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Ellis MM, Eberhart ND, Warner NS, Hooten WM. Low dose lofexidine for medically directed outpatient opioid tapering in adults with chronic pain: a prospective case series. J Med Case Rep 2024; 18:20. [PMID: 38229200 DOI: 10.1186/s13256-023-04309-x] [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: 07/04/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND In adults with chronic pain, mild-to-moderate withdrawal symptoms during medically directed opioid tapering in the outpatient setting may not be accompanied by hypertension or tachycardia. This clinical scenario could limit the use of lofexidine at dosages reported in clinical trials of opioid withdrawal precipitated by abrupt opioid discontinuation. Thus, the primary aim of this prospective case series is to describe the use of low dose lofexidine for opioid withdrawal in patients with chronic pain undergoing medically directed opioid tapering in an outpatient setting. METHODS Six patients (white 5, Latino 1) admitted to an outpatient interdisciplinary pain rehabilitation program met inclusion and exclusion criteria. Patients self-selected to undergo medically directed opioid tapering, and the medication the patients were prescribed upon admission was used in the taper schedule. Upon initiation of the opioid taper, patients received 0.18 mg of lofexidine every 6 hours. RESULTS Five of the six patients were women, and the median morphine milligram equivalents at baseline were 36.9. The median taper duration was 15 days, and the median duration of lofexidine administration was 14 days. Withdrawal scores were mild throughout the taper in four patients, and two patients with fibromyalgia experienced single episodes of moderately severe withdrawal symptoms at the median morphine milligram equivalent midpoint of the taper. No hypotension or sustained bradycardia were observed, and no adverse effects related to lofexidine were reported. CONCLUSION The observations from this prospective case series suggest that low-dose lofexidine may be a feasible adjunct medication to attenuate withdrawal symptoms in adults with chronic pain undergoing outpatient opioid tapering.
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Affiliation(s)
- Megan M Ellis
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA
| | - Nathan D Eberhart
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Graduate Education, Mayo Clinic, 200 First St SW, Charlton 1-145, Rochester, MN, 55905, USA.
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2
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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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3
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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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4
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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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5
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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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6
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Brown-Taylor L, Beckner A, Scaff KE, Fritz JM, Buys MJ, Patel S, Bayless K, Brooke BS. Relationships between physical therapy intervention and opioid use: A scoping review. PM R 2021; 14:837-854. [PMID: 34153178 DOI: 10.1002/pmrj.12654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To synthesize available evidence that has examined the relationship between physical therapy (PT) and opioid use. TYPE: Scoping Review LITERATURE SURVEY: Data sources including Google Scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to October 24, 2019 using terms ("physical therapy"[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]). METHODOLOGY Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design. SYNTHESIS Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) of using opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopedic surgery was also associated with lower odds of using opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT. CONCLUSIONS The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes because of heterogeneity between studies.
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Affiliation(s)
- Lindsey Brown-Taylor
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Medpace Inc., Cincinnati, Ohio, USA
| | - Aaron Beckner
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Ochsner Health System, New Orleans, Louisiana, USA
| | - Katie E Scaff
- Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington, USA
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
| | - Michael J Buys
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Department of Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Shardool Patel
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Kim Bayless
- Department of Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Benjamin S Brooke
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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7
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Wilson SH, Hellman KM, James D, Adler AC, Chandrakantan A. Mechanisms, diagnosis, prevention and management of perioperative opioid-induced hyperalgesia. Pain Manag 2021; 11:405-417. [PMID: 33779215 DOI: 10.2217/pmt-2020-0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.
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Affiliation(s)
- Sylvia H Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kevin M Hellman
- Department of Obstetrics & Gynecology, NorthShore University Health System & Pritzker School of Medicine at the University of Chicago, Evanston, IL 60201, USA
| | - Dominika James
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Adam C Adler
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
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8
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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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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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10
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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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11
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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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Shechter R, Speed TJ, Blume E, Singh S, Williams K, Koch CG, Hanna MN. Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program. Am J Med Qual 2019; 35:5-15. [DOI: 10.1177/1062860619851170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.
