Papers by Abid Azam
In an era of considerable advances in anaesthesiology and pain medicine, chronic pain after major... more In an era of considerable advances in anaesthesiology and pain medicine, chronic pain after major surgery continues to be problematic. This article briefly reviews the known psychological risk and protective factors associated with the development of chronic postsurgical pain (CPSP). We begin with a definition of CPSP and then explain what we mean by a risk/protective factor. Next, we summarize known psychological risk and protective factors for CPSP. Psychological interventions that target risk factors and may impact postsurgical pain are reviewed, including the acceptance and commitment therapy (ACT)-based approach to CPSP prevention and management we use in the Transitional Pain Service (TPS) at the Toronto General Hospital. Finally, we conclude with recommendations for research in risk factor identification and psychological interventions to prevent CPSP. Several pre-surgical psychological risk factors for CPSP have been consistently identified in recent years. These include negative affective constructs, such as anxiety symptoms, depressive symptoms, pain catastrophizing and general psychological distress. In contrast, relatively few studies have examined psychological protective factors for CPSP. Psychological interventions that target known psychological risk factors while enhancing protective psychological factors may reduce new incidence of CPSP. The primary goal of our ACT intervention is to teach patients a mindful way of responding to their postsurgical pain that empowers them to interrupt the negative cycle of pain, distress, behavioural avoidance and escalating opioid use that can limit functioning and quality of life while paradoxically amplifying pain over time. Early clinical outcome data suggest that patients who receive care from TPS physicians reduce their pain and opioid use, yet patients who also receive our ACT intervention have a larger decrease in daily opioid dose while reporting less pain interference and lower depression scores.
Objectives: The present study examined relationships among gaze behaviour and cardiac vagal tone ... more Objectives: The present study examined relationships among gaze behaviour and cardiac vagal tone using a novel stress-inducing task.
Methods: Participants’ (N = 40) eye movements and heart rate variability (HRV) were measured during an unsolvable computer-based task randomly presenting feedback of “Right” and “Wrong” answers distinctly onscreen after each trial. Subgroups were created on the basis of more frequent eye movements to the right (“Correct”-Attenders; n = 23) or wrong (“Incorrect”-Attenders; n = 17) areas onscreen.
Results: Correct-Attenders maintained HRV from baseline to the stress task. In contrast, Incorrect-Attenders spent significantly more time viewing “Wrong” feedback, exhibited a reduction in HRV during the stress condition (p < .01), and were more likely to negatively self-evaluate performance.
Conclusions: Results demonstrate that pervasive attention to negative feedback (“Wrong”) elicits perseverative stress and negative self-evaluations among university students. This study highlights the potential for studying attentional biases and emotional distress through combined measures of gaze behaviour and cardiac vagal tone.
Background: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public... more Background: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public health concerns. Aims: The Toronto General Hospital Transitional Pain Service (TPS) is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. This clinical practice–based study reports on preliminary outcomes of the TPS psychology program, which provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use. Methods: Ninety-one patients received ACT, whereas 252 patients did not (no ACT group). Patient outcomes were compared for the two groups at first and last TPS visits. Pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use were analyzed using two-way (Group [ACT, no ACT] × Time [first, last visit]) analyses of variance (ANOVAs). Results: Patients referred to ACT were more likely to report a mental health condition preoperatively (P < 0.001), had higher opioid use (P < 0.001) at the first postsurgical visit, and reported higher sensitivity to pain traumatization (P < 0.05) and anxiety (P < 0.05) than the no ACT group at both time points. Both groups showed reductions in pain, pain interference, pain catastrophizing, anxiety, and opioid use by the last TPS visit (P < 0.05). The ACT group demonstrated greater reductions in opioid use and pain interference and showed reductions in depressed mood (P = 0.001) by the end of treatment compared to the no ACT group. Conclusion: Preliminary outcomes suggest that ACT was effective in reducing opioid use while pain interference and mood improved.
In an era of growing concern about opioid prescribing, the postsurgical period remains a critical... more In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.
