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Mattenklodt P, Ingenhorst A, Flatau B, Becker K, Grießinger N. [Interdisciplinary pain therapy in the elderly]. Schmerz 2024; 38:89-98. [PMID: 37266908 DOI: 10.1007/s00482-023-00721-w] [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: 02/02/2023] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 06/03/2023]
Abstract
Chronic pain in the elderly is becoming increasingly important and is associated with serious health impacts. Therefore, international guidelines demand that pain therapy for the elderly preferably be a multimodal therapy based on a bio-psycho-social pain model. Specific psychometric tests and interview guidelines are available for the interdisciplinary pain assessment. Evidence for the effectiveness of multimodal pain therapy in the elderly remains limited. However, controlled clinical trials have shown that these patients benefit-especially if the intervention is adapted to their specific needs. The focus of movement therapy is not only muscle strengthening but also coordination exercises. In individual physical therapy and occupational therapy, everyday solutions can be developed for individual physical limitations that are more frequent in old age. In psychological training, pain acceptance, balancing rest and activity, social integration and dealing with aging are particularly important topics. Relaxation and mindfulness techniques can also favorably affect pain and function. Thus, these are popular with patients and are often adopted in everyday pain management. Pain education is considered useful as an adjunctive measure and can also be increasingly supported by digital media in the elderly. Complementary therapy components include confrontational treatment of fear-avoidance beliefs (the German AMIKA scale, Ältere Menschen in körperlicher Aktion, "older people in physical action") and naturopathic applications as an active self-help strategy. Since it is unclear how long the achieved therapeutic effects last, follow-up care is of particular importance in therapy for older patients.
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Affiliation(s)
- Peter Mattenklodt
- Schmerzzentrum, Uniklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland.
| | - Anne Ingenhorst
- Schmerzzentrum, Uniklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland
| | - Brigitta Flatau
- medi train - Bewegungstherapie Physiotherapie, Erlangen, Deutschland
| | - Kristina Becker
- medi train - Bewegungstherapie Physiotherapie, Erlangen, Deutschland
| | - Norbert Grießinger
- Schmerzzentrum, Uniklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland
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2
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Mattenklodt P, Ingenhorst A, Flatau B, Becker K, Grießinger N. [Interdisciplinary pain therapy in the elderly]. DIE ANAESTHESIOLOGIE 2024; 73:147-155. [PMID: 38376754 DOI: 10.1007/s00101-024-01392-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Chronic pain in the elderly is becoming increasingly important and is associated with serious health impacts. Therefore, international guidelines demand that pain therapy for the elderly preferably be a multimodal therapy based on a bio-psycho-social pain model. Specific psychometric tests and interview guidelines are available for the interdisciplinary pain assessment. Evidence for the effectiveness of multimodal pain therapy in the elderly remains limited. However, controlled clinical trials have shown that these patients benefit-especially if the intervention is adapted to their specific needs. The focus of movement therapy is not only muscle strengthening but also coordination exercises. In individual physical therapy and occupational therapy, everyday solutions can be developed for individual physical limitations that are more frequent in old age. In psychological training, pain acceptance, balancing rest and activity, social integration and dealing with aging are particularly important topics. Relaxation and mindfulness techniques can also favorably affect pain and function. Thus, these are popular with patients and are often adopted in everyday pain management. Pain education is considered useful as an adjunctive measure and can also be increasingly supported by digital media in the elderly. Complementary therapy components include confrontational treatment of fear-avoidance beliefs (the German AMIKA scale, Ältere Menschen in körperlicher Aktion, "older people in physical action") and naturopathic applications as an active self-help strategy. Since it is unclear how long the achieved therapeutic effects last, follow-up care is of particular importance in therapy for older patients.
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Affiliation(s)
- Peter Mattenklodt
- Schmerzzentrum, Uniklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland.
| | - Anne Ingenhorst
- Schmerzzentrum, Uniklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland
| | - Brigitta Flatau
- medi train - Bewegungstherapie Physiotherapie, Erlangen, Deutschland
| | - Kristina Becker
- medi train - Bewegungstherapie Physiotherapie, Erlangen, Deutschland
| | - Norbert Grießinger
- Schmerzzentrum, Uniklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland
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3
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Margraf AM, Davoodi NM, Chen K, Shield RR, McAuliffe LM, Collins CM, Zullo AR. Provider beliefs about the ideal design of an opioid deprescribing and substitution intervention for older adults. Am J Health Syst Pharm 2023; 80:53-60. [PMID: 36205419 DOI: 10.1093/ajhp/zxac282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Opportunities exist to meaningfully reduce suboptimal prescription opioid use among older adults. Deprescribing is one possible approach to reducing suboptimal use. Appropriate interventions should outline how to carefully taper opioids, closely monitor adverse events, substitute viable alternative and affordable nonopioid pain treatments, and initiate medications for opioid use disorder to properly manage use disorders, as needed. We sought to document and understand provider perceptions to begin developing effective and safe opioid deprescribing interventions. METHODS We conducted 3 semistructured focus groups that covered topics such as participant perspectives on opioid deprescribing in older adults, how to design an ideal intervention, and how to identify potential barriers or facilitators in implementing an intervention. Focus group transcripts were double coded and qualitatively analyzed to identify overarching themes. RESULTS Healthcare providers (n = 17), including physicians, pharmacists, nurses, social workers, and administrative staff, participated in 3 focus groups. We identified 4 key themes: (1) involve pharmacists in deprescribing and empower them as leaders of an opioid deprescribing service; (2) ensure tight integration and close collaboration throughout the deprescribing process from the inpatient to outpatient settings; (3) more expansive inclusion criteria than age alone; and (4) provision of access to alternative pharmacological and nonpharmacological pain management modalities to patients. CONCLUSION Our findings, which highlight various healthcare provider beliefs about opioid deprescribing interventions, are expected to serve as a framework for other organizations to develop and implement interventions. Future studies should incorporate patients' and family caregivers' perspectives.
