Frontiers in Pain Research

Deficient descending pain inhibition assessed by conditioned pain modulation (CPM) is considered a common feature of various chronic pain disorders. Typically, CPM studies focus on one particular disorder making direct comparisons between disorders difficult. This cross-sectional study aimed to compare CPM effects between three clearly distinct chronic pain disorders and pain-free controls. Furthermore, patients were pooled with controls to explore whether subgroups showing different CPM effects could be separated independent of cohort membership. One hundred and forty participants (patients: 53 non-specific chronic low back pain [nsCLBP], 15 complex regional pain syndrome [CRPS], 14 neuropathic pain after spinal cord injury [painSCI]; 58 controls) were included. CPM effects were assessed in a remote, pain-free area using pressure pain thresholds as test stimulus and a cold water bath as conditioning stimulus. Cohort differences in CPM effects were analyzed using linear mixed models. The presence of subgroups showing different CPM effects was tested using latent class linear mixed models. CPM effects differed between cohorts (p = 0.011), driven mainly by reduced inhibitory CPM effects in patients with nsCLBP compared to patients with painSCI. Latent class analysis detected 3 subgroups with varying degrees of significant inhibitory CPM effects (ps [≤] 0.002). All subgroups comprised patients and controls. These results oppose deficient descending pain inhibition as a common feature of chronic pain disorders. Additionally, the failure to identify subgroups without inhibitory CPM effects within a heterogenous patient/control sample challenges the utility of deficient CPM as predictor of chronic pain or treatment efficacy. PerspectiveInhibitory conditioned pain modulation, a measure of descending pain inhibition, is not consistently impaired across distinct chronic pain disorders. Furthermore, identifying individuals with impaired conditioned pain modulation within a heterogenous sample is difficult. Thus, for conditioned pain modulation to be clinically useful, its variability needs to be better understood.

Chemotherapy-induced peripheral neuropathy (CIPN) is a common and painful side effect of paclitaxel (PTX) treatment. The most common measures of painful neuropathy focus on evoked mechanical hypersensitivity, but clinically relevant ongoing pain remains understudied in preclinical models. Automated machine learning methods for pose estimation and behavioral classification have been proposed to capture non-evoked pain-like behaviors, though these approaches have primarily been applied to unilateral injury models such as spared nerve injury or unilateral inflammatory compound injection. Here, we evaluated the extent to which paclitaxel-induced CIPN affects the posture and spontaneous behavior of freely moving mice using a commercially available automated recording system (BlackBox). We found that paclitaxel-treated mice develop a broad and reproducible behavioral and postural phenotype relative to vehicle-treated controls, characterized by reduced front paw luminance and print size, increased front paw lifting, and altered body measurements consistent with a guarded posture. This phenotype was replicated across two independent cohorts and was detectable at both day 2 and day 6 following the final paclitaxel injection. To identify behavioral features specific to CIPN, we administered gabapentin, an analgesic often used to treat neuropathic pain in patients, to determine whether paclitaxel-induced behavioral changes could be attenuated. Gabapentin reduced several behavioral features in both paclitaxel-treated and vehicle-treated animals, suggesting that its effects on posture and gait are not specific pain in CIPN. These findings demonstrate that automated behavioral recording captures a robust paclitaxel-induced postural phenotype but question whether captured behaviors are indicative of ongoing pain as alleviated by gabapentin.

BackgroundAcute postoperative pain remains a major clinical therapeutic challenge. Current peripheral nerve blockade (PNB) techniques are effective for some patients but are limited by invasiveness, short duration, reliance on highly trained providers, and off-target motor and sensory effects. Focused ultrasound (FUS) is a novel neuromodulatory technology with the potential to achieve noninvasive, selective, reversible, and prolonged inhibition of peripheral nociceptive fibers to prevent and treat acute pain. We hypothesized that noninvasive transcutaneous targeting of the rat sciatic nerve using co-aligned diagnostic ultrasound (dUS) and FUS transducers could produce selective and reversible inhibition of nociceptive pain behaviors while preserving motor and non-nociceptive sensory functions. MethodsIn an in vivo rat hindpaw incisional (HPI) pain model, using a novel, transcutaneous dUS-guided FUS system, the sciatic nerve was located with dUS, and FUS energy was applied to it just prior to hindpaw incision. FUS parameters were iteratively adjusted to achieve reversible, selective inhibition of nociceptive behaviors without changing motor and non-pain sensory behaviors. Animals were randomized into six groups: No Intervention (Control), HPI Only (Disease Control), Sham FUS, FUS Only, FUS+HPI (Intervention), and LA+HPI (Positive Control). Primary outcomes were changes in nociceptive sensory functions, assessed by thermal and mechanical sensitivity. Secondary outcomes were changes in non-nociceptive sensory and motor functions, assessed by hindpaw flexion and extension reflexes. ResultsCompared with the HPI Only group, the FUS+HPI group demonstrated (1) significant attenuation of hindpaw thermal hypersensitivity from day 0 - week 5.0 and week 8.0 - 16.0 (p < 0.05-0.001); (2) significant attenuation of mechanical hypersensitivity from day 0 until week 4.0 (p < 0.05-0.001); (3) no significant attenuation of flexion; and (4) no significant attenuation of extension. ConclusionsTranscutaneous dUS-guided FUS enables selective, reversible inhibition of A{delta} and C nociceptive fiber mediated behaviors while sparing A motor and A{beta} sensory behaviors. FUS-induced PNB prevented both acute and persistent pain behaviors. These findings support FUS as a promising noninvasive peripheral nerve blockade strategy for acute pain management.

