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Vora A, Kennedy-Spaien E, Gray S, Estudillo-Guerra AM, Phillips G, Mesia-Toledo I, Glenn M, Chin BS, Morales-Quezada L. Interdisciplinary pain program participants with high catastrophizing scores improve function utilizing enriched therapeutic encounters and integrative health techniques: a retrospective study. Front Psychol 2024; 15:1448117. [PMID: 39355290 PMCID: PMC11443975 DOI: 10.3389/fpsyg.2024.1448117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/28/2024] [Indexed: 10/03/2024] Open
Abstract
Introduction Pain catastrophizing describes helplessness, rumination, and magnification of a pain experience. High pain catastrophizing is an independent risk factor for disability, pain severity, inadequate treatment response, chronicity, and opioid misuse. Interdisciplinary pain programs (IPPs) are beneficial and cost-effective for individuals with chronic pain, but their functional impact on individuals with high pain catastrophizing is not well established. The emerging field of placebo studies suggests that patient-provider relationships, positive treatment expectations, and sociobiologically informed care trigger physiological responses that may enhance therapeutic interventions. Methods In this retrospective observational cohort study, we compared admission and discharge data for 428 adults with high-impact chronic pain (mean 8.5 years) who completed the Spaulding-Medford Functional Restoration Program (FRP). The interdisciplinary FRP team of physiatrists, behavioral health clinicians, physical therapists, and occupational therapists specializes in evidenced-based conventional rehabilitation, integrative health, and pain psychoeducation via enriched therapeutic encounters, fostering collaboration, validation, trust, self-efficacy, and positive expectations. Clinical outcome measures included the Canadian Occupational Performance Measure (COPM) assessing functional performance (COPM-PS) and satisfaction with function (COPM-SS), the Pain Numeric Rating Scale (NRS), the Pain Catastrophizing Scale (PCS), and the Patient Health Questionnaire-9 (PHQ-9). Results FRP participants with clinically elevated catastrophizing at baseline (PCS ≥30, mean PCS 39) achieved statistically significant improvements in function (mean delta -2.09, CHI2 = 15.56, p < 0.001), satisfaction with function (COPM-SS mean delta -2.50, CHI2 = 7.42, p = 0.007), pain (NRS mean delta 2.7), mood (PHQ-9 mean delta 1.87, p = 0.002), and catastrophizing (PCS mean delta 4.16, p < 0.001). Subgroup analysis revealed racial disparities in pain scores, and exploratory analysis showed a trend toward reducing opiate consumption. Discussion Despite the known association of adverse outcomes with high catastrophizing, FRP participation was associated with increased productive engagement, reduced pain, reduced maladaptive thought processes, and improved mood. Although causation and efficacy cannot be established from a retrospective design, this is the first study to identify functional improvement in patients with high-impact chronic pain and clinically relevant high pain catastrophizing who participate in an IPP combining conventional and complementary rehabilitation with psychoeducation. These enriched therapeutic encounters may enhance the treatment process by promoting trust, empathy, collaboration, and beneficial reframing of patients' experiences, expectations, and goals.
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Affiliation(s)
- Ariana Vora
- Spaulding Integrative Health Initiative, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Eve Kennedy-Spaien
- Spaulding Integrative Health Initiative, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Pain and Functional Restoration Program, Spaulding Rehabilitation Hospital, Medford, MA, United States
- Department of Occupational Therapy, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Sarah Gray
- Harvard Medical School, Boston, MA, United States
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Anayali Maria Estudillo-Guerra
- Harvard Medical School, Boston, MA, United States
- Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, United States
| | - Gabriele Phillips
- Pain and Functional Restoration Program, Spaulding Rehabilitation Hospital, Medford, MA, United States
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, United States
| | | | - Mel Glenn
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Bridget S Chin
- Spaulding Integrative Health Initiative, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- College of Human Medicine, Michigan State University, East Lansing, MI, United States
| | - Leon Morales-Quezada
- Spaulding Integrative Health Initiative, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, United States
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Coffee Z, Cheng K, Slebodnik M, Mulligan K, Yu CH, Vanderah TW, Gordon JS. The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:794. [PMID: 38929040 PMCID: PMC11203961 DOI: 10.3390/ijerph21060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.
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Affiliation(s)
- Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| | - Kevin Cheng
- College of Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Kimberly Mulligan
- Veterans Health Administration, Central California, Fresno, CA 93706, USA
| | - Chong Ho Yu
- Department of Mathematics, Hawaii Pacific University, Honolulu, HI 96813, USA;
| | - Todd W. Vanderah
- Department of Pharmacology, Comprehensive Center for Pain and Addiction, University of Arizona, Tucson, AZ 85721, USA;
| | - Judith S. Gordon
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
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Konzelmann M, Vuistiner P, Burrus C, Luthi F, Léger B. Analgesic consumption in a large sample of people in musculoskeletal rehabilitation: A descriptive study. Ann Phys Rehabil Med 2024; 67:101776. [PMID: 38118341 DOI: 10.1016/j.rehab.2023.101776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 04/15/2023] [Accepted: 06/03/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Consumption of opioids is increasing worldwide in people with chronic non-cancer pain, although their effectiveness is debated. OBJECTIVES The aim of the current study was to evaluate analgesic consumption and its association with different variables (demographic variables, pain, anxiety/depression, catastrophism, and kinesiophobia), in the field of musculoskeletal rehabilitation, where no data are available. METHODS This was a retrospective study over a period of 8 years on people hospitalised for rehabilitation after injury. Participants were classified into 3 categories: no analgesics (NA), non-opioid analgesics (NOA), and opioid analgesics (OPA). ANOVA or chi-squared tests were used to compare the 3 groups. RESULTS A total of 4,350 people (84% men; mean [SD] age, 44 [11] years) were included. In total, 20% were taking OPA, 40% NOA and 40% NA. In the OPA group, tramadol was mainly used, and the morphine equivalent median dose was 8.3 mg/day. In the NOA group, paracetamol and ibuprofen were mostly used. Symptoms increased progressively across the 3 groups (NA/NOA/OPA), with increased levels of pain severity/interference, anxiety/depression and catastrophizing, and a higher prevalence of neuropathic pain in the OPA group versus the others. CONCLUSIONS These results are consistent with those found in groups of people with chronic pain taking larger doses of opioids and following opioid reduction or cessation programs. Opioid prescription did not increase over the 8 years, which was reassuring. These factors are important to emphasise because they can be modified in the rehabilitation setting with interdisciplinary management. REGISTRATION Our database was registered on Mendeley Data.
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Affiliation(s)
- Michel Konzelmann
- Research service. Clinique Romande de réadaptation, Sion, Switzerland; Assessment and consultation service. Clinique Romande de réadaptation, Sion, Switzerland.
| | | | - Cyrille Burrus
- Research service. Clinique Romande de réadaptation, Sion, Switzerland; Rehabilitation of locomotor apparatus service. Clinique Romande de réadaptation, Sion, Switzerland
| | - François Luthi
- Rehabilitation of locomotor apparatus service. Clinique Romande de réadaptation, Sion, Switzerland; Department of locomotor apparatus. Hôpital Orthopédique, Lausanne. Switzerland
| | - Bertrand Léger
- Research service. Clinique Romande de réadaptation, Sion, Switzerland
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Gagnon CM, Yuen M, Palmer K. An Exploration of Physical Therapy Outcomes and Psychometric Properties of the Patient-Specific Functional Scale After an Interdisciplinary Pain Management Program. Clin J Pain 2023; 39:663-671. [PMID: 37712294 DOI: 10.1097/ajp.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/24/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVES The Patient-Specific Functional Scale (PSFS) has been used to assess physical functioning in various chronic pain populations. There is a lack of evidence for its use with diverse pain populations who have high-impact chronic pain (HICP). The primary aim of this study was to assess the psychometric properties of the PSFS with a heterogeneous sample of patients with HICP. MATERIALS AND METHODS A retrospective observational study of prospective functional outcomes collected before and after participation in an intensive pain management program: PSFS, Disabilities of the Arm, Shoulder, and Hand, Lower Extremity Functional Scale, Neck Disability Index, Oswestry Disability Index, multidimensional patient impression of change, pain intensity, pain limitation, and fear-avoidance from the charts of 509 intensive pain management program completers. The reliability, validity, and responsiveness of the PSFS were analyzed using Cronbach α, Pearson correlations, and receiver operating characteristics. RESULTS Statistically significant improvements were found for all outcomes after program participation (all P < 0.0001). Correlations of the PSFS with similar outcomes (convergent validity) were lower than expected ( r = 0.16 to 0.33). A low correlation ( r = -0.12) with an unrelated measure, fear avoidance, supported divergent validity. PSFS change score correlations with similar outcome measures ranged from 0.46 to 0.53. The area under the curve values for the PSFS ranged from 0.801 to 0.857, suggesting a moderate ability for the PSFS to detect improvement. DISCUSSION The psychometric properties of the PSFS showed mixed support for construct validity but good support for the responsiveness of the PSFS when used with a heterogeneous sample of patients with HICP.