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Affiliation(s)
- Alissa M Margraf
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | | | - Kevin Chen
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Renee R Shield
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Laura M McAuliffe
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Christine M Collins
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Andrew R Zullo
- Department of Pharmacy, Rhode Island Hospital, Providence, RI.,Departments of Epidemiology, Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
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Craner JR, Schumann ME, Barr A, Morrison EJ, Lake ES, Sutor B, Flegge LG, Gilliam WP. Mediators of change in depressed mood following pain rehabilitation among participants with mild, moderate, or severe depressive symptoms. J Affect Disord 2022; 307:286-293. [PMID: 35351491 DOI: 10.1016/j.jad.2022.03.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/19/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Prior research indicates that depression and chronic pain commonly co-exist and impact each other. Interdisciplinary pain rehabilitation programs (IPRPs) have been shown to lead to statistically and clinically significant improvements for patients who report both depressed mood and chronic pain, however there is a gap in the literature regarding the mechanisms by which these improvements occur. METHODS This two-site, distinct sample study (Study 1: N = 303, 10-week, individual format, ACT-based program; Study 2: N = 406, 3-week, group format, CBT-based program) evaluated mediators of treatment improvement in depressive symptoms among adult IPRP participants who reported elevated depressive symptoms at program admission and examined treatment mechanisms for depressive symptoms. RESULTS Self-reported pain self-efficacy and pain catastrophizing - particularly the helplessness domain - mediated the treatment-related change in depression among IPRP participants with elevated depressive symptoms across the two sites and samples. In one sample, full mediation was achieved while in the other sample, partial mediation was achieved. Participants in both samples showed improvement on all measures. LIMITATIONS This study relied on self-report measures of depressive severity and not clinical diagnosis. Results may not generalize to other populations of patients with chronic pain. There was no control condition in either study. CONCLUSION Increasing pain self-efficacy and decreasing a sense of helplessness are important treatment targets among IPRP participants who endorse symptoms of depression.
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Affiliation(s)
- Julia R Craner
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, United States of America; Michigan State University College of Human Medicine, Grand Rapids, MI, United States of America.
| | - Matthew E Schumann
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Aex Barr
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, United States of America; Michigan State University College of Human Medicine, Grand Rapids, MI, United States of America
| | - Eleshia J Morrison
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Eric S Lake
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, United States of America; Michigan State University College of Human Medicine, Grand Rapids, MI, United States of America
| | - Bruce Sutor
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Lindsay G Flegge
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, United States of America; Michigan State University College of Human Medicine, Grand Rapids, MI, United States of America
| | - Wesley P Gilliam
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, United States of America
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Niznik JD, Collins BJ, Armistead LT, Larson CK, Kelley CJ, Hughes TD, Sanders KA, Carlson R, Ferreri SP. Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review. Res Social Adm Pharm 2022; 18:2913-2921. [PMID: 34281786 PMCID: PMC8836277 DOI: 10.1016/j.sapharm.2021.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.
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Affiliation(s)
- Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA; VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Brendan J Collins
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Claire K Larson
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Casey J Kelley
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Tamera D Hughes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Kimberly A Sanders
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Rebecca Carlson
- University of North Carolina, Health Sciences Library, Chapel Hill, NC, USA
| | - Stefanie P Ferreri
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Skúladóttir H, Björnsdottir A, Holden JE, Gunnarsdóttir TJ, Halldorsdottir S, Sveinsdottir H. Pain Rehabilitation's Effect on People in Chronic Pain: A Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910306. [PMID: 34639608 PMCID: PMC8508161 DOI: 10.3390/ijerph181910306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/12/2021] [Accepted: 09/28/2021] [Indexed: 11/27/2022]
Abstract
Multidisciplinary long-term pain rehabilitation programs with a team of healthcare professionals are an integrated approach to treat patients with chronic non-malignant pain. In this longitudinal prospective cohort study, we investigated the long-term effects of multidisciplinary pain rehabilitation on the self-reported causes of pain, pain self-management strategies, sleep, pain severity, and pain’s interference with life, pre- and post-treatment. Eighty-one patients, aged 20–69 years, with chronic pain responded. The two most frequently reported perceived causes of pain were fibromyalgia and accidents. The difference in average self-reported pain severity decreased significantly at one-year follow-up (p < 0.001), as did pain’s interference with general activities, mood, walking ability, sleep, and enjoyment of life. At one-year follow-up, participants (21%) rated their health as good/very good and were more likely to state that it was better than a year before (20%). No change was found in the use of pain self-management strategies such as physical training at one-year follow-up. The intervention was effective for the participants, as reflected in the decreased pain severity and pain interference with life.
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Affiliation(s)
- Hafdís Skúladóttir
- School of Health Science, University of Akureyri, Solborg v/Nordurslod, 600 Akureyri, Iceland;
- Correspondence: ; Tel.: +354-460-8456
| | - Amalia Björnsdottir
- School of Education, Faculty of Education and Pedagogy, University of Iceland, Stakkahlid 1, 105 Reykjavík, Iceland;
| | - Janean E. Holden
- School of Nursing, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Thóra Jenný Gunnarsdóttir
- School of Health Science, University of Iceland, Eiríksgata 34, 101 Reykjavík, Iceland; (T.J.G.); (H.S.)
| | - Sigridur Halldorsdottir
- School of Health Science, University of Akureyri, Solborg v/Nordurslod, 600 Akureyri, Iceland;
| | - Herdis Sveinsdottir
- School of Health Science, University of Iceland, Eiríksgata 34, 101 Reykjavík, Iceland; (T.J.G.); (H.S.)
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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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9
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Adverse Childhood Experiences and Chronic Pain Rehabilitation Treatment Outcomes in Adults. Clin J Pain 2021; 37:321-329. [PMID: 33830091 DOI: 10.1097/ajp.0000000000000924] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/22/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) are commonly reported by individuals with chronic pain. However, little is known about how ACE exposure influences treatment outcomes. The goal of the current study was to evaluate group and treatment-related differences among adults with varying levels of ACE exposure participating in a pain rehabilitation treatment program. METHODS Adult participants (N=269) were categorized as 0 ACEs (n=65), 1 to 2 ACEs (n=87), or ≥3 ACEs (n=117). Participants completed self-report measures of pain, physical functioning, and psychosocial functioning at intake and discharge from a 10-week interdisciplinary pain rehabilitation program. RESULTS ACE exposure was frequently endorsed in this sample, with the majority of participants (78.5%) reporting at least 1 form of childhood adversity. Adults in the ≥3 ACEs group reported a greater level of impairment in mental health symptoms and adjustment to chronic pain; however, all groups endorsed treatment improvements and there were no differences in response to treatment. There were also no differences between groups on measures of pain or physical functioning at intake or discharge. DISCUSSION ACE exposure appears common among treatment-seeking adults with chronic pain and is associated with increased clinical complexity. However, adults with and without exposure to ACEs endorsed significant improvements in pain and functioning following participation in an interdisciplinary pain rehabilitation program. This model of treatment may be especially well situated to address the biopsychosocial contributions to pain among those with a history of adversity.