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Affiliation(s)
- Tim J Lamer
- Professor of Anesthesiology, Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine
- Mayo Clinic Rochester, Minnesota President, American Academy of Pain Medicine
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14
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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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15
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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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Darnall BD, Colloca L. Optimizing Placebo and Minimizing Nocebo to Reduce Pain, Catastrophizing, and Opioid Use: A Review of the Science and an Evidence-Informed Clinical Toolkit. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:129-157. [PMID: 30146045 PMCID: PMC6175287 DOI: 10.1016/bs.irn.2018.07.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pain, a noxious psychosensory experience, motivates escape behavior to assure protection and survival. Psychological factors alter the experience and trajectory of pain, as well as behavior and treatment response. In the context of pain, the placebo effect (expectation for pain relief) releases endogenous opioids and facilitates analgesia from exogenously administered opioids. Nocebo hyperalgesia (expectation for persistent or worsening pain) opposes endogenous opioid analgesia and patient engagement in prescription opioid tapering. Reductions in nocebo hyperalgesia and pain catastrophizing may enhance descending modulation of pain, mediate adaptive structural brain changes and promote patient engagement in opioid tapering. Interventions that minimize nocebo and optimize placebo may adaptively shape the central nervous system toward pain relief and potentially opioid reduction. Here we provide a critical description of catastrophizing and its impact on pain, placebo and nocebo effects. We also consider the importance of minimizing nocebo and optimizing placebo effects during prescription opioid tapering, and offer a clinical toolkit of resources to accomplish these goals clinically.
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Affiliation(s)
- Beth D Darnall
- School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Psychiatry and Behavioral Sciences (by courtesy), Stanford University, Palo Alto, CA, United States.
| | - Luana Colloca
- Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States; Departments of Anesthesiology and Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, United States; Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, United States
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Abstract
OBJECTIVES Cognitive functioning is commonly disrupted in people living with chronic pain, yet it is an aspect of pain that is often not routinely assessed in pain management settings, and there is a paucity of research on treatments or strategies to alleviate the problem. The purpose of this review is to outline recent research on cognitive deficits seen in chronic pain, to give an overview of the mechanisms involved, advocate cognitive functioning as an important target for treatment in pain populations, and discuss ways in which it may be assessed and potentially remediated. METHODS A narrative review. RESULTS There are several options for remediation, including compensatory, restorative, and neuromodulatory approaches to directly modify cognitive functioning, as well as physical, psychological, and medication optimization methods to target secondary factors (mood, sleep, and medications) that may interfere with cognition. DISCUSSION We highlight the potential to enhance cognitive functions and identify the major gaps in the research literature.
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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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20
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Cunningham JL, Craner JR, Evans MM, Hooten WM. Benzodiazepine use in patients with chronic pain in an interdisciplinary pain rehabilitation program. J Pain Res 2017; 10:311-317. [PMID: 28223841 PMCID: PMC5310637 DOI: 10.2147/jpr.s123487] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objectives In the context of widespread opioid use, increased emphasis has been placed on the potentially deleterious effects of concurrent benzodiazepine (BZD) and opioid use. Although use of opioids in chronic pain has been a major focus, BZD use is equally concerning. Thus, the primary aim of this study was to determine the associations between BZD and opioid use in adults with chronic pain upon admission to an outpatient interdisciplinary pain rehabilitation (IPR) program. Methods The study cohort involved 847 consecutive patients admitted to a 3-week outpatient IPR program from January 2013 through December 2014. Study variables included baseline demographic and clinical characteristics, Center for Epidemiologic Studies-Depression Scale, Pain Catastrophizing Scale, and the pain severity subscale of the Multidimensional Pain Inventory. Results Upon admission, 248 (29%) patients were taking BZDs. Patients using BZDs were significantly more likely to use opioids and to be female. Additionally, patients using BZDs had significantly greater depression, pain catastrophizing, and pain severity scores. In univariable logistic regression analysis, opioid use, female sex, and greater scores of depression, pain catastrophizing, and pain severity were significantly associated with BZD use. In multivariable logistic regression analysis adjusted for age, sex, pain duration, opioid use, depression, pain catastrophizing, and pain severity, only female sex and greater depression scores were significantly associated with BZD use. Discussion Among patients participating in an outpatient IPR program, female sex and greater depression scores were associated with BZD use. Results identify a high prevalence of BZD use in patients with chronic pain and reinforce the need to weigh the risks versus benefits when prescribing in this patient population.