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Affiliation(s)
- Christine M Gagnon
- Shirley Ryan AbilityLab
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL
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Hamilton M, Gnjidic D, Christine Lin CW, Jansen J, Weir KR, Shaheed CA, Blyth F, Mathieson S. Opioid deprescribing: Qualitative perspectives from those with chronic non-cancer pain. Res Social Adm Pharm 2022; 18:4083-4091. [DOI: 10.1016/j.sapharm.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/06/2022] [Accepted: 07/24/2022] [Indexed: 11/24/2022]
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Bhattacharya D, Whiteside H, Tang E, Kantilal K, Loke Y, Atkins B, Hill C. A review of trial and real-world data applying elements of a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids. Br J Clin Pharmacol 2022; 88:4019-4042. [PMID: 35561033 PMCID: PMC9543530 DOI: 10.1111/bcp.15379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022] Open
Abstract
This evidence synthesis applying realist concepts and behavioural science aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid‐tapering interventions and services from a 2018 international systematic review and a 2019 England‐wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid‐tapering success. A stakeholder group (n = 23) generated draft programme theories based around the 14 domains of the Theoretical Domains Framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified 6 programme theories comprising 5 behavioural mechanisms: prescribers' knowledge about how to taper; build prescribers' beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all 6 mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive‐based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.
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Affiliation(s)
- Debi Bhattacharya
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | | | - Emma Tang
- School of Pharmacy, University of East Anglia, Norwich, UK
| | - Kumud Kantilal
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Bethany Atkins
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | - Caroline Hill
- School of Pharmacy, University of East Anglia, Norwich, UK
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Stein BD, Sherry TB, O'Neill B, Taylor EA, Sorbero M. Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain: Prevalence and Associated Factors. J Gen Intern Med 2022; 37:1603-1609. [PMID: 34608565 PMCID: PMC9130349 DOI: 10.1007/s11606-021-07119-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors. METHODS Using 2017-2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics. RESULTS We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty. CONCLUSIONS Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.
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Affiliation(s)
- Bradley D Stein
- RAND Corporation, Pittsburgh, PA, USA.
- University of Pittsburgh School of Medicine, Pittsburgh, USA.
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Engelberg-Cook E, Hu D, Kurklinsky S, Mack A, Sletten CD, Qu W, Osborne MD. Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1056-1065. [PMID: 34820597 PMCID: PMC8601967 DOI: 10.1016/j.mayocpiqo.2021.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE To analyze opioid intake interference with psychological, well-being, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Pain Rehabilitation Program (MCPRP) in Florida. PATIENTS AND METHODS A retrospective study on MCPRP outcomes was conducted. We reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to fill out a survey at admission to and dismissal from the program. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Center for Epidemiological Studies-Depression Scale, Pain Catastrophizing Scale, 36-Item Short-Form Health Status Survey (general health perceptions subscale), and Pain Self-Efficacy Questionnaire. A medical record review identified categories and number of medications at program admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did not include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group). RESULTS By dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a significant (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially higher percentage in the opioids group. CONCLUSION Benefit of the comprehensive pain rehabilitation program in patients with fibromyalgia was indicated by clinical improvements in pain severity, physical and emotional health, and functional capacity while successfully tapering medication. Opioid intake at admission may modify the program outcomes.
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Key Words
- CESD, Center for Epidemiological Studies–Depression Scale
- CSS, central sensitization syndrome
- FM, fibromyalgia
- MCPRP, Mayo Clinic Comprehensive Pain Rehabilitation Program
- MPI, Multidimensional Pain Inventory
- NO, no opioids on admission
- NSAID, nonsteroidal anti-inflammatory drug
- OME, oral morphine equivalent
- OP, opioids on admission
- PCS, Pain Catastrophizing Scale
- PSEQ, Pain Self-Efficacy Questionnaire
- SF-36, 36-Item Short-Form Health Status Survey
- SS, Symptom Severity Scale
- WPI, Widespread Pain Index
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Affiliation(s)
| | - Danqing Hu
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | | | - Anwar Mack
- Department of Pain Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Wenchun Qu
- Department of Pain Medicine, Mayo Clinic, Jacksonville, FL
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Hobelmann JG, Huhn AS. Comprehensive pain management as a frontline treatment to address the opioid crisis. Brain Behav 2021; 11:e2369. [PMID: 34555260 PMCID: PMC8613403 DOI: 10.1002/brb3.2369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/31/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The opioid crisis continues to devastate individuals and communities in the United States and abroad. While there have been several measures to address the over-prescription of opioid analgesics, the number of overdose deaths related to prescription opioids has not changed appreciably in the last 10 years. Comprehensive (or multidisciplinary) pain recovery programs consist of providers from multiple backgrounds that treat pain on an individual level through a combination of approaches including physical therapy, emotional and spiritual support, cognitive behavioral therapy, and non-opioid pharmacotherapies. Because there is a dynamic interplay between a given chronic pain patient and multiple providers, comprehensive pain programs are not as "standardized" as other medical treatments because they are meant to meet the individual needs of each patient and their specific pain diagnoses Methods: Review of the literature. RESULTS There is evidence that comprehensive pain treatment can reduce pain severity and improve functioning; comprehensive pain treatment can be used to treat those with post-surgical pain, thus preventing the onset of non-medical opioid use and opioid use disorder, and in persons with chronic pain who are on long-term opioid therapy, as a method to reduce or eliminate opioid medication use. Comprehensive pain recovery programs were abundant for a period from the 1960s through the 1980s, but for a variety of reasons, they became financially unsustainable as the national reimbursement environment evolved. CONCLUSIONS In the context of the protracted and deadly opioid crisis, revitalizing and expanding comprehensive pain treatment should be considered as a frontline approach to treat chronic pain.
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Affiliation(s)
- Joseph Gregory Hobelmann
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Ashley Addiction TreatmentHavre de GraceMarylandUSA
| | - Andrew S. Huhn
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Ashley Addiction TreatmentHavre de GraceMarylandUSA
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Pudalov LR, Krause SJ, Heinberg LJ, Hogue O. Refractory Chronic Pain and Obesity: Promising Implications for Multidisciplinary Pain Rehabilitation. PAIN MEDICINE 2021; 22:2290-2297. [PMID: 33565599 DOI: 10.1093/pm/pnab055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Individuals with obesity frequently contend with chronic pain, but few studies address the clinical impact of coordinated pain services on this population. The current study addresses this topic by comparing the effectiveness of a comprehensive pain rehabilitation program for patients with and without obesity. METHODS A retrospective analysis of registry data was conducted. Obesity was considered as one of three weight groups, based on the following body mass index cutoffs: normal weight (18.5 to < 25 kg/m2), overweight (25 to < 30 kg/m2), and obese (> 30 kg/m2). These groups were compared on the Pain Severity Ratings (PSR) Scale, the Pain Disability Index (PDI), and the Depression, Anxiety, Stress Scales-Short Form (DASS-SF). RESULTS Groups differed on baseline pain disability and depression. Patients with obesity had higher scores on both the PDI (P = .028) and the DASS-SF depression subscale (P = .006). Contrary to the hypothesis, after controlling for baseline score and sex there were no significant differences between weight groups with regards to PSR, PDI, or any DASS-SF subscale at discharge. At 1-year follow-up, individuals who were overweight and obese had significantly more anxiety compared to individuals whose weight was in the normal range. CONCLUSIONS Multidisciplinary pain rehabilitation programs appear to be an effective treatment intervention for patients who have concomitant chronic pain and obesity, to a degree comparable to patients who have chronic pain but do not contend with obesity. Implications for program development, clinical interventions, and future research are discussed.
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Affiliation(s)
| | - Steven J Krause
- Case Western Reserve University, Department of Psychiatry, Cleveland, Ohio
| | - Leslie J Heinberg
- Cleveland Clinic Lerner College of Medicine, Department of Psychiatry and Psychology, Cleveland, Ohio
| | - Olivia Hogue
- Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, Ohio, USA
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Schumann ME, Coombes BJ, Gascho KE, Geske JR, McDermott MC, Morrison EJ, Reynolds AL, Bernau JL, Gilliam WP. Pain Catastrophizing and Pain Self-Efficacy Mediate Interdisciplinary Pain Rehabilitation Program Outcomes at Posttreatment and Follow-Up. PAIN MEDICINE 2021; 23:697-706. [PMID: 34519826 DOI: 10.1093/pm/pnab271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/15/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Decreasing pain catastrophizing and improving self-efficacy to self-manage chronic pain symptoms are important treatment targets in the context of interdisciplinary cognitive behavioral therapy for chronic pain. Greater pain catastrophizing has been shown to be associated with greater impact of pain symptoms on functioning, while conversely, greater pain self-efficacy has been associated with lower pain intensity and lower levels of disability. OBJECTIVE To prospectively evaluate interdisciplinary cognitive behavioral therapy for pain outcomes, as well as to the mediating effects of both pain catastrophizing and pain self-efficacy on outcome. METHODS Participants were 315 patients with chronic pain between April 2017 and April 2018 who completed a three-week interdisciplinary pain rehabilitation program. Pain severity, pain interference, pain catastrophizing, pain self-efficacy, quality of life, and depressive symptom questionnaires, and measures of physical performance were assessed at pre- and posttreatment. Follow-up questionnaires were returned by 163 participants. Effect size and reliable change analyses were conducted from pre- to posttreatment and pretreatment to 6-month follow-up. Mediation analyses were conducted to determine the mediating effect of pain catastrophizing and pain self-efficacy on pain outcome. RESULTS Significant improvements from pre- to posttreatment in pain outcomes were observed, and over 80% evidenced reliable change in at least one pain-relevant measure. Pain catastrophizing and pain self-efficacy mediated the relationship between changes in pain outcomes. CONCLUSIONS Interdisciplinary pain rehabilitation is an effective treatment and decreasing pain catastrophizing and increasing pain self-efficacy can influence maintenance of treatment gains.