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10
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Brintz CE, Cheatle MD, Dember LM, Heapy AA, Jhamb M, Shallcross AJ, Steel JL, Kimmel PL, Cukor D. Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease. Semin Nephrol 2021; 41:68-81. [PMID: 33896475 DOI: 10.1016/j.semnephrol.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.
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Affiliation(s)
- Carrie E Brintz
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alicia A Heapy
- Pain Research Informatics Multimorbidities and Education Center of Innovation, Veterans' Affairs Connecticut Healthcare System, West Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amanda J Shallcross
- Department of Population Health, New York University School of Medicine, New York, NY
| | - Jennifer L Steel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA; Department of Psychology, University of Pittsburgh, Pittsburgh, PA; Behavioral Health, The Rogosin Institute, New York, NY
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Daniel Cukor
- Behavioral Health, The Rogosin Institute, New York, NY
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11
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Binswanger IA, Glanz JM, Faul M, Shoup JA, Quintana LM, Lyden J, Xu S, Narwaney KJ. The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study. Drug Alcohol Depend 2020; 217:108248. [PMID: 32927194 PMCID: PMC10959283 DOI: 10.1016/j.drugalcdep.2020.108248] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Opioid prescribing guidelines recommend reducing or discontinuing opioids for chronic pain if harms of opioid treatment outweigh benefits. As opioid discontinuation becomes more prevalent, it is important to understand whether opioid discontinuation is associated with heroin use. In this study, we sought to assess the association between opioid discontinuation and heroin use documented in the medical record. METHODS A matched nested case-control study was conducted in an integrated health plan and delivery system in Colorado. Patients receiving opioid therapy in the study period (January 2006-June 2018) were included. Opioid discontinuation was defined as ≥45 days with no opioids dispensed after initiating opioid therapy. The heroin use onset date represented the index date. Case patients were matched to up to 20 randomly selected patients without heroin use (control patients) by age, sex, calendar time, and time between initiating opioid therapy and the index date. Conditional logistic regression models estimated matched odds ratios (mOR) for the association between an opioid discontinuation prior to the index date and heroin use. RESULTS Among 22,962 patients prescribed opioid therapy, 125 patients (0.54%) used heroin after initiating opioid therapy, of which 74 met criteria for inclusion in the analysis. The odds of opioid discontinuation were approximately two times higher in case patients (n = 74) than control patients (n = 1045; mOR = 2.19; 95% CI 1.27-3.78). CONCLUSIONS Among patients prescribed chronic opioid therapy, the observed increased risk for heroin use associated with opioid discontinuation should be balanced with potential benefits.
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Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado Permanente Medical Group, Aurora, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado School of Public Health, Aurora, CO
| | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - LeeAnn M Quintana
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jennifer Lyden
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health, Department of Medicine, Denver, CO
| | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
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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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Gagnon CM, Scholten P, Atchison J, Jabakhanji R, Wakaizumi K, Baliki M. Structural MRI Analysis of Chronic Pain Patients Following Interdisciplinary Treatment Shows Changes in Brain Volume and Opiate-Dependent Reorganization of the Amygdala and Hippocampus. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2765-2776. [PMID: 32488262 PMCID: PMC8463093 DOI: 10.1093/pm/pnaa129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE The present study examined pre- to post-treatment changes in volumes for brain structures known to be associated with pain processing (thalamus, caudate, putamen, pallidum, hippocampus, amygdala, and accumbens) following an interdisciplinary pain management program. DESIGN Twenty-one patients participating in a four-week interdisciplinary pain management program completed the study. The program consisted of individual and group therapies with the following disciplines: physical therapy, occupational therapy, pain psychology, biofeedback/relaxation training, nursing lectures, and medical management. All patients underwent functional magnetic resonance imaging of the brain before the start and at completion of the program. They also completed standard outcome measures assessing pain, symptoms of central sensitization, disability, mood, coping, pain acceptance, and impressions of change. RESULTS Our results showed a significant increase in total brain volume, as well as increased volumes in the thalamus, hippocampus, and amygdala. As expected, we also found significant improvements in our standard outcome measures. The majority of patients rated themselves as much or very much improved. The increase in volume in the hippocampus was significantly associated with patient perceptions of change. However, the correlations were in the unexpected direction, such that greater increases in hippocampal volume were associated with perceptions of less improvement. Further exploratory analyses comparing patients by their opioid use status (use vs no use) showed differential program effects on volume increases in the hippocampus and amygdala. CONCLUSIONS These findings show that a four-week interdisciplinary pain management program resulted in changes in the brain, which adds objective findings further demonstrating program efficacy.