Objective: To evaluate whether glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are associated with improvements in pain severity, disability, quality of life, and physical function in adults with obesity and chronic low back pain (cLBP), and to explore potential mechanisms. Design: Prospective, single-arm cohort study. Subjects: Thirty-five adults (median age 41 years; 86% women) with obesity (median BMI 39.9 kg/m2) and cLBP initiating GLP-1 RAs (tirzepatide, n=24; semaglutide, n=11). Methods: Participants completed questionnaires at baseline, 3, 6, 9, and 12 months. The primary outcome was Brief Pain Inventory-Short Form (BPI-SF) pain severity. Secondary outcomes included body mass index (BMI), BPI-SF pain interference, Numerical Rating Scale (NRS) back pain, Oswestry Disability Index (ODI), and Short Form-12 (SF-12). At baseline and 6 months, a subset (n=24) underwent quantitative sensory testing, physical performance testing, and blood draws for inflammatory biomarkers (C-reactive protein, TNF-, IL-6, IL-10), adipokines (leptin, adiponectin), and hemoglobin A1c. Results: Over 12 months, BMI decreased by 12.5% (median 39.9 to 34.9 kg/m2, 95% CI [-6.6, -4.2]). BPI-SF pain severity improved (median 4.8 to 2.0, 95% CI [-2.1, -0.8]), as did pain interference, ODI, NRS back pain, and SF-12 physical component scores. Hemoglobin A1c, leptin, and C-reactive protein decreased. Adiponectin increased and physical performance improved, but neither reached significance. Experimental pain sensitivity was unchanged. Conclusions: GLP-1 RAs were associated with clinically meaningful improvements in pain, disability, and quality of life. These findings suggest GLP-1 RAs may be a promising nonsurgical therapy for cLBP; randomized controlled trials are needed to establish causality and mechanisms.

Background: Psychedelics are emerging as potential management options for chronic musculoskeletal pain due to preliminary evidence of effectiveness and low addictive potential, but patients perceptions remain unknown. This study assessed patient perceptions regarding psilocybin for musculoskeletal pain. Methods: We conducted a cross-sectional survey of adults ([&ge;]19) with musculoskeletal pain attending a hospital-based orthopaedic clinic. Participants reported demographics, perceptions of psychedelics for pain management, and willingness to participate in psychedelic research. Multivariable regression explored factors associated with perceived analgesic potential, and willingness to try a full therapeutic dose of psilocybin or a microdose. Results: Among 295 participants, 73% reported moderate-to-severe pain; 75% used analgesics; of these, 41% used opioids (86/209). While 24% reported prior psychedelic use, only 3% had discussed psychedelics with a healthcare provider. Most perceived that psilocybin had moderate-to-high effectiveness for pain (76%). Most respondents endorsed a moderate-to-high willingness to try microdoses (58%) and macrodoses (53%) of psilocybin for pain. Prior non-therapeutic psychedelic use predicted a 1.05-unit increase in perceived analgesic potential on the 10-point scale (p=.013). Willingness to try a macrodose of psilocybin was most strongly associated with prior non-therapeutic (B=3.16) and therapeutic (B=2.42) psychedelic use; in contrast, pain severity had a significant but modest association, with a 0.21-point increase in willingness for every 1-unit increase in pain severity (p=.017). Similarly, willingness to try a microdose of psilocybin was predicted by non-therapeutic (B=2.82) and therapeutic (B=2.48) use, whereas the effects of pain severity (B=0.20) and younger age (B=-0.30) were significant but small. Most respondents (52%) reported moderate-to-high willingness to participate in a trial of psilocybin for pain relief, and health risks were the primary concern (33%). Conclusions: Study findings suggest a majority hold neutral-to-positive perceptions of psilocybin for pain. Addressing perceived barriers, including health effects and gaps in patient knowledge, should be considered when designing future trials.

