Abstract
Background
Heart failure (HF) is a costly and growing health problem that is routinely complicated by chronic pain and depression. The purpose of this paper is to describe the characteristics of pain and pain management in depressed HF patients.
Design/Participants
In this descriptive cross-sectional study, we analyzed data from 62 participants with depression and Class II–IV HF. Study variables of interest were collected from the Brief Pain Inventory, Beck Depression Inventory, and Rand-36.
Results
Almost all participants (98%) had some pain in the past month and most had pain in the last 24 hours (66%). The median pain score was 4 (0–10 scale) with the majority reporting moderate to severe pain. The median pain interference score was 4.42 (0–10 scale) with the majority reporting moderate to extreme interference. Medication to treat pain was used by all participants who reported pain with only 5% also using non-pharmacologic treatment.
Conclusion
The majority of participants reported moderate or severe pain while also having moderate to extreme pain interference. Non- pharmacologic pain treatments were severely underutilized. Women were more likely to have higher levels of pain intensity and more pain interference than men suggesting that, additional screening for the impact of pain is especially important in women. The wide variety of body areas affected along with moderate to high intensity pain and considerable interference scores reported, indicate that pain was ineffectively treated. Non-pharmacologic treatments should be considered to decrease the impact of pain.
Keywords: Heart Failure, Pain, Depression
Background
Heart failure (HF) is a costly and growing health problem that is routinely complicated by chronic pain and depression (Evangelista, Sackett, & Dracup, 2009). Non-cardiac pain is not routinely assessed by cardiac health care providers, but is present in the majority (67%) of patients with HF and is common in all stages of HF (Evangelista et al., 2009). The most common causes of non-cardiac pain are degenerative joint disease and arthritis (Evangelista et al., 2009; Goodlin et al., 2012; Hunt et al., 2009). Musculoskeletal pain is commonly treated with prescription and over the counter non-steroidal anti-inflammatory drugs (NSAIDS). NSAIDS are contraindicated in HF patients due to increased fluid retention, edema and increased blood pressure leading to increased hospitalizations (Hillis, 2002). Also, NSAIDS increase the risk of additional cardiac events so much so that the U.S. food and drug administration has strengthened the warning label on NSAIDs (Hossain, 2015; Ong, Ong, Tan, & Chean, 2013).
Depression is also common among patients with HF, as 22 to 42% are diagnosed with clinically significant depression (Rutledge, Reis, Linke, Greenberg, & Mills, 2006; Turvey, Schultz, Arndt, Wallace, & Herzog, 2002). With the addition of comorbid depression, HF patients have increased hospitalizations, poorer self-care behaviors, and higher rates of death (Kato et al., 2012). In a study examining the prevalence of pain in HF patients, 38% of HF patients had pain and depression which markedly increased illness burden (Goodlin et al., 2012; Poole, White, Blake, Murphy, & Bramwell, 2009). When depression is combined with HF and pain, patients are even less able to follow recommendations, treatment plans and engage in self-care behaviors, and length of time to treat chronic pain and depression is extended.
The purpose of this paper is to examine the characteristics of pain in patients with depression and HF. The main research questions (aims) include: 1) How many patients with HF and depression report pain and does pain presence differ based on demographic variables and health related characteristics? 2) What is the pain intensity and pain interference reported by depressed HF patients? 3) Is there a difference in pain intensity and pain interference based on depression level categories among HF patients? 4) What body areas do depressed HF patients report as causing pain? 5) What treatments do depressed HF patients use to manage their pain and what is their perceived effectiveness?
Design
The sample (n=62) is a subset of participants who were enrolled in the COPE trial from August 2012 through December 2014. The study is a two-arm randomized controlled trial in which the efficacy of an interpersonal psychotherapy-based treatment combined with chronic illness management is compared to a chronic illness management only. Participants were recruited from a tertiary medical center, VA medical center, and federally qualified health center in a Midwest state. Participants could also be referred from clinic personnel or self-refer from advertisements.