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Affiliation(s)
- Christine M Gagnon
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul Scholten
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James Atchison
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of PM&R, Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - Rami Jabakhanji
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kenta Wakaizumi
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marwan Baliki
- Shirley Ryan Abilitylab, Pain Management Center, Chicago, Illinois
- Department of PM&R, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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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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Treatment Effectiveness and Medication Use Reduction for Older Adults in Interdisciplinary Pain Rehabilitation. Mayo Clin Proc Innov Qual Outcomes 2020; 4:276-286. [PMID: 32542219 PMCID: PMC7283568 DOI: 10.1016/j.mayocpiqo.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To examine the effectiveness of an interdisciplinary pain rehabilitation program (IPRP) that incorporates medication tapering on improving pain-related and performance-based outcomes for older adults with chronic noncancer pain and determine the proportion who demonstrated reliable improvement in outcome. Patients and Methods This 2-year retrospective clinical cohort study examined treatment outcomes of 134 older adult patients 65 years or older with chronic noncancer pain who completed a 3-week IPRP with physician-supervised medication tapering between January 1, 2015, and December 31, 2017. Pain, pain catastrophizing, depressive symptoms, and quality of life were assessed at pretreatment, posttreatment, and follow-up. Physical performance and medication use were assessed pre- and posttreatment. Outcomes were examined using a series of repeated-measures analyses of variance, examining effect size and reliable change. Results Significant treatment effects (P<.001) with large effect sizes were observed for all self-report and physical performance outcome measures at posttreatment and 6-month follow-up (42.5% response rate). There were no significant differences in outcome based on opioid use status at admission. Reliable change analyses revealed that 76.9% (n=103 of 134) evidenced improvement in at least 1 pain-related outcome measure at posttreatment, and 87.7% (n=50 of 57), at follow-up. Patients also had significant reductions (P<.01) in medications at posttreatment (opioids, benzodiazepines, sedative-hypnotics, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants). Conclusion Older adults with chronic noncancer pain demonstrated improved pain-related outcomes, physical performance, and decreased medication use following IPRP treatment. Results support the effectiveness of IPRPs in enhancing the physical and emotional functioning of older adults with chronic pain while also facilitating the reduction of medications that place them at risk for adverse events.
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Key Words
- ANCOVA, analysis of covariance
- ANOVA, analysis of variance
- BZD, benzodiazepine
- CES-D, Center for Epidemiologic Studies- Depression Scale
- CNP, chronic noncancer pain
- IPRP, interdisciplinary pain rehabilitation program
- MME, morphine milligram equivalent
- OA, older adult
- PCS, Pain Catastrophizing Scale
- PHQ-9, Patient Health Questionnaire-9
- PI, pain interference
- PRC, Mayo Clinic Pain Rehabilitation Center
- PS, pain severity
- QOL, quality of life
- Sdiff, standard error of the difference
- WYMHPI, West Haven-Yale Multidimensional Pain Inventory
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Hassan S, Zheng Q, Rizzolo E, Tezcanli E, Bhardwaj S, Cooley K. Does Integrative Medicine Reduce Prescribed Opioid Use for Chronic Pain? A Systematic Literature Review. PAIN MEDICINE 2019; 21:836-859. [DOI: 10.1093/pm/pnz291] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AbstractBackgroundChronic pain (CP) is a major public health problem. Many patients with CP are increasingly prescribed opioids, which has led to an opioid crisis. Integrative medicine (IM), which combines pharmacological and complementary and alternative medicine (CAM), has been proposed as an opioid alternative for CP treatment. Nevertheless, the role of CAM therapies in reducing opioid use remains unclear.ObjectivesTo explore the effectiveness of the IM approach or any of the CAM therapies to reduce or cease opioid use in CP patients.MethodsAn online search of MEDLINE and Embase, CINAHL, PubMed supp., and Allied and Complementary Medicine Database (AMED) for studies published in English from inception until February 15, 2018, was conducted. The Mixed Methods Appraisal Tool (MMAT) was used to critically appraise selected studies.ResultsThe electronic search yielded 5,200 citations. Twenty-three studies were selected. Eight studies were randomized controlled trials, seven were retrospective studies, four studies were prospective observational, three were cross-sectional, and one was quasi-experimental. The majority of the studies showed that opioid use was reduced significantly after using IM. Cannabinoids were among the most commonly investigated approaches in reducing opioid use, followed by multidisciplinary approaches, cognitive-behavioral therapy, and acupuncture. The majority of the studies had limitations related to sample size, duration, and study design.ConclusionsThere is a small but defined body of literature demonstrating positive preliminary evidence that the IM approach including CAM therapies can help in reducing opioid use. As the opioid crisis continues to grow, it is vital that clinicians and patients be adequately informed regarding the evidence and opportunities for IM/CAM therapies for CP.
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Affiliation(s)
- Samah Hassan
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Qingping Zheng
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Erica Rizzolo
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Evrim Tezcanli
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Sukriti Bhardwaj
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Kieran Cooley
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, Australia
- Pacific College of Oriental Medicine, San Diego, California, USA
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Bujak BK, Regan E, Beattie PF, Harrington S. The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis. Pain Manag 2019; 9:417-429. [DOI: 10.2217/pmt-2018-0087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aim: To explore the overall effectiveness of interdisciplinary intensive outpatient treatment programs in adults with chronic pain. The secondary aim was to examine the effect of the intervention on individual outcome measures including pain intensity, pain catastrophizing, depressive symptoms, quality of life and describe its effect on medication use. Methods: The preferred reporting items for systematic review and meta-analysis protocols reporting guidelines were followed in this systematic review and meta-analysis. Results: A total of 13 peer-reviewed studies were included in analysis: one randomized controlled trial and 12 observational studies. Conclusion: Although interdisciplinary intensive outpatient programs for chronic pain have only been examined in a limited number of studies, trends suggest that participation in these programs may improve physical, emotional, social and mental health as measured by quality of life measures, while decreasing pain intensity, pain catastrophizing and depressive symptoms in a population with diverse diagnoses.