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Affiliation(s)
| | - Julia R Craner
- Department of Psychiatry and Psychology, Mayo Clinic, Mayo Clinic College of Medicine, Rochester, MN; Department of Psychiatry and Behavioral Medicine, Spectrum Health System, Grand Rapids, MI
| | - Michele M Evans
- Department of Psychiatry and Psychology, Mayo Clinic, Mayo Clinic College of Medicine, Rochester, MN
| | - W Michael Hooten
- Department of Anesthesiology, Mayo Clinic, and Mayo Clinic College of Medicine, Rochester, MN, USA
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21
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Carroll CP, Lanzkron S, Haywood C, Kiley K, Pejsa M, Moscou-Jackson G, Haythornthwaite JA, Campbell CM. Chronic Opioid Therapy and Central Sensitization in Sickle Cell Disease. Am J Prev Med 2016; 51:S69-77. [PMID: 27320469 PMCID: PMC5379857 DOI: 10.1016/j.amepre.2016.02.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/22/2016] [Accepted: 02/12/2016] [Indexed: 01/04/2023]
Abstract
Chronic opioid therapy (COT) for chronic non-cancer pain is frequently debated, and its effectiveness is unproven in sickle cell disease (SCD). The authors conducted a descriptive study among 83 adult SCD patients and compared the severity of disease and pain symptoms among those who were prescribed COT (n=29) with those who were not using COT. All patients completed baseline laboratory pain assessment and questionnaires between January 2010 and June 2014. Thereafter, participants recorded daily pain, crises, function, and healthcare utilization for 90 days using electronic diaries. Analyses were conducted shortly after the final diary data collection period. Patients on COT did not differ on age, sex, or measures of disease severity. However, patients on COT exhibited greater levels of clinical pain (particularly non-crisis); central sensitization; and depression and increased diary measures of pain severity, function, and healthcare utilization on crisis and non-crisis diary days, as well as a greater proportion of days in crisis. Including depressive symptoms in multivariate models did not change the associations between COT and pain, interference, central sensitization, or utilization. Additionally, participants not on COT displayed the expected positive relationship between central sensitization and clinical pain, whereas those on COT demonstrated no such relationship, despite having both higher central sensitization and higher clinical pain. Overall, the results point out a high symptom burden in SCD patients on COT, including those on high-dose COT, and suggest that nociceptive processing in SCD patients on COT differs from those who are not.
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Affiliation(s)
- C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Sophie Lanzkron
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlton Haywood
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kasey Kiley
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Megan Pejsa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jennifer A Haythornthwaite
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hooten WM. Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment. Mayo Clin Proc 2016; 91:955-70. [PMID: 27344405 DOI: 10.1016/j.mayocp.2016.04.029] [Citation(s) in RCA: 305] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 04/28/2016] [Indexed: 12/12/2022]
Abstract
Chronic pain and mental health disorders are common in the general population, and epidemiological studies suggest that a bidirectional relationship exists between these 2 conditions. The observations from functional imaging studies suggest that this bidirectional relationship is due in part to shared neural mechanisms. In addition to depression, anxiety, and substance use disorders, individuals with chronic pain are at risk of other mental health problems including suicide and cigarette smoking and many have sustained sexual violence. Within the broader biopsychosocial model of pain, the fear-avoidance model explains how behavioral factors affect the temporal course of chronic pain and provides the framework for an array of efficacious behavioral interventions including cognitive-behavioral therapy, acceptance-based therapies, and multidisciplinary pain rehabilitation. Concomitant pain and mental health disorders often complicate pharmacological management, but several drug classes, including serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants, have efficacy for both conditions and should be considered first-line treatment agents.
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Affiliation(s)
- W Michael Hooten
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN.
