Target Audience (click to view)
This activity is designed to meet the needs of physicians and nurses.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Discuss the findings of a study that examined if changes in depression, pain catastrophizing, and anxiety could predict a subsequent reduction in pain intensity or interference and pain-related disability among patients with chronic musculoskeletal pain.
Method of Participation(click to view)
Release Date: 01/16/2017
Expiration Date: 01/16/2018
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at http://akhcme.com/akhcme/lessons/32. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.
AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity is awarded 0.5 contact hours.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Complete the Post Test(click to view)
According to published research, chronic musculoskeletal pain conditions account for four of the top nine diseases that contribute to years lived with disability in the United States. These disorders are associated with significant adverse health-related, work, and economic effects on patients. In many cases, conventional analgesic therapy is only moderately effective in many people who suffer from these conditions. As such, strategies are needed to augment standard pain treatments for chronic musculoskeletal pain. Studies suggest that treating common psychological comorbidities may help in the managing of patients with chronic pain.
“Chronic pain sufferers frequently report experiencing many comorbidities, including depression, pain catastrophizing, and anxiety, among others,” says Kurt Kroenke, MD. Researchers have suggested that the severity of these comorbidities is related to the degree of pain and pain-related disability. However, few studies have explored the independent effects of depression, anxiety, and pain catastrophizing on pain outcomes over time. “Understanding the relative influence of these psychological conditions on pain outcomes is important to help us refine our understanding of how we manage people living with chronic pain,” Dr. Kroenke adds.
A Longitudinal Analysis
For a study published in the Journal of Pain, Dr. Kroenke and colleagues analyzed data from 250 patients enrolled in the Stepped Care to Optimize Pain Care Effectiveness (SCOPE) trial. SCOPE participants were managed in the primary care setting and had chronic musculoskeletal pain, and investigators gathered various data points at baseline and at 3 and 12 months. The study authors then examined if changes in depression, pain catastrophizing, and anxiety could predict a subsequent reduction in pain intensity or interference and pain-related disability.
“Patients with chronic pain who exhibited improvements in depression, anxiety, and pain catastrophizing scores on screening tests experienced reductions in their intensity of pain and disability from their pain,” says Dr. Kroenke (Table). Improvements in depression appeared to have the strongest benefit, followed by improvements in pain catastrophizing and anxiety. “The beneficial effects of psychological improvement on pain outcomes were significant even after we adjusted for the effects of optimizing the use of analgesic medications,” adds Dr. Kroenke. The benefits regarding pain-specific disability were also stronger for those who had improvements in these mental health domains.
More Research Needed
According to the study, head-to-head trials are needed to explore the effects of analgesic therapy versus targeting psychological comorbidity on pain outcomes. “That said, treatment of pain and psychological comorbidity—either simultaneously or in a stepped-care approach for patients with pain who do not respond to treatment—is a reasonable approach and one that has some supporting evidence,” Dr. Kroenke says. “Depression, anxiety, and catastrophizing are common occurrences for people with chronic pain. These factors should be treated in order to improve outcomes.”
Optimization of analgesics and improvement of psychological comorbidity each had discrete effects on the reduction of pain in the study. “Our study suggests that optimizing analgesics in conjunction with treating concomitant psychological comorbidities might have additive benefits in reducing pain intensity or interference,” says Dr. Kroenke. “It may be particularly important to reduce catastrophizing because these individuals may experience a cascade of events that inhibits their chances of achieving pain relief.” The study group noted, however, that the more complex interaction between anxiety and analgesic optimization on pain disability warrants further study.
Analyzing the Implications
There are currently many brief measures for detecting and monitoring depression, anxiety, and pain catastrophizing. Dr. Kroenke says assessing these psychological factors is important because they can exacerbate pain and adversely influence pain outcomes. “These comorbidities must be addressed in order to optimize how we manage patients,” he says. Assessments of these comorbidities are also important for when researchers conduct studies that interpret pain outcomes in clinical research.
Effective treatments are available for the psychological comorbidities examined in the study. These therapies should be considered when they coexist in patients with chronic pain, particularly if pain does not respond adequately to conventional analgesics and non-pharmacological pain therapies.
“It’s also important to desegregate the treatment of pain and psychological comorbidities,” Dr. Kroenke says. “Clinicians should ask their patients with chronic pain about their mood during visits, especially if medications are not having their expected effect on pain reduction. Patients may exhibit catastrophizing tendencies if they state that they’re concerned about how they will manage their pain or that the pain will persist even with treatment. As physicians, it’s critical that we be vigilant and ask patients about depression, anxiety, and catastrophizing because these issues do not operate in silos.”
With greater use of integrated approaches, there is potential to further improve functional outcomes and reduce pain-related disability, according to the study. The research team noted that the following potential strategies should be considered:
- Increasing the number of mental health professionals trained in caring for pain patients.
- Incorporating mental and behavioral healthcare into patient-centered medical homes.
- Reinvigorating and incentivizing multidisciplinary pain care.
- Advocating for quality indicators that assess pain and psychological metrics.
Readings & Resources (click to view)
Scott EL, Kroenke K, Wu J, Yu Z. Beneficial effects of improvement in depression, pain catastrophizing, and anxiety on pain outcomes: a 12-month longitudinal analysis. J Pain. 2016;17:215-222. Available at: http://www.jpain.org/article/S1526-5900(15)00926-8/fulltext.
Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: a randomized clinical trial. JAMA. 2014;312: 240-248.
Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain. 2011;12:964-973.
Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009;301:2099-2110.