Multidisciplinary Treatment of Benign Chronic Pain Syndrome in Substance Abusing Patients

Perspectives on the opioid crisis from pain medicine clinicians

Patients experiencing a terminal drug related event reflect a sentinel event. If this pharmacotherapy is a widely used agent, it may be viewed as a catastrophic problem. If patients are dying from illegal drug use when the medical establishment fails them by withdrawing or minimizing their medically prescribed medication, then the burden rests with their health care providers, legislation, and insurance carriers to actively participate in a collegial fashion to achieve parity. Causing a decay in functionality in previously functional patients, may occur with appropriately prescribed opioid medications addressing non-cancer pain when withdrawing or diminishing either with or without patient consent. The members of the medical profession have diminished their prescribing of opioids for their patients out of apparent fear of reprisal, state or federal government sanctions, and other concerned groups. Diminishing former dosages or deleting the opioid medication, preferably in concert with the patient, often results in inequitable patient care. Enforcing sanctioned decreases or ceasing to prescribe from their former required/established opioid medications precipitate patient discord. In absence of opioid misuse, abuse, diversion or addiction based upon medical "guidelines" and with a poor foundation of Evidence Based Medicine the CDC guidelines, it may be masked as a true guideline reflecting a decrement of clinical judgment, wisdom, and compassion. This article also discusses the role of pharmacy chains, insurance carriers, and their pharmacy benefit managers (PBMs) contribution to this multidimensional problem. There may be a potential solution, identified in this paper, if all the associated political, medical and insurance groups work cohesively to improve patient care. This article and the CDC guidelines are not focused at hospice, palliative, end of life care pain management.

Development of the Italian version of the 42-item Chronic Pain Coping Inventory, CPCI-I: cross-cultural adaptation, factor analysis, reliability and validity

PURPOSE

The aim of this study was to translate and adapt the Italian version of the Chronic Pain Coping Inventory (CPCI) and validate the translation in subjects with chronic non-specific pain of the locomotor system.

METHODS

The questionnaire was developed following international recommendations. The psychometric analyses included factor analysis, reliability by internal consistency (Cronbach's alpha) and test-retest reliability (intraclass coefficient correlation, ICC), and construct validity by calculating the correlations between the subscales of the CPCI with measures of pain (numerical rating scale, NRS), disability (SIP-Roland Scale) and depression (CES-D) (Pearson's correlation).

RESULTS

The CPCI was satisfactorily administered to 270 subjects with chronic non-specific pain. Results of confirmatory factor analyses revealed that, of the CPCI-I 8 subscales, 6 demonstrated good data-model fit (CFI and NFI ≥ 0.90, RMSEA ≤ 0.08). Cronbach's alpha was satisfactory in all of the subscales (0.71-0.80); the ICCs were good/excellent in all of the subscales (0.80-0.91). The correlations with the NRS, SIP-Roland and CES-D were poor in most cases as only the CPCI-Guarding subscale moderately correlated with disability (r = 0.31).

CONCLUSION

The CPCI was successfully translated into Italian and proved to have a good factorial structure and psychometric properties similar to the original and adapted versions. The use of the Italian version of the CPCI is recommended for clinical and research purposes.

Further validation of the chronic pain coping inventory

Multidisciplinary treatment programs for chronic pain typically emphasize the importance of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Support. A previous validation study with 210 patients in a Canadian academic hospital setting supported an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564 veterans with a more extended history of chronic pain. Patients completed the study questionnaires before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed with depression, pain interference, general activity level, disability, and pain severity as the criterion variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demographic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and the regression analyses supported the predictive validity of the CPCI scales, as indicated by their association with measures of patient adjustment to chronic pain.

PERSPECTIVE

This article validated the 8-factor structure of the CPCI by using a confirmatory factor analysis and a series of linear regressions. The results support the applicability and utility of the CPCI in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral pain coping strategies that might have an impact on patient outcomes.