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24
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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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Kadimpati S, Zale EL, Hooten MW, Ditre JW, Warner DO. Associations between Neuroticism and Depression in Relation to Catastrophizing and Pain-Related Anxiety in Chronic Pain Patients. PLoS One 2015; 10:e0126351. [PMID: 25902153 PMCID: PMC4406532 DOI: 10.1371/journal.pone.0126351] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 04/01/2015] [Indexed: 11/18/2022] Open
Abstract
Several cognitive-affective constructs, including pain catastrophizing and pain-related anxiety, have been implicated in the onset and progression of chronic pain, and both constructs have been identified as key targets for multidisciplinary pain treatment. Both neuroticism and depression have been linked to these constructs (and to each other), but how each may contribute to the pain experience is unknown. This study tested associations between neuroticism, depression, and indices of catastrophizing and pain-related anxiety among persons seeking treatment for chronic non-malignant pain. We hypothesized, as a higher-order personality trait, neuroticism would remain uniquely associated with both pain catastrophizing and pain-related anxiety, even after accounting for current symptoms of depression. A retrospective study design assessed depression (as measured by the Centers for Epidemiologic Studies-Depression scale), neuroticism (measured with the Neuroticism-Extraversion-Openness Personality Inventory), the Pain Catastrophizing Scale, and the Pain Anxiety Symptom Score in a consecutive series of patients (n=595) admitted to a 3-week outpatient pain treatment program from March 2009 through January 2011. Hierarchical regression indicated that neuroticism was independently associated with greater pain catastrophizing and pain-related anxiety, above-and-beyond the contributions of sociodemographic characteristics, pain severity, and depression. A depression by neuroticism interaction was not observed, suggesting that associations between neuroticism and cognitive-affective pain constructs remained stable across varying levels of current depression. These findings represent an early but important step towards the clarification of complex associations between trait neuroticism, current depression, and tendencies toward catastrophic and anxiety-provoking appraisals of pain among persons seeking treatment for chronic pain.
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Affiliation(s)
- Sandeep Kadimpati
- Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Emily L. Zale
- Department of Psychology, Syracuse University, Syracuse, New York, United States of America
| | - Michael W. Hooten
- Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, New York, United States of America
| | - David O. Warner
- Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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Abstract
Back pain affects most adults, causes disability for some, and is a common reason for seeking healthcare. In the United States, opioid prescription for low back pain has increased, and opioids are now the most commonly prescribed drug class. More than half of regular opioid users report back pain. Rates of opioid prescribing in the US and Canada are two to three times higher than in most European countries. The analgesic efficacy of opioids for acute back pain is inferred from evidence in other acute pain conditions. Opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care. For chronic back pain, systematic reviews find scant evidence of efficacy. Randomized controlled trials have high dropout rates, brief duration (four months or less), and highly selected patients. Opioids seem to have short term analgesic efficacy for chronic back pain, but benefits for function are less clear. The magnitude of pain relief across chronic non-cancer pain conditions is about 30%. Given the brevity of randomized controlled trials, the long term effectiveness and safety of opioids are unknown. Loss of long term efficacy could result from drug tolerance and emergence of hyperalgesia. Complications of opioid use include addiction and overdose related mortality, which have risen in parallel with prescription rates. Common short term side effects are constipation, nausea, sedation, and increased risk of falls and fractures. Longer term side effects may include depression and sexual dysfunction. Screening for high risk patients, treatment agreements, and urine testing have not reduced overall rates of opioid prescribing, misuse, or overdose. Newer strategies for reducing risks include more selective prescription of opioids and lower doses; use of prescription monitoring programs; avoidance of co-prescription with sedative hypnotics; and reformulations that make drugs more difficult to snort, smoke, or inject.
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Affiliation(s)
- Richard A Deyo
- Departments of Family Medicine, Internal Medicine, and Public Health and Preventive Medicine and Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland, OR 97239, USA Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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Windmill J, Fisher E, Eccleston C, 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 2013:CD010323. [PMID: 23996347 DOI: 10.1002/14651858.cd010323.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients 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. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE from inception to 8th April 2013, as well as bibliographies. 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 We sought data relating to prescribed opioid use, adverse events of opioid reduction, pain, and psychological and physical function. MAIN RESULTS Two studies provided information on 86 participants. One compared electroacupuncture with sham acupuncture for 20 minutes twice a week for six weeks; there was no difference between treatments. The other followed 11 weeks of cognitive behavioural therapy with either therapeutic interactive voice response through a computer for four months or usual treatment; the active group had a significant reduction in opioid use, while the usual care group had a significant increase. AUTHORS' CONCLUSIONS Both included studies were at significant risk of bias because of their small size, together with other important issues, including blinding. Because of this risk and the paucity of relevant studies, no conclusions can be drawn regarding the effectiveness of interventions for opioid withdrawal in chronic non-cancer pain.
