The enabler.

1. PSYCHOLOGY, PSYCHIATRY & BRAIN
NEUROSCIENCE SECTION
Original Research Article
Associations Between Spousal or Significant
Other Solicitous Responses and Opioid Dose
in Patients with Chronic Painpme_1434 1034..1039
Julie L. Cunningham, PharmD,* Sarah E. Hayes,
BA,†
Cynthia O. Townsend, PhD,‡
Heidi J. Laures,
BS,§
and W. Michael Hooten, MD‡¶
*Department of Pharmacy, Mayo Clinic College of
Medicine, Rochester, Minnesota;
†
Department of Psychology, West Virginia university,
Morgantown, West Virginia;
‡
Department of Psychiatry and Psychology, Mayo
Clinic College of Medicine, Rochester, Minnesota;
§
Mayo Clinic Foundation, Rochester, Minnesota;
¶
Department of Anesthesiology, Mayo Clinic College
of Medicine, Rochester, Minnesota, USA
Reprint requests to: W. Michael Hooten, MD,
Department of Anesthesiology, and Psychiatry and
Psychology, Mayo Clinic College of Medicine, 200
First St SW, Rochester, MN 55905, USA. Tel:
507-266-9672; Fax: 507-255-1877; E-mail:
hooten.william@mayo.edu.
Conflict of interest/disclosure: All authors had full
access to the data, analysis, and manuscript. We
declare that all authors listed on the manuscript have
no financial disclosures to declare.
The research was conducted at the Mayo Pain
Rehabilitation Center, Department of Psychiatry and
Psychology, and the Translational Research Unit for
Chronic and Acute Pain, Department of
Anesthesiology, Mayo Clinic, Rochester, MN.
Abstract
Objective. The primary aim of this study was to
determine the effects of spouse or significant other
solicitous responses on morphine equivalent dose
among adults with chronic pain.
Design. Retrospective design.
Setting. Multidisciplinary pain rehabilitation center.
Patients. The cohort included 466 consecutively
admitted patients who had a spouse or significant
other and were using daily opioids.
Intervention. Three-week outpatient pain rehabilita-
tion program.
Outcome Measures. Solicitous subscale of the
Multidimensional Pain Inventory and morphine
equivalent dose upon admission.
Results. The mean solicitous subscale score and
morphine equivalent dose were 49.8 (standard
deviation [SD] = 8.7) and 118 mg/day (SD = 149),
respectively. Univariate linear regression analysis
showed that greater subscale scores were associ-
ated with greater doses of opioids (P = 0.007). In a
multivariate model adjusted for age, sex, ethnicity,
years of education, employment status, pain dura-
tion, depression, and pain severity, the association
retained significance (P = 0.007).
Conclusions. These findings suggest solicitous
responses from a spouse or significant other may
have an important influence on opioid dose among
adults with chronic pain.
Key words. Opioids; Chronic Pain; Solicitous
Response; Spouse or Significant Other
Introduction
Opioids are a widely recognized treatment for chronic
non-cancer pain [1,2], and prescriptions for opioids have
increased dramatically in the United States over the past
15 years [3–5]. Various demographic and clinical factors
have been associated with the use of opioids for chronic
pain including male sex, younger age, longer pain dura-
tion, greater pain intensity, and depression [6–11].
However, the clinical factors associated with the use of
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Pain Medicine 2012; 13: 1034–1039
Wiley Periodicals, Inc.
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2. greater dosages of opioids have not been widely investi-
gated. In a retrospective study, the use of Ն180 mg/day
morphine equivalents was associated with having four or
more pain diagnoses, and greater rates of comorbid
medical, psychiatric, and substance use disorders com-
pared with a cohort of adults using <180 mg/day mor-
phine equivalents [12]. Further knowledge about the
clinical factors related to the use of greater opioid dosages
is important in that the use of Ն100 mg/day morphine
equivalents has been associated with an increased risk of
death due to unintentional overdose [13,14].
In addition to demographic and clinical factors previously
associated with use of greater dosages of opioids,
operant models of chronic pain [15] suggest that social
interactions, particularly with spouses and significant
others (S/SO), may positively reinforce various behaviors
that could potentially influence opioid dose. Solicitous
responses are verbal and behavioral social interactions
that indicate concern or anxiousness about an individual’s
well-being, including the individual’s experience of pain.
Examples include frequently asking about pain-related
symptoms, or excessive attentiveness to the individual’s
physical and emotional needs. Previous studies suggest
that solicitous responses from S/SO influence several key
features of chronic pain including pain intensity, physical
disability, and pain behaviors [16–18]. However, the
potential influence of S/SO solicitous responses on
another key feature of chronic pain, specifically opioid
dose, has not been previously reported. Knowledge of the
association between S/SO solicitous responses and
opioid dose could further highlight the important role of
family members in the clinical course of adults receiving
long-term opioid therapy for chronic pain.