Background: Chronic pain is a multidimensional condition that often persists despite conventional treatment and adversely affects multiple domains of daily life. Music listening has emerged as a promising non-pharmacological intervention, with accumulating evidence supporting its beneficial effects on pain and associated psychological outcomes. However, despite growing evidence of efficacy, the translation of music listening into routine clinical practice remains limited, partly because intervention reporting has received comparatively little attention. Objective: To evaluate the effectiveness of music listening interventions for chronic pain and systematically assess the methodological quality and completeness of intervention reporting to identify barriers to reproducibility and clinical implementation. Methods: Systematic searches were conducted in PubMed, Cochrane Library, CINAHL, and Web of Science through June 2025, with no date restrictions on publication. Randomized controlled trials involving adults with chronic pain receiving music listening interventions were included. Two independent reviewers screened studies, extracted data, and assessed risk of bias. Intervention reporting was evaluated using the TIDieR checklist, and a random-effects meta-analysis was performed for pain intensity outcomes. Results: Ten RCTs involving 538 participants were included. Music listening interventions varied substantially in delivery, duration, and music selection procedures, reflecting considerable heterogeneity in intervention design. Most studies reported significant improvements in pain and psychological outcomes. Meta-analysis of eight trials (10 effect estimates), demonstrated a moderate reduction in pain intensity (SMD = -0.53, 95% CI: -0.96 to -0.11, p = 0.014; I2 = 76.2%). Although intervention rationale and procedures were generally well described, reporting of intervention modifications, treatment fidelity, and adherence was frequently incomplete. These reporting deficiencies may compromise reproducibility and limit translation into clinical practice. Conclusions: Music listening appears to be a safe, accessible, and scalable non-pharmacological intervention for chronic pain management, with benefits extending beyond pain reduction to psychological wellbeing, quality of life, and functioning. However, incomplete reporting of key intervention components may limit reproducibility and hinder clinical implementation. Future trials should adopt standardized and transparent reporting standards to facilitate implementation into clinical practice.

Introduction: Pain catastrophizing and pain self-efficacy are well-established predictors of health outcomes in chronic pain. Higher pain catastrophizing, a maladaptive cognitive process, predicts worse health outcomes, whereas higher pain self-efficacy, an adaptive cognitive process, predicts better health outcomes. This study examined whether pain catastrophizing and pain self-efficacy interactions predict physical and psychosocial health outcomes at 3 months and their change over 3-months among patients with chronic pain who sought care at a tertiary pain clinic. Methods: Adults with chronic pain (N = 181; 66.7% female; Mage = 58.7) completed baseline assessments of the Pain Catastrophizing Scale (PCS), Chronic Pain Self-Efficacy Scale (CPSS), and PROMIS measures of physical (pain intensity, pain interference, physical function) and psychosocial health (depression, anxiety, anger, loneliness). PROMIS measures were repeated at 3 months. Hierarchical multiple regression analyses tested PCS, CPSS, and their interaction as predictors of outcomes at 3 months and change scores from baseline to 3 months. Results: The PCS by CPSS interaction significantly improved prediction for physical function (Change in R2 = 0.02, p = .02). Higher baseline self-efficacy predicted better physical function (Beta = 0.65, p < .001), but this effect weakened with higher levels of pain catastrophizing. The interaction also predicted change scores in physical function (p = .025) but was marginal after false discovery rate correction (p = .059). Additionally, a significant interaction emerged for loneliness change scores (p = .01): higher self-efficacy predicted greater reductions in loneliness, attenuated by higher catastrophizing. Conclusion: Pain self-efficacy interacted with pain catastrophizing to predict physical function and loneliness at 3 months. Greater self-efficacy was associated with better outcomes, with associations diminished with higher levels of pain catastrophizing. Findings highlight the moderating role of adaptive and maladaptive cognitions and suggest interventions should address both processes to optimize recovery in physical and social functioning.

