Spotlight on Pain Management 

Complex Associations Between Pain and Smoking

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Complex Associations Between Pain and Smoking

Lori Bastian, MD, MPH

Research Associate and 

Primary Care Physician

VA Connecticut (Newington)

Professor of Medicine

Division Chief, General Internal Medicine

Associate Dean for Career Development

University Connecticut Health Center

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Outline
        - Examine the published literature on the association of smoking status and pain 
        - Review a patient case
        - Describe preliminary data on the impact of smoking cessation and pain levels
        - Discuss clinical and research implications

Poll Question #1

Who is in the audience?

Researchers

Clinicians

Other

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Poll Question #2

Patients that smoke cigarettes report:

Similar pain levels compared to patients that don’t smoke

Higher pain levels compared to patients that don’t smoke

Lower pain levels compared to patients that don’t smoke

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The pain/smoking association is complex
        - Studies show pain prevalence and intensity are higher among current smokers
        - Yet, nicotine has analgesic properties
        - Pathophysiology is different for cigarette smoking and nicotine therapy

Shi Y et al Anesthiology 2010; 113:977

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Smokers with lung cancer report higher pain levels
        - We published the first study on smoking and cancer pain
        - Surveyed 893 patients with lung cancer 
        - 76% Stage IIIB/IV and 41% mod/severe pain
        - 17% persistent smokers
        - Persistent smokers were 1.6 times more likely to report moderate or severe pain compared to non-smokers and former smokers.

Daniel (Bastian) et al Journal of Pain 2009;10:323.

Smokers with Head & Neck cancer have higher pain
        - 112 patients with head & neck cancers 
        - 34% current smokers  
        - Smokers reported higher general pain and oral pain levels even after controlling for stage of diagnosis
        - Smokers reported significantly greater interference from the pain

Logan HL et al J Pain 2010;11:528

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What about other cancers?
        - 224 patients with breast (35%), lung (33%), bladder (6%), ovarian (6%), colon (4%) and other cancers 
        - 63% female
        - Persistent  smokers (after a cancer diagnosis) reported more severe pain and more interference from pain than non-smokers

Ditre JW et al Pain 2011;152:60

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Smokers treated for Cancer pain report higher pain
        - 486 patients treated for cancer pain
        - 20% smokers
        - Smokers had higher pain intensity and depression
        - Among 192 patients on opioid therapy, smokers continued to report higher pain

Novy DM et al. J Pain 2012;13:1058

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Mr. B

Age 76

stage IV lung cancer 

Hospice patient

Persistent smoker with 70 pack/year history

Shortness of breath and pain with any activity

Oxygen not allowed in home because of fire risk

Clinical Recommendation:

Nicotine replacement therapy

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Mr. B, 2 weeks later

Wearing 21mg nicotine patch and reduced cigarettes to 3 per day (only smokes outside)

Able to shave and walk in house using oxygen

Pain and breathing improved

Family working on quitting, too.** They no longer smoke in the house or near patient.

Clinical Recommendation:

	Add Nicotine inhaler for urges

**Social-network effect. Christakis, BMJ 2004;329:184.

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Mr. B, 3 months later

Quit smoking and uses oxygen and electric scooter to get around outside of his house

Requires less opioid medications for pain

His wife also quit smoking

Hospice nurse (a smoker) was reluctant to encourage cessation but was impressed that patients’ quality of life improved after he quit 

	Key Point: Health Care workers can be a barrier to smoking cessation for patients with cancer.

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Case Highlights
        - Mr. B’s pain and quality of life improved
        - Family members were motivated to quit
        - Initially, his hospice nurse was reluctant to address smoking cessation, she said “did not seem fair”
        - Important to inform the patient, family members, and clinicians that there are benefits to quitting.

Poll Question #3

Is there a role for smoking cessation in the management of cancer pain?

Yes

No

Unsure

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Is this complex association unique to cancer patients?
        - No
        - Brief review of smoking and non-cancer pain 
        - Like with cancer pain, studies are observational and do not determine causality.