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Affiliation(s)
- Matthew E Schumann
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Brandon J Coombes
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Keith E Gascho
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jennifer R Geske
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Mary C McDermott
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleshia J Morrison
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Andrea L Reynolds
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jessica L Bernau
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Wesley P Gilliam
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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13
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Silva MJ, Coffee Z, Yu CH, Martel MO. Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain-Results from a Preliminary Study. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:2106-2116. [PMID: 33595642 PMCID: PMC8427345 DOI: 10.1093/pm/pnab069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe differences between patients with chronic, non-cancer pain (CNCP) who were successfully able to cease full mu agonist chronic opioid analgesic therapy (COAT), and those who exhibited refractory COAT reliance, among those who participated in a multidisciplinary program designed for COAT cessation. DESIGN A retrospective review of electronic medical records (EMR) data was organized for preliminary analysis. SETTING A multicenter private practice specializing in CNCP, which received patient referrals from the surrounding geographical area of primary and specialty care offices in Northern California. SUBJECTS Data from 109 patients with CNCP who participated in a multidisciplinary program to cease COAT between the dates of October 2017 to December 2019 were examined. METHODS EMR data, pre-COAT cessation, of oral morphine milligram equivalence (MME) and validated questionnaire responses assessing anxiety and fear-based beliefs and behavior, as well as opioid misuse, were extracted and compared between those who successfully ceased COAT and those who did not. RESULTS Patients who were unsuccessful at COAT cessation reported significantly higher Fear Avoidance Beliefs Questionnaire (FAB) scores. No significant differences were found based on incoming MME amounts, Current Opioid Misuse Measure (COMM) or Tampa Scale of Kinesiophobia (TSK) scores. Pain Catastrophizing Scale (PCS) scores showed a split pattern with unclear significance. CONCLUSIONS Results suggest that fear avoidance beliefs and behavior, as measured by the FAB, play a significant role in refractory COAT reliance for patients with CNCP.
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Affiliation(s)
- Marcelina Jasmine Silva
- Founder and former Medical Director of The Focus on Opioid Transitions Program, Integrated Pain Management Medical Group Inc, Walnut Creek, California, USA
| | - Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, Arizona, USA
| | - Chong Ho Yu
- Department of Behavioral and Applied Science, Azusa Pacific University, Azusa, California, USA
| | - Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Quebec, Canada
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14
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Adverse Childhood Experiences and Chronic Pain Rehabilitation Treatment Outcomes in Adults. Clin J Pain 2021; 37:321-329. [PMID: 33830091 DOI: 10.1097/ajp.0000000000000924] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/22/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) are commonly reported by individuals with chronic pain. However, little is known about how ACE exposure influences treatment outcomes. The goal of the current study was to evaluate group and treatment-related differences among adults with varying levels of ACE exposure participating in a pain rehabilitation treatment program. METHODS Adult participants (N=269) were categorized as 0 ACEs (n=65), 1 to 2 ACEs (n=87), or ≥3 ACEs (n=117). Participants completed self-report measures of pain, physical functioning, and psychosocial functioning at intake and discharge from a 10-week interdisciplinary pain rehabilitation program. RESULTS ACE exposure was frequently endorsed in this sample, with the majority of participants (78.5%) reporting at least 1 form of childhood adversity. Adults in the ≥3 ACEs group reported a greater level of impairment in mental health symptoms and adjustment to chronic pain; however, all groups endorsed treatment improvements and there were no differences in response to treatment. There were also no differences between groups on measures of pain or physical functioning at intake or discharge. DISCUSSION ACE exposure appears common among treatment-seeking adults with chronic pain and is associated with increased clinical complexity. However, adults with and without exposure to ACEs endorsed significant improvements in pain and functioning following participation in an interdisciplinary pain rehabilitation program. This model of treatment may be especially well situated to address the biopsychosocial contributions to pain among those with a history of adversity.
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15
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Craner JR, Flegge LG, Lake ES, Perra AEA. Patients with Clinically Elevated Depressive Symptoms Report Improvements in Mood, Pain, and Functioning following Participation in Interdisciplinary Pain Rehabilitation. PAIN MEDICINE 2021; 23:362-374. [PMID: 34343314 DOI: 10.1093/pm/pnab242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Chronic pain and depression frequently co-occur and exacerbate one another; therefore, it is important to treat both conditions to improve patient outcomes. The current study evaluates an interdisciplinary pain rehabilitation program (IPRP) with respect to the following questions: 1) How do clinically elevated depressive symptoms impact pain-related treatment outcomes? and 2) To what extent does IPRP participation yield reliable and clinically significant change in depressed mood? METHODS Participants in this study included 425 adults who engaged in a 10-week IPRP and completed self-report measures of pain, mood, and functioning at intake and discharge. Participants were categorized into 4 groups based on self-reported depressive symptoms (PROMIS Depression): within normal limits (WNL; n = 121), Mild (n = 115), Moderate (n = 153), and Severe (n = 36). RESULTS Participants reported significant improvement in pain, pain-related life interference, health-related quality of life, pain catastrophizing, and depressed mood regardless of initial symptom level. In addition, 43.4% of patients with Mild, Moderate, or Severe depressed mood reported reliable and clinically significant improvement in depressive symptoms and 30.3% were in remission at the end of treatment. CONCLUSIONS These findings support the assertion that IPRPs represent an effective treatment for patients with comorbid chronic pain and depression and that participation is associated with improvement in both conditions.
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Affiliation(s)
- Julia R Craner
- Mary Free Bed Rehabilitation Hospital, 235 Wealthy St. SE, Grand Rapids, MI, 49503.,Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, 49503
| | - Lindsay G Flegge
- Mary Free Bed Rehabilitation Hospital, 235 Wealthy St. SE, Grand Rapids, MI, 49503.,Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, 49503
| | - Eric S Lake
- Mary Free Bed Rehabilitation Hospital, 235 Wealthy St. SE, Grand Rapids, MI, 49503
| | - Arianna E A Perra
- Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, 49503.,Mary Free Bed Rehabilitation Hospital at Munson Medical Center, 5191 Rosewood Dr., Traverse City, MI, 49684
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16
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Pudalov LR, Martin-Fernandez K, Krause S, Heinberg L. The Relationship Between Presurgical Pain and Early Postbariatric Surgery Outcomes. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2021.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Lauren R. Pudalov
- Department of Pain Medicine and Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Steven Krause
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio, USA
| | - Leslie Heinberg
- Department of Psychiatry and Psychology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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17
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Estudillo-Guerra MA, Mesia-Toledo I, Schneider JC, Morales-Quezada L. The Use of Conditioning Open-Label Placebo in Opioid Dose Reduction: A Case Report and Literature Review. FRONTIERS IN PAIN RESEARCH 2021; 2:697475. [PMID: 35295534 PMCID: PMC8915754 DOI: 10.3389/fpain.2021.697475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Adequate pain management for inpatients in rehabilitation units is essential for achieving therapeutic goals. Opioid treatments are commonly prescribed, but these are associated with numerous adverse effects, including the risk of addiction and decreased quality of life. Conditioning an open-label placebo is a promising approach to extend the analgesic effect of the opioid while reducing its overall dosage. Objectives: To describe a patient's experience in using conditioning open-label placebo (COLP) as a pharmaco-behavioral intervention to decrease opioid intake and its side effects after inpatient rehabilitation discharge, and to perform a literature review about the use of open-label placebo in pain. Methods: This case study has been extracted from a clinical trial initiated in 2018. A 61-year-old male was recruited at a tertiary rehabilitation hospital after suffering a traumatic sport-related injury and orthopedic surgery. Pain management included prescription of non-steroidal anti-inflammatory drugs (NSAIDs) and short-acting oxycodone. After trial participation, the patient requested off-label COLP treatment to help him decrease outpatient opioid utilization. Results: After COLP treatment, the patient could discontinue oxycodone intake (a reduction from 15 morphine equivalents/day) after rehabilitation discharge. Moreover, opioid side effects decreased from 46 to 9 points on the numerical opioid side-effects scale. A literature review identified five clinical trials using "honest" open-label placebo (OLP) or COLP as an experimental intervention for pain control. From these studies, two were in the area of chronic lower back pain, one in post spine surgery, one in irritable bowel syndrome, and another in spinal cord injury and polytrauma. Four studies reported positive outcomes related to pain control, while one study showed no significant differences in pain management between treatment-as-usual and the COLP group. Conclusion: The case report illustrates how a pharmaco-behavioral intervention can facilitate downward opioid titration safely after inpatient rehabilitation. It initiates a discussion about new approaches for opioid management using conditioning and the patient's expectation of pain relief.