Abstract Background: Non-specific chronic low back pain (NSCLBP) is associated with persistent pain, reduced health-related quality of life (HRQoL), and low-grade systemic inflammation. This study examined associations among changes in inflammatory biomarkers, pain intensity, and HRQoL following a 12-week aerobic exercise programme. Methods: This secondary analysis used data from a randomized controlled trial involving 41 participants with NSCLBP (intervention, n = 21; control, n = 20). Participants received either supervised aerobic exercise plus health education or health education alone for 12 weeks. Change scores for tumour necrosis factor-alpha (TNF-), interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), pain intensity, and HRQoL domains were analysed using correlation and multiple regression analyses. Results: Improvements in IL-6 (r = 0.434, p = 0.005) and hs-CRP (r = 0.444, p = 0.004) were significantly associated with improvements in pain intensity. No significant associations were observed between biomarker changes and HRQoL domains. Treatment allocation was the strongest independent predictor of improvement in physical HRQoL ({beta} = 0.492, p = 0.017) and pain intensity ({beta} = -0.512, p = 0.006). Conclusions: Improvements in IL-6 and hs-CRP were associated with reductions in pain intensity but not with improvements in HRQoL. Treatment allocation was the strongest predictor of clinical improvement, suggesting that mechanisms beyond systemic inflammation may contribute to the benefits of aerobic exercise in NSCLBP. Keywords: non-specific chronic low back pain; aerobic exercise; inflammation; interleukin-6; high-sensitivity C-reactive protein; pain intensity; health-related quality of life.

IntroductionCannabis is increasingly used for pain management, with many patients reporting relief from chronic pain that did not respond to conventional treatments. However, cannabis is also associated with unwanted side effects including psychomimetic effects and the potential of developing a cannabis use disorder. To circumvent the central nervous system effects, we investigated whether a peripherally restricted cannabinoid receptor (CB1) agonist, PrNMI [(4-{2-[-(1E)-1[(4-propylnaphthalen-1-yl)methylidene]-1H-inden-3yl]ethyl}morpholine] attenuated pain hypersensitivity associated with nerve injury and profiled its abuse potential. Materials and MethodsMice with chronic constriction injury (CCI) of the sciatic nerve developed hypersensitivity to mechanical stimulation. Paw withdrawal thresholds were assessed following administration of PrNMI (i.p. 0.3 mg/kg and 0.6 mg/kg) or vehicle in CCI and sham mice. The conditioned place preference model was used to measure drug-reward to 0.6 mg/kg i.p. PrNMI in CCI and sham-injury control animals. We further assessed abuse potential to determine if PrNMI (0.5 mg/kg) would reinstate drug-seeking behavior in mice trained to self-administer intravenous fentanyl (10 g/kg/infusion). ResultsPrNMI administration transiently increased paw withdrawal thresholds in mice with CCI-induced allodynia in a dose-dependent manner. PrNMI conditioning did not produce a conditioned place preference in mice with either CCI or sham injury. Mice who had learned to self-administer fentanyl and went through extinction training did not reinstate drug-seeking behavior when administered PrNMI. DiscussionThe systemic CB1 receptor agonist PrNMI demonstrated analgesic benefit in alleviating mechanical allodynia associated with chronic constriction injury of the sciatic nerve without increasing addiction related behaviors associated with the establishment of addiction.

Pain demands attention and can disrupt task-related goals. Attention allocation is a key cognitive process supporting motor learning and disruption of internal schemas associated with attentional control during motor learning can result in interference in improvements in performance. Movement-contingent pain is an important characteristic of persistent musculoskeletal pain. Despite this, research exploring pain interference with motor learning and attention has exclusively utilised tonic pain paradigms. Understanding the impacts of movement-contingent pain on motor learning and attention may provide important insights into the interaction between pain and motor learning. The aim of this study was to; 1) explore the robustness of a movement-contingent pain paradigm across an extended period of training, 2) explore the impact of movement-contingent pain on improvements in performance and attentional allocation during motor learning. Three groups (healthy non-pain, healthy experimental-pain and persistent pain experimental-pain) completed ten trials of a motor sequence learning task while experiencing a movement-contingent electrical stimulation. Three task performance measures and five gaze indices, previously associated with attentional control, were collected. Results showed that; 1) low frequency electro-cutaneous stimulation could produce a valid and consistent pain experience across a sustained period of training, 2) attentional allocation becomes more efficient across learning, accompanied by improvements in task performance, 3) changes in task performance and attentional measures across training were similar in all groups despite the presence of pain, 4) movement-contingent experimental pain enhanced spatial performance at all time points in healthy participants but was not accompanied by a different pattern of attentional allocation. This study demonstrates that the impact of movement-contingent pain on motor learning is comparable to the impacts of tonic experimental pain and provides interesting insights into patterns of attentional allocation across time but little evidence that these attentional allocations are impacted by the presence of pain or a past history of pain.