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Affiliation(s)
- Jude Windmill
- Pain Research and Nuffield Department of Clinical Neurosciences, University of Oxford, Churchill Hospital, Oxford, UK, OX3 7LE
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28
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Hooten WM, Knight-Brown M, Townsend CO, Laures HJ. Clinical Outcomes of Multidisciplinary Pain Rehabilitation Among African American Compared with Caucasian Patients with Chronic Pain. PAIN MEDICINE 2012; 13:1499-508. [DOI: 10.1111/j.1526-4637.2012.01489.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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29
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Darnall BD, Stacey BR, Chou R. Medical and psychological risks and consequences of long-term opioid therapy in women. PAIN MEDICINE 2012; 13:1181-211. [PMID: 22905834 DOI: 10.1111/j.1526-4637.2012.01467.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Long-term opioid use has increased substantially over the past decade for U.S. women. Women are more likely than men to have a chronic pain condition, to be treated with opioids, and may receive higher doses. Prescribing trends persist despite limited evidence to support the long-term benefit of this pain treatment approach. PURPOSE To review the medical and psychological risks and consequences of long-term opioid therapy in women. METHOD Scientific literature containing relevant keywords and content were reviewed. RESULTS AND CONCLUSIONS Long-term opioid use exposes women to unique risks, including endocrinopathy, reduced fertility, neonatal risks, as well as greater risk for polypharmacy, cardiac risks, poisoning and unintentional overdose, among other risks. Risks for women appear to vary by age and psychosocial factors may be bidirectionally related to opioid use. Gaps in understanding and priorities for future research are highlighted.
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Affiliation(s)
- Beth D Darnall
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Abstract
BACKGROUND In 1980 the Waddell score, consisting of 8 non-organic or behavioural signs, was developed to measure illness behaviour in patients with low back pain. There is some debate about whether the Waddell score is a valid screening instrument for illness behaviour and psychological distress, or whether it merely reflects elevated pain levels and diminished functional physical capacities. OBJECTIVE The purpose of this study was to examine the construct validity of the Waddell score. METHODS In this cross-sectional study, a total of 20 hypotheses about the associations between the Waddell score and measures from different domains were formulated a priori, based on a Medline database search (1980-2010). These hypotheses were tested in a sample of 229 patients with chronic low back pain who attended an outpatient rehabilitation centre. RESULTS The percentage of hypotheses that were confirmed for the association between the Waddell score and the domain pain was 100%, for the domain physical 80%, for the domain illness behaviour 80% and 50% for the domain psychological. Correlation coefficients and kappa values varied between 0.06 and 0.44 for the measures that were expected to be associated with the Waddell score. CONCLUSION Most of our challenging a priori hypotheses were accepted, and the Waddell score was found to have satisfactory cross-sectional construct validity. However, the presence of Waddell signs does not indicate exactly what the specific problems are and must therefore be conceptualized and understood in the total clinical picture of the patient. The association between the Waddell score and measures from different domains is weak. The Waddell score cannot be regarded as a straightforward psychological "screener".
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Froholdt A, Reikeraas O, Holm I, Keller A, Brox JI. No difference in 9-year outcome in CLBP patients randomized to lumbar fusion versus cognitive intervention and exercises. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21:2531-8. [PMID: 22669708 DOI: 10.1007/s00586-012-2382-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 01/11/2012] [Accepted: 05/18/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To compare the 9-year outcome in patients with chronic low back pain treated by instrumented lumbar fusion versus cognitive intervention and exercises. METHODS The main outcome measure was the Oswestry Disability Index (ODI). Secondary outcome measures included pain, fear-avoidance beliefs, trunk muscle strength, medication, and return to work. RESULTS One-third of the patients randomized to cognitive intervention and exercises had crossed over and been operated and one-third of the patients allocated to lumbar fusion had been re-operated. The intention-to-treat analysis detected no differences between the two groups. The mean adjusted treatment effect for ODI was 1.9 (95 % CI -7.8 to 11.6). Analysed according to the treatment received, more operated patients used pain medication and were out of work. CONCLUSIONS The outcome at 9 years was not different between instrumented lumbar fusion and cognitive intervention and exercises.
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Affiliation(s)
- Anne Froholdt
- Department of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet 0027, Oslo, Norway.