Participants/Subjects
Patients were eligible for the study if they were 55 or older, diagnosed with HF or chronic obstructive pulmonary disease (excluded from this analysis) and endorsed depressive symptoms (scoring ≥10 on the Beck Depression Inventory-II). Diagnosis of HF was based on radiographic evidence of an ejection fraction less than or equal to 40% or documented response to HF medication regimens based on chart review. Patients needed to present with functional impairment indicated by a score of ≤70 on the physical impairment subscale of the Rand MOS 36.
Exclusion criteria included: currently participating in psychotherapy (part of the study intervention), other significant psychiatric diagnoses (i.e. bipolar disorder, schizophrenia, substance abuse etc.) suicidal ideation with plan or intent, cognitive impairment (documented in medical record or MMSE ≤ 23), awaiting transplant, residence in a long term care facility, or significant hearing impairment that limited ability to participate in phone conversations (the study intervention is based on using the phone).
Methods
In this descriptive, cross-sectional design, pre-intervention assessment data from depressed HF participants along with pain assessment scales that were added to data collection instruments. All data were collected by research assistants who were trained and supervised by the principal investigator; and all study procedures were approved by the affiliated institutional review boards. Written informed consent for this secondary analysis was included as part of the parent project as the additional instruments were added to the original study procedure while recruitment was ongoing.
Instruments/Measures
The Beck Depression Inventory (BDI-II) was used to assess level of depression. The BDI-II contains 21 questions that are scored on a scale value of 0 to 3 for a total score range of 0 to 63. The BDI is recommended for chronic pain clinical trials by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) (Dworkin et al., 2008).
The Brief Pain Inventory Short Form (BPI-SF) was used to assess pain intensity and interference in the past 24 hours along with currently used pain management therapies. The BPI-SF assesses presence of pain, intensity of pain, current treatments being used, perceived pain relief from treatments, and extent that pain interferes with daily living (Kapstad, Rokne, & Stavem, 2010; Mendoza, Mayne, Rublee, & Cleeland, 2006). The 15-item BPI-SF was developed for cancer pain patients, but has shown consistent validity and reliability for many conditions (Kumar, 2011). The BPI-SF is recommended by IMMPACT for chronic pain clinical trials (Furlanetto, Mendlowicz, & Romildo Bueno, 2005).
The Rand 36 Item Short Form Survey Version 2 (Rand-36) was used to measure health-related quality of life (HRQoL). The Rand-36 is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by emotional problems, role limitations due to physical health, social functioning, mental health, energy/fatigue, pain and general health perceptions (McHorney, Ware, & Raczek, 1993). The RAND-36 is perhaps the most widely used HRQoL survey and has well-documented reliability exceeding 0.90 and validity 0.80–0.90 (McHorney et al., 1993).
A demographic and health related questionnaire was developed to obtain data on personal characteristics. Demographic variables included: age, gender, ethnicity, race, marital status, income level, health insurance, employment status, veteran status and education level. Health characteristics assessed include: depression level, HF classification, smoking status, and antidepressant use. Also, the Charlson Comorbidity Index was used to describe the sample as part of the health characteristics of participants. Higher scores are associated with greater likelihood of mortality or higher resource use (Charlson, Pompei, Ales, & MacKenzie, 1987).
Statistical Analyses
Data were analyzed using SAS (version 9.3, SAS Institute Inc., Cary, NC). Summary statistics were created for the variables of interest. This included frequency counts, percentages, means, standard deviations, and quartile values. Demographic variables were compared among individuals with and without pain, and for those with mild, moderate and severe pain intensity and interference. Depression categories score of 14–19 as mild, 20–28 as moderate, 29+ severe on the BDI-II (Beck, Epstein, Brown, & Steer, 1988). To determine differences between these categories, Fisher’s Exact test was used when there was not an expected count of at least 5 cases per category; Chi Square was used when there was an expected count of at least 5 cases per category; and Mantel-Haenszel was used when there was an expected count of at least 5 in each category and the variable was ordinal. The power analysis was conducted using the statistical program G*Power and demonstrated that 52 participants were needed to find statistically significant differences with alpha at .05 (Type 1 error), beta at 0.80 (Power), and effect size at .35 (Faul, Erdfelder, Lang, & Buchner, 2007).