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Affiliation(s)
| | | | | | - Leon Morales-Quezada
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, MA, United States
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18
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Wartko PD, Boudreau DM, Turner JA, Cook AJ, Wellman RD, Fujii MM, Garcia RC, Moser KA, Sullivan MD. STRategies to Improve Pain and Enjoy life (STRIPE): Protocol for a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy. Contemp Clin Trials 2021; 110:106499. [PMID: 34217889 DOI: 10.1016/j.cct.2021.106499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/05/2021] [Accepted: 06/28/2021] [Indexed: 10/21/2022]
Abstract
High-dose, long-term opioid therapy (LtOT) is associated with risk for serious harms. Rapid opioid discontinuation may lead to increased pain, psychological distress, and illicit opioid use, but gradual, supported opioid taper may reduce these risks. We previously demonstrated that an opioid taper support and pain coping skills training intervention reduced opioid dose more than usual care (43% vs 19% dose reduction from baseline), with no increase in pain intensity and a significant reduction in activity interference. We aim to adapt and test this intervention in the Kaiser Permanente Washington healthcare system with STRategies to Improve Pain and Enjoy life (STRIPE), a pragmatic, randomized trial. Our goal was to randomize 215 participants on moderate-high dose (≥40 morphine milligram equivalent/day) LtOT to either cognitive-behavioral therapy-based pain coping skills training involving 18 telephone sessions over 52 weeks with optional opioid taper support or usual care. Data are collected from electronic health records, claims, and self-report. The primary outcomes are mean daily opioid dose and the pain intensity, interference with enjoyment of life, and interference with general activity (PEG) score at 12 months (primary time point) and 6 months (secondary time point). Secondary outcomes include having ≥30% opioid dose reduction from baseline, and patient-reported problem opioid use, opioid-related difficulties, pain self-efficacy, opioid craving, global impression of change, and anxiety and depressive symptoms at 6 and 12 months. If effective, this treatment could reduce opioid exposure and associated risks to patients, families, and communities while offering patients an alternative for managing pain. Trial registration: The study was first registered at Clinicaltrials.gov on November 16, 2018 (identifier: NCT03743402).
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America.
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America; Department of Pharmacy, University of Washington, Seattle, WA, United States of America; Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Judith A Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
| | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America; Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Robert D Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Monica M Fujii
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Robin C Garcia
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Kathryn A Moser
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Mark D Sullivan
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
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19
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Regular dosing compared with as-needed dosing of opioids for management of chronic cancer pain: systematic review and meta-analysis. Pain 2021; 161:703-712. [PMID: 31770157 DOI: 10.1097/j.pain.0000000000001755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Opioids are the recommended form of analgesia for patients with persistent cancer pain, and regular dosing "by the clock" is advocated in many international guidelines on cancer pain management. The development of sustained-release opioid preparations has made regular dosing easier for patients. However, patients report that the intensity and impact of their cancer pain varies considerably day to day, and many try to find a trade-off between acceptable pain control and impact of cognitive (and other) adverse effects on daily activities. In acute care settings, (eg, postoperative) as-needed dosing and other opioid-sparing approaches have resulted in better patient outcomes compared with regular dosing. The aim of this study was to determine whether regular dosing of opioids was superior to as-needed dosing for persistent cancer pain. We systematically searched for randomised controlled trials that directly compared pain outcomes from regular dosing of opioids with as-needed dosing in adult cancer patients. We identified 4347 records, 25 randomised controlled trials meet the inclusion criteria, 9 were included in the review, and 7 of these included in meta-analysis. We found no clear evidence demonstrating superiority of regular dosing of opioids compared with as-needed dosing in persistent cancer pain, and regular dosing was associated with significantly higher total opioid doses. There was, however, a paucity of trials directly answering this question, and low-quality evidence limits the conclusions that can be drawn. It is clear that further high-quality clinical trials are needed to answer this question and to guide clinical practice.
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20
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Reducing the use of opioids by patients with chronic pain: an effectiveness study with long-term follow-up. Pain 2021; 161:509-519. [PMID: 31764391 DOI: 10.1097/j.pain.0000000000001763] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study addresses the problem of long-term opioid use by chronic pain patients. The study involved a secondary analysis of unanalyzed data from a published study of 2 versions of cognitive-behavioural therapy-based interdisciplinary treatment for chronic pain. In this study, we examined whether the use of opioids by 140 chronic pain patients could be ceased sustainably over 12 months after participation in the comprehensive interdisciplinary pain management program aimed at enhancing pain self-management. On admission to the treatment, there were no significant differences between those patients taking or not taking opioids on usual pain, pain interference in daily activities, pain-related disability, depression severity, as well as in pain cognitions. After the treatment, the use of opioids was significantly reduced, both in numbers taking any and in mean doses, and these gains were maintained over the 12-month follow-up. Finally, cessation of opioids during treatment was associated with more substantial and consistent improvements in usual pain, depression severity, pain interference, pain-related disability, and pain cognitions, relative to those who reduced their opioids but did not cease them. These findings support the idea of using training in pain self-management strategies as a viable alternative to long-term opioid use by patients with chronic pain.
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21
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Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review. J Gen Intern Med 2020; 35:935-944. [PMID: 33145689 PMCID: PMC7728933 DOI: 10.1007/s11606-020-06253-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/17/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide. METHODS We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking. RESULTS We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown. DISCUSSION The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.
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22
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Gagnon CM, Scholten P, Atchison J, Jabakhanji R, Wakaizumi K, Baliki M. Structural MRI Analysis of Chronic Pain Patients Following Interdisciplinary Treatment Shows Changes in Brain Volume and Opiate-Dependent Reorganization of the Amygdala and Hippocampus. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2765-2776. [PMID: 32488262 PMCID: PMC8463093 DOI: 10.1093/pm/pnaa129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE The present study examined pre- to post-treatment changes in volumes for brain structures known to be associated with pain processing (thalamus, caudate, putamen, pallidum, hippocampus, amygdala, and accumbens) following an interdisciplinary pain management program. DESIGN Twenty-one patients participating in a four-week interdisciplinary pain management program completed the study. The program consisted of individual and group therapies with the following disciplines: physical therapy, occupational therapy, pain psychology, biofeedback/relaxation training, nursing lectures, and medical management. All patients underwent functional magnetic resonance imaging of the brain before the start and at completion of the program. They also completed standard outcome measures assessing pain, symptoms of central sensitization, disability, mood, coping, pain acceptance, and impressions of change. RESULTS Our results showed a significant increase in total brain volume, as well as increased volumes in the thalamus, hippocampus, and amygdala. As expected, we also found significant improvements in our standard outcome measures. The majority of patients rated themselves as much or very much improved. The increase in volume in the hippocampus was significantly associated with patient perceptions of change. However, the correlations were in the unexpected direction, such that greater increases in hippocampal volume were associated with perceptions of less improvement. Further exploratory analyses comparing patients by their opioid use status (use vs no use) showed differential program effects on volume increases in the hippocampus and amygdala. CONCLUSIONS These findings show that a four-week interdisciplinary pain management program resulted in changes in the brain, which adds objective findings further demonstrating program efficacy.
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Affiliation(s)
- Christine M Gagnon
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul Scholten
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James Atchison
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of PM&R, Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - Rami Jabakhanji
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kenta Wakaizumi
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marwan Baliki
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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23
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Covington EC, Argoff CE, Ballantyne JC, Cowan P, Gazelka HM, Hooten WM, Kertesz SG, Manhapra A, Murphy JL, Stanos SP, Sullivan MD. Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations. Mayo Clin Proc 2020; 95:2155-2171. [PMID: 33012347 DOI: 10.1016/j.mayocp.2020.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022]
Abstract
Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.