Background: Whether a patient's pain improved after emergency department (ED) treatment is read from the record to benchmark EDs, compare drugs, and label research outcomes. It is interpretable only if a post-treatment score is recorded, appropriately timed, and chosen by a fixed rule; its stability across these choices is unknown. Methods: Retrospective measurement study of adult headache visits in a de-identified ED database (MIMIC-IV-ED, 2011-2019). Among treated visits, we quantified reassessment completeness by time window, estimated meaningful relief (a reduction of at least 2 points) under score-selection rules and missing-data assumptions, tested whether reassessment was predictable at treatment, and compared headache with other painful presentations. Results: Among 19,501 visits (15,273 patients), 13,682 (70.2%) were treated. A post-treatment pain score appeared at any time for 77.1% (95% CI, 76.4 to 77.8), but within 2 hours of the analgesic for only 47.9% and within 1 hour for 27.5%. Meaningful relief was 66.9% using the first post-treatment score but 81.0% and 83.4% using the last or lowest score; it was 67.5% under inverse-probability weighting and could be bounded only between 51.8% and 74.4%. Whether a score was recorded was weakly predictable at treatment (area under the curve, 0.566) and unrelated to baseline pain. Completeness was similar across headache strata and comparator painful presentations. In an independent ED (MC-MED, a different EHR), the score-selection effect replicated: relief rose from 71.1% (first) to 80.6% (last) and 83.4% (lowest). Conclusions: Documented pain relief after ED headache treatment was not a stable outcome: it varied with the reassessment window and score-selection rule, was not point-identified for unreassessed patients, and behaved like other painful ED presentations. Programs and research that use documented relief should prespecify the reassessment window, score-selection rule, completeness denominator, and a missing-data range, and favor protocol-timed reassessment.

Neuropilin-1 (NRP1) is a single pass transmembrane glycoprotein that can form a receptor complex with several tyrosine kinase receptors, including the vascular endothelial growth factor (VEGF) receptor. Previous studies have reported that binding of VEGFA to this receptor complex elicits mechanical allodynia and thermal hyperalgesia through potentiation of voltage-gated sodium and calcium channel activity. We find that Nrp1 mRNA and protein is widely distributed in naIve mouse and rat DRG neurons, including peptidergic afferents. A CGRPcreER: NRP1fl/fl transgenic mice was generated to investigate the role of peptidergic NRP1 in basal nociception. Following in vivo loss of NRP1, mice are hyposensitive to both noxious heat and mechanical stimuli. Under normal conditions, VEGFA elicits mechanical hypersensitivity, an effect that was absent in our NRP1 knockout mouse. Furthermore, VEGFA induced neuronal hyperexcitability was lost in CGRP expressing neurons isolated from this NRP1 knockout mouse. This study validates the NRP1 knockout mouse and confirms previous findings that VEGFA, often released during pathological pain conditions, requires peptidergic NRP1. Interestingly, we find that in the absence of ongoing injury or inflammation, peptidergic NRP1 regulates basal nociception and pain-like behaviors. PerspectiveNRP1 is expressed in sensory neurons including the peptidergic subpopulation. Genetic deletion of NRP1 in healthy adults alters nociception without altering innervation; NRP1 knockout mice are hyposensitive to noxious heat and mechanical stimuli, but lose sensitivity to VEGFA, confirming it is a therapeutic target for growth factor mediated pain conditions.

Spinal cord injury (SCI) results in dysfunction of both motor and sensory systems, which can be characterized by neuropathic pain, hypersensitivity, muscular spasticity and rigidity. Most SCIs result from incidents such as vehicle accidents or falls, resulting in polytraumatic SCI that includes peripheral injuries in addition to direct CNS damage. Recent findings suggest that spinal cord synaptic plasticity plays a crucial role in neuropathic pain pathophysiology, specifically in association with spinal sensitization and the consequent onset of AMPA-related maladaptive plasticity. Further findings have demonstrated that nociceptive peripheral stimulation in the acute phase of SCI results in maladaptive spinal synaptic plasticity by overdriving GluA2-lacking calcium-permeable AMPARs (CP-AMPARs). Here, we investigated the effect of a spared nerve injury (SNI) in conjunction with SCI to determine the effect of polytraumatic SCI on maladaptive plasticity in the spinal cord. Near-IR quantitative Western blot analysis demonstrated that SCI+SNI increases spinal GluA1 expression, but not GluA2. Patch-clamp confirmed that AMPAR currents in spinal motorneurons increase after SCI with SNI, and decrease after the administration of NASPM, a CP-AMPAR antagonist. Data-driven analysis using non-linear principal components analysis (NL-PCA) also demonstrated that SCI with SNI produces a multivariate signature of AMPAR plasticity that is observed in other forms of nociceptive peripheral input, indicating a general mechanism for maladaptive plasticity in spinal motor systems in response to polytraumatic SCI.

