who have undergone the surgery to determine whether depression is developing and needs to be treated. Also noted was the difficulty in determining whether the psychiatric disorder caused the reduction in benefits from the surgery or if the reason for continuing or new-onset depression was the lower level of improvement following the surgery.

The association between psychiatric disorders, most notably depression and anxiety, and pain is well established. However, mental health professionals, and especially psychiatrists, are still often excluded from treating patients with pain.