Veterans Health Administration. (PROSPERO: CRD42015020347).

HRONIC NONCANCER PAIN IS associated with considerable physical and psychosocial impairment, distress, comorbid depression, and increased health care use and costs. [1][2][3][4] Many primary care patients report chronic pain, 2,5,6 most commonly musculoskeletal pain. 2,7 Guidelines for chronic pain treatment have been developed. 8,9 However, implementation has been problematic, especially in busy primary care practices in which access to recommended treatment components may be limited.Multifaceted, collaborative interventions can promote guideline-concordant care and improve outcomes for chronic conditions in primary care. 10,11 These interventions, based on the chronic care model, 10 attempt to optimize patient and clinician interactions via education and activation while providing system support, including care management and clinician feedback. Several investigators have demonstrated improvements in pain intensity and pain-related function in studies of interventions using collaborative approaches. 12-14 However, one of these studies used a pre-post design, 14 and the

The wide range of mTBI/PTSD frequency levels was likely due to variation across studyparameters, including aims and assessment methods. Studies using consistent, validated methods to define and measure mTBI history andPTSD are needed.

Little is known about patients prescribed high doses of opioids to treat chronic non-cancer pain, though these patients may be at higher risk for medication-related complications. We describe the prevalence of high-dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non-cancer pain prescribed high doses of opioids (>=180 mg/day morphine equivalent; n=478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional-dose (5-179 mg/day; n=500) or no opioid (n=500). High-dose opioid use occurred in 2.4% of all chronic pain patients and in 3.4% of all chronic pain patients prescribed opioids long-term. The average dose in the high-dose group was 324.9 (SD=285.1) mg/day. The only significant demographic difference among groups was race (p=0.03) with black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high-dose prescriptions. High-dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short-acting opioids, urine drug screens were administered to only 40.8% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high-dose usage, as well as the efficacy and safety of such dosing.

OBJECTIVES To determine associations between use of three different modes of social contact (in person, telephone, written or e-mail), contact with different types of people, and risk of depressive symptoms in a nationally representative, longitudinal sample of older adults. DESIGN Population-based observational cohort. SETTING Urban and suburban communities throughout the contiguous United States. PARTICIPANTS Individuals aged 50 and older who participated in the Health and Retirement Survey between 2004 and 2010 (N = 11,065). MEASUREMENTS Frequency of participant use of the three modes of social contact with children, other family members, and friends at baseline were used to predict depressive symptoms (measured using the eight-item Center for Epidemiologic Studies Depression Scale) 2 years later using multivariable logistic regression models. RESULTS Probability of having depressive symptoms steadily increased as frequency of in-person—but not telephone or written or e-mail contact—decreased. After controlling for demographic, clinical, and social variables, individuals with in-person social contact every few months or less with children, other family, and friends had a significantly higher probability of clinically significant depressive symptoms 2 years later (11.5%) than those having in-person contact once or twice per month (8.1%; P < .001) or once or twice per week (7.3%; P < .001). Older age, interpersonal conflict, and depression at baseline moderated some of the effects of social contact on depressive symptoms. CONCLUSION Frequency of in-person social contact with friends and family independently predicts risk of subsequent depression in older adults. Clinicians should consider encouraging face-to-face social interactions as a preventive strategy for depression.

Background Opioid prescribing for non-cancer pain has increased dramatically. We examined whether the prevalence of unhealthy lifestyles, psychological distress, healthcare utilization, and co-prescribing of sedative-hypnotics increased with increasing duration of prescription opioid use. Methods We analyzed electronic data for 6 months before and after an index visit for back pain in a large managed care plan. Use of opioids was characterized as “none”, “acute” (≤ 90 days), “episodic”, or “long-term.” Associations with lifestyle factors, psychological distress, and utilization were adjusted for demographics and comorbidity. Results There were 26,014 eligible patients. Among these, 61% received a course of opioid therapy, and 19% were long-term users. Psychological distress, unhealthy lifestyles, and utilization were associated in stepwise fashion with duration of opioid prescribing, not just with chronic use. Among long-term opioid users, 59% received only short-acting drugs; 39% received both long and short acting drugs; 44% received a sedative-hypnotic. Of those with any opioid use, 36% had an emergency visit. Conclusions Opioid prescribing was common among patients with back pain. The prevalence of psychological distress, unhealthy lifestyles, and healthcare utilization increased incrementally with duration of opioid use. Despite safety concerns, co-prescribing of sedative-hypnotics was common. These data may help in predicting long-term opioid use and improving the safety of opioid prescribing.

The VHB is a demonstrably useful accessory to treatment-an easily accessible tool that can increase stress coping skills. Because the app is easily disseminated across a large population, it is likely to have broad, positive utility in behavioral health care.

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