Results
Data from 62 depressed HF participants were analyzed for this study. Mean age was 67.4 years (8.8 S.D.). The majority of the participants were male, white, non-Hispanic, married individuals with some college education and an annual income level less than $20,000. The mean Charlson Comorbidity Index Score with HF diagnosis not counted as all patients had HF was 5.37 with a standard deviation of 2.289. Most had a HF classification of stage III, were not current smokers, and did not take antidepressant medications (Table 1).
Table 1.
Demographic and Health-Related Characteristics based on Pain Presence in the Past 24 hours
| Variable | Total Sample n (%) |
Any Pain n (%) |
No Pain n (%) |
p value* | |
|---|---|---|---|---|---|
| Demographic | |||||
| Age | N=61 | 40 (66%) | 21 (34%) | .81 | |
| 55–69 | 39 (64%) | 26 (67%) | 13 (33%) | ||
| 70+ | 22 (36%) | 14 (64%) | 8 (36%) | ||
|
| |||||
| Gender | N=61 | 40 (66%) | 21 (34%) | .55 | |
| Male | 46 (75%) | 29 (63%) | 17 (37%) | ||
| Female | 15 (25%) | 12 (73%) | 4 (27%) | ||
|
| |||||
| Race | N=61 | 40 (66%) | 21 (34%) | .33 | |
| White | 56 (92%) | 39 (68%) | 18 (32%) | ||
| Other (2 AA***; 3 other) | 5 (8%) | 2 (5%) | 3 (14%) | ||
|
| |||||
| Ethnic | N=61 | 40 (66%) | 21 (34%) | .27 | |
| Hispanic | 3 (5%) | 1 (33%) | 2 (67%) | ||
| Non-Hispanic | 58 (95%) | 39 (67%) | 19 (33%) | ||
|
| |||||
| Marital Status | N=61 | 40 (66%) | 21 (34%) | .99 | |
| Married | 32 (53%) | 22 (67%) | 11 (33%) | ||
| Single | 29 (48%) | 19 (66%) | 10 (34%) | ||
|
| |||||
| Income level | N=56 | 36 (65%) | 20 (35%) | .97 | |
| ≤20,000 | 31 (55%) | 20 (65%) | 11 (35%) | ||
| >20,000 | 25 (45%) | 16 (64%) | 9 (36%) | ||
|
| |||||
| Health insurance | N=62 | 41 (66%) | 21 (34%) | .42 | |
| Yes | 53 (85%) | 34 (64%) | 19 (36%) | ||
| No | 9 (15%) | 7 (78%) | 2 (22%) | ||
|
| |||||
| Employment status | N=62 | 41 (66%) | 21 (34%) | .64 | |
| Employed | 17 (27%) | 12 (71%) | 5 (29%) | ||
| Unemployed/Retired | 45 (73%) | 29 (64%) | 16 (36%) | ||
|
| |||||
| Veteran Status | N=61 | 40 (66%) | 21(34%) | .29 | |
| Veteran | 26 (43%) | 19 (73%) | 7 (27%) | ||
| Non-Veteran | 35 (57%) | 22 (61%) | 14 (39%) | ||
|
| |||||
| Education Level | N=61 | 40 (66%) | 21(34%) | .09 | |
| High School or less | 23 (38%) | 12 (52%) | 11(48%) | ||
| Some college or more | 38 (62%) | 28 (74%) | 10 (26%) | ||
|
| |||||
| Health Characteristics | |||||
| Heart Failure Classification | N=58 | 40 (69%) | 18 (31%) | 1.00 | |
| Stage II | 19 (32%) | 13 (68%) | 6 (32%) | ||
| Stage III | 37 (62%) | 24 (65%) | 13 (35%) | ||
| Stage IV | 4 (7%) | 3 (75%) | 1 (25%) | ||
|
| |||||
| Dichotomized Charlson | N= 58 | 29 (50%) | 29 (50%) | .54 | |
| Comorbidity Index Score | |||||
| Low | 14 (24%) | 8 (57%) | 6 (43%) | ||
| High | 44 (76%) | 21 (48%) | 23 (52%) | ||
|
| |||||
| Smoking status | N=62 | 41 (66%) | 21 (34%) | .36 | |
| Ever smoked | 43 (70%) | 30 (70%) | 13 (30%) | ||
| Never smoked | 19 (30%) | 11 (58%) | 8 (42%) | ||
| Current smoking status | N=44 | 33 (75%) | 11 (25%) | ||
| Current smoker | 6 (14%) | 6 (100%) | 0 | .13 | |
| Nonsmoker | 33 (71%) | 27 (71%) | 11 (29%) | ||
|
| |||||
| Antidepressant use | N=52 | 34 (60%) | 18 (40%) | .66 | |
| Yes | 21 (40%) | 13 (62%) | 8 (38%) | ||
| No | 31 (60%) | 21 (68%) | 10 (32%) | ||
|
| |||||
| General Health Perception | N=62 | 41 (66%) | 21 (34%) | .18 | |
