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Tefera YG, Gray S, Nielsen S, Gelaw A, Collie A. Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review. JOURNAL OF OCCUPATIONAL REHABILITATION 2024; 34:398-414. [PMID: 37934329 PMCID: PMC11180015 DOI: 10.1007/s10926-023-10138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/10/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes. METHODS We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible. RESULTS From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes. CONCLUSION Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.
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Affiliation(s)
- Yonas Getaye Tefera
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Shannon Gray
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, 47-49 Moorooduc Hwy, Frankston, 3199, Australia
| | - Asmare Gelaw
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Alex Collie
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
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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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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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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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5
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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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6
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Trajectories of sickness absence and disability pension before and after opioid initiation for noncancer pain: a 10-year population-based study. Pain 2020; 160:1224-1233. [PMID: 31009421 DOI: 10.1097/j.pain.0000000000001500] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic noncancer pain is a leading cause of sickness absence (SA) and disability pension (DP). The objectives of this study were to identify trajectories of SA/DP before and after strong and weak opioid initiation for noncancer pain and the factors associated with these trajectories. A longitudinal population-based study of 201,641 people (24-59 years) without cancer who initiated opioid analgesics in 2009 in Sweden was conducted. Trajectories of net annual SA/DP days in the 5 years before/after opioid initiation were estimated with group-based trajectory modelling. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with trajectory groups. Among the 6.9% of people initiating strong opioids, 12.5% had persistent high SA/DP (estimated 320 days/year) before and after opioid initiation and 72.9% had persistent low/minimum SA/DP (estimated 30 days/year). Approximately 8.6% of people had increasing SA/DP, and 6.1% had decreasing SA/DP after opioid initiation, although this seemed to reflect continuation of preinitiation patterns. Trajectories were similar at lower SA/DP days/year among those initiating weak opioids. Persistent high SA/DP among strong opioid initiators were associated with ≥5 comorbidities (OR = 8.72, 95% CI 5.61-13.56), ≤9 years of education (OR = 5.83, 95% CI 4.84-7.03), and previous use of antidepressants (OR = 4.57, 95% CI 3.89-5.37) and antipsychotics (OR = 4.49, 95% CI 2.93-6.88). Three-quarters of people initiating opioids for noncancer pain had persistent low/minimum levels of SA/DP 5 years before and after initiation. Increasing and decreasing SA/DP after opioid initiation seemed to reflect a continuation of preinitiation patterns. Our findings highlight the complex range of sociodemographic and medication-related factors associated with persistent SA/DP.
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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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8
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An Interdisciplinary Pain Rehabilitation Program for Veterans with Chronic Pain: Description and Initial Evaluation of Outcomes. Pain Res Manag 2018; 2018:3941682. [PMID: 29849842 PMCID: PMC5932417 DOI: 10.1155/2018/3941682] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/13/2018] [Accepted: 03/18/2018] [Indexed: 12/02/2022]
Abstract
Objective Chronic pain conditions are prominent among Veterans. To leverage the biopsychosocial model of pain and comprehensively serve Veterans with chronic pain, the San Francisco Veterans Affairs Healthcare System has implemented the interdisciplinary pain rehabilitation program (IPRP). This study aims to (1) understand initial changes in treatment outcomes following IPRP, (2) investigate relationships between psychological factors and pain outcomes, and (3) explore whether changes in psychological factors predict changes in pain outcomes. Methods A retrospective study evaluated relationships between clinical pain outcomes (pain intensity, pain disability, and opioid use) and psychological factors (depressive symptoms, catastrophizing, and “acceptable” level of pain) and changes in these outcomes following treatment. Multiple regression analysis explored whether changes in psychological variables significantly predicted changes in pain disability. Results Catastrophizing and depressive symptoms were positively related to pain disability, while “acceptable” level of pain was idiosyncratically related to pain intensity. Pain disability and psychological variables showed significant changes in their expected directions. Regression analysis indicated that only changes in depressive symptoms significantly predicted changes in pain disability. Conclusion Our results are consistent with evidence-based clinical practice guidelines for the management of chronic pain in Veterans. Further investigation of interdisciplinary treatment programs in Veterans is warranted.
