S64 The Journal of Pain
and naloxone-induced changes in touch pleasantness were signifi-
cantly more correlated with subsequent mood and anxiety ratings
than were changes during saline (mood p = 0.04; anxiety p < 0.01).
This suggests that during opioid blockade pleasant touch more
strongly impacts mood, and may be more anxiolytic, potentially
explaining the desirability of pleasant touch in previous studies. 1.
Case et al., eneuro, 2016.
(358) The Effects of Pleasant, Chill-Inducing Music on Acute
Pain in Healthy Volunteers: An fMRI Study
M. Shpaner, H. Perelman, J. Mantegna, M. Naylor, and B. Wang;
University of Vermont
Pleasant music has been shown to attenuate the perception of pain
intensity. To better understand the mechanism of this perceptual
effect, we examined neural responses to acute thermal pain in the
presence of pleasant chill-inducing music, using functional Mag-
netic Resonance Imaging. Individual moderate pain levels (7 out of
10 on a Numerical Rating Scale) were first determined in nineteen
healthy volunteers (both sexes, mean age 22§2.5). Prior to the scan-
ning session, participants provided their own favorite chill-inducing
musical excerpts. Painful stimulation of moderate intensity, admin-
istered at the peak of the pleasure-invoking response (i.e., the
chill), was contrasted to the same painful stimulation presented
alone and in the context of neutral (artificially constructed) music.
At the end of the experiment, participants retrospectively rated
pain intensity and emotional unpleasantness of the pain presented
in different contexts. Consistent with prior research, pain intensity
and unpleasantness were lower in the presence of chill-inducing
music. Regions of the pain neuromatrix, such as the insular cortex
(IC), secondary somatosensory cortex, and dorsal anterior cingulate
cortex (ACC), were less active for pain presented alone or with neu-
tral music than to pain presented in the context of chill-inducing
music. Documented functional changes within the pain neuroma-
trix reflect multisensory mechanisms that modulate pain intensity.
(359) Resilience and Pain-Related Areas in the Brain:
Consideration of Sex and Ethnic/Race Differences
A. Johnson, J. Tanner, E. Terry, J. Cardoso, C. Garvan, R. Staud,
G. Deutsch, H. Deshpande, S. Lai, B. McEwen, B. Goodin, C. Price,
R. Fillingim, and K. Sibille; University of Florida
In adults with osteoarthritis, clinical pain and disability have been
shown to differ across sex and ethnicity/race. Recent evidence also
indicates changes in pain-related brain structure across these
groups. Resilience is associated with lower pain and greater func-
tioning. However, the relationship between resilience and the
brain is not well understood. We investigated if resilience was asso-
ciated with pain-related brain structure in individuals with/without
knee pain and if patterns differed by sex and ethnicity/race. Study
participants included 171 individuals (mean age 57.97§8.50;
62 male/109 female; 72 Non-Hispanic Black (NHB)/99 Non-Hispanic
White (NHW) with and without knee pain. Participants completed
measures of resilience: biobehavioral (tobacco use and waist/hip
ratio) and psychosocial (optimism, affect, coping, perceived stress,
and social support). Responses were dichotomized based on pub-
lished norms/means and summed, creating a composite resilience
score. High and low resilience was defined by median split. T1-
weighted MRI data were processed using FreeSurfer for a priori
region analyses. Potential covariates included age, sex, race, study
site, education level, body mass index, and chronic pain severity
based on the FITT index (frequency, intensity, time/duration, and
total pain sites). MANCOVAs were completed for analyses. The
high and low resilience groups differed in amygdala volume
(p=0.021) with trends for medial prefrontal cortex (MPFC; p=0.064)
and thalamus (p=0.094). Males with high resilience had thicker
MPFC than low resilience males (p=0.037). Females with high resil-
ience had larger amygdala than low resilience females (p=0.005).
NHB with high resilience had larger amygdala (p=0.025) and a
trend for thicker somatosensory cortex (p=0.064). NHW with high
resilience had a trend for thicker insula (p=0.081). Preliminary find-
ings indicate resilience may be associated with pain-related brain
structure. Sex and ethnic/race group differences were also
observed. Prospective research is needed to elucidate the influence
of resilience on the experience of pain, neurobiological underpin-
nings, and sex and ethnicity/race differences.