Fishbain DA et al Pain Medicine 2012; 13:1212

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Hypothesized Feedback Loop
        - Does smoking increase pain? Or does pain increase urge to smoke?
        - Reciprocal relationship between pain and smoking that operates as a positive feedback loop, leading to greater pain, increased smoking, and the maintenance of nicotine dependence

Ditre JW & Brandon TH J Abnorm Psychol 2008;117:467

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Smokers have more severe back pain
        - National Spine Network database (U.S.) 
        - 11,494 men and 13,961 women
        - 16.7% smokers
        - Smokers were more likely to report severe pain and to report symptoms of depression
        - Smokers also reported less improvement after back surgery compared to non-smokers

Vogt MT et al Spine 2002; 27:313

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Smokers have more back pain
        - Meta-analysis of 40 studies
        - Current Smokers had an increased prevalence of low back pain compared to non-smokers OR=1.30 (95% CI 1.16-1.45)
        - Former smokers OR=1.24 (95% CI 1.11-1.38)
        - Lower rates for former smokers suggests that smoking cessation will reduce back pain

Shiri R et al. Am J Med 2010;123:87e7-87e35

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Smokers report more pain locations & more analgesic use
        - 7,124 survey respondents from population database in Germany
        - Ages 18-79 
        - Heavy smokers (>20cigs/d) 8.6% women and 17.1% men
        - Heavy Smokers report more pain locations and higher pain intensity in past 7 days
        - Heavy Smokers have more analgesic use 

John U, et al Prev Med 2006;43:477 & John U, et al Drug Alc Dep 2006;85:49.

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Smokers with fibromyalgia report greater pain intensity
        - 984 patients evaluated in the Mayo Clinic Fibromyalgia Program
        - 14.7% current smokers
        - Smokers reported greater pain intensity and higher scores on the Fibromyalgia Impact Questionnaire

Weingarten TN et al Clin J Pain 2009;25:39

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Combination of smoking and depression 2 times risk of pain
        - 18,439 Health & Retirement Study 
        - 15% depression
        - 34% troubled by pain
        - Smoking increased the likelihood of incident pain only in those subjects who also reported depression

Shi Y et al Pain 2010; 151:366

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Effects of Depression and Smoking on opioid use
        - 1,241 in out-patient pain treatment program
        - 25% current smokers
        - Smokers had higher depressive symptoms and pain and greater morphine equivalent dose
        - Multivariable model, smoking associated with greater opioid use

Hooten WM et al. Pain 2011; 152:223

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Older smokers have more intense pain
        - 1,141 patients (ages 65-103) in Sweden
        - 54% women and 38% chronic pain
        - 9% smokers
        - Female smokers have higher pain prevalence and pain intensity
        - Male smokers have higher pain intensity

Jakobsson U et al Pain Practice 2013; in press

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Smokers with chronic pain have greater pain intensity
        - 230 patients in Mayo Chronic Pain Clinic
        - 15% smokers
        - Smokers report greater pain intensity and pain interference with functioning
        - Nicotine dependence was also associated with greater pain.

Weingarten TN et al Pain Physician 2008;11:643

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Veterans with Chronic Pain
        - 6,377 Veterans ages 19-97 (9% female)
        - 36.7% current smokers
        - Smokers were 1.4 times more likely to have any abuse of prescription drugs adjusting for depression and pain
        - Smokers were 1.8 times more likely to have frequent prescription drug abuse

Becker WC et al Pain Medicine 2009; 10:531

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Smoking cessation in patients with chronic pain
        - 112 patients in chronic pain clinic
        - 50% smokers
        - Smokers were encouraged to quit by their pain clinic physician and 91% reduced the number of cigarettes they smoked
        - Reduction in number of cigarettes was associated with improved breathing, feeling better, and less pain.

Kaye AD et al Ochsner J 2012;12:17

Kaye AD et al Ochsner J 2012;12:17

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Effect of smoking cessation on pain in older adults
        - 6,258 smokers in Health & Retirement Study
        - 50% female and 31% pain
        - 44% quit smoking between 1993 and 2006
        - In this longitudinal study, no association was found for the effect of smoking cessation on pain in older adults (OR=0.87 95%CI 0.70-1.08)

Shi Y et al Nicotine &Tobacco Res 2011;13;919

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Impact of smoking cessation on pain outcomes
        - To date, only observational studies have peen published.
        - Next step is to examine the effect of smoking cessation on pain in randomized clinical trials

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Smoking Cessation Trial at the Durham VA in North Carolina

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Funding support: VA HSR&D IIR 05-202

Bastian et al. Comparative Effectiveness Research 2012;2:45.

Key Investigators from Durham NC
        - Laura Fish, PhD
        - Jennifer Gierisch, PhD, MPH
        - Steve Grambow, PhD
        - Karen Stechuchak, MS
        - Lesley Rohrer, MPH
        - Funding support: VA HSR&D IIR 05-202

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Smoking cessation for chronically ill veterans

Veteran’s environment and social support (in particular family support) impacts their motivation and self efficacy to stop smoking.

Higher cessation rates have been noted among smokers who report receiving greater positive support relative to negative support.