The primary aim of this retrospective study was to deter-
mine the effects of S/SO solicitous responses on mor-
phine equivalent dose among chronic pain patients
enrolled in a 3-week pain rehabilitation program. Upon
admission, the self-report baseline level of S/SO solicitous
responses was assessed by patients using the solicitous
subscale of the Multidimensional Pain Inventory (MPI).
Methods
Study Participants
All adult patients consecutively admitted to the Mayo
Comprehensive Pain Rehabilitation Center from Septem-
ber 2003 to February 2007 with chronic nonmalignant
pain were eligible for inclusion. During this period, 1,241
patients with chronic pain were admitted of which 466
(37.6%) had a spouse or significant other, and were
using opioids on a daily basis. All patients provided
consent for the use of their medical records for research
purposes. The study protocol was approved by the
Mayo Foundation Institutional Review Board. The current
report represents a secondary analysis of an extensive
dataset, portions of which have been previously
published [19–23].
Study Setting
The Mayo Clinic pain rehabilitation program is an outpa-
tient intervention of 3-week duration. The clinical setting
has been previously described [24]. To briefly summa-
rize, the program is based on a cognitive behavioral
model where the primary treatment goal is functional res-
toration. Patients were involved in daily physical and
occupational therapy, and all patients attended daily
educational group sessions related to management of
depressive symptoms, relaxation and stress manage-
ment training, the use of pain medications for chronic
pain, sleep hygiene, moderation of daily activities, and
the elimination of pain behaviors.
Determination of Morphine Equivalent Dose
Upon admission, all medication use was determined by
self-report and a detailed medication history interview, as
previously described [19]. Specifically, a detailed phar-
macist interview with the patient and examination of all
medication containers was completed at admission to
determine the specific dosage and interval of use for each
medication. In patients taking daily opioids, the opioid
dose was converted to a daily oral morphine equivalent
dose using an equianalgesic conversion software program
[25] that has been used extensively at our treatment
center [9,19,21–23].
Measures
Baseline demographic and clinical characteristics were
collected at admission including age, sex, duration of
pain, marital status, years of education, employment
status, primary pain site, and medication use.
The MPI has been widely used to assess the psychosocial
impact of chronic pain [26]. This self-report questionnaire
has proven reliability and construct validity [27]. The
52-item self-report questionnaire contains 12 subscales,
and raw scores were converted to standardized T-scores
with a mean of 50 and a standard deviation (SD) of 10
(range 0–100) [28]. The solicitous subscale comprised six
questions (e.g., “How supportive or helpful is your spouse
or significant other to you in relation to your pain?”) and
provides a measure of solicitous responses from S/SO
where higher scores signify greater levels of solicitous
responses. The pain severity subscale quantifies pain
intensity and pain-related suffering based on responses to
the following three questions: 1) “Rate the level of your
pain at the present moment”; 2) “On average, how severe
has your pain been during the last week”; and 3) “How
much suffering do you experience because of your pain?”
The higher scores on the pain severity subscale indicate
greater pain and suffering as assessed by the patient.
The Center for Epidemiologic Studies-Depression Scale
is a measure of the severity of depressive symptoms
[29]. The 20-item self-administered questionnaire has
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3. established reliability and validity [30,31]. Total scores
range from 0 to 60 with higher scores indicating higher
levels of depression.
Data Analyses
Demographics (age, sex, ethnicity, educational status, and
employment status) and clinical characteristics (pain dura-
tion, primary pain site, depression, pain severity, solicitous
response, and morphine oral equivalent dose) were sum-
marized for the study cohort. Mean and SD were reported
for continuous variables, and count and proportion were
reported for categorical variables. Univariate and multivari-
ate linear regression analyses were performed with
morphine equivalent dose as the dependent variable.
Univariate regressions were first performed with morphine
equivalent dose as the dependent variable, and the inde-
pendent variables included age, sex, ethnicity, years of
education, employment status, pain duration, depression,
and pain severity. These variables have been previously
shown to influence opioid dose among adults with chronic
pain [6–11,32]. Multivariate linear regression was then per-
formed with morphine equivalent dose as the dependent
variable, and adjusted for all the above listed factors. The
level of significance for all statistical tests were set at
P < 0.05, and all analyses were completed using PASW
(Version 18.0, IBM, Inc., Chicago, IL, USA).