Abstracts
Treatment Approaches (Complementary
& Alternative)
(360) Can CBD Reduce the Use of Pain Medication? Lessons
from a Survey in a Pain Clinic Environment
T. Moeller-Bertram, J. Schilling, C. Hughes, M. Wallace, M. Sexton, and
M. Backonja; Vitamed Research, LLC
During the past decade, Cannabis derivatives in pain medicine have
been of increasing interest. Specifically, the non-psychoactive Can-
nabidiol (CBD) has received recent attention. CBD has been used as
a treatment for childhood epilepsy, chronic pain, and anxiety disor-
ders, and presents a unique situation in healthcare: patients may
be more familiar with it than their physician. We asked patients
and staff in the environment of seven pain clinics in Southern Cali-
fornia about their knowledge, beliefs, and personal experience sur-
rounding CBD products. After IRB review (exempt status) we
utilized the internet survey platform SurveyMonkey to administer
the survey online. Our participants were 45.26§14.02 (Mean§SD)
years old, the majority identified as white, has an annual household
income of less than $20,000, and is insured by Medicare or Medic-
aid. Among our participants, 63% report to have tried a CBD prod-
uct (including products containing THC) and 37.30% of these
answered that the used CBD product did not contain THC. Of these,
the majority responded that CBD products have helped their condi-
tion (57.45%) and reduced their pain medication (61.7%), includ-
ing opioids (44.68%). Among the pain conditions patients reported
relieve were back pain (63.83%), nerve pain (38.30%), neck pain
(38.30%), migraines (29.79%), limb pain (19.15%), fibromyalgia
(19.15%), and other (19.15%). Overall, participants familiarity with
the dosing of their CBD product varied. Generally, participants
believe CBD is a good treatment option, and not harmful. The over-
all attitude and experience of participants regarding CBD products
was positive and CBD only was reported to reduce pain medication,
including opioids. With the voluntary nature of a survey design
come some study limitations that warrant attention. However,
studies like this can help identify areas of interest for future
research and more controlled research has to follow. Supported by
a grant from Versea Pharmaceuticals
(361) Acupuncture: Could this be a Non-Narcotic Option to
Improve Pain?
C. Heritage, J. Kram, K. Heslin, K. Fairchild, J. Burns, and E. Michelson;
Aurora Sinai Medical Center
Acupuncture has been used for centuries by practitioners around
the world for treatment of a variety of conditions. Even so, limited
studies have evaluated the patient population that utilizes acu-
puncture. We aimed to explore the associations between patient
characteristics and utilization of acupuncture services, as well as
treatment outcomes. We conducted an exploratory retrospective
study of adult patients in a large, eastern Wisconsin medical system
that either (1) received acupuncture referral and treatment, (2)
received acupuncture referral only, or (3) received treatment only,
during 1/2005 - 6/2016. Basic descriptive statistics were performed.
Chi-square tests were used to analyze the categorical variables, and
t-tests were used to analyze the continuous variables. Among the
1,161 patients identified, 1,057 were seen for a pain related diag-
nosis of which 93.4% (987) were referred to acupuncture services.
The majority of referrals for pain were ordered by primary care
(40.5%) and orthopedic (37.3%) physicians. Those who were
referred and attended a visit for pain (375; 35.5%) in comparison to
those referred only were more likely to be older (57.0 vs 51.9 years;
p=<0.0001), be Caucasian (86.7% vs 79.3%; p=0.01), have a history
of cancer (9.9% vs 2.0%; p=<0.0001), and have a history of trauma
(65.9% vs 51.5%; p=<0.0001). Overall, 445 patients with pain had a
visit with an acupuncturist regardless of referral. After the first visit,
patients were more likely to complete additional visits if referred
(87.7% vs 75.7% not referred; p=0.01). Patients who were not
referred were more likely to be on opioids or psychotherapeutics
(38.6% vs 22.1%; p=0.03). Notably, 75.7% of patients who received
acupuncture services for pain reported improvement in symptoms,
regardless of medication use. Ultimately, patients who receive acu-
puncture services are more likely to complete additional acupunc-
ture visits if they were referred, and acupuncture is likely to
improve pain symptoms.