Examples of Family Support

Positive Support
        - Affirmation “Good Job”
        - Encouragement for discussing a plan with the person’s provider
        - Support for person’s efforts to try and quit

Negative Support
        - Nagging or complaining about their smoking
        - Calling them idiots or telling them they are disgusting
        - Making ultimatums

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Family Matters Trial

A telephone-based family-supported intervention that teaches how to minimize negative support and maximize positive support could improve cessation.

A comparative effectiveness trial to test a family-supported telephone counseling intervention compared to standard telephone counseling for increasing smoking cessation among veterans with chronic illness.

Sample

Sample size = 471 veterans

Diagnosed with chronic illness at Durham VA

Heart disease, cancer, hypertension, COPD, diabetes

Currently smoking

Planning to quit in the next 30 days

Able to identify one person (relative/friend) to support them while they quit smoking. 

Proactive recruitment

Patients identified using computerized medical record. 

Mailed an introductory letter informing them of the study and encouraging them to quit. 

Patients are called to assess eligibility criteria  and invited to enroll in the Family Matters study.  

2 telephone-based interventions
        - Family support:
        - Letter from MD
        - Self-help materials
        - Choice of NRT
        - Five family-supported  telephone counseling sessions; including an 8-page family support booklet with activities to enhance positive support and minimize negative support
        - Standard counseling:
        - Letter from MD
        - Self-help materials
        - Choice of NRT	
        - Five standard telephone counseling sessions

Baseline Characteristics

*Hypertension, COPD, Diabetes
| Variable               | Family-support(n=235) | Standard (n=236) |
|------------------------|-----------------------|------------------|
| Age, mean              | 59                    | 59               |
| Female                 | 9%                    | 8%               |
| Cardiac                | 43%                   | 42%              |
| Cancer                 | 33%                   | 35%              |
| Other chronic illness* | 23%                   | 23%              |

Smoking history 
| Variable                               | Family-support(n=235) | Standard (n=236) |
|----------------------------------------|-----------------------|------------------|
| Quit attempt after diagnosis           | 74%                   | 75%              |
| Self-efficacy for quitting (scale 1-7) | 5.8                   | 5.7              |
| Heaviness of Smoking(scale 0-6)        | 2.8                   | 2.8              |
| Lives with a smoker                    | 38%                   | 32%              |

Depression and Pain
| Variable                           | Family-support(n=235) | Standard (n=236) |
|------------------------------------|-----------------------|------------------|
| Depressive Sx(Brief CES-D > 10) | 53%                   | 56%              |
| Mean Pain level(Pain scale 0-10)   | 5.1                   | 5.2              |
| Poor/Fair Self-rated Health        | 59%                   | 60%              |

Results of Comparative Effectiveness Trial

*86% follow-up at 5 months and 81% follow-up at 12 months
| Variable                     | Family-support(n=235) | Standard (n=236) |
|------------------------------|-----------------------|------------------|
| Smoking cessation 5 months*  | 20%                   | 22%              |
| Smoking cessation 12 months* | 22%                   | 22%              |

Factors associated with Pain
| Variable                            | Pain at 5 monthsUnadjusted | Pain at 5 monthsAdjusted |
|-------------------------------------|----------------------------|--------------------------|
| Arm                                 | NS                         | NS                       |
| Age                                 | -0.11                      | -0.05                    |
| Abstinent at 5m CancerBaseline pain | -1.07NS0.68                | NSNS0.60                 |
| CES_D score                         | 0.18                       | NS                       |
| Rated fair/poor health              | 1.73                       | NS                       |

Research Implications
        - Need more prospective studies to examine impact of smoking cessation on pain severity
        - Family Matters was 90% men and there may be gender differences (i.e., women may be more affected by this association than men)
        - Potential  study populations: chronic pain, back pain, fibromyalgia, and cancer

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Clinical Implications
        - Qualitative study on physician attitudes
        - Focus group of 7 physicians (specialists)
        - Physicians identified many barriers to smoking cessation in a pain treatment clinic
        - Don’t have time for counseling
        - Hard to “zone in on the smoking part”
        - Patients smoke to cope with pain and they are under too much stress to try and quit

Hooten WM et al Pain Practice 2011;11:552

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Clinician Advice Matters
        - Compared to smokers who receive no advice from a clinician, smokers who receive such advice are 1.7–2.2 times as likely to quit smoking.
        - 3-minute MD advice results in a 10% quit rate.
        - Focus on the clinical benefits of quitting. If you are treating their low back pain, inform them of the potential pain improvement with quitting.

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. USDHHS, PHS, 2000

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