| Excellent | 0 | 0 | 0 | ||
| Very good | 1 (2%) | 0 | 1 (100%) | ||
| Good | 11 (18%) | 5 (45%) | 6 (55%) | ||
| Fair | 23 (37%) | 16 (39%) | 7 (33%) | ||
| Poor | 27 (44%) | 20 (49%) | 7 (33%) | ||
|
| |||||
| Depression Level | N=61 | 40 (66%) | 21 (34%) | .16 | |
| Low/Mild | 22 (35%) | 11 (50%) | 11 (50%) | ||
| Moderate | 29 (48%) | 22 (76%) | 7 (24%) | ||
| Severe | 10 (16%) | 7 (70%) | 3 (30%) | ||
Note: Numbers in cells vary based on missing data.
Fisher’s Exact test was used when there were not at least 5 cases expected per category; Chi Square was used when there were at least 5 cases per category; and Mantel-Haenszel was used when there were at least 5 in each category and an order to both variables.
African American
The majority (66%) of participants experienced pain in the last 24 hours. Differences in presence of pain by demographic and health related variables are reported in Table 1. There were no statistically significant differences in pain frequencies between any of the demographic groups (p≥.05). Following BPI-SF scoring instructions, the four pain intensity questions and seven interference items were averaged to derive a single overall score for each. The median score for pain intensity was 4.0 (items rated 0 to 10) with an interquartile range of 1.75 to 6.25. The median for pain interference was 4.42 (items rated 0 to 10) an interquartile range from 0 to 6.7. Median scores of 4 and 4.42 indicate a moderate amount of pain intensity and pain interference respectively. The interquartile ranges demonstrate the wide variability of pain experiences in this sample.
Pain intensity scores from the BPI-SF were categorized as no/mild pain (0–3), moderate pain (4–6), and severe pain (7–10). Analyses identified significant, and trends towards, differences between pain severity categories for gender (p=.04), race (p=.06), and health insurance status (p=.03), as reported in Table 2. Women were more likely to report higher pain intensity then men (p=.04). There were no differences based on depression level or HF classifications.
Table 2.
Demographic and Health-Related Characteristics based on Pain Intensity in the Past 24 hours
| Variable | Total Sample | No/mild Pain n (%) |
Mod Pain n (%) |
Severe Pain n (%) |
p value* |
|---|---|---|---|---|---|
| Gender | N=58 | 22 (38%) | 21 (36%) | 15 (26%) | .04 |
| Male | 44 (75%) | 18 (41%) | 16 (36%) | 10 (22%) | |
| Female | 14 (24%) | 4 (29%) | 5 (36%) | 5 (36%) | |
|
| |||||
| Race | N=58 | 22 (38%) | 21 (36%) | 15 (26%) | .06 |
| White | 54 (93%) | 20 (37%) | 21 (39%) | 13 (24%) | |
| Other (2 AA***; 3 other) | 4 (7%) | 2 (50%) | 0 (0%) | 2 (50%) | |
|
| |||||
| Health insurance | N=58 | 22 (38%) | 21 (37%) | 15 (26%) | .03 |
| Yes | 50 (86%) | 19 (36%) | 34 (64%) | 19 (36%) | |
| No | 8 (14%) | 0 (0%) | 5 (63%) | 3 (38%) | |
|
| |||||
| Heart Failure Classification | N=57 | 21 (37%) | 21(37%) | 15 (26%) | .61 |
| Stage II | 19 (33%) | 6 (32%) | 5 (26%) | 8 (42%) | |
| Stage III | 35 (61%) | 15 (43%) | 15 (43%) | 5 (14%) | |
| Stage IV | 3 (5%) | 0 (0%) | 1 (33%) | 2 (67%) | |
|
| |||||
| Depression Level | N=58 | 22 (38%) | 21 (36%) | 15 (26%) | .99 |
| Low/Mild | 19 (33%) | 8 (42%) | 7 (37%) | 4 (21%) | |
| Moderate | 28 (48%) | 10 (36%) | 10 (36%) | 8 (29%) | |
| Severe | 11 (19%) | 4 (36%) | 4 (37%) | 3 (27%) | |
Note: Numbers in cells vary based on missing data.