Background: Current research suggests that associations between headache conditions (migraine, te... more Background: Current research suggests that associations between headache conditions (migraine, tension) and imbalances in the autonomic nervous system (ANS) are due to stress-related dysregulation in the activity of the parasympathetic-sympathetic branches. Mindfulness meditation has demonstrated effectiveness in reducing pain-related distress, and in enhancing heart rate variability-a vagal-mediated marker of ANS balance. This study examined HRV during cognitive stress and mindfulness meditation in individuals with migraine and tension headaches. Methods: Undergraduate students with tension and migraine headaches (n = 36) and headache-free students (n = 39) were recruited for an experiment involving HRV measurement during baseline, cognitive stress-induction, and after randomization to post-stress conditions of audio-guided mindfulness meditation practice (MMP) or mindfulness meditation description (MMD). HRV was derived using electrocardiograms as the absolute power in the high frequency bandwidth (ms 2 ). A three-way ANOVA tested the effects of Group (headache vs. headachefree), Phase (baseline, stress, & post-stress), and Condition (MMP vs. MMD) on HRV. Results: ANOVA revealed a significant three-way interaction. Simple effects tests indicated: 1) HRV increased significantly from stress to MMP for headache and headache-free groups (p b 0.001), 2) significantly greater HRV for headache (p b 0.001) and headache-free (p b 0.05) groups during MMP compared to MMD, and 3) significantly lower HRV in the headache vs. headache-free group during the post-stress MMD condition (p b 0.05). Discussion: Results suggest mindfulness practice can promote effective heart rate regulation, and thereby promote effective recovery after a stressful event for individuals with headache conditions. Moreover, headache conditions may be associated with dysregulated stress recovery, thus more research is needed on the cardiovascular health and stress resilience of headache sufferers.
Aim:
To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in ... more Aim:
To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital.
Methods:
200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery.
Results:
51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood.
Conclusion:
Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.
F1000 - Post-publication peer review of the biomedical literature, 2000
F1000 - Post-publication peer review of the biomedical literature, 2000
F1000 - Post-publication peer review of the biomedical literature, 2000
Increases in university-based mental health problems require alternative mental health programs, ... more Increases in university-based mental health problems require alternative mental health programs, applicable to students with elevated psychological risks due to personality traits. This study examined the cognitive-emotional outcomes of a university mindfulness
meditation (MM) program and their relationship with Self-Criticism (SC), a personality factor linked to depressive vulnerability. University students (n = 71) were assessed at baseline with the Depressive Experiences Questionnaire (DEQ), a measure of depressive personality traits, and two outcome measures: Profile of Mood States (POMS) and Anxiety Sensitivity Index (ASI). Students attending the MM program were reassessed for outcomes at 3 follow up
assessments over 2 semesters. Repeated measures analyses of variance revealed improved within-subjects effects with large or very large effect sizes for the subsample that completed the MM program (n = 18) on the POMS Tension-Anxiety, POMS Depression, POMS
Fatigue, and Anxiety Sensitivity Index. Multiple linear regression using self-criticism as a predictor of change in depressed mood revealed that higher self-criticism predicted greater reductions in POMS Depression. This study provides evidence for MM-related cognitive-emotional benefits, suggesting that students with elevated self-critical traits may derive exceptional benefits evident in greater reductions of depressed mood.
Heart rate variability (HRV) is a vagal nerve-mediated biomarker of cardiac function used to inve... more Heart rate variability (HRV) is a vagal nerve-mediated biomarker of cardiac function used to investigate chronic illness, psychopathology, stress and, more recently, attention-regulation processes such as meditation. This study investigated HRV in relation to maladaptive perfectionism, a stress-related personality factor, and mindfulness meditation, a stress coping practice expected to elevate HRV, and thereby promote relaxation. Maladaptive perfectionists (n=21) and healthy controls (n=39) were exposed to a lab-based assessment in which HRV was measured during (1) 5-minute baseline resting phase (2) a 5-minute cognitive stress-induction phase, and (3) a post-stress phase. In the post-stress phase, participants were randomly assigned to a 10-minute audio-instructed mindfulness meditation condition or a 10-minute rest condition with audio-description of mindfulness meditation. Analyses revealed a significant elevation in HRV during meditation for controls but not for Perfectionists. These results suggest that mindfulness meditation promotes relaxation following cognitive stress and that the perfectionist personality hinders relaxation possibly because of decreased cardiac vagal tone. The results are discussed in the context of developing psychophysiological models to advance therapeutic interventions for distressed populations.