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Affiliation(s)
- Barbara K Bujak
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, USA
- Army Medical Department Center & School, JBSA-Fort Sam Houston, 2450 Stanley Road, San Antonio, TX 78234, USA
| | - Elizabeth Regan
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street, Columbia, SC 29208, USA
| | - Paul F Beattie
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street, Columbia, SC 29208, USA
| | - Shana Harrington
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street, Columbia, SC 29208, USA
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Shindo Y, Iwasaki S, Yamakage M. Efficacy and Practicality of Opioid Therapy in Japanese Chronic Noncancer Pain Patients. Pain Manag Nurs 2019; 20:222-231. [PMID: 31126747 DOI: 10.1016/j.pmn.2018.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/06/2018] [Accepted: 09/30/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Many Japanese adults suffer from chronic pain. However, 50% of these individuals discontinue treatment despite the persistence of pain. Both clinicians and patients in Japan tend to be concerned about the safety and efficacy of opioid therapy, and the use of opioids in chronic non-cancer pain remains less common in Japan than elsewhere. AIMS This study examined the effects of opioid therapy on the daily lives of patients with chronic noncancer pain in Japan, where use of opioids for this type of pain remains uncommon. DESIGN Prospective cross-sectional questionnaire study. SETTING Data were collected over two periods, between March and April 2014 at one hospital, and between February and April 2015 at the other hospital. Subjects were recruited at the respective clinics by the study interviewer between March 1, 2014 and April 15, 2014 and between February 1, 2015 and April 15, 2015. PARTICIPANTS/SUBJECTS This study included 34 outpatients with chronic non-cancer pain who were being treated with opioid analgesics at pain clinics in two hospitals in Sapporo. METHODS Thirty-four Japanese patients receiving opioid medications for chronic noncancer pain in outpatient pain clinics were enrolled. Participants underwent interviews and completed the Japanese versions of the Short Form 36 (SF-36v2) and the Coping Strategies Questionnaire (CSQ). RESULTS Sleep disruption, claiming compensation for work-related accidents, and current pain level were negatively correlated with opioid effectiveness (p < .05). Additionally, opioid effectiveness was negatively correlated with the catastrophizing subscale of the CSQ (r = -0.50, p < .01). The effects of opioid therapy had a low positive correlation with the emotional functioning role subscale of the SF-36v2 (r = 0.38, p < .05). Daily equivalent morphine dose was positively correlated with opioid therapy duration, interference with appetite, and current pain intensity. Morphine dose was also positively correlated with scores for the catastrophizing subscale of the CSQ (r = 0.36, p < .05) and negatively correlated with scores in all subdomains of the SF-36v2. CONCLUSIONS It is important to focus on adaptive, cognitive, and emotional factors, such as emotional role functioning, to determine the efficacy of opioid treatment for chronic noncancer pain. Moreover, patients with catastrophizing significantly increased their morphine doses, resulting in an increased risk of overdose.
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Affiliation(s)
- Yukari Shindo
- The Faculty of Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan.
| | - Soushi Iwasaki
- Sapporo Medical University School of Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Michiaki Yamakage
- Sapporo Medical University School of Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Gagnon CM, Brewington DV, Scholten PM, Atchison J, Chang CH. Impact of Symptom Reporting Agreement on Interdisciplinary Pain Program Participation. Pain Pract 2019; 19:621-632. [PMID: 30891911 DOI: 10.1111/papr.12783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate whether physician-patient agreement of potential patient problem areas impacts subsequent patient enrollment in an interdisciplinary pain management program. DESIGN Retrospective chart review of 544 patients who underwent evaluation of their chronic pain. Physicians and their patients endorsed perceived patient problems during the evaluation. The potential problems included 7 clinical domains: pain, sleep, mood, physical functioning, ability to cope with pain, ability to manage pain flare-ups, and pain medication effectiveness. RESULTS Results indicated statistically significant levels of agreement among the physicians and their patients (free-marginal kappa range, 0.19 to 0.94, P's < 0.001). The highest agreement occurred for pain and the lowest for pain medication effectiveness. Patients who enrolled in a recommended program did not differ from those who did not enroll based on either levels of agreement or average number of physician-patient agreements for the 7 clinical domains (P's > 0.05). Patients recommended for higher-intensity programs were perceived by their evaluating physician to have a significantly greater number of problematic clinical domains than those recommended for less intense pain programs. CONCLUSION The level of physician-patient agreement regarding the patients' current difficulties did not appear to influence patients' decisions to participate in interdisciplinary pain management. Extraneous, nonclinical factors may have had a greater impact on participation in interdisciplinary pain management than physician-patient agreement. Future research should focus on identifying these factors and their impact. Also, studying the impact of physician-patient agreement beyond enrollment status (eg, on successful program completion) may be helpful in potentially enhancing patient outcomes.
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Affiliation(s)
- Christine M Gagnon
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | | | - Paul M Scholten
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - James Atchison
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Department of PM&R, Mayo Clinic Jacksonville, Jacksonville, Florida, U.S.A
| | - Chih-Hung Chang
- Shirley Ryan AbilityLab, Chicago, Illinois, U.S.A.,Department of PM&R, Northwestern Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Washington University School of Medicine, St. Louis, Missouri, U.S.A
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20
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Bailey JC, Kurklinsky S, Sletten CD, Osborne MD. The Effectiveness of an Intensive Interdisciplinary Pain Rehabilitation Program in the Treatment of Post-Laminectomy Syndrome in Patients Who Have Failed Spinal Cord Stimulation. PAIN MEDICINE 2019; 19:385-392. [PMID: 28402524 DOI: 10.1093/pm/pnx060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction Post-laminectomy syndrome (PLS) patients who have previously undergone spinal cord stimulation and failed to have significant improvement create a unique challenge for ongoing pain management. We hypothesize that, following successful completion of intensive, interdisciplinary pain rehabilitation (IPR), this patient population can achieve a significant reduction in pain, improvement in mood, functional levels, and self-efficacy. Materials and methods A retrospective chart review was conducted comparing the following for patients prior to enrollment in the IPR program and upon completion: numeric rating scale (NRS) pain scores; functional status via the six-minute walk test; mood via the Center for Epidemiologic Studies Depression Scale (CES-D), Multidimensional Pain Inventory (MPI) Life control scores and MPI Interference, and the Pain Catastrophizing Scale (PCS); and self-efficacy via the Pain Self-Efficacy Questionnaire (PSEQ). Results Forty-three patients met inclusion criteria, with 17 males and 26 females and a mean age of 64 years. Patients demonstrated a statistically significant increase in six-minute walk test distance of 104 m, a decrease in average NRS pain score of 1.4 points, an increase in average MPI life control by 8.3 points, a decrease average MPI interference by 5.3 points, an increase in average Short Form-36 by 6.5 points, an increase in average PCS by 4.4 points, and an increase in average PSEQ score of 18.1. Their average mood via CES-D improved by 4.2 points. Conclusions Intensive, interdisciplinary pain rehabilitation provides an effective therapeutic modality for patients with post-laminectomy syndrome who have failed spinal cord stimulation by decreasing pain levels and by increasing functional status and self-efficacy.
