Specific Pain Conditions/Pain in Specific Populations

Death by suicide has become a global epidemic. Certain patient populations are at higher risk for suicidal ideation and suicidal behavior including patients that suffer from chronic pain and individuals with substance use disorders. Extant literature reveals that the prevalence of suicidal ideation in patients with chronic pain ranges from 20 to 50%. Another vulnerable population to death by suicide are patients with substance use disorders. Greater than 40 % of individuals presenting for treatment of a substance use disorder endorse a past history of attempting suicide. Patients with pain and co-occurring substance use disorders maybe be at high risk for attempting and ending their lives by suicide, but there is scant literature on the prevalence and unique risk factors for this patient population.

This presentation will discuss the results of a series of studies that evaluated the risk of suicidal ideation and identified risk factors of suicidal ideation in a cohort of patients with chronic pain on opioid therapy with no evidence of opioid use disorder and patients with chronic pain and concomitant opioid use disorders.  These results will be discussed in the context of a theoretical model of suicide and provide practical mitigation strategies.

Individuals with substance use disorders, including opioid-related problems, are at clear elevated risk for suicide. However, little is known about how to reduce suicide risk in these individuals. This presentation will review results of a study that examine the specific components of Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) delivered as part of a large, ongoing clinical trial. 

Methods: Materials will be presented from a multi-site randomized control trial (n=300) evaluating CBT-SP in Veterans with substance-related problems. Following each session and at the end of the treatment, patients provided feedback regarding their session experiences.
Results: Of the patients randomized to the CBT-SP, 69.3 % completed all 8 therapy sessions. Patients who completed fewer than 8 sessions were significantly more likely to be of younger age, have prior combat experience, and report more intense suicidal ideation over the past month (p< 0.01) Overall, patients responded positively to the CBT-SP treatment, with 70.8% reporting improvement in their mood immediately following the session.
Conclusions: Patients assigned to receive CBT-SP reported active engagement and positive experiences, suggesting CBT-SP was well-received among these Veterans. Exploring patient feedback is essential in understanding the effective components of CBT-SP and what helps patients engage in treatment.

In this talk, Dr. Tang will consider the role of mental defeat in explaining variations in distress, and relatedly suicidality, experienced by people with chronic pain. Defeat has been featured as a key cognitive factor driving suicidal ideation and behaviors in two of the most influential models, the Cry for Pain Model and the Schematic Appraisals Model. Dr. Tang will present findings from recent questionnaire and experimental studies in which the role of mental defeat in predicting suicidality and in altering pain, attention and mood responses was empirically tested. Ideas on how the concept of mental defeat could be added to augment existing psychological models of chronic pain and be used for developing screening tools for detecting suicidality in patients with chronic pain will be discussed.

Individuals with chronic pain commonly have significant concomitant psychiatric and medical disorders placing them at higher risk for death by suicide. A seminal systematic review revealed that the risk of successful suicide was doubled in patients with chronic pain as compared to non-pain controls. Individuals with substance use disorders are also highly susceptible to suicidal ideation and engaging in suicidal behavior. For example, patients with an alcohol use disorder are 10 times more likely to die by suicide and individuals with a injection drug use disorder are 14 times more likely to die by suicide as compared to the general population. The individual who suffers from both pain and a substance use disorder are particularly vulnerable to ending their life by suicide and the prevalence of individuals with pain developing a substance use disorder has been burgeoning worldwide making this an international issue. This presentation will review the current literature on the epidemiology and theoretical models of suicidal ideation and suicidal behavior in individuals with pain and pain and concomitant substance use disorder and discuss assessing the risk of suicide in these populations and identifying modifiable mediators of pain, substance use disorder and suicide employing findings from original research.

Psychological processes can influence symptom experience in gastrointestinal (GI) disorders, where visceral pain is a predominant symptom. Attempts to protect oneself from pain can trigger maladaptive cognitive-affective and behavioral processes, such as hypervigilance, visceral anxiety, and avoidance behaviors. These responses are reinforced when symptoms decrease in the short-term, resulting in long-term adverse consequences. Given the role of gut-brain dysregulation in symptom etiology, research has historically focused on disorders of gut-brain interaction (irritable bowel syndrome, functional heartburn). However, principles of classical conditioning and fear-learning are increasingly implicated as mechanisms of visceral pain perception and modulation across the GI spectrum, including organic disease. Given the modifiable nature of these processes, behavioral intervention has proven effective in decoupling learned associations and teaching effective skills. Consistent with a cognitive-behavioral framework, treatment focuses on psychoeducation about the gut-brain axis, skills-training in relaxation and adaptive coping, restructuring unhelpful thinking patterns, and behavioral exposure. This talk will review the translational aspects of visceral pain perception and modulation, specifically focusing on conceptualizing a patient’s symptom experience through a biopsychosocial lens and applying brain-gut behavioral therapy to the GI patient population.

Chronic inflammatory conditions are common. Approximately 10% women have endometriosis, ~0.5% of the adult population have a diagnosis of inflammatory bowel disease (IBD) and ~1% a confirmed diagnosis of rheumatoid arthritis. All these conditions have pain as a key symptom, yet current therapies tend to target the inflammatory pathology and the extent to which pain is experienced varies widely between individuals, with little (if any) relationship between severity of pain and measures of disease severity. Interestingly these conditions are frequently comorbid, suggesting that they may share common underlying mechanisms, however, because they affect specific organ systems and are cared for by distinct specialties (gynaecologists, gastroenterologists and rheumatologists respectively) there is little overlap in research and clinical practice.
This session will consider three areas of importance to our understanding of pain in chronic inflammatory conditions: genetics, pain mechanisms and the lived experience. The presentations will each focus on one of the conditions but explore the overlap with the other diseases, areas for translation between the conditions and for further collaborative research will be highlighted and further developed in the discussion time.

Musculoskeletal pain is the leading cause of disability in the world, and the number one reason patients with arthritis visit healthcare providers. Safe and effective, non-opioid analgesics are lacking, and over half of patients with inflammatory arthritis report pain, despite treatment with strong immunomodulatory drugs. Our research team was one of the first to show that patients with rheumatoid arthritis (RA) have impairments in pain processing, consistent with CNS pain sensitization, otherwise termed nociplastic pain. Once established, nociplastic pain often occurs in the absence of detectable peripheral inflammation. Inflammation may, however, serve as a trigger for developing nociplastic pain and/or be a factor in maintaining nociplastic pain. In animal models, an acute episode of inflammation can prime the hyperalgesic response to a second stimulus, resulting in long-lasting hyperalgesia. In humans, there is an increased prevalence of fibromyalgia (FM), the prototypical nociplastic pain condition, among patients with chronic inflammatory diseases, including RA, endometriosis, and inflammatory bowel disease. Little is known, however, about the cellular, physiologic, and biopsychosocial pathways that drive the transition from acute peripheral/visceral pain to chronic nociplastic pain in these diseases. In this presentation, we will review existing literature and discuss challenges and opportunities for future interdisciplinary research.

This presentation will draw on qualitative and quantitative research exploring the patient experience of pain and treatment options in Inflammatory Bowel Disease. The implications for treatment strategies that include both biomedical and cognitive behavioural aspects will be presented, emphasising a partnership between the patient and the multidisciplinary team when managing pain. Similarities and differences with patient experience of pain in endometriosis and RA will also be explored, including whether similar pain management strategies might be indicated.