(362) ED Acupuncture: Feasibility, Acceptability, and Impact
on Pain
J. Kram, J. Burns, V. Xiong, J. StarkCasadont, T. Mullen, N. Conway, and
D. Baumgardner; Aurora Health Care, Inc.
When patients present to the emergency department (ED) for pain,
conventional treatment is often limited to prescription medica-
tions. Hospitals are now seeking non-pharmacological manage-
ment options for acute pain due to the opioid crisis. Our quality
improvement study aimed to determine the feasibility of implant-
ing an employed acupuncturist within an urban ED to provide acu-
puncture as a nonpharmacological acute pain management option
and to determine the impact of acupuncture on acute pain reduc-
tion. To our knowledge, few ED acupuncture models exist world-
wide. Limited information has been reported about acceptance of
acupuncture in the ED setting by physicians and patients, and it is
unknown if there is enough time for acupuncture during the ED
visit. The ED selected for this study had an average 1.5-2 hour wait
time for treatment and annually treated an average of 34,000
patients of which 66% presented with an emergency severity index
between 3-5(ESI; highest severity [1] - lowest severity [5]). In 2017,
acupuncture services were offered to adult patients with ED physi-
cian approval based on their ESI level and reason for visit. Patient
self-reported pre- and post-acupuncture pain scores (i.e., no pain
[0] - worst pain [10]) were compared using paired t-tests. Multivari-
able regression models were also constructed. A total of 706
patients were approached, of which 379 (53.7%) consented to
receive acupuncture services. Overall, patients presented with a
median ESI score of 3, and 53.6% did not receive opioids at any
time during their ED visit. Mean pain score improvement (6.5 vs.
3.4; p<0.001) was not impacted by receipt of opioids during the ED
visit (p=0.948). Ultimately, ED acupuncture was well received by
both patients and physicians and enrollment was higher than antic-
ipated. ED acupuncture also significantly decreased pain regardless
of whether a patient received opioids during their ED visit.
Treatment Approaches (Medical/
Interventional)
(363) Antidepressant Use in Patients with a History of
Depression is Associated with Reduced Opioid Use after Total
Knee Arthroplasty
J. Starr, T. BBaker, M. Backonja, and I. Rozel; University of Washington
Chronic post-surgical pain (CPSP) affects up to 40% of patients
and is associated with prolonged postoperative opioid use.
Depression is one risk factor for CPSP, but it is unknown if antide-
pressants modulate the risk for CPSP or prolonged postoperative
opioid use in patients undergoing procedures at high-risk for
CPSP. This retrospective cohort study utilized the records of Vet-
erans Affairs patients who underwent a total knee arthroplasty
(TKA) between April 2012 − April 2016. Selective serotonin reup-
take inhibitor (SSRI) and serotonin-norepinephrine reuptake
inhibitor (SNRI) use was recorded. Exclusion criteria were no
depression diagnosis, opioid use preoperatively, other antide-
pressant use, and chronic pain diagnoses. Outcomes included
morphine equivalents through postoperative day one and opioid
use through 30, 90, and 365 days after surgery. Generalized lin-
ear models were created to adjust for confounding covariates,
and a secondary analysis stratified outcomes by antidepressant
class. The study cohort included 1,655 TKAs after applying all
exclusion criteria, and it was 90.6% male and 77.1% white with a
mean age of 65 years. Patients meeting inclusion criteria and
using an SSRI or SNRI comprised 454 cases (27.4%). After adjust-
ment for age, BMI, sex, race, general or regional anesthesia,
non-opioid adjunct pain medication use, and comorbidities
recorded in the VA Surgical Quality Improvement Program (VAS-
QIP), SSRI or SNRI use was associated with reduced opioid use
through 30 days after surgery (OR = 0.74 (0.57, 0.95), p = 0.020).
In the secondary analysis, SSRI use was associated with reduced
opioid use through 90 days after surgery compared to SNRI use
(OR = 0.35 (0.14, 0.89), p = 0.022). Perioperative SSRI or SNRI use,
in patients with depression, is associated with reduced prescrip-
tion opioid use 30 days after TKA. Prospective research is war-
ranted to elucidate if there is a role for antidepressants as non-
opioid analgesics in specific surgical populations.