University education confronts students with stressful developmental challenges that can lead to ... more University education confronts students with stressful developmental challenges that can lead to mental health problems. Innovative programs must address an increasing prevalence of these problems but are impeded by the high costs involved. In this study, thirty-nine undergraduate students attended weekly one hour mindfulness meditation tutorials during a single (14 week) semester. Tutorials involved 40 minutes of guided meditation, followed by open-ended discussions on mindfulness and related scientific research. Multiple regression analysis tested associations between self-reported changes in mindfulness, in negative automatic thoughts and in satisfaction with life. Reductions in automatic thoughts accounted for a significant proportion of variance in life satisfaction and decreases in automatic thoughts were associated with an increased life satisfaction. This finding suggests guided meditation tutorials merit consideration in promoting student mental health on university campuses.
Conference Presentations by Abid Azam
RESULTS METHODS Chronic pain occurs in ~10% of patients following cardiac surgery [1]. Little is ... more RESULTS METHODS Chronic pain occurs in ~10% of patients following cardiac surgery [1]. Little is known about sensory processing changes related to chronic post-surgical pain (CPSP). Quantitative sensory testing (QST) is comprised of methods to assess differential responses to noxious/non-noxious stimulation. This cross-sectional study examined QST measures in patients who had undergone coronary artery bypass graft surgery (CABGS) at least 6 months earlier. 367 patients (Age M = 66.05 years, SD = 11.58; 75% Male) underwent CPSP assessment and were grouped for presence of chronic pain at CABGS sites (CPSP; n = 133), other chronic pain (OCP; n = 97), or no pain (NP; n = 137). Pain detection thermal (cold/heat pain) thresholds (TPT) were measured at the chest and right forearm. Cold pressor task (CPT) was conducted with one arm submerged in cold water (M = 1.47 degrees Celsius, SD = .77) until pain was intolerable. Pain intensity and unpleasantness ratings were obtained using a 0-10 numeric rating scale seconds after CPT arm withdrawal. One-way ANOVAs were conducted followed by Bonferroni post-hoc comparisons (α<.017). Figure 1. Coronary artery bypass graft procedure Group differences were found for the following: 1) Thermal Pain Threshold Forearm A. Heat (F(2, 197) = 6.81, p = .001) B. Cold (F(2, 197) = 3.19, p < .05) (Figure 1) 2) Cold Pressor Pain Test A. Pain intensity (F(2, 199) = 6.42, p < .005) (Figure 2a) B. Pain unpleasantness (F(2, 199) = 5.60, p < .005) (Figure 2b) Results summary: CPSP group had lower heat TPT-forearm pain thresholds compared to OCP (p = .016) and NP (p = .001) groups, and higher cold TPT-forearm thresholds compared to NP group (p = .01). CPSP group had higher CPT pain intensity (p < .001) and unpleasantness (p = .001) compared to NP group.
Chronic post-surgical pain (CPSP) leads to significant disability [1]. Research is needed on psyc... more Chronic post-surgical pain (CPSP) leads to significant disability [1]. Research is needed on psychological processes that support people with CPSP in improving pain-related disability. One proposed process is pain acceptance [2], characterized as the willingness to experience pain without attempting to control or avoid it. For people with CPSP, pain acceptance may reduce disability by fostering greater re-engagement with valued life activities. The purpose of this study was to test the mediating role of pain acceptance in the relationship between pain intensity and disability in patients who had undergone coronary artery bypass graft surgery (CABGS) at least 6 months earlier.
N = 133 patients (Age M = 62.67 years, SD = 11.74; 72% Male) reported CPSP. Pain intensity was measured using a 0-10 scale. Disability was measured using the Pain Disability Index. Pain acceptance was measured using the Chronic Pain Acceptance Questionnaire. Mediation with pain acceptance (mediator), pain intensity (predictor), and disability (outcome) was tested according to Hayes (2016) specifications.
Pain intensity was positively correlated with disability (r = .44, p < .001) and inversely correlated with pain acceptance (r = -.45, p < .001). The mediation model revealed pain acceptance was a significant inverse predictor of disability (β = -.73, p < .001), while the direct effect of pain intensity on disability was not significant (β = .11, p = .22), supporting a full mediation.