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Affiliation(s)
- Joshua C Bailey
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Michael D Osborne
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain. Clin Obstet Gynecol 2019; 62:48-58. [DOI: 10.1097/grf.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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E. Bolton J, Lacayo E, Kurklinsky S, D. Sletten C. Improvement in montreal cognitive assessment score following three-week pain rehabilitation program. AIMS MEDICAL SCIENCE 2019. [DOI: 10.3934/medsci.2019.3.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. PAIN MEDICINE 2018; 20:2179-2197. [DOI: 10.1093/pm/pny231] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Objective
To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.
Methods
Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.
Results
No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.
Conclusions
There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry
- Departments of Neurological Surgery
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
| | - Aditya Pulikal
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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Abstract
The use of opioid drug therapy in older adults has increased over the past decade. Although use of opioid drugs may be clinically warranted, ongoing use needs to be monitored closely to evaluate risks and benefits, especially with the potential for adverse events and misuse. An opioid drug deprescribing protocol would provide clinicians with a method to assess an individual's need for opioid agents, as well as a systematic process to taper opioid drug therapy when deemed appropriate. Although more than 60 studies have reported methods for deprescribing, there is currently no established guideline for discontinuing opioid medications. The U.S. Department of Veterans Affairs has developed an algorithm to assist clinicians with opioid drug discontinuation decision making. As efforts to discontinue opioid drugs for chronic non-cancer pain in older adults continue to expand, nurses, as an integral part of the inter-professional team, will play a key role in monitoring and assessing patients' pain and care plans. [Journal of Gerontological Nursing, 44(1), 9-14.].
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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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Hooten WM, Townsend CO, Sletten CD. The triallelic serotonin transporter gene polymorphism is associated with depressive symptoms in adults with chronic pain. J Pain Res 2017; 10:1071-1078. [PMID: 28533695 PMCID: PMC5431744 DOI: 10.2147/jpr.s134231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The serotonin (5-HT) transporter-linked polymorphic region (5-HTTLPR) moderates the relationship between stressful life events and depression. Given the high prevalence of depression in chronic pain, the primary aim of this preliminary study was to investigate the associations between the 5-HTTLPR and the severity of depressive symptoms in a cohort of adults with chronic pain. METHODS Adults with chronic pain who were consecutively admitted to an outpatient pain rehabilitation program and met inclusion criteria were recruited for study participation (n=277). Individuals were genotyped for the 5-HTTLPR (including rs25531) and categorized as high, intermediate, or low expressors of the 5-HT transporter. The severity of depressive symptoms at admission was measured by using the Center for Epidemiologic Depression scale (CES-D). RESULTS The distribution of the high-, intermediate-, and low-expressing genotypes was 61 (22%), 149 (54%), and 67 (24%), respectively. The Hardy-Weinberg P-value was 0.204, which indicated no departure from equilibrium. A main effect of 5-HTTLPR was observed for depressive symptoms (P=0.040) where Center for Epidemiologic Depression scale (CES-D) scores were significantly greater in the low-expressing group compared to the high- (P=0.019) and intermediate (P=0.029)-expressing groups. In multivariate multinomial logistic regression analysis adjusted for age, sex, pain severity, pain catastrophizing, and pain anxiety, greater CES-D scores were significantly associated with the 5-HTTLPR low-expressing group compared to the high-expressing group (P=0.023), but not for the low-expressing group compared to the intermediate-expressing group (P=0.056). CONCLUSION These preliminary findings suggest that the triallelic 5-HTTLPR could influence the severity of depressive symptoms in adults with chronic pain. Individuals with chronic pain may be particularly vulnerable to the moderating effects of 5-HTTLPR due to high levels of pain-related stress that are inherently present in this population.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Cynthia O Townsend
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Scottsdale, AZ
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Choi NG, Snow AL, Kunik ME. Pain severity, interference, and prescription analgesic use among depressed, low-income homebound older adults. Aging Ment Health 2016; 20:804-13. [PMID: 25923452 DOI: 10.1080/13607863.2015.1037244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Disabled, homebound individuals tend to suffer both chronic pain and depression; however, low-income, homebound older adults have been underexposed in pain and depression research. We examined the extent of pain frequency, intensity, and interference; the relationship between pain and depressive symptoms; and prescription analgesic use and its association with use of antidepressant and anxiolytic medications among these older adults. METHOD The data came from the baseline assessment of 215 homebound individuals aged 50+ who were referred to a clinical trial of depression treatment. Bivariate and multivariate analyses were used to examine the research questions. RESULTS Almost 87% (n = 186) of the participants reported having had chronic pain in the preceding three months. Of the pain reporters, the mean frequency, intensity, and interference of pain were 8.65 ± 2.05, 7.71 ± 2.10, and 7.80 ± 2.82, respectively, on a 1-10 scale, and 61% were taking a prescription analgesic. Analgesic users and nonusers did not differ in depressive symptoms and in pain frequency and intensity, but analgesic users reported higher pain interference than nonusers (8.22 ± 2.46 vs. 7.14 ± 3.22; t = 2.44, df = 184, p = .016). Pain frequency and interference were significantly associated with depressive symptoms, and pain interference was significantly associated with analgesic use in multivariate analysis. Anxiolytic medication use was also correlated with analgesic use. CONCLUSION The findings underscore the significant pain-related problems in these vulnerable individuals and the need for recognizing and treating both pain and depression more effectively using both pharmacologic and nonpharmacologic interventions.