The Journal of Pain S65
(364) Administration of Pre-Operative Gabapentin to Patients
Undergoing Laparoscopy: A Double-Blind, Placebo-Controlled
Randomized Trial
A. Benton, G. Harkins, C. Stetter, A. Kunselman, T. Deimling, and K. Riley;
Penn State Health - Milton S Hershey Medical Center
The objective of this study was to determine the influence of imme-
diate pre-operative gabapentin on postoperative pain in patients
undergoing laparoscopy for benign gynecologic indications. We
completed a double-blind, placebo controlled, randomized trial at
an academic tertiary care hospital. One-hundred-nine gynecologic
patients undergoing laparoscopy between June 2015 and January
2016 were included in our study. We randomized 109 patients to
receive pre-operative gabapentin (300mg) or placebo. The
patients were stratified based on a history of chronic pelvic pain.
Pain scores were assessed at 2, 4, 6 and 8 hours post-operatively as
well as post-operative days 1-7. We found no difference between
the groups in terms of age, body mass index, gravidity, parity, or
past surgical history. Post-operative pain was assessed using the
numeric pain rating scale (NRS), rated as 0-10, and the visual analog
scale (VAS), rated as 0-100. These values were adjusted for mor-
phine dose received. Findings included, no significant difference in
pain scores at any of the immediate post-operative hours. A sec-
ondary analysis stratified by procedure, hysterectomy or operative
laparoscopy, showed no significant difference in pain scores. There
was also no significant difference in pain scores on post-operative
days one through seven. In this study, a single dose of pre-opera-
tive gabapentin did not significantly decrease post-operative pain
in gynecologic patients undergoing laparoscopy for benign indica-
tions. The study was supported in part by an award from The Penn
State Hershey Department of Obstetrics and Gynecology.
(365) Is it Exercise or Pain Associated with Exercise that Leads
to Hypoalgesia?
K. Rudolph, E. Jacobsen, T. Nelson, and C. Welsh; University of New
England
The opioid epidemic has brought attention to the pain relieving
effect of exercise, but exercise prescription for pain relief may be
quite different from that typically recommended for cardiovascular
and other health benefits. Exercise induced hypoalgesia (EIH) is
complex and not entirely understood but possible mechanisms
include the opioid and non-opioid systems. Hypoalgesia is also
known to occur in response to pain itself. Conditioned pain modu-
lation (CPM) is the inhibition of pain from a test stimulus by a pain-
ful conditioning stimulus. Studies of EIH often involve exercise
paradigms in which long duration muscle contractions are used.
Long duration muscle contractions are often painful so it raises the
question, “Is it exercise or the pain associated with exercise that
leads to EIH?” Nine individuals underwent pain testing on the right
and left knees and middle finger before and after three conditions:
10 voluntary isometric contractions, 10 contractions elicited by neu-
romuscular electrical stimulation (NMES) and 10 bursts of noxious
electrical stimulation without muscle contraction all on the right
quadriceps muscles. The contractions or stimuli lasted 10 s sepa-
rated by 50 s off. The average pain rating (0-100 VAS) during the
noxious stimulation (84.4 +/- 12.1) was higher than during the
NMES elicited contractions (61.4 +/- 18.9; p=0.001). Subjects
reported no pain during the volitional contractions. The force of
the contractions is reported in % maximum voluntary contraction
(%MVIC) and the volitional contraction force averaged 59.6 (+/-
18.0) % MVIC while the NMES elicited contraction force averaged
52.0 (+/-14.5) % MVIC. Hypoalgesia was observed in the right and
left knees response to the noxious stimulation and NMES elicited
contractions but not the volitional contractions. The results suggest
that the hypoalgesia associated with the NMES elicited contractions
was due to the noxious nature of the contractions and that the
mechanism involves spinal mechanisms.
(366) Opioid Prescription Practices in the Setting of Pediatric
Fractures
E. Wynia, and J. Schrock; MetroHealth
Opioids are frequently prescribed to children with fractures.
Although much research has been done surrounding the use of
opioids in adult populations, use of opioids among children is
much less understood. The purpose of this study was to investigate