Fisher’s Exact test was used when there were not at least 5 cases expected per category; Chi Square was used when there were at least 5 cases per category; and Mantel-Haenszel was used when there were at least 5 in each category and an order to both variables.
African American
Pain interference was categorized as no/mild pain interference (0–3) moderate pain interference (4–6), and severe pain interference (7–10). As shown in Table 3, women reported significantly greater interference than men (p=.04). Depression level and HF classification did not differ significantly between these groups.
Table 3.
Pain Inference, Heart Failure classification and depression level
| Variable | Total Sample | No/mild Pain Interference | Mod Pain Interference | Severe Pain Interference | p value* |
|---|---|---|---|---|---|
| Gender | N=59 | 25 (42%) | 13 (22%) | 21 (36%) | .04 |
| Male | 45 (76%) | 21 (47%) | 12 (27%) | 12 (27%) | |
| Female | 14 (24%) | 4 (29%) | 1 (7%) | 9 (43%) | |
|
| |||||
| Heart Failure | |||||
| Classification | N= 58 | 24 (41%) | 13 (22%) | 21 (36%) | .44 |
| Stage II | 20 (34%) | 8 (40%) | 4 (20%) | 8 (40%) | |
| Stage III | 35 (60%) | 16 (46%) | 7 (20%) | 12 (34%) | |
| Stage IV | 3 (5%) | 0 (0%) | 2 (67%) | 1 (33%) | |
|
| |||||
| Depression Level | N=59 | 25 (42%) | 13 (22%) | 21(36%) | .15 |
| Low/Mild | 20 (34%) | 10 (50%) | 6 (30%) | 4 (20%) | |
| Moderate | 28 (47%) | 10 (36%) | 7 (25%) | 11 (39%) | |
| Severe | 11 (19%) | 5 (45%) | 0 (0%) | 6 (55%) | |
Areas of the body most commonly reported as painful were the back, hips/upper legs, and lower legs suggesting that non-cardiac pain was common (see Table 4). By comparison, pain in the chest, neck or shoulders that might represent heart-related pain was less often reported. Only 30 participants marked an area of the body that was painful, and of those 22% reported more than one area was painful.
Table 4.
Areas of the Body That Had Pain in the Past 24 Hours*
| Area of the body | N | Percentages |
|---|---|---|
| Back | 23 | 37% |
| Hips/Upper legs | 11 | 18% |
| Lower leas | 9 | 15% |
| Shoulders | 8 | 13% |
| Chest | 8 | 13% |
| Genitals/Buttocks | 7 | 11% |
| Feet | 7 | 11% |
| Neck | 4 | 6% |
| Arms | 4 | 6% |
| Hand | 4 | 6% |
| Abdomen | 3 | 4% |
| Head | 2 | 3% |
Data from the Brief pain Inventory-Short Form; multiple body sites could be reported.
Thirty of 62 participants (48%) provided a response for pain treatments used. The vast majority (95%) reported using only medications. Opioids were the most commonly reported medication used, followed by acetaminophen (Tables 5–6). Only two participants reported doing something in addition to taking pain medication. One person reported going to physical therapy and a chiropractor and another participant reported going to the chiropractor and using heating pad.
Table 5.