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Affiliation(s)
- Namkee G Choi
- a The University of Texas at Austin School of Social Work , Austin , TX , USA
| | - A Lynn Snow
- b Department of Psychology , University of Alabama Center for Mental Health and Aging , Tuscaloosa , AL , USA
| | - Mark E Kunik
- c The Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413) , Michael E. DeBakey VA Medical Center , Houston , TX , USA.,d Houston VA Health Services Research and Development Center of Excellence , Houston , TX , USA.,e Department of Psychiatry , Baylor College of Medicine , Houston , TX , USA
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de Waal MWM, Hegeman JM, Gussekloo J, Verhaak PFM, van der Mast RC, Comijs HC. The effect of pain on presence and severity of depressive disorders in older persons: The role of perceived control as mediator. J Affect Disord 2016; 197:239-44. [PMID: 26995467 DOI: 10.1016/j.jad.2016.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/19/2016] [Accepted: 03/07/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The relation between pain and depression is reported repeatedly. It is suggested that pain by itself is not sufficient for the development of depression. We aim to study the role of perceived control as mediating factor in the relation between pain and depressive disorders at old age. METHODS Baseline data of the Netherlands Study of Depression in Older Persons (NESDO) were used, including 345 persons with DSM-IV depressive disorders (CIDI) and 125 control persons without depressive disorders, aged 60 years and over. Measures included severity of depression (Inventory of Depressive Symptomatology), presence and intensity of pain and pain-related disability (Chronic Graded Pain scale), and a general measure of perceived control over life (Pearlin Mastery Scale). In mediation analyses direct and indirect effects were estimated. RESULTS Older persons with depressive disorders reported pain more frequently with higher intensity than controls. After controlling for confounding, the direct effect of pain intensity and the indirect effect through perceived control on depression were OR=1.10 (CI 95% .98;1.25) and OR=1.24 (1.15;1.35). For pain-related disability these were OR=1.14 (1.02;1.29) and OR=1.21 (1.13;1.29). In depressed persons there was a strong direct effect of pain intensity and disability and a smaller indirect effect through perceived control on severity of depressive symptoms. LIMITATIONS This cross-sectional study cannot give evidence on causal direction. CONCLUSIONS Perceived control plays an important role as mediator in the association between pain and presence of depression. In depressed persons however, the direct role of pain seems more important in the association with depression severity.
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Affiliation(s)
- M W M de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - J M Hegeman
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - J Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - P F M Verhaak
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, The Netherlands; NIVEL, Netherlands Institute of Health Services Research, The Netherlands
| | - R C van der Mast
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands; Department of Psychiatry, CAPRI-University of Antwerp, Belgium
| | - H C Comijs
- Department of Psychiatry/GGZ in Geest and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Kurklinsky S, Perez RB, Lacayo ER, Sletten CD. The Efficacy of Interdisciplinary Rehabilitation for Improving Function in People with Chronic Pain. PAIN RESEARCH AND TREATMENT 2016; 2016:7217684. [PMID: 27242925 PMCID: PMC4875999 DOI: 10.1155/2016/7217684] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/25/2016] [Accepted: 04/13/2016] [Indexed: 11/25/2022]
Abstract
Objective. To examine the efficacy of interdisciplinary rehabilitation for improving function in people with chronic pain. Design. Retrospective Chart Review. Setting. The Pain Rehabilitation Center (PRC) at a medical center. Participants. Individuals admitted to the PRC. Interventions. The PRC operates a 3-week outpatient program that utilizes an interdisciplinary approach to treat people with chronic pain. The main treatment elements include physical therapy, occupational therapy, cognitive behavioral therapy (CBT), and medication management. Physical therapy groups focus on moderate exercise despite symptoms. Occupational therapists teach moderation, time management, and activity modification. CBT groups, led by a pain psychologist, address the psychosocial comorbidities of chronic pain. Medical staff oversee the tapering of opiate analgesics and other symptom targeted treatments. This integrated approach is indicated when conventional treatments have been ineffective. Outcome Measures. The objective outcome was the 6-minute walk test (6 mWT) distance. The subjective outcomes were performance (COPM-PER) and satisfaction (COPM-SAT) as measured by the Canadian Occupational Performance Measure (COPM). Results. Average 6 mWT distances improved by 39% from 375 m to 523 m. Average COPM-PER scores increased from 3.4 to 7.5. Average COPM-SAT scores increased from 2.4 to 7.5. Conclusions. Comprehensive interdisciplinary outpatient rehabilitation can significantly improve function in people with chronic pain.
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Affiliation(s)
- Svetlana Kurklinsky
- Department of Pain Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Rachel B. Perez
- Department of Pain Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Elke R. Lacayo
- Department of Pain Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Wood BM, Nicholas MK, Blyth F, Asghari A, Gibson S. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis. Scand J Pain 2016; 11:157-162. [PMID: 28850461 DOI: 10.1016/j.sjpain.2015.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 12/18/2015] [Accepted: 12/20/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Depression is common in older adults with persistent pain. Cognitive-behavioural models of pain propose that the relationship between pain and depression is influenced or mediated by interpretations of events (cognitions), rather than by the event itself. Almost exclusively, the evidence for this position has come from studies of people aged less than 65 years. The role of cognitions in the pain experience of older adults has been unclear due to the limited and conflicting evidence available. The aim of our study was to examine the role of catastrophizing in mediating the relationship between pain intensity and depressed mood in older adults with persistent pain using reliable and valid measures for this population. METHODS In a two-wave longitudinal design, a sample of 141 patients (89 women, 52 men) 65 years and over with persistent pain participating in an evaluation of a pain self-management programme completed questionnaires measuring usual level of pain intensity (NRS), depressed mood (DASS-21) and the catastrophizing factors of magnification and helplessness (PRSS) at the beginning of the programme and 6 months later. Demographic data and pain history were collected by self-completion questionnaires, which were mailed to patients prior to participating in the programme and returned by post. RESULTS Change scores for usual level of pain intensity (NRS), depressed mood (DASS-21) and the magnification and helplessness factors on the PRSS-Catastrophizing were calculated by subtracting the scores at 6 months after completion of the study (Time 2) from the scores at the beginning of the study (Time 1). In the longitudinal analyses of mediation, using a series of regression analyses, change scores for both factors (magnification, helplessness) of the measure of catastrophizing (PRSS) totally and significantly mediated the relationship between change scores for pain intensity and depressed mood. The significant relative magnitude of beta between pain intensity and depression reduced from 0.22 to 0.13 and became non-significant after introducing magnification as a mediating variable, whilst the significant relative magnitude of beta reduced from 0.22 to 0.12 and also became non-significant after introducing helplessness as a mediating variable. CONCLUSIONS These results support a cognitive-behavioural model and highlight the importance of cognitive factors, in this case catastrophizing, in the relationship between pain intensity and depressed mood in older adults with persistent pain. IMPLICATIONS These findings also have important clinical implications for the treatment of older adults with persistent pain. They highlight the importance of targeting interventions to reduce the influence of catastrophizing as a prerequisite for reducing depressive symptoms in this growing population.
