BackgroundConsensus guidelines recommend multi-modal chronic pain treatment with increased uptake of non-pharmacological pain treatment modalities (NPMs). We aimed to identify the barriers and facilitators to uptake of evidence-based NPMs from the perspectives of patients, nurses and primary care providers (PCPs).MethodsWe convened eight separate groups and engaged each in a Nominal Group Technique (NGT) in which participants: (1) created an individual list of barriers (and, in a subsequent round, facilitators) to uptake of NPMs; (2) compiled a group list from the individual lists; and (3) anonymously voted on the top three most important barriers and facilitators. In a separate process, research staff reviewed each group’s responses and categorized them based on staff consensus.ResultsOverall, 26 patients (14 women) with chronic pain participated; their mean age was 55. Overall, 14 nurses and 12 PCPs participated. Seven healthcare professionals were men and 19 were women; the mean age was 45. We categorized barriers and facilitators as related to access, patient-provider interaction, treatment beliefs and support. Top-ranked patient-reported barriers included high cost, transportation problems and low motivation, while top-ranked facilitators included availability of a wider array of NPMs and a team-based approach that included follow-up. Top-ranked provider-reported barriers included inability to promote NPMs once opioid therapy was started and patient skepticism about efficacy of NPMs, while top-ranked facilitators included promotion of a facility-wide treatment philosophy and increased patient knowledge about risks and benefits of NPMs.ConclusionsIn a multi-stakeholder qualitative study using NGT, we found a diverse array of potentially modifiable barriers and facilitators to NPM uptake that may serve as important targets for program development.

Practice guidelines and empirical research related to pain management encourage clinicians to take active roles in providing education about self management and promoting adoption of a self-management approach. The purpose of the study was to review the relevant literature, summarize aspects of the patientprovider interaction that influence patient engagement in self management for chronic pain, and outline practice recommendations in this area. Review of the literature on aspects of the patient-provider interaction that promote engagement in pain self-management was used. Findings are synthesized into recommendations for providers. Patients benefit from a biopsychosocial and patient-centered approach. Patients are more likely to fully disclose when providers respond empathically, which can improve conceptualization and treatment. Patient education and motivation play important roles in engaging patients in self management. Self management is influenced in part by the patient-provider communication process. Suggestions for communication strategies to facilitate patient engagement in self-management techniques, including empathic discussion of barriers and motivation enhancement, are provided. KEYWORDSChronic pain, Self management, Doctor-patient communication, Patient-centered care, Adherence Pain is one of the most common presenting problems in medical settings [1], and the majority of pain treatment tends to be carried out in the primary care context [2]. Pain that persists beyond 3 months and that does not remit with typical treatments for acute pain, such as rest, non-steroidal anti-inflammatory drugs, and heat or ice, is considered chronic pain. It is estimated that more than 100 million Americans have chronic pain [3], and prevalence in other countries varies from about 10-50 % of the general population [4]. Not only is chronic pain a prevalent health issue but it also significantly impacts quality of life [5][6][7][8] and the costs of care, and lost productivity are estimated to total almost $635 billion each year [3].Pain guidelines have recommended selfmanagement strategies in the treatment of chronic pain [9,10]. Self management differs from other treatments such as surgery and medication in that it emphasizes the patient's own control over his/her pain experience rather than relying on external factors to treat pain symptoms. At its most rudimentary level, self management consists of basic methods such as distraction, physical activity, and ice or heat to manage pain. Many patients use these practices on their own or are able to easily implement them after receiving reassurance and encouragement from their providers. Other patients may benefit from additional self-management techniques, such as those emphasized in cognitivebehavioral treatment for chronic pain, that aim to modify the thoughts and behaviors that contribute to the maintenance and exacerbation of pain. Such self-management skills include time-based pacing, relaxation, stress management, and identifying and modifying catastrophic ...

BACKGROUND: Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. OBJECTIVE: Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period. DESIGN: As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period. SUBJECTS: We studied Veterans receiving long-term (90+ consecutive days) OT through primary care. INTERVENTIONS:We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives. MAIN MEASURES: We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics. KEY RESULTS: The proportion of patients receiving highdose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased. CONCLUSIONS: We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

Objective: Despite the high prevalence of overweight and obesity in the US military veterans, binge eating has not been examined in this population. Design and Methods: Using a secondary data analysis approach, the prevalence and correlates of selfreported binge eating among 45,477 overweight or obese veterans receiving care in Veterans Health Administration facilities were examined. Participants completed a 23-item survey that assessed demographics, weight history, physical and mental health comorbidities, and eating habits during routine medical clinic visits. v 2 and logistic regression were used to examine the relationships among binge eating and demographic variables and medical and psychiatric comorbidities.Results: Nearly, three-quarters of the sample reported clinically meaningful binge eating (i.e., two or more times per week). Binge-eaters were more likely to report higher body mass index, depression, anxiety, and type 2 diabetes (P <0.0001). After controlling for potentially confounding variables, male veterans were significantly more likely to report clinically meaningful binge eating than female veterans (P < 0.001).Conclusion: These results have important implications for modifying weight management programs and highlight the need for the assessment and treatment to address binge eating, particularly among men and patients with type 2 diabetes.Obesity (2013) 21, 900-903.

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Individuals who smoke are more likely to experience panic attacks and develop panic disorder than those in the general population. One possible explanation is that smokers may experience a heightened fear response to somatic disturbances. To date, few laboratory studies have tested this hypothesis directly. The present study examined 24 adult heavy smokers (10 females) in 12-hr nicotine withdrawal and 24 adult nonsmokers (12 females) on subjective and physiological reactivity to a 4-min carbon dioxide rebreathing challenge. Results indicate that, despite an attenuated acceleration in respiration during the challenge, smokers experienced a significantly greater increase in self-reported panic symptoms than nonsmokers. In addition, smokers reported significantly greater trait levels of suffocation fear prior to the challenge. Findings are discussed with respect to the role of smoking in panic vulnerability.

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