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Affiliation(s)
- Edward C Covington
- Neurological Center for Pain (Emeritus), Cleveland Clinic, Cleveland, OH.
| | | | - Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | | | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Stefan G Kertesz
- Birmingham Veterans Affairs Medical Center and Division of Preventive Medicine, University of Alabama School of Medicine, Birmingham, AL
| | - Ajay Manhapra
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT; New England Mental Illness Research and Education Center, West Haven, CT; Advanced Pain Clinic, Hampton VA Medical Center, Hampton, VA
| | - Jennifer L Murphy
- James A. Haley Veterans Hospital and Department of Neurology, University of South Florida Morsani College of Medicine, Tampa
| | | | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, Department of Anesthesiology and Pain Medicine, and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
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24
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DiBenedetto DJ, Wawrzyniak KM, Finkelman M, Kulich RJ, Chen L, Schatman ME, Stone MT, Mao J. Relationships Between Opioid Dosing, Pain Severity, and Disability in a Community-Based Chronic Pain Population: An Exploratory Retrospective Analysis. PAIN MEDICINE 2020; 20:2155-2165. [PMID: 30657983 DOI: 10.1093/pm/pny240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the relationship between opioid dose change, pain severity, and function in patients with chronic pain. DESIGN Retrospective cohort study. SETTING Community interdisciplinary pain management practice. SUBJECTS A total of 778 patients with chronic pain prescribed opioids for three or more consecutive months between April 1, 2013, and March 1, 2015. METHODS Changes in opioid dose, pain severity rating, modified Roland Morris Disability Questionnaire score, and opioid risk data were extracted from medical records and analyzed for associations. RESULTS Two hundred forty-three subjects (31.2%) had an overall dose decrease, 223 (28.7%) had a dose increase, and 312 (40.1%) had no significant change in dose (<20% change). There was a weak negative correlation between change in opioid dose and change in pain severity (r = -0.08, P = 0.04) but no association between change in disability scores and dose change (N = 526, P = 0.13). There was a weak positive correlation between change in pain severity rating and change in disability scores (r = 0.16, P < 0.001). CONCLUSIONS The results suggest that escalating opioid doses may not necessarily result in clinically significant improvement of pain or disability. Similarly, significant opioid dose reductions may not necessarily result in worsened pain or disability. This exploratory investigation raised questions of possible subgroups of patients who might demonstrate improvement of pain and disability with opioid dose adjustments, and further research should prospectively explore this potential, given the limitations inherent in retrospective analyses. Prescribers should still consider reduction of opioid doses as recommended by current guidelines, in an effort to mitigate the potential risks associated with high-dose treatment.
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Affiliation(s)
- David J DiBenedetto
- Boston Pain Care, Waltham, Massachusetts.,Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts
| | - Kelly M Wawrzyniak
- Boston Pain Care, Waltham, Massachusetts.,Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts
| | - Matthew Finkelman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts.,Division of Biostatistics and Experimental Design, Tufts University School of Dental Medicine, Boston, Massachusetts
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts.,Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts
| | - Lucy Chen
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts
| | - Michael E Schatman
- Boston Pain Care, Waltham, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Melissa T Stone
- Child and Family Psychological Services, Inc., Norwood, Massachusetts, USA
| | - Jianren Mao
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts
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Crouch TB, Wedin S, Kilpatrick RL, Christon L, Balliet W, Borckardt J, Barth K. Pain rehabilitation's dual power: Treatment for chronic pain and prevention of opioid-related risks. ACTA ACUST UNITED AC 2020; 75:825-839. [PMID: 32915026 DOI: 10.1037/amp0000663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The purpose of this article is to provide a data-driven exploration of an interdisciplinary pain rehabilitation program (PRP) as a viable option for addressing the dual crises of chronic pain and opioid use. Psychologists are crucial providers in the PRP, in both intervention and leadership roles. There is well-established literature supporting pain rehabilitation as an effective treatment for chronic pain and functioning, but there are few studies examining the effects of pain rehabilitation on opioid misuse risk. We evaluated data from 60 patients with diverse chronic pain conditions who completed an interdisciplinary PRP to evaluate changes in pain, functioning (self-report and objective physical measure), psychological symptoms, and health-related quality of life. To evaluate the effect of pain rehabilitation on opioid-related risks, we examined opioid use and opioid misuse behaviors (measured by the Current Opioid Misuse Measure; COMM) pre- and posttreatment. Results demonstrated statistically significant improvements in all outcomes, with medium effect sizes for pain severity and large effect sizes for functioning, psychological symptoms, and emotional quality of life. Fifty-eight percent of patients were on opioid medications at entry compared with 15% at discharge. Among patients who entered on opioids, mean COMM scores were significantly reduced from above the cutoff for misuse risk (M = 13.57) to below the cutoff (M = 5.86). Overall, this study provided strong support for pain rehabilitation as an effective treatment for chronic pain and related suffering, while also providing a prevention-based opportunity for reducing opioid-related risk. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Taylor B Crouch
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
| | - Sharlene Wedin
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
| | - Rebecca L Kilpatrick
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
| | - Lillian Christon
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
| | - Wendy Balliet
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
| | - Jeffrey Borckardt
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
| | - Kelly Barth
- Department of Psychiatry and Behavioral Sciences, Division of Bio-Behavioral Medicine, Medical University of South Carolina
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Rich RC, Chou R, Mariano ER, Dopp AL, Sullenger R, Burstin H. Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings. NAM Perspect 2020; 2020:202008c. [PMID: 35291734 PMCID: PMC8916797 DOI: 10.31478/202008c] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
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Sud A, Armas A, Cunningham H, Tracy S, Foat K, Persaud N, Hosseiny F, Hyland S, Lowe L, Zlahtic E, Murti R, Derue H, Birnbaum I, Bonin K, Upshur R, Nelson MLA. Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review. PLoS One 2020; 15:e0236419. [PMID: 32716982 PMCID: PMC7384622 DOI: 10.1371/journal.pone.0236419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022] Open
Abstract
CONTEXT Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined. OBJECTIVE Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit. STUDY DESIGN Systematic rapid realist review. DATASET Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation. RESULTS 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion. CONCLUSIONS Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.
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Affiliation(s)
- Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alana Armas
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Heather Cunningham
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Tracy
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Kirk Foat
- Independent Researcher, London, Ontario, Canada
| | - Navindra Persaud
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Keenan Research Centre, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Fardous Hosseiny
- Canadian Mental Health Association National, Toronto, Ontario, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
| | - Leyna Lowe
- Canadian Mental Health Association National, Toronto, Ontario, Canada
| | - Erin Zlahtic
- Kinesiology, Western University, London, Ontario, Canada
| | - Rhea Murti
- Arts & Science, McMaster University, Hamilton, Ontario, Canada
| | - Hannah Derue
- Psychology, University of Guelph-Humber, Toronto, Ontario, Canada
| | - Ilana Birnbaum
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Katija Bonin
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ross Upshur
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle L. A. Nelson
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Ashton-James CE, Chemke-Dreyfus A, Costa D, Glare P. Time for change: an experimental investigation of chronic pain patients' emotional and attitudinal responses to simulated opioid-tapering advice. Pain 2020; 160:1586-1593. [PMID: 30839428 DOI: 10.1097/j.pain.0000000000001543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Clinicians report reluctance to deliver opioid-tapering advice to patients with chronic pain, in part due to concerns that patients will be angry and dissatisfied. An experiment was conducted to examine chronic pain patients' emotional and attitudinal responses to simulated opioid-tapering advice. Patients scheduled for an initial assessment at a tertiary pain clinic and currently taking opioid medications for pain (N = 196) were randomly assigned to view video footage of a standardized patient receiving 1 of 3 forms of treatment advice: (1) stay on current medication (2) change to a different pain medication, or (3) taper off pain medications and participate in a CBT-based pain self-management program. Participants reported how positive/enthusiastic, anxious/worried, and angry/irritable they felt in response to the simulated treatment advice, and how satisfied with and willing they would be to accept and follow the advice. Participants expressed more positive emotional and attitudinal responses to simulated opioid-tapering advice than to simulated opioid-maintenance advice. Furthermore, participants' responses to simulated opioid-tapering and opioid-change advice were not significantly different, suggesting that participants responded positively to the prospect of change in treatment strategy. Additional analyses revealed that participants with a longer history of chronic pain and opioid use responded less positively to simulated opioid-tapering advice. The results of this study contribute to our understanding of factors that may shape chronic pain patients' responses to opioid-tapering advice and suggest that patients may respond more positively to opioid-tapering advice if it is presented together with an alternative treatment approach.
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Affiliation(s)
- Claire E Ashton-James
- Faculty of Medicine and Health, Pain Management Research Institute, The University of Sydney, Sydney, Australia
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Abstract
OBJECTIVE Experts cautioned that patients affected by the November 2010 withdrawal of the opioid analgesic propoxyphene might receive riskier prescriptions. To explore this, we compared drug receipts and outcomes among propoxyphene users before and aftermarket withdrawal. STUDY DESIGN Using OptumLabs data, we studied 3 populations: commercial, Medicare Advantage (MA) aged (age 65+ y) and MA disabled (age below 65 y) enrollees. The exposed enrollees received propoxyphene in the 3 months before market withdrawal (n=13,622); historical controls (unexposed) received propoxyphene 1 year earlier (n=9971). Regression models estimated daily milligrams morphine equivalent (MME), daily prescription acetaminophen dose, potentially toxic acetaminophen doses, nonopioid prescription analgesics receipt, emergency room visits, and diagnosed falls, motor vehicle accidents, and hip fractures. PRINCIPAL FINDINGS Aged MA enrollees illustrate the experience of all 3 populations examined. Following the market withdrawal, propoxyphene users in the exposed cohort experienced an abrupt decline of 69% in average daily MME, compared with a 14% decline in the unexposed. Opioids were discontinued by 34% of the exposed cohort and 18% of the unexposed. Tramadol and hydrocodone were the most common opioids substituted for propoxyphene. The proportion of each group receiving ≥4 g of prescription acetaminophen per day decreased from 12% to 2% in the exposed group but increased from 6% to 8% among the unexposed. Adverse events were rare and not significantly different in exposed versus unexposed groups. CONCLUSIONS After propoxyphene market withdrawal, many individuals experienced abrupt discontinuation of opioids. Policymakers might consider supporting appropriate treatment transitions and monitoring responses following drug withdrawals.