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Hellum C, Johnsen LG, Gjertsen Ø, Berg L, Neckelmann G, Grundnes O, Rossvoll I, Skouen JS, Brox JI, Storheim K. Predictors of outcome after surgery with disc prosthesis and rehabilitation in patients with chronic low back pain and degenerative disc: 2-year follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21:681-90. [PMID: 22246644 DOI: 10.1007/s00586-011-2145-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/15/2011] [Accepted: 12/31/2011] [Indexed: 01/24/2023]
Abstract
PURPOSE A prospective study to evaluate whether certain baseline characteristics can predict outcome in patients treated with disc prosthesis or multidisciplinary rehabilitation. METHODS Secondary analysis of 154 patients with chronic low back pain (LBP) for at least 1 year and degenerative discs originally recruited for a randomized trial. Outcome measures were Oswestry Disability Index (ODI) dichotomized to < or ≥15 points improvement and whether subjects were working at 2-year follow-up. A multiple logistic regression analysis was used. RESULTS In patients treated with disc prosthesis, long duration of LBP and high Fear-Avoidance Beliefs for work (FABQ-W) predicted worse ODI outcome [odds ratio (OR) = 1.9, 95% confidence interval (CI) 1.2-3.2 and OR = 1.7, CI 1.2-2.4 for every 5 years or 5 points]. Modic type I or II predicted better ODI outcome (OR = 5.3, CI 1.1-25.3). In patients treated with rehabilitation, a high ODI, low emotional distress (HSCL-25), and no daily narcotics predicted better outcome for ODI (OR = 2.5, CI 1.4-4.5 for every 5 ODI points, OR = 2.1, CI 1.1-5.1 for every 0.5 HSCL points and OR = 23.6, CI 2.1-266.8 for no daily narcotics). Low FABQ-W and working at baseline predicted working at 2-year follow-up after both treatments (OR = 1.3, CI 1.0-1.5 for every 5 points and OR = 4.1, CI 1.2-13.2, respectively). CONCLUSIONS Shorter duration of LBP, Modic type I or II changes and low FABQ-W were the best predictors of success after treatment with disc prosthesis, while high ODI, low distress and not using narcotics daily predicted better outcome of rehabilitation. Low FABQ-W and working predicted working at follow-up.
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Affiliation(s)
- Christian Hellum
- Department of Orthopaedics, Oslo University Hospital, University of Oslo, Kirkevn 166, 0407, Oslo, Norway.
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Identification of Patients With Chronic Low Back Pain Who Might Benefit From Additional Psychological Assessment. Clin J Pain 2012; 28:23-31. [DOI: 10.1097/ajp.0b013e31822019d0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kahan M, Mailis-Gagnon A, Tunks E. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain: implications for pain physicians. Pain Res Manag 2011; 16:157-8. [PMID: 21766064 PMCID: PMC3198108 DOI: 10.1155/2011/434298] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Meldon Kahan
- Department of Family Medicine, University of Toronto, Toronto, Ontario, Canada.
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Abstract
BACKGROUND Chronic low back pain (CLBP) and osteoarthritis (OA) of any joint are highly prevalent, occurring in > 50% of US adults aged ≥ 60 years. Opioids are prescribed more frequently for CLBP and OA than for any other noncancer pain, and the judicious use of opioids is recommended by treatment guidelines for the management of CLBP and OA pain. OBJECTIVE To review the appropriate role of opioid analgesics in the treatment of patients with moderate-to-severe pain due to CLBP or OA and provide recommendations for best practices when prescribing opioids. METHODS Articles were identified through a search of PubMed. Additional references were identified for inclusion from the reference lists of articles identified via the literature search, treatment guidelines, and Cochrane Reviews. RESULTS The available data suggest that opioid therapy represents a valuable treatment option in patients who do not respond to other analgesics and in whom the potential benefits of treatment outweigh the potential risks. Prescribing physicians need to perform vigilant patient screening and monitoring for signs of abuse, intervene promptly to manage or prevent adverse events and drug interactions, tailor opioid therapy to individual patients' comorbidities, and know how to switch or rotate opioids to find the best treatment option. CONCLUSIONS Prescribers need to understand the place of opioid therapy in a multimodal treatment program that includes patient rehabilitation to reduce pain and improve function. The analgesic benefits of opioids must be balanced against concerns about addiction and abuse, adverse events, and their potential impact on other aspects of treatment.
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Affiliation(s)
- Roy D Altman
- Department of Rheumatology and Immunology, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA.