Results
Sample Characteristics
The study cohort included 466 adult patients with
chronic pain who had an S/SO and were using opioids
daily. Table 1 contains a summary of baseline demo-
graphic and clinical characteristics. The mean solicitous
subscale score and daily morphine equivalent dose for
the study cohort were 49.8 (SD = 8.7) and 118 mg/day
(SD = 149), respectively.
Associations Between Solicitous Response and
Opioid Use
Univariate regression analysis demonstrated that greater
solicitous subscale scores were associated with greater
morphine equivalent dose (P = 0.007), where every one-
point increase in the solicitous subscale score was asso-
ciated with a 2.0 mg/day increase in opioid dose (Table 2).
In addition, younger age (P = 0.018) and male sex
(P < 0.001) were significantly associated with greater mor-
phine equivalent dose. In a multivariate model adjusted
for age, sex, ethnicity, years of education, employment
status, pain duration, depression, and pain severity, the
association between the solicitous subscale score and the
opioid dose retained significance (P = 0.007) where every
one-point increase was associated with a 2.1 mg/day
increase in morphine equivalent dose. In this multivariate
analysis, younger age (P = 0.006) and male sex
(P = 0.026) were significantly associated with greater mor-
phine equivalent dose.
Discussion
The primary finding of this study was that higher scores on
the solicitous subscale of the MPI were associated with
greater daily morphine equivalent dose among a commu-
nity sample of adults with chronic pain. In both univariate
and multivariate linear regression analyses, every one-
point increase in the solicitous subscale score was asso-
ciated with a 2.0 mg/day and 2.1 mg/day increase in daily
morphine equivalent dose, respectively. The multivariate
analysis further showed that the association between the
solicitous response subscale and morphine equivalent
dose retained statistical significance after adjusting for
other demographic and clinical characteristics including
age, sex, ethnicity, years of education, employment
status, pain duration, depression, and pain severity. In this
multivariate model, younger age and male sex were also
significantly associated with greater morphine equivalent
dose, which is consistent with previous observations [6].
The potential clinical mechanisms by which higher self-
report scores on the MPI solicitous subscale contribute to
the use of greater quantities of prescribed opioids warrant
further consideration. As previously noted, operant theo-
ries of chronic pain suggest that social interactions posi-
tively reinforce behaviors and, in turn, may influence
several key clinical aspects of chronic pain [15]. More
Table 1 Demographic and clinical characteristics
Variable
Patients
(N = 466)
Age, mean Ϯ standard deviation (SD) 48.2 Ϯ 13.2
Female sex, No. (%) 325 (70)
Pain duration (years), mean Ϯ SD 9.9 Ϯ 10.4
Years of education, mean Ϯ SD 14.8 Ϯ 2.8
Currently working, No. (%) 101 (22)
Ethnicity, No. (%)
Caucasian 454 (97)
African American 4 (1)
Hispanic 6 (1)
Other 2 (<1)
Primary pain site, No. (%)
Low back pain 152 (33)
Fibromyalgia 75 (16)
Headache 32 (7)
Neck 28 (6)
Generalized 50 (11)
Abdominal 37 (8)
Pelvic 21 (4)
Upper extremity 27 (6)
Lower extremity 32 (7)
Face 9 (2)
Chestwall 3 (<1)
Depression,* mean Ϯ SD 27.7 Ϯ 12.2
Pain severity,* mean Ϯ SD 49.9 Ϯ 8.9
* Center for Epidemiologic Studies-Depression Scale; Multidi-
mensional Pain Inventory pain severity subscale.
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4. specifically, S/SO solicitous responses have been associ-
ated with greater measures of pain, but the association
may be influenced by sex and marital status [18,33–35].
The associations between S/SO solicitous responses and
pain may be partly influenced by marital satisfaction in that
the association between solicitous responses and pain
were stronger among couples who were martially satisfied
[36]. Additionally, S/SO solicitous responses have been
associated with greater measures of physical disability,
pain interference, and more frequent use of pain behaviors
[16–18,37–39]. Similar to the associations between solici-
tous responses and greater levels of pain, the association
between S/SO solicitous responses and measures of
functionality were stronger among couples who reported
greater levels of marital satisfaction in some, but not all,
studies [17,18]. Regarding the influence of marital satis-
faction within the framework of an operant model, previ-
ous investigators have suggested that S/SO solicitous
responses may be “more reinforcing” to the individual with
chronic pain when the “quality of the relationship is good”
[40]. Collectively, these observations suggest that S/SO
solicitous responses, particularly among martially satisfied
couples, positively reinforce several key characteristics of
chronic pain that are routinely assessed in clinical practice.
Consequently, greater pain intensity, poorer levels of
physical dysfunction, and the more frequent occurrence of
pain behaviors in this particular group of patients may
secondarily predispose clinicians to prescribe greater
quantities of opioids to manage pain symptoms.