Results demonstrate that pain acceptance mediates the relationship between pain and disability in CPSP patients. Acceptance- based chronic pain interventions may assist sufferers in engaging in flexible and committed patterns of valued activities.
• Research indicates that mindfulness-based interventions are effective in improving clinical out... more • Research indicates that mindfulness-based interventions are effective in improving clinical outcomes in individuals with chronic pain, depression, and anxiety conditions (Hofmann, Sawyer, Witt, & Oh, 2010). • Research assessing the immediate anxiety-related benefits of mobile-based mindfulness practices for individuals living with these conditions is still in its infancy. • The present study tested the effects of a newly developed 12minute mindful breathing mobile app on anxiety levels in 154 university students (age 17 to 38 yrs, M = 20.1, SD = 3.3).
Moderate-to-severe chronic postsurgical pain (CPSP) develops in between 5 and 10% of patients one... more Moderate-to-severe chronic postsurgical pain (CPSP) develops in between 5 and 10% of patients one year after major surgeries, causing significant pain-related distress and disability. After hospital discharge, patients are commonly prescribed opioids for postsurgical pain
relief which can lead to adverse effects such opioid-induced hyperalgesia, withdrawal symptoms (e.g. muscle aches, cramping), and opioid dependency. The negative sequelae of postsurgical pain can be
prevented through communication and intervention by pain specialists in the critical 3-month period after surgery. Unfortunately, most patients are too ill or physically limited after surgery to access pain management services, creating needless suffering and raising risks for CPSP and opioid misuse.
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Papers by Abid Azam
Methods: Participants’ (N = 40) eye movements and heart rate variability (HRV) were measured during an unsolvable computer-based task randomly presenting feedback of “Right” and “Wrong” answers distinctly onscreen after each trial. Subgroups were created on the basis of more frequent eye movements to the right (“Correct”-Attenders; n = 23) or wrong (“Incorrect”-Attenders; n = 17) areas onscreen.
Results: Correct-Attenders maintained HRV from baseline to the stress task. In contrast, Incorrect-Attenders spent significantly more time viewing “Wrong” feedback, exhibited a reduction in HRV during the stress condition (p < .01), and were more likely to negatively self-evaluate performance.
Conclusions: Results demonstrate that pervasive attention to negative feedback (“Wrong”) elicits perseverative stress and negative self-evaluations among university students. This study highlights the potential for studying attentional biases and emotional distress through combined measures of gaze behaviour and cardiac vagal tone.
To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital.
Methods:
200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery.
Results:
51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood.
Conclusion:
Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.
meditation (MM) program and their relationship with Self-Criticism (SC), a personality factor linked to depressive vulnerability. University students (n = 71) were assessed at baseline with the Depressive Experiences Questionnaire (DEQ), a measure of depressive personality traits, and two outcome measures: Profile of Mood States (POMS) and Anxiety Sensitivity Index (ASI). Students attending the MM program were reassessed for outcomes at 3 follow up
assessments over 2 semesters. Repeated measures analyses of variance revealed improved within-subjects effects with large or very large effect sizes for the subsample that completed the MM program (n = 18) on the POMS Tension-Anxiety, POMS Depression, POMS
Fatigue, and Anxiety Sensitivity Index. Multiple linear regression using self-criticism as a predictor of change in depressed mood revealed that higher self-criticism predicted greater reductions in POMS Depression. This study provides evidence for MM-related cognitive-emotional benefits, suggesting that students with elevated self-critical traits may derive exceptional benefits evident in greater reductions of depressed mood.
Conference Presentations by Abid Azam
N = 133 patients (Age M = 62.67 years, SD = 11.74; 72% Male) reported CPSP. Pain intensity was measured using a 0-10 scale. Disability was measured using the Pain Disability Index. Pain acceptance was measured using the Chronic Pain Acceptance Questionnaire. Mediation with pain acceptance (mediator), pain intensity (predictor), and disability (outcome) was tested according to Hayes (2016) specifications.