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Clinical and Demographic Predictors of Interdisciplinary Chronic Pain Rehabilitation Program Treatment Response. THE JOURNAL OF PAIN 2019; 20:1470-1485. [DOI: 10.1016/j.jpain.2019.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 04/24/2019] [Accepted: 05/24/2019] [Indexed: 11/18/2022]
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Hassan S, Zheng Q, Rizzolo E, Tezcanli E, Bhardwaj S, Cooley K. Does Integrative Medicine Reduce Prescribed Opioid Use for Chronic Pain? A Systematic Literature Review. PAIN MEDICINE 2019; 21:836-859. [DOI: 10.1093/pm/pnz291] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractBackgroundChronic pain (CP) is a major public health problem. Many patients with CP are increasingly prescribed opioids, which has led to an opioid crisis. Integrative medicine (IM), which combines pharmacological and complementary and alternative medicine (CAM), has been proposed as an opioid alternative for CP treatment. Nevertheless, the role of CAM therapies in reducing opioid use remains unclear.ObjectivesTo explore the effectiveness of the IM approach or any of the CAM therapies to reduce or cease opioid use in CP patients.MethodsAn online search of MEDLINE and Embase, CINAHL, PubMed supp., and Allied and Complementary Medicine Database (AMED) for studies published in English from inception until February 15, 2018, was conducted. The Mixed Methods Appraisal Tool (MMAT) was used to critically appraise selected studies.ResultsThe electronic search yielded 5,200 citations. Twenty-three studies were selected. Eight studies were randomized controlled trials, seven were retrospective studies, four studies were prospective observational, three were cross-sectional, and one was quasi-experimental. The majority of the studies showed that opioid use was reduced significantly after using IM. Cannabinoids were among the most commonly investigated approaches in reducing opioid use, followed by multidisciplinary approaches, cognitive-behavioral therapy, and acupuncture. The majority of the studies had limitations related to sample size, duration, and study design.ConclusionsThere is a small but defined body of literature demonstrating positive preliminary evidence that the IM approach including CAM therapies can help in reducing opioid use. As the opioid crisis continues to grow, it is vital that clinicians and patients be adequately informed regarding the evidence and opportunities for IM/CAM therapies for CP.
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Affiliation(s)
- Samah Hassan
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Qingping Zheng
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Erica Rizzolo
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Evrim Tezcanli
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Sukriti Bhardwaj
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Kieran Cooley
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, Australia
- Pacific College of Oriental Medicine, San Diego, California, USA
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Huhn AS, Tompkins DA, Campbell CM, Dunn KE. Individuals with Chronic Pain Who Misuse Prescription Opioids Report Sex-Based Differences in Pain and Opioid Withdrawal. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:1942-1947. [PMID: 30690594 PMCID: PMC6784741 DOI: 10.1093/pm/pny295] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Individuals with chronic pain who misuse prescription opioids are at high risk for developing opioid use disorder and/or succumbing to opioid overdose. The current study conducted a survey to evaluate sex-based differences in pain catastrophizing, opioid withdrawal, and current pain in persons with co-occurring chronic pain and opioid misuse. We hypothesized that women with chronic pain who misused prescription opioids would self-report higher pain ratings compared with men and that the relationship between pain catastrophizing and self-reported current pain would be moderated by symptoms of opioid withdrawal in women only. Design Survey assessment of the relationship between pain and opioid misuse. Setting Online via Amazon Mechanical Turk. Participants Persons with ongoing chronic pain who also misused prescription opioids on one or more days in the last 30 days were eligible (N = 181). Methods Participants completed demographic and standardized assessments including the Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), and Subjective Opiate Withdrawal Scale (SOWS). Results Women reported higher levels of current (P < 0.001), average (P < 0.001), and worst (P = .002) pain in the last 24 hours compared with men. Women also endorsed higher scores on the PCS (P = 0.006) and marginally higher past-30-day SOWS ratings (P = 0.068) compared with men. SOWS ratings moderated the relationship between PCS and BPI Worst Pain in women (ΔR2 < 0.127, ΔF(1, 78) = 12.39, P = 0.001), but not in men (ΔR2 < 0.000, ΔF(1, 98) = 0.003, P = 0.954). Conclusions These data suggest a strong relationship between opioid withdrawal, pain catastrophizing, and the experience of pain in women with chronic pain who misuse opioids.
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Affiliation(s)
- Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D Andrew Tompkins
- Department of Psychiatry, UCSF School of Medicine, San Francisco, California, USA
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Craner JR, Lake ES, Bancroft KA, George LL. Treatment Outcomes and Mechanisms for an
ACT
‐Based 10‐Week Interdisciplinary Chronic Pain Rehabilitation Program. Pain Pract 2019; 20:44-54. [DOI: 10.1111/papr.12824] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Julia R. Craner
- Mary Free Bed Rehabilitation Hospital Grand Rapids Michigan U.S.A
- Michigan State University College of Human Medicine Grand Rapids Michigan U.S.A
| | - Eric S. Lake
- Mary Free Bed Rehabilitation Hospital Grand Rapids Michigan U.S.A
| | | | - Logan L. George
- Michigan State University College of Human Medicine Grand Rapids Michigan U.S.A
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Bujak BK, Regan E, Beattie PF, Harrington S. The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis. Pain Manag 2019; 9:417-429. [DOI: 10.2217/pmt-2018-0087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aim: To explore the overall effectiveness of interdisciplinary intensive outpatient treatment programs in adults with chronic pain. The secondary aim was to examine the effect of the intervention on individual outcome measures including pain intensity, pain catastrophizing, depressive symptoms, quality of life and describe its effect on medication use. Methods: The preferred reporting items for systematic review and meta-analysis protocols reporting guidelines were followed in this systematic review and meta-analysis. Results: A total of 13 peer-reviewed studies were included in analysis: one randomized controlled trial and 12 observational studies. Conclusion: Although interdisciplinary intensive outpatient programs for chronic pain have only been examined in a limited number of studies, trends suggest that participation in these programs may improve physical, emotional, social and mental health as measured by quality of life measures, while decreasing pain intensity, pain catastrophizing and depressive symptoms in a population with diverse diagnoses.
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Affiliation(s)
- Barbara K Bujak
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, USA
- Army Medical Department Center & School, JBSA-Fort Sam Houston, 2450 Stanley Road, San Antonio, TX 78234, USA
| | - Elizabeth Regan
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street, Columbia, SC 29208, USA
| | - Paul F Beattie
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street, Columbia, SC 29208, USA
| | - Shana Harrington
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street, Columbia, SC 29208, USA
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Rosenberg JM, Bilka BM, Wilson SM, Spevak C. Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. PAIN MEDICINE 2019; 19:928-941. [PMID: 29025128 DOI: 10.1093/pm/pnx203] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Description The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids. Patient Population This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families. Methods The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development. Results There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain. Conclusions Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.
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Affiliation(s)
- Jack M Rosenberg
- Department of Veterans Affairs, Physical Medicine and Rehabilitation, Ann Arbor, Michigan
| | - Brandon M Bilka
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Sara M Wilson
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Gagnon CM, Brewington DV, Scholten PM, Atchison J, Chang CH. Impact of Symptom Reporting Agreement on Interdisciplinary Pain Program Participation. Pain Pract 2019; 19:621-632. [PMID: 30891911 DOI: 10.1111/papr.12783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate whether physician-patient agreement of potential patient problem areas impacts subsequent patient enrollment in an interdisciplinary pain management program. DESIGN Retrospective chart review of 544 patients who underwent evaluation of their chronic pain. Physicians and their patients endorsed perceived patient problems during the evaluation. The potential problems included 7 clinical domains: pain, sleep, mood, physical functioning, ability to cope with pain, ability to manage pain flare-ups, and pain medication effectiveness. RESULTS Results indicated statistically significant levels of agreement among the physicians and their patients (free-marginal kappa range, 0.19 to 0.94, P's < 0.001). The highest agreement occurred for pain and the lowest for pain medication effectiveness. Patients who enrolled in a recommended program did not differ from those who did not enroll based on either levels of agreement or average number of physician-patient agreements for the 7 clinical domains (P's > 0.05). Patients recommended for higher-intensity programs were perceived by their evaluating physician to have a significantly greater number of problematic clinical domains than those recommended for less intense pain programs. CONCLUSION The level of physician-patient agreement regarding the patients' current difficulties did not appear to influence patients' decisions to participate in interdisciplinary pain management. Extraneous, nonclinical factors may have had a greater impact on participation in interdisciplinary pain management than physician-patient agreement. Future research should focus on identifying these factors and their impact. Also, studying the impact of physician-patient agreement beyond enrollment status (eg, on successful program completion) may be helpful in potentially enhancing patient outcomes.