The observations from this study have clinical implica-
tions with regard to the cognitive-behavioral treatment
model of chronic pain. Previous research suggests that
involvement of the spouse in cognitive-behavioral-based
coping skills training can have favorable effects on pain
and functionality in randomized trials [41–43]. In general,
spouse-assisted coping skills training refers to the sys-
tematic involvement of the spouse as the patient
receives training in attention-diversion skills (relaxation,
imagery, and distraction), cognitive training strategies
(cognitive restructuring), and paced-activity training
(activity-rest cycling and pleasant activity scheduling)
[43–45]. In addition, the couple is encouraged to
develop a “menu of couples skills” including mutual goal
setting, behavioral rehearsal, and home-based practice
[43]. The findings from these studies, and the observa-
tions from our current study, support the supposition
that incorporation of the spouse in the cognitive-
behavioral treatment plan could potentially mitigate the
deleterious effects that solicitous responses have on
clinically assessed pain-related functioning, and second-
arily mollify the association between S/SO solicitous
responses and opioid dose.
This study has limitations. The demographics of the study
cohort could limit the generalization of the results. For
example, the mean age of the cohort was 48 years, and
majority of study participants were Caucasian women with
an average educational level 2 years beyond high school.
However, the demographic characteristics of our study
population were similar to the characteristics of a
community-based sample (N = 3,575) of adults with
chronic pain derived from the surrounding area of our
institution [46]. In this study, the mean age of study par-
ticipants was 54 years, the majority of individuals were
self-identified as “white” and “female,” and 77% had
greater than 12 years of education [46]. Despite these
demographic similarities, the clinical characteristics of
patients receiving long-term opioid therapy and referred
for multidisciplinary pain rehabilitation at a tertiary care
medical center could be different from the clinical charac-
teristics of a random population-based sample of adults
with chronic pain. Thus, the risk of referral bias cannot be
excluded in that the association between S/SO solicitous
responses and daily morphine equivalent dose among our
patients may not be applicable in other populations of
adults with chronic pain. Previous studies from our pain
treatment center have found a significant association
among pain severity, depression, and opioid dose
[20,23,47]. The absence of these associations herein
could have been due, in part, to selection bias in that the
study cohort was limited to patients receiving daily opioid
therapy and who were self-identified as having an S/SO.
Given the important associations between marital satis-
Table 2 Linear regression analyses with baseline morphine equivalent dose as the outcome variable
Variables
B Coefficient
in Univariate
Analysis (95% CI) P Value
B Coefficient
in Multivariate
Analysis (95% CI) P Value
Solicitous responses 2.02 (0.52, 3.54) 0.007 2.12 (0.59, 3.66) 0.007
Age -1.02 (-1.86, -0.17) 0.018 -1.49 (-2.44, -0.42) 0.006
Male sex 47.98 (21.95, 74.01) <0.001 33.28 (4.06, 62,49) 0.026
Ethnicity -15.79 (-31.69, 0.11) 0.052 -15.06 (-38.36, 8.23) 0.205
Years of education -1.01 (-5.11, 3.09) 0.628 2.05 (-2.85, 6.95) 0.412
Currently employed 9.99 (-19.00, 38.99) 0.499 18.73 (-15.18, 52.64) 0.278
Pain duration 0.08 (-1.08., 1.24) 0.894 0.64 (-0.69, 1.96) 0.344
CES-D score 0.58 (-0.43, 1.58) 0.259 0.36 (-1.42, 1.80) 0.543
MPI pain severity 0.89 (-0.49, 2.28) 0.206 0.19 (-1.42, 1.80) 0.817
CES = Center for Epidemiology Studies-Depression Scale; MPI = Multidimensional Pain Inventory pain severity subscale;
CI = confidence interval.
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5. faction and S/SO solicitous responses, the inclusion of a
measure of marital satisfaction in our statistical models
could have influenced the study findings. Additionally, the
correlational study design limits the ability to infer a direct
causal link between S/SO solicitous responses and
opioid dose despite the inclusion of multiple variables in
the data analyses.
In conclusion, the findings from this study suggest that
higher patient self-report scores on the solicitous subscale
of the MPI were associated with greater daily morphine
equivalent dose. This observation is consistent with
operant theories of pain and highlights the important influ-
ence that S/SO solicitous responses can have on the
temporal course of chronic pain. Future research that
incorporates S/SO involvement in cognitive-behavioral
treatment protocols could further elucidate the clinical
mechanisms by which S/SO solicitous responses influ-
ence opioid dose.
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Solicitous Responses and Opioid Dose
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on 04 September 2017