Pain Treatments used in the last 24 hours
| Pain Treatments | N | Percentage | |||
|---|---|---|---|---|---|
| Medications | 30* | ||||
| Opioids | 17 | 40% | |||
| Acetaminophen | 12 | 28% | |||
| NSAIDS | 6 | 14% | |||
| Muscle relaxant | 5 | 12% | |||
|
| |||||
| Non-Medications | 2* | 8% | |||
| Physical Therapy | 1 | 2% | |||
| Chiropractor | 2 | 5% | |||
| Heating pad | 1 | 2% | |||
Participants could report more than 1 pain treatment.
Table 6.
Those who used opioid pain medications
| Worse Pain Score | Area of the body(s) reported | Medication | |
|---|---|---|---|
| 10 | Knees | Acetaminophen with codeine | |
| 10 | Both upper and lower legs, knees, low back | Tramadol | |
| 9 | Neck, low back, right knee | Hydrocodone | |
| 9 | Both feet, low back, upper back, chest, shoulders, upper arms, | Tramadol | |
| 8 | Low back | Hydrocodone | |
| 8 | Shoulders, arms, neck, hands, upper and low back, both legs, knees | Hydrocodone | |
| 8 | Upper back, low back | Hydrocodone | |
| 8 | Both knees, buttocks, low back | Tramadol | |
| 8 | Right upper leg and knee, right hand, low back, chest, neck | Oxycodone and Baclofen | |
| 8 | Both shoulder, neck, buttock, upper legs, knees | Hydrocodone | |
| 8 | Upper back, upper left leg | Tramadol | |
| 7 | Both shoulders, head | Tramadol | |
| 7 | Abdomen, low back, genitals, buttocks, upper and lower legs with knees and feet | Hydrocodone | |
| 7 | Low back | Hydrocodone | |
| 7 | Both knees, abdomen, low back, | Hydrocodone | |
| 5 | Low back | Tramadol and Fentanyl | |
| 4 | Low back, both feet and knees | Tramadol | |
Opioid medication use by the area of body pain reported revealed that oxycodone and tramadol were the most commonly used drugs for low back and knee pain (Table 6). Of the thirteen reports of low back pain, 7 participants reported using hydrocodone, 5 used tramadol and 1 used another medication. Among the 10 who reported knee pain, 5 used hydrocodone, 3 used tramadol, and 2 used other medications. Of note, participants who reported use of opioids (Table 6) reported from 1 to 8 locations of pain, with a range of 5 to 10 for their worst pain level (on a scale of 1–10).
Fifty-six participants responded to the question “How much relief did you get from the pain management strategies you used”. Of those reporting, the majority (56%) had little or no relief. Of note, most of those who reported no pain in the last 24 hours also reported no relief from pain treatments or medications (n=16), thus only four people who had pain reported little or no pain relief from their pain management treatment of choice. Twenty-eight% (n=16) reported 70–100% relief, 16% (n=9) reported 40–60% relief, while 20% (n=11) reported 10–30% relief.
Discussion
Patients with HF and depression report high prevalence of pain that interferes with their function and quality of life. In this study, almost all participants had some pain in the past month (98%) and most had pain in the last 24 hours (66%). This is consistent with other limited reports in the literature (Evangelista et al., 2009; Nahin, 2015; Park, Clement, Hooyman, Cavalie, & Ouslander, 2015). Although other studies of HF patients did not include only those with depression, this study found a similar prevalence of pain as compared to HF patients in general (Goodlin et al., 2012). Studies of the general U.S. population indicate that 31% of adults report having pain in the last 3 months (Johannes, Le, Zhou, Johnston, & Dworkin, 2010), which is roughly half the rate reported by participants in this study. However, when age categories in the general population are considered, these findings are similar to rates of 40 to 63% among adults aged 65 and older (Johannes et al., 2010; Nahin, 2015).