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Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clin Proc 2015; 90:828-42. [PMID: 26046416 DOI: 10.1016/j.mayocp.2015.04.003] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/31/2015] [Accepted: 04/07/2015] [Indexed: 11/22/2022]
Abstract
Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In addition to overt addiction or diversion, the presence of adverse effects, diminishing analgesia, reduced function and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients' psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers. The aim of this article is to review the existing literature and formulate recommendations for practitioners aiming to discontinue long-term opioid therapy. Specifically, this review aims to answer the following questions: What is an optimal opioid tapering regimen? How can the risks involved in a taper be managed? What are the alternatives to an opioid taper? A PubMed literature search was conducted using the keywords chronic pain combined with opioid withdrawal, taper, wean and detoxification. Six hundred ninety-five documents were identified and screened; 117 were deemed directly relevant and are included. On the base of this literature review, this article proposes evidence-based recommendations and expert-based suggestions for clinical practice. Furthermore, areas of lack of evidence are identified, providing opportunities for further research.
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Affiliation(s)
- Chantal Berna
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ronald J Kulich
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Tufts University School of Dental Medicine, Boston, MA
| | - James P Rathmell
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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10
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Vowles KE, Ashworth J. Is opioid withdrawal necessary within comprehensive pain rehabilitation programs? Pain 2011; 152:1948-1950. [DOI: 10.1016/j.pain.2011.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 02/09/2011] [Accepted: 03/11/2011] [Indexed: 10/18/2022]
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Effect of opioid administration on cardiorespiratory and muscle oxygenation during lifting in chronic back pain patients. Eur J Appl Physiol 2010; 109:241-50. [DOI: 10.1007/s00421-009-1332-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2009] [Indexed: 10/20/2022]
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12
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Brennan MJ. Summary of Short-term and Long-term Oxymorphone Efficacy (Pain) Studies in Low Back Pain, Cancer Pain, Osteoarthritis, and Neuropathic Pain. PAIN MEDICINE 2009. [DOI: 10.1111/j.1526-4637.2009.00595.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Townsend CO, Kerkvliet JL, Bruce BK, Rome JD, Hooten MW, Luedtke CA, Hodgson JE. A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission. Pain 2008; 140:177-189. [PMID: 18804915 DOI: 10.1016/j.pain.2008.08.005] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 07/22/2008] [Accepted: 08/11/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Use of opioids for chronic non-cancer pain is controversial and the efficacy of comprehensive pain rehabilitation programs (CPRPs) that incorporate opioid withdrawal requires further investigation. We test the hypothesis that patients with chronic pain and longstanding opioid use who undergo opioid withdrawal in the course of rehabilitative treatment will experience significant and sustained improvement in pain and functioning similar to patients who were not taking opioids. A longitudinal design study compared 373 consecutive patients admitted to the Mayo Clinic Pain Rehabilitation Center at admission, discharge and six-month posttreatment by opioid status at admission. Measures of pain severity, depression, psychosocial functioning, health status, and pain catastrophizing were used to assess between- and within-group differences. Treatment involved a 3-week interdisciplinary pain rehabilitation program focused on functional restoration. Over one-half of patients (57.1%) were taking opioids daily at admission. The majority of patients (91%) completed rehabilitation and 70% of patients who completed the program returned questionnaires six months posttreatment. On admission, patients taking low- and high-dose opioids reported significantly greater pain severity (P=.001) and depression (P=.001) than the non-opioid group. Significant improvement was found on all outcome variables following treatment (P<.001) and six-month posttreatment (P<.001) regardless of opioid status at admission. There were no differences between the opioid and non-opioid groups upon discharge from the program or at six months following treatment. CONCLUSION Patients with longstanding CPRP on chronic opioid therapy, who choose to participate in interdisciplinary rehabilitation that incorporates opioid withdrawal, can experience significant and sustained improvement in pain severity and functioning.
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Affiliation(s)
- Cynthia O Townsend
- Mayo Clinic, Department of Psychiatry and Psychology, Pain Rehabilitation Center, Generose 2W, 1216 Second Street SW, Rochester, MN 55902, USA
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14
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Evidence-informed management of chronic low back pain with opioid analgesics. Spine J 2008; 8:185-94. [PMID: 18164466 DOI: 10.1016/j.spinee.2007.10.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/13/2007] [Indexed: 02/03/2023]
Abstract
The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.
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Weiss M, Vanderlin D, Hietpas J. Controlling chronic pain in the workplace: nerve stimulation and intrathecal drug delivery systems. AAOHN JOURNAL : OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION OF OCCUPATIONAL HEALTH NURSES 2007; 55:463-469. [PMID: 18019770 DOI: 10.1177/216507990705501105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Chronic pain can have a major effect on both workers and the workplace. Collaboration among workers, occupational health nurses, and specialist providers is important for ongoing management of mechanism-based therapies for chronic pain. This article examines collaborative care issues relative to nerve stimulation and intrathecal drug delivery systems.
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Affiliation(s)
- Margie Weiss
- Neuroscience Group of NE Wisconsin, Neenah, WI, USA
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