Approximately 90% of individuals with limb amputation experience the persistent sensation of the missing extremity and up to 85% experience debilitating pain in the missing limb, a condition termed phantom limb pain (PLP). In this registered clinical trial (NCT05296265), we tested the efficacy of Virtual Reality (VR) treatment of phantom leg pain in a sample of transtibial and transfemoral amputees with PLP. Adaptive randomization was used to assign 36 participants (19 transfemoral, 17 transtibial) recruited across three study sites to eight sessions of an active or distractor VR treatment. The active VR treatment required leg movements and provided virtual visual feedback. The distractor treatment was a commercially available VR treatment for pain based on the principle of distraction. The primary outcome measures were the comparison of ratings of pain intensity and quality at baseline versus immediately post-treatment and at 1-week and 8-week follow up. The secondary outcome measure, obtained in each session, was average pain intensity since the last treatment. Pain on both intensity and quality measures was significantly reduced with moderate effect sizes for the active treatment only; intensity effects persisted at 1-week follow-up, and quality effects persisted at 8-weeks follow-up. Ratings of pain intensity since the last treatment showed a large effect size for the active treatment and was significant for both treatments. This clinical trial showed significant efficacy of VR treatment for PLP, particularly for an active treatment providing virtual visual feedback of the amputated limb.

Introduction: Acute low back pain is a leading cause of disability worldwide. Clinical guidelines recommend non-pharmacological therapies as first-line treatment and advise caution with opioid prescribing. However pharmacological therapies, including opioids and gabapentinoids, remain commonly used. The comparative risks of subsequent opioid use disorder (OUD) and overdose diagnosis associated with initial treatment modality in large, real-world populations is not well characterized. We estimated the incidence of new-onset OUD and overdose diagnosis among opioid-naive, Medicaid-insured adults with newly diagnosed acute low back pain and estimated the association between initial treatment modalities and subsequent OUD and overdose diagnosis risk. Methods: We conducted a retrospective cohort study using Medicaid T-MSIS Analytic files from 25 states (2016-2019). We identified opioid-naive adults with a new diagnosis of acute low back pain who initiated pharmacologic or non-pharmacologic treatment within 1 month of diagnosis. The primary outcome was incident OUD and overdose diagnosis (based on diagnosis codes in claims) during follow-up. Associations between initial treatment modality and OUD and overdose diagnosis risk were estimated using a non-parametric, doubly robust estimator to adjust for measured confounding. Results: The cohort included 525,002 opioid-naive adults initiating treatment for low back pain. The cumulative incidence of OUD and overdose diagnosis was 1.5% and 2.4% at 7 and 13 months, respectively. Compared to non-use, use of gabapentinoids during the first month of treatment was associated with the highest relative risk (increasing risk) by 130.1%, 95% confidence interval (CI): 117.8%, 142.3%), the second-highest relative risk was estimated for higher-dose opioids, defined as > 50 daily Morphine Milligram Equivalents (MME) (118.1%, 95% CI: 99.2%, 137.0%). Lower-dose, short-duration opioids ([&le;] 50 MME, [&le;] 7 days) were also associated with elevated risk, though substantially smaller in magnitude (20.8%, 95% CI: 13.8%, 27.9%). In contrast, non-pharmacologic, non-interventional therapies were associated with reduced OUD and overdose diagnosis risk, with physical therapy demonstrating the largest relative reduction of 34.0% (95% CI: -40.9%, -27.1%). Discussion: In opioid-naive Medicaid patients with acute low back pain, initial non-pharmacologic treatment was associated with reduced OUD and overdose diagnosis risk. Gabapentinoids and opioids were each associated with increased risk; for opioids, the degree of risk increased with higher doses and durations. These results support guideline recommendations favoring non-pharmacologic treatment as first-line therapy and indicate the importance of cautious prescribing when pharmacologic treatment is considered.