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Affiliation(s)
- Christine M Gagnon
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | | | - Paul M Scholten
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - James Atchison
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Department of PM&R, Mayo Clinic Jacksonville, Jacksonville, Florida, U.S.A
| | - Chih-Hung Chang
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Washington University School of Medicine, St. Louis, Missouri, U.S.A
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Goesling J, Moser SE, Lin LA, Hassett AL, Wasserman RA, Brummett CM. Discrepancies Between Perceived Benefit of Opioids and Self-Reported Patient Outcomes. PAIN MEDICINE 2019; 19:297-306. [PMID: 28034978 PMCID: PMC5914338 DOI: 10.1093/pm/pnw263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective There is little empirical evidence supporting the long-term use of opioid therapy for chronic pain, suggesting the need to reevaluate the role of opioids in chronic pain management. Few studies have considered opioid use and opioid cessation from the perspective of the patient. Methods This prospective structured interview study included 150 new patients seeking treatment for chronic pain at an outpatient tertiary care pain clinic. Results Of the 150 patients, 56% (N = 84) reported current opioid use. Opioids users reported higher pain severity (t(137) = -3.75, P < 0.001), worse physical functioning (t(136) = -3.82, P < 0.001), and more symptoms of depression (t(136) = -1.98, P = 0.050) than nonusers. Among opioid users, 45.6% reported high pain (>7), 60.8% reported low functioning (>7), and 71.4% reported less than a 30% reduction in pain severity since starting opioids, suggesting that many patients are unlikely to be receiving adequate benefit. Overall, 66.3% of current opioid users reported moderate to high opioid-related difficulties on the prescribed opioids difficulties scale, and patients with depression were more likely to report greater difficulties. There was no association between helpfulness of opioids over the past month and opioid-related difficulties (r(75) = -0.07, P = 0.559), current pain severity (r(72)=0.05, P = 0.705), or current pain interference (r(72) = 0.20, P = 0.095). Conclusions Despite clinical indicators that question the benefit, patients may continue to report that their opioids are helpful. Such discrepancies in patients' perceptions will likely pose significant barriers for implementing opioid cessation guidelines in clinical practice.
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Affiliation(s)
- Jenna Goesling
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephanie E Moser
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lewei A Lin
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Afton L Hassett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ronald A Wasserman
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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Bailey JC, Kurklinsky S, Sletten CD, Osborne MD. The Effectiveness of an Intensive Interdisciplinary Pain Rehabilitation Program in the Treatment of Post-Laminectomy Syndrome in Patients Who Have Failed Spinal Cord Stimulation. PAIN MEDICINE 2019; 19:385-392. [PMID: 28402524 DOI: 10.1093/pm/pnx060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction Post-laminectomy syndrome (PLS) patients who have previously undergone spinal cord stimulation and failed to have significant improvement create a unique challenge for ongoing pain management. We hypothesize that, following successful completion of intensive, interdisciplinary pain rehabilitation (IPR), this patient population can achieve a significant reduction in pain, improvement in mood, functional levels, and self-efficacy. Materials and methods A retrospective chart review was conducted comparing the following for patients prior to enrollment in the IPR program and upon completion: numeric rating scale (NRS) pain scores; functional status via the six-minute walk test; mood via the Center for Epidemiologic Studies Depression Scale (CES-D), Multidimensional Pain Inventory (MPI) Life control scores and MPI Interference, and the Pain Catastrophizing Scale (PCS); and self-efficacy via the Pain Self-Efficacy Questionnaire (PSEQ). Results Forty-three patients met inclusion criteria, with 17 males and 26 females and a mean age of 64 years. Patients demonstrated a statistically significant increase in six-minute walk test distance of 104 m, a decrease in average NRS pain score of 1.4 points, an increase in average MPI life control by 8.3 points, a decrease average MPI interference by 5.3 points, an increase in average Short Form-36 by 6.5 points, an increase in average PCS by 4.4 points, and an increase in average PSEQ score of 18.1. Their average mood via CES-D improved by 4.2 points. Conclusions Intensive, interdisciplinary pain rehabilitation provides an effective therapeutic modality for patients with post-laminectomy syndrome who have failed spinal cord stimulation by decreasing pain levels and by increasing functional status and self-efficacy.
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Affiliation(s)
- Joshua C Bailey
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Michael D Osborne
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain. Clin Obstet Gynecol 2019; 62:48-58. [DOI: 10.1097/grf.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bienek N, Maier C, Kaisler M, Michel-Lauter B, Schwarzer A, Meyer-Frießem CH. Intensity of Withdrawal Symptoms During Opioid Taper in Patients with Chronic Pain—Individualized or Fixed Starting Dosage? PAIN MEDICINE 2019; 20:2438-2449. [DOI: 10.1093/pm/pny320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AbstractObjectiveControlled opioid withdrawal is recommended for patients with chronic noncancer pain (CNCP) with insufficient pain reduction or intolerable side effects while on opioid treatment. Few studies have investigated the management of opioid withdrawal (OW). Most common are protocols with an individualized starting dosage (ISD), calculated from the last opioid intake. After two cases of overdose, we introduced a novel withdrawal protocol using a low fixed starting dosage (FSD) for safety reasons. The present study compares the intensity of withdrawal symptoms using the Subjective Opioid Withdrawal Scale (SOWS) and incidences of serious adverse events (SAE) and dropouts in each taper schedule in 195 CNCP patients with OW in an inpatient facility.MethodsTwo protocols were compared: FSD (2014–2016): N = 68, starting dose: 90 mg morphine/d; and ISD (2010–2014): N = 127, starting dose: 70% of the patient’s daily morphine equivalent dose (MED). Outcome criteria: primary: mean daily SOWS score during the first 10 days (16 questions, daily score 0–64); secondary: change in pain intensity on a numeric rating scale (0–10), rate of dropouts and SAEs. Statistics: Student test, Mann-Whitney U test, chi-square test, analysis of variance, P < 0.05.ResultsThe mean daily SOWS score was lower in the FSD group (14.9 ± 9.4 vs 16.1 ± 10, P < 0.05) due to a lower rate of high-intensity withdrawal symptoms (12.4% vs 17.6%, P < 0.01), particularly in patients on >180 mg MED (9.7% vs 18.4%, P < 0.01). Pain intensity decreased after withdrawal, and the incidence of SAEs and dropouts was low in both groups.ConclusionsThe FSD protocol provides a lesser burden of withdrawal symptoms and equal patient safety. It can be recommended for OW in CNCP patients.
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Affiliation(s)
- Natalia Bienek
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology and Intensive Care, Klinikum Dortmund, Dortmund, Germany
| | | | | | | | | | - Christine H Meyer-Frießem
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management, Medical Faculty of Ruhr-University Bochum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH Bochum, Bochum, Germany
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E. Bolton J, Lacayo E, Kurklinsky S, D. Sletten C. Improvement in montreal cognitive assessment score following three-week pain rehabilitation program. AIMS MEDICAL SCIENCE 2019. [DOI: 10.3934/medsci.2019.3.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. PAIN MEDICINE 2018; 20:2179-2197. [DOI: 10.1093/pm/pny231] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Objective
To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.
Methods
Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.
Results
No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.