Pain intensity was positively correlated with disability (r = .44, p < .001) and inversely correlated with pain acceptance (r = -.45, p < .001). The mediation model revealed pain acceptance was a significant inverse predictor of disability (β = -.73, p < .001), while the direct effect of pain intensity on disability was not significant (β = .11, p = .22), supporting a full mediation.
Results demonstrate that pain acceptance mediates the relationship between pain and disability in CPSP patients. Acceptance- based chronic pain interventions may assist sufferers in engaging in flexible and committed patterns of valued activities.
relief which can lead to adverse effects such opioid-induced hyperalgesia, withdrawal symptoms (e.g. muscle aches, cramping), and opioid dependency. The negative sequelae of postsurgical pain can be
prevented through communication and intervention by pain specialists in the critical 3-month period after surgery. Unfortunately, most patients are too ill or physically limited after surgery to access pain management services, creating needless suffering and raising risks for CPSP and opioid misuse.
Methods: Participants’ (N = 40) eye movements and heart rate variability (HRV) were measured during an unsolvable computer-based task randomly presenting feedback of “Right” and “Wrong” answers distinctly onscreen after each trial. Subgroups were created on the basis of more frequent eye movements to the right (“Correct”-Attenders; n = 23) or wrong (“Incorrect”-Attenders; n = 17) areas onscreen.
Results: Correct-Attenders maintained HRV from baseline to the stress task. In contrast, Incorrect-Attenders spent significantly more time viewing “Wrong” feedback, exhibited a reduction in HRV during the stress condition (p < .01), and were more likely to negatively self-evaluate performance.
Conclusions: Results demonstrate that pervasive attention to negative feedback (“Wrong”) elicits perseverative stress and negative self-evaluations among university students. This study highlights the potential for studying attentional biases and emotional distress through combined measures of gaze behaviour and cardiac vagal tone.
To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital.
Methods:
200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery.
Results:
51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood.
Conclusion:
Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.
meditation (MM) program and their relationship with Self-Criticism (SC), a personality factor linked to depressive vulnerability. University students (n = 71) were assessed at baseline with the Depressive Experiences Questionnaire (DEQ), a measure of depressive personality traits, and two outcome measures: Profile of Mood States (POMS) and Anxiety Sensitivity Index (ASI). Students attending the MM program were reassessed for outcomes at 3 follow up
assessments over 2 semesters. Repeated measures analyses of variance revealed improved within-subjects effects with large or very large effect sizes for the subsample that completed the MM program (n = 18) on the POMS Tension-Anxiety, POMS Depression, POMS
Fatigue, and Anxiety Sensitivity Index. Multiple linear regression using self-criticism as a predictor of change in depressed mood revealed that higher self-criticism predicted greater reductions in POMS Depression. This study provides evidence for MM-related cognitive-emotional benefits, suggesting that students with elevated self-critical traits may derive exceptional benefits evident in greater reductions of depressed mood.
N = 133 patients (Age M = 62.67 years, SD = 11.74; 72% Male) reported CPSP. Pain intensity was measured using a 0-10 scale. Disability was measured using the Pain Disability Index. Pain acceptance was measured using the Chronic Pain Acceptance Questionnaire. Mediation with pain acceptance (mediator), pain intensity (predictor), and disability (outcome) was tested according to Hayes (2016) specifications.
Pain intensity was positively correlated with disability (r = .44, p < .001) and inversely correlated with pain acceptance (r = -.45, p < .001). The mediation model revealed pain acceptance was a significant inverse predictor of disability (β = -.73, p < .001), while the direct effect of pain intensity on disability was not significant (β = .11, p = .22), supporting a full mediation.
Results demonstrate that pain acceptance mediates the relationship between pain and disability in CPSP patients. Acceptance- based chronic pain interventions may assist sufferers in engaging in flexible and committed patterns of valued activities.
relief which can lead to adverse effects such opioid-induced hyperalgesia, withdrawal symptoms (e.g. muscle aches, cramping), and opioid dependency. The negative sequelae of postsurgical pain can be
prevented through communication and intervention by pain specialists in the critical 3-month period after surgery. Unfortunately, most patients are too ill or physically limited after surgery to access pain management services, creating needless suffering and raising risks for CPSP and opioid misuse.