Multipotent mesenchymal stem cells (MSCs) including bone marrow stromal cells (BMSCs) have shown analgesic efficacy in recent years. Studies suggested that the therapeutic effect of MSCs was mediated by their secreted small extracellular vesicles (sEVs) mainly exosomes. The present study evaluated the antihyperalgesic effect of BMSC-related sEVs in a mouse model of neuropathic pain involving chronic constriction injury of the infraorbital nerve (CCI-ION). Our separation protocol generated EV particles mostly sized in the range of exosomes (30-170 nm) and express exosome marker proteins CD9, CD81, and Tsg101, suggesting their endosome origin. We show that intravenous injection of BMSC-related sEVs attenuated pain hypersensitivity induced by CCI-ION as indicated by decreased mechanical hypersensitivity (von Frey test) and reduced aversion to noxious stimulation (conditioned place avoidance test). The antihyperalgesic effect of sEVs was observed in both female and male animals, and the effect was dose-dependent. sEVs from NAIVE serum-treated BMSC cultures produced short-lasting antihyperalgesia in male but not female mice, suggesting a subtle sex difference. The antihyperalgesia of sEVs from BMSC culture was blocked by the pretreatment of the culture with GM4869, the antagonist of exosome secretion, suggesting that the effect was not related to other co-isolated soluble mediators but mediated by MSC-derived exosomes. Interestingly, the prior injury condition in which sEVs were isolated favors the pain-relieving effect of sEVs. sEVs isolated from the serum of BMSC-treated animals receiving tendon ligation (TL) injury attenuated hyperalgesia for 24 h, while sEVs from the serum of BMSC-treated NAIVE animals only attenuated hyperalgesia at 3 h after injection. sEVs from the BMSC culture treated with the serum of TL rats were antihyperalgesic, but sEVs from the BMSC culture treated with the serum of naive animals were ineffective. Our results indicate that BMSC-related sEVs produced antihyperalgesia similar to that produced by BMSCs. The results suggest that the interactions between BMSCs and injury conditions are crucially important for producing efficacious sEVs/exosomes and support that the effect of sEVs could be optimized by priming BMSCs with injury-related conditions.

Myofascial pain syndrome (MPS) is a major cause of chronic neck pain, with tissue ischemia implicated as a contributing factor. This prospective, single-arm interventional study evaluated the analgesic effect of ultrasound-guided fascia hydrorelease (US-FHR) performed around arteries supplying the neck in patients with chronic neck MPS. Thirteen adults (median age 53.0 years; 38.5% female) underwent US-FHR targeting the perivascular fascia of either the transverse cervical or dorsal scapular artery using 2 mL of normal saline. Pain intensity was assessed by visual analog scale (VAS) at rest and during movement; disability by the 5-item Pain Disability Index, Japanese version (PDI-5-J); and arterial blood flow volume before and after the procedure. The primary outcome, pain VAS during movement, decreased from 49.0 mm (interquartile range [IQR], 44.5-64.0) at baseline to 22.0 mm (IQR, 14.5-31.5) at 15 min and 22.0 mm (IQR, 14.0-34.0) at 1 week (Hodges&-Lehmann median difference, 30.5 mm [95% CI, 24.5 to 36.5] and 28.5 mm [95% CI, 18.5 to 37.0]; both P < 0.001). Pain VAS at rest improved from 21.0 mm (IQR, 13.0-43.5) to 8.0 mm at 15 min and 1 week (median difference, 14.5 mm [95% CI, 9.0 to 24.0; P = 0.001] and 13.5 mm [95% CI, 6.0 to 21.0; P = 0.007]). PDI-5-J decreased from 17.0 (IQR, 10.5-23.0) to 13.0 (IQR, 4.0-17.5) at 1 week (median difference, 5 [95% CI, 2 to 8; P = 0.004]). Blood flow volume increased from 11.2 mL/min (IQR, 4.5-14.4) to 17.2 mL/min (IQR, 6.1-23.7) immediately after US-FHR (median difference, +4.1 mL/min [95% CI, +2.5 to +8.9; P = 0.001]), although transient. One patient experienced transient bleeding that was promptly controlled. In this single-arm feasibility study, US-FHR around the target artery was simple and safe to perform and was associated with reduced neck pain. Because the study lacked a control group, these preliminary findings should be regarded as hypothesis-generating and require confirmation in controlled trials; they may also inform the future evaluation of MPS in other anatomical regions. Trial registration: UMIN Clinical Trials Registry, UMIN000053612.