The more important finding is that depressed HF patients reported all areas of the body as sources of pain. Although the common pain locations typically reported by older adults were present in this study, less common sources of pain were also reported. Of the few studies that have reported on locations of pain in HF patients, Goodlin et al. found below the knee’s most common (38%) followed by the lower back (31%), where we found back was (37%), followed by hips/upper thighs (18%) as most common (Goodlin et al., 2012). Goebel et al. grouped arms, legs, and joints together and found 71% the HF participants reported those areas and back area was reported 55% (Goebel et al., 2009). It is difficult to make direct comparisons as the body area groupings are different, or only certain areas were reported. Despite this problem it seems clear that, a thorough pain assessment is indicated to assure that pain is accurately identified, discussed with patients, and treated appropriately. For example, decreased heart function may cause pain in areas of the chest, stomach, and/or lower legs that may require additional HF treatment. Pain in the back, lower legs, shoulders could be due to other causes such arthritis, previous injuries, or peripheral vascular disease, and may have very different treatment options based on causal factors. In short, thorough assessment is critical to determining underlying causes and the best treatment options.
Perhaps the most important finding related to pain treatment, however, was the reliance on medications and lack of alternative pain treatments reported. Combining pharmacologic and non-pharmacologic treatments is recommended by the American Chronic Pain Association as best practice, but was rarely reported by participants (Feinberg, 2015). This finding is alarming in light of the levels of pain intensity and interference that were reported while using medication interventions. Only one study was found that looked at alternative pain treatment practices in HF patients. As they required participants to currently use alternative pain treatments prior to being enrolled in the study we are unable to assess how many HF pain patients had pain but did not use alternative pain treatments (McDonald, Soutar, Chan, & Afriyie, 2015). With that said, the study did find 25 hospitalized HF participants who were using alternative treatments and 18 combined medications with the alternative treatment. Potential non- pharmacologic pain treatments that have shown some benefit depending on the cause of pain include acupuncture, reflexology, aroma therapy, music therapy, dance therapy, yoga, hypnosis, relaxation and imagery, distraction and cognitive reframing, psychotherapy, peer support group, spiritual, chiropractic, magnet therapy, bio-feedback, meditation, and relaxation techniques (Hochberg et al., 2012; Jersey, 2006; McDonald, Soutar, Chan, & Afriyie, 2015). In short, wide varieties of options exist but must be specifically tailored to the person, their characteristics and abilities, and the type of pain they experience.
For those who reported pain, the experience had an important impact on their daily lives as illustrated by median score of 4.42 for pain interference. This finding is consistent with Goodlin’s report of a mean interference score of 4.0 (0–10 scale) in patients with advanced HF where 38% also had significant depressive symptoms (Goodlin et al., 2012). Another important finding was that HF patients with higher depression scores didn’t have significantly different pain intensity or interference scores than those with lower depression scores. This finding is inconsistent with a considerable body of literature supports the strong relationship between chronic pain and depression (Arnow et al., 2009; Bair, Robinson, Katon, & Kroenke, 2003; Gambassi, 2009; Poole et al., 2009; Thielke, Fan, Sullivan, & Unutzer, 2007). These studies demonstrated that presence of depression intensifies pain experiences. Several explanations for the lack of difference observed in this sample are possible. Because clinical depression was part of the inclusion criteria, the restricted score range may have influenced outcomes. Another possibility is that presence of clinical depression among HF patients, without regard to the level of depressive symptoms, may be sufficient to escalate the experience of pain. A third explanation for why level of depression did not significantly impact pain could be that patients were already so debilitated that worsening depressive symptoms didn’t have an additional effect.
Reports of pain location in this sample support the presence of multiple non-cardiac sites of chronic pain that can impact life activities. This study’s findings of back pain (37%), pain in hips/upper legs (18%), and knees/lower legs (15%) are consistent with other reports (Johannes et al., 2010). Findings related to pain treatments used by depressed HF patients reinforce the existing literature that medications with known risks are used. Opioids were the most commonly used type, followed by acetaminophen and NSAIDS. These trends are consistent with McDonald’s findings related to analgesic use in hospitalized HF patients, and level of opioid use was similar to that reported by others (Goodlin et al., 2012; McDonald et al., 2015; Toblin, Mack, Perveen, & Paulozzi, 2011). Because of known adverse effects of opioids and NSAIDS, careful evaluation of the appropriateness of patient’s medication pain treatment plan is essential. Education regarding the risks/benefits of medications appears to be needed, as well as discussion of various types of non- pharmacologic pain treatments that may be effective with less risk for the patient. Education on contraindications and risks related to NSAID use, in particular, should be part of routine HF care, particularly since these medications are available over-the-counter and thus may be viewed as being “harmless” by patients.