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Hooten MW, Shi Y, Gazelka HM, Warner DO. The effects of depression and smoking on pain severity and opioid use in patients with chronic pain. Pain 2010; 152:223-229. [PMID: 21126821 DOI: 10.1016/j.pain.2010.10.045] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 10/11/2010] [Accepted: 10/28/2010] [Indexed: 11/28/2022]
Abstract
Depression and smoking are common comorbid conditions among adults with chronic pain. The aim of this study was to determine the independent effects of depression on clinical pain and opioid use among patients with chronic pain according to smoking status. A retrospective design was used to assess baseline levels of depression, clinical pain, opioid dose (calculated as morphine equivalents), and smoking status in a consecutive series of patients admitted to a 3-week outpatient pain treatment program from September 2003 through February 2007. Depression was assessed using the Centers for Epidemiologic Studies-Depression scale, and clinical pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. The study cohort (n=1241) included 313 current smokers, 294 former smokers, and 634 never smokers. Baseline depression (P=.001) and clinical pain (P=.001) were greater among current smokers compared to former and never smokers, and the daily morphine equivalent dose was greater among smokers compared to never smokers (P=.005). In multivariate linear regression analyses, baseline pain severity was independently associated with greater levels of depression, but not with smoking status. However, status as a current smoker was independently associated with greater opioid use (by 27mg/d), independent of depression scores. The relationship between depression, smoking status, opioid use, and chronic pain is complex, and both depression and smoking status may be potentially important considerations in the treatment of patients with chronic pain who utilize opioids. This study found that pain severity was associated with greater depression but not smoking; however, smoking was associated with greater opioid use, independent of depression.
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Affiliation(s)
- Michael W Hooten
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55902, USA Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN 55902, USA Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA Department of Anesthesiology, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Hooten WM, Mantilla CB, Sandroni P, Townsend CO. Associations between Heat Pain Perception and Opioid Dose among Patients with Chronic Pain Undergoing Opioid Tapering. PAIN MEDICINE 2010; 11:1587-98. [DOI: 10.1111/j.1526-4637.2010.00962.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hooten WM, Sandroni P, Mantilla CB, Townsend CO. Associations between Heat Pain Perception and Pain Severity among Patients with Chronic Pain. PAIN MEDICINE 2010; 11:1554-63. [DOI: 10.1111/j.1526-4637.2010.00940.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nicolson SE, Caplan JP, Williams DE, Stern TA. Comorbid pain, depression, and anxiety: multifaceted pathology allows for multifaceted treatment. Harv Rev Psychiatry 2010; 17:407-20. [PMID: 19968455 DOI: 10.3109/10673220903463226] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The care of patients who suffer from physical pain and a psychiatric illness is typically challenging because of the complex interplay of affective, behavioral, cognitive, and physical aspects of pain. Psychiatrists are often asked to evaluate patients with pain because of a concern for comorbid depression and anxiety, and fears of suicidality as a result of pain. This article reviews the pathophysiology of comorbid pain, anxiety, and depression, along with the treatment modalities (pharmacologic, psychotherapeutic, and "alternative") that may benefit all three conditions.
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Affiliation(s)
- Stephen E Nicolson
- Departments of Psychiatry, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
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40
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:46-51. [DOI: 10.1097/spc.0b013e3283372479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2009; 69:1643-8. [PMID: 19635718 PMCID: PMC2938881 DOI: 10.1136/ard.2009.108902] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives To compare the long-term effectiveness of surgical and non-surgical treatment in patients with chronic low back pain. Methods Two merged randomised clinical trials compared instrumented transpedicular fusion with cognitive intervention and exercises in 124 patients with disc degeneration and at least 1 year of symptoms after or without previous surgery for disc herniation. The main outcome measure was the Oswestry disability index. Results At 4 years 14 (24%) patients randomly assigned to cognitive intervention and exercises had also undergone surgery. 15 (23%) patients assigned fusion had undergone re-surgery. The mean treatment effect for the primary outcome was 1.1; 95% CI −5.9 to 8.2, according to the intention-to-treat analysis and −1.6; 95% CI −8.9 to 5.6 in the as-treated analysis. There was no difference in return to work. Conclusions Long-term improvement was not better after instrumented transpedicular fusion compared with cognitive intervention and exercises.
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Affiliation(s)
- Jens Ivar Brox
- Orthopaedic Department, Oslo University Hospital-Rikshospitalet, Sognsvannsveien, 0027 Oslo, Norway.
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