Nerve injury causes an imbalance of glutamatergic excitation over GABAergic inhibition, contributing thereby to lasting neuropathic pain. Transgenic GAD67-GFP knock-in reporter mice were developed to visualize GABAergic interneurons. The knock-in into glutamate decarboxylase (GAD67) causes haploinsufficiency that manifest in low GABA levels. In this model, we studied if diminished GABA exacerbates neuropathic pain after nerve injury. Adolescent male and female GAD67-GFP knock-in mice were subjected to Spared Sciatic Nerve Injury (SNI). At baseline, nociception and thermal preferences were equal but after SNI, GAD67-GFP mice developed thermal allodynia which was not detected in wildtype littermates. At the electrophysiology level, SNI caused a partial decrease in the excitability in layer 2/3 pyramidal neurons in the projection-hemisphere in wildtype mice. This effect was exacerbated in GAD67-GFP, affecting both sides, and was accompanied with imbalance of field-potential (FP) amplitudes between projection and non-projection hemisphere, which did not occur in wildtype mice. The results suggest that GABA deficiency can be compensated to protect from hyperexcitability at baseline, but it cannot be further upscaled, ultimately leading to network hyperactivity after injury. Metabolomic studies confirmed the moderate loss of GABA in ipsi- and contralateral cortex and lumbar spinal cord of GAD67-GFP mice and failure to raise GABA in the ipsilateral dorsal horn after injury. Carnosine, cystathionine, and glutathione, three important anti-oxidative metabolites, were co-reduced with GABA suggesting that GABAergic activity and anti-oxidative capacity are interconnected and failure of this axis contributes to neuropathic "pain".

Chronic pelvic pain (CPP) affects up to 26% of women worldwide. While its pathophysiology is poorly understood, disturbances in body perception have been identified in various similar chronic musculoskeletal disorders. The Fremantle Perineal Awareness Questionnaire (FrePAQ) is a novel tool designed to specifically assess disturbed body perception in the pelvic region, but its structural validity and reliability require formal evaluation. Methods: Patient partners with lived experience contributed to study design. Participants with (n=417 and without (n=277) chronic pelvic pain completed the FrePAQ at baseline, as well as one week later. We assessed the validity and reliability of the FrePAQ following COSMIN guidelines for Classical Test Theory. Results: The validated FrePAQ comprises a two factor model, with a six item Distress & Disconnection (D&D) subscale and a two item Size & Shape (S&S) subscale. Confirmatory analysis showed excellent fit (CFI = .988; RMSEA = .048) and measurement invariance between diagnostic groups. Internal consistency was high (cronbach alpha = .838 CPP, .819 controls). Test retest reliability was high for D&D (ICC = .863) and acceptable for S&S (ICC = .695). FrePAQ scores showed a weak to moderate correlation with pain scores (r = .234 to .255), psychological distress (r = .226 to .443), and functional impact (r = .172 to .295), particularly for the D&D subscale. Conclusion: The FrePAQ is a reliable and valid instrument to measure perineal perceptual disturbances in CPP. Future research will evaluate the tools potential to support phenotyping and guide individualised interventions. Improved understanding of body perception disturbance in CPP can enhance diagnosis and treatment precision.

Cannabidiol (CBD) is a non-psychoactive component of cannabis that has been studied as a potential therapy for chronic pain. CBD attenuates behavioral hypersensitivities in models of neuropathic pain, and promotes production of bioactive lipids (e.g., anandamide), altering lipid signaling. However, a lack of understanding of the mechanisms underlying the therapeutic effects of CBD has hindered development and application of CBD to mechanism-based therapies for pain in people. We asked whether the analgesics effects of CBD were dependent upon the enzyme NAPE-PLD. We used a mouse model of chemotherapy-induced peripheral neuropathy (CIPN) to evaluate the acute and chronic antinociceptive effects of CBD and investigate its mechanisms. Pharmacological specificity was tested with antagonists targeting CB1, CB2, PPAR{gamma}, and PPAR receptors. Mechanisms were further examined using NAPE-PLD and GPR55 knockout mice. We also assessed repeated CBD dosing during both the development and maintenance of paclitaxel-induced CIPN in wild-type, GPR55 KO, and NAPE-PLD KO mice. CBD suppressed paclitaxel-induced behavioral hypersensitivities; these effects were attenuated by a PPAR and PPAR{gamma} antagonists, but not CB1 or CB2 antagonists. CBD reduced both the development and maintenance of neuropathic nociception in a model CIPN in wild-type mice, but these effects were absent in NAPE-PLD KO mice. By contrast, anti-allodynic efficacy of CBD was fully preserved in GPR55 KO mice. Pharmacological blockade of the PPAR receptor and genetic deletion of NAPE-PLD abolished the antinociceptive effects of CBD in a model of CIPN, suggesting a pivotal role for NAPE-PLD and PPAR receptors in CBD-mediated analgesia in chemotherapy-induced neuropathic pain.