Limitations
The data for this study was collected during an ongoing study that focused on both HF and chronic obstructive pulmonary disease which influenced the number of HF participants available in the time frame of this study. The inclusion criteria of having depressive disorder limited analyses to examination of pain experience by levels of depression, and thus did not allow comparison of those with and without depression. Recruitment was conducted in an area of low racial and ethnic diversity so the majority of participants were Caucasian Americans. Therefore, the results of this study may not reflect the pain characteristics of other ethnic and racial populations. In addition, the data collection procedures did not allow for interviewing the participants.
Nursing Implications
The majority of participants had moderate to severe pain intensity and pain interference. This important finding demonstrates why all patients need to have a thorough pain assessment. The wide variety of pain sites noted by this sample suggests many different causes of pain that will likely respond better to a variety of treatments. As HF providers tend to focus on cardiac pain, patients are often educated about what to do for that type of pain but not others. Furthermore, making referrals to obtain the most effective treatment plan, with additional follow up to assure the best pain management is achieved, will likely improve numerous outcomes for patients. Referrals to pain specialists, physical therapy, chiropractors, occupational therapy, cardiac rehabilitation, as is appropriate for that patient’s care, have the potential to decrease pain intensity, pain interference, depression symptoms, issues around managing activities of daily living, and quality of life.
While NSAIDS are contraindicated for HF patients, they were used by some of the participants. Clinicians need to ask specifically about NSAIDs, as well as what other treatments patients are using as part of their pain assessment. While it is possible that the clinicians thought NSAIDS were the best pain treatment option for participants in the study, it is more likely that the clinician was unaware of NSAID use as it can be bought without a prescription (i.e., over-the-counter). For example, the person may have used the medication intermittently over a long period of time for musculoskeletal pain, but now has HF that increases risks of untoward side-effects. In the absence of specific medication review including occasional use of over the counter medications, contraindicated medication use may go undetected. The other possibility is that providers are unaware of the contraindication.
Lastly, non-pharmacological pain interventions are recommended in best practice guidelines but are a neglected source of relief for the patients in this sample. Greater knowledge among clinicians related to treatment options and resources in the community is an important first step in their making needed referrals. Of equal importance, the amount of pain interference was moderately high in spite of using pharmacologic pain treatments. This finding suggests that pain medications are not enough by themselves to keep pain interference in the mild range and thus alternative pain treatments are needed to assist patients in managing their pain.
Highlights.
Majority of patients reported moderate to severe pain intensity and interference
Medication was the primary treatment and was insufficient
Women were more likely to have higher pain intensity and interference
There was a wide variety of body areas reported as painful
Best practice of using both types of treatments were not utilized
Acknowledgments
This work was supported by the National Institutes of Mental Health [grant number R01MH086482] and by the National Institutes of Health, [grant number T32HL091812].
Footnotes
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Disclosures: All authors have no disclosures or conflicts of interest.
Contributor Information
Christine Haedtke, University of Iowa, College of Nursing, 50 Newton Road, Iowa City, IA, 52242, USA.
Marianne Smith, Associate Professor and the Education Director for the Hartford Center of Geriatric Nursing Excellence, University of Iowa, College of Nursing, 50 Newton Road, Iowa City, IA, 52242 USA.
John VanBuren, Assistant Professor, Department of Pediatrics - Division of Critical Care, University of Utah School of Medicine, 30 N. 1900 E., Salt Lake City, Utah 84132 USA.
Dawn Klein, Research Manager, University of Iowa, Psychiatry Research, 451 Newton Road; 200 Medicine Administration Building; Research Coordinator (Affiliate), Iowa City VA Health Care System, Iowa City, IA, 52242 USA.
Carolyn Turvey, Professor of Psychiatry and of Epidemiology, The University of Iowa Carver College of Medicine, 451 Newton Road,; 200 Medicine Administration Building, Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, IA, 52242 USA.
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