Conclusions
There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry
- Departments of Neurological Surgery
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
| | - Aditya Pulikal
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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Pergolizzi JV, Rosenblatt M, Mariano DJ, Bisney J. Tapering opioid therapy: clinical strategies. Pain Manag 2018; 8:409-413. [PMID: 30394191 DOI: 10.2217/pmt-2018-0040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
| | - Melanie Rosenblatt
- Pain Management Strategies, Pompano Beach, Florida & Co-founder of MelRose Pain Solutions, Naples, FL, USA
| | - Dean J Mariano
- Mariano Medical LLC, Pain/Addiction Consultants, West Hartford, CT, USA
| | - John Bisney
- NEMA Research Inc. & Co-founder of MelRose Pain Solutions, Naples, FL, USA
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Murimi IB, Chang HY, Bicket M, Jones CM, Alexander GC. Using trajectory models to assess the effect of hydrocodone upscheduling among chronic hydrocodone users. Pharmacoepidemiol Drug Saf 2018; 28:70-79. [DOI: 10.1002/pds.4639] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/09/2018] [Accepted: 07/17/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Irene B. Murimi
- Center for Drug Safety and Effectiveness; Johns Hopkins University; Baltimore MD USA
- Department of Epidemiology; Johns Hopkins Bloomberg School of Public Health; Baltimore MD USA
| | - Hsien-Yen Chang
- Center for Drug Safety and Effectiveness; Johns Hopkins University; Baltimore MD USA
- Department of Health Policy and Management; Johns Hopkins Bloomberg School of Public Health; Baltimore MD USA
| | - Mark Bicket
- Center for Drug Safety and Effectiveness; Johns Hopkins University; Baltimore MD USA
- Department of Anesthesiology and Critical Care; Johns Hopkins Medicine; Baltimore MD USA
| | - Christopher M. Jones
- Substance Abuse and Mental Health Services Administration; US Department of Health and Human Services; Rockville MD USA
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness; Johns Hopkins University; Baltimore MD USA
- Department of Epidemiology; Johns Hopkins Bloomberg School of Public Health; Baltimore MD USA
- Division of General Internal Medicine, Department of Medicine; Johns Hopkins Medicine; Baltimore MD USA
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Gilliam WP, Craner JR, Cunningham JL, Evans MM, Luedtke CA, Morrison EJ, Sperry JA, Loukianova LL. Longitudinal Treatment Outcomes for an Interdisciplinary Pain Rehabilitation Program: Comparisons of Subjective and Objective Outcomes on the Basis of Opioid Use Status. THE JOURNAL OF PAIN 2018; 19:678-689. [DOI: 10.1016/j.jpain.2018.02.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/15/2017] [Accepted: 02/02/2018] [Indexed: 01/19/2023]
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Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program. Clin J Pain 2018; 33:535-542. [PMID: 27584815 DOI: 10.1097/ajp.0000000000000433] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up. METHODS Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up. RESULTS Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up. DISCUSSION This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.
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The Mediating Effects of the Different Dimensions of Pain Catastrophizing on Outcomes in an Interdisciplinary Pain Rehabilitation Program. Clin J Pain 2017; 33:443-451. [PMID: 27437567 DOI: 10.1097/ajp.0000000000000419] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although reducing pain catastrophizing has been shown to contribute to functional improvement in patients receiving interdisciplinary pain care, little is known about how changes in the different dimensions of pain catastrophizing uniquely contribute to improvement in outcome. The study examined the unique relationship between changes in the 3 distinct factors of pain catastrophizing-helplessness, rumination, and magnification-and changes in pain outcomes. MATERIALS AND METHODS In this nonrandomized study, 641 patients who completed treatment in a 3-week interdisciplinary pain rehabilitation program between the years 2013 and 2014 completed a battery of psychometrically validated measures of pain catastrophizing, pain severity, pain interference, mental and physical health-related quality of life, and depressive symptoms at pretreatment and posttreatment. RESULTS A series of within groups (repeated measures) mediation analyses were conducted. Change in the helplessness, rumination, and magnification subscales were entered as multiple mediators in the model. Analyses revealed that change in helplessness partially mediated improvement in all outcome variables beyond the influence of change in other variables in the model, whereas change in rumination partially mediated improvement in pain severity, interference, and depressive symptoms. Change in magnification had the least impact on outcome, partially mediating improvements in only mental health quality of life. DISCUSSION Results suggest that changes in the 3 dimensions of pain catastrophizing differentially mediate improvement in pain outcome. Treatment approaches that specifically target helplessness and rumination may be particularly useful in improving the outcomes of patients with refractory pain conditions enrolled in interdisciplinary pain rehabilitation program.
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Pestka EL, Craner J, Evans M, Nash V, Kimondo N, Pestka D, Loukianova L, Sperry J. Impact of Family History of Substance Abuse on Admission Opioid Dose, Depressive Symptoms, and Pain Catastrophizing in Patients with Chronic Pain. Pain Manag Nurs 2017; 19:115-124. [PMID: 29153294 DOI: 10.1016/j.pmn.2017.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 09/22/2017] [Accepted: 09/30/2017] [Indexed: 10/18/2022]
Abstract
The objectives of this study were to examine association between a family history of substance abuse and admission morphine equivalent dose, depression and pain catastrophizing screening scores, as well as reported personal history of substance use. The retrospective research was completed in an interdisciplinary three-week pain rehabilitation center. The subject cohort included admissions from January through December 2014 with 351 datasets for family history of substance abuse and oral morphine equivalency and 341 for depression, pain catastrophizing and use of substances. Outcome measures included admission self-reported data on family history of substance abuse and past and current substance use, admission morphine equivalency dose, and scores on the Center for Epidemiologic Studies-Depression Scale and the Pain Catastrophizing Scale. One hundred forty-seven patients were using opioid medications on admission and those with a positive family history of substance abuse had an oral morphine equivalency (M = 92.12, SD = 95.32) compared to a negative history (M = 80.34, SD = 64.86); the difference was not statistically significant, t (120.01) =.87, p = .39. Patients with a positive family history reported higher levels of both depression, t (327.40) = 3.15, p = .002 and pain catastrophizing, t (338) = 2.76, p = .01. Those with a positive family history endorsed greater frequency of past alcohol use χ2 (1, N = 326) = 6.67, p = 0.1 and marijuana use χ2 (1, N = 341) = 4.23, p = .04 and past χ2 (1, N = 329) = 9.90, p = .002 and current tobacco use χ2 (1, N = 327) = 8.81, p = .003. Use of family history of substance abuse information may help provide data for multimodal treatments of chronic non-cancer-pain. The findings from this study can be used to guide future research.
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Affiliation(s)
| | - Julia Craner
- Department of Psychiatry and Behavioral Medicine, Spectrum Health System, Grand Rapids, Michigan
| | - Michele Evans
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Virginia Nash
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Njoki Kimondo
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Deborah Pestka
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | - Jeannie Sperry
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
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Eccleston C, Fisher E, Thomas KH, Hearn L, Derry S, Stannard C, Knaggs R, Moore RA. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev 2017; 11:CD010323. [PMID: 29130474 PMCID: PMC6486018 DOI: 10.1002/14651858.cd010323.pub3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This is the first update of the original Cochrane Review published in 2013. The conclusions of this review have not changed from the 2013 publication. People with chronic non-cancer pain who are prescribed and are taking opioids can have a history of long-term, high-dose opioid use without effective pain relief. In those without good pain relief, reduction of prescribed opioid dose may be the desired and shared goal of both patient and clinician. Simple, unsupervised reduction of opioid use is clinically challenging, and very difficult to achieve and maintain. OBJECTIVES To investigate the effectiveness of different methods designed to achieve reduction or cessation of prescribed opioid use for the management of chronic non-cancer pain in adults compared to controls. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, and Embase in January 2017, as well as bibliographies and citation searches of included studies. We also searched one trial registry for ongoing trials. SELECTION CRITERIA Included studies had to be randomised controlled trials comparing opioid users receiving an intervention with a control group receiving treatment as usual, active control, or placebo. The aim of the study had to include a treatment goal of dose reduction or cessation of opioid medication. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We sought data relating to prescribed opioid use, adverse events of opioid reduction, pain, and psychological and physical function. We planned to assess the certainty of the evidence using the GRADE approach, however, due to the heterogeneity of studies, we were unable to combine outcomes in a meta-analysis and therefore we did not assess the evidence with GRADE. MAIN RESULTS Three studies are new to this update, resulting in five included studies in total (278 participants). Participants were primarily women (mean age 49.63 years, SD = 11.74) with different chronic pain conditions. We judged the studies too heterogeneous to pool data in a meta-analysis, so we have summarised the results from each study qualitatively. The studies included acupuncture, mindfulness, and cognitive behavioral therapy interventions aimed at reducing opioid consumption, misuse of opioids, or maintenance of chronic pain management treatments. We found mixed results from the studies. Three of the five studies reported opioid consumption at post-treatment and follow-up. Two studies that delivered 'Mindfulness-Oriented Recovery Enhancement' or 'Therapeutic Interactive Voice Response' found a significant difference between groups at post-treatment and follow-up in opioid consumption. The remaining study found reduction in opioid consumption in both treatment and control groups, and between-group differences were not significant. Three studies reported adverse events related to the study and two studies did not have study-related adverse events. We also found mixed findings for pain intensity and physical functioning. The interventions did not show between-group differences for psychological functioning across all studies. Overall, the risk of bias was mixed across studies. All studies included sample sizes of fewer than 100 and so we judged all studies as high risk of bias for that category. AUTHORS' CONCLUSIONS There is no evidence for the efficacy or safety of methods for reducing prescribed opioid use in chronic pain. There is a small number of randomised controlled trials investigating opioid reduction, which means our conclusions are limited regarding the benefit of psychological, pharmacological, or other types of interventions for people with chronic pain trying to reduce their opioid consumption. The findings to date are mixed: there were reductions in opioid consumption after intervention, and often in control groups too.
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Abstract
Supplemental Digital Content is Available in the Text. This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal. Withdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation—a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.
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