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Affiliation(s)
- Bradley M Wood
- Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia.
| | - Michael K Nicholas
- Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia
| | - Fiona Blyth
- Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia; School of Public Health, University of Sydney, Sydney, Australia
| | - Ali Asghari
- Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia; School of Psychology, Shahed University, Tehran, Iran
| | - Stephen Gibson
- National Ageing Research Institute, Royal Melbourne Hospital, VIC, Australia; Caulfield Pain Management and Research Centre, Caulfield, VIC, Australia
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Vallerand AH, Crawley J, Pieper B, Templin TN. The Perceived Control Over Pain Construct and Functional Status. PAIN MEDICINE 2016; 17:692-703. [PMID: 26350223 DOI: 10.1111/pme.12924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Belief in one's ability to control pain is a significant predictor of health outcomes and is related to improved functional status. The purpose of this study was to introduce a novel formulation of the construct, Perceived Control Over Pain and to test its effects on functional status. METHODS Participants (N = 301) were primarily African American (92%); and were adults with low income attending a primary care clinic and reporting pain within the past 2 weeks. A cross-sectional design was used with confirmatory factor analysis and structural equation modeling. The Perceived Control Over Pain construct consisted of four measures-two specific measures of control over pain and two general measures of control over life events. Perceived Control Over Pain has not been defined in this way previously. RESULTS Mean worst pain scores for the past week were 8.4, where "0" (no pain) to "10" (pain as bad as you can imagine). The model demonstrated good construct validity for the components of pain, Perceived Control Over Pain and functional status. Mediation by Perceived Control Over Pain was partial but strong, accounting for a reduction of 29% in the effect of pain on functional status. DISCUSSION In minority populations with low income, factors such as perceived control over pain and its effect on the outcome of patient function need to be considered. Improving Perceived Control Over Pain has the potential for improving patients' feelings of life control and purpose or meaning in life, and psychological and physical functioning for adults living with pain.
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Affiliation(s)
| | - Jamie Crawley
- University of Windsor, Faculty of Nursing, Windsor, Canada
| | - Barbara Pieper
- *Wayne State University, College of Nursing, Detroit, Michigan, USA
| | - Thomas N Templin
- *Wayne State University, College of Nursing, Detroit, Michigan, USA
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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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Abstract
Systematic reviews of psychosocial assessment and effectiveness of psychotherapy for chronic pain syndromes in older patients are rare. However, it is of particular importance to consider the psychosocial aspects of elderly people with chronic pain. This narrative review describes recommended German-language assessments of the psychosocial dimensions of pain and summarizes existing studies of psychological therapy approaches for chronic pain in old age. Effective psychometric instruments are available for the assessment of cognitive function, pain-specific attitudes, depression, fear of falling, interpersonal processes and social activities, pain management, pain acceptance, disability, psychological well-being, and quality of life. Further experience with the use of these instruments with cognitively impaired or geriatric patients is required. The efficacy of age-adapted cognitive behavioral therapy and multimodal therapy for older patients has been documented. However, there is often a lack of supporting documentation about important result parameters (e.g., quality of life, functioning in everyday life, or pain acceptance). Overall, chronic pain in elderly people requires a biopsychosocial-spiritual model of pain. More attention should be given in research and daily practice to religiosity/spirituality as a possible means of coping, while mindfulness- and acceptance-based therapies should be further explored.
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Hooten WM, Smith JM, Eldrige JS, Olsen DA, Mauck WD, Moeschler SM. Pain severity is associated with muscle strength and peak oxygen uptake in adults with fibromyalgia. J Pain Res 2014; 7:237-42. [PMID: 24833914 PMCID: PMC4014369 DOI: 10.2147/jpr.s61312] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The associations between pain, lower extremity strength, and aerobic conditioning have not been widely investigated in adults with fibromyalgia (FM). The principle objective of this study was to investigate the relationship between pain severity and knee strength in patients seeking treatment for FM. A secondary objective was to investigate the relationship between pain scores and aerobic conditioning. Methods Three measures of knee strength (isokinetic extensor, isokinetic flexor, isometric extensor) were quantified in the dominant leg of 69 adults with FM using a dynamometer at speeds of 60 degrees per second (60°/s) and 180°/s. Peak oxygen uptake (VO2) was assessed using a cycle ergometer, and pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. Results In univariable linear regression analyses using pain severity as the dependent variable, lesser values of isokinetic knee extensor strength at 60°/s (P=0.041) and 180°/s (P=0.010), isokinetic knee flexor strength at 60°/s (P=0.028) and 180°/s (P=0.003), and peak VO2 uptake (P=0.031) were predictive of greater pain severity scores. In multiple variable linear regression models adjusted for age, sex, body mass index, and opioid use, the following associations retained statistical significance; isokinetic knee extensor strength at 60°/s (P=0.020) and 180°/s (P=0.003), isokinetic knee flexor strength at 60°/s (P=0.015) and 180°/s (P=0.001), and peak VO2 uptake (P=0.014). However, no significant associations were found between pain severity and isometric knee extensor strength. Conclusion The main findings from this study were that lesser values of isokinetic knee strength and peak VO2 uptake were predictive of greater pain severity scores. These results build on the findings of previous investigations, but ongoing research is needed to further characterize the effects of strength and peak VO2 uptake on the pathophysiology of FM.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology, Mayo Clinic College of Medicine ; Department of Psychiatry and Psychology, Mayo Clinic College of Medicine
| | - Jolene M Smith
- Mayo School of Graduate Medical Education, Rochester, MN, USA
| | - Jason S Eldrige
- Department of Anesthesiology, Mayo Clinic College of Medicine
| | - David A Olsen
- Mayo School of Graduate Medical Education, Rochester, MN, USA
| | - W David Mauck
- Department of Anesthesiology, Mayo Clinic College of Medicine
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Bach E, Beissner K, Murtaugh C, Trachtenberg M, Reid MC. Implementing a cognitive-behavioral pain self-management program in home health care, part 2: feasibility and acceptability cohort study. J Geriatr Phys Ther 2013; 36:130-7. [PMID: 22976815 DOI: 10.1519/jpt.0b013e31826ef84d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE The prevalence of pain in older adults receiving home health care is high, yet safety concerns for analgesic therapy point to a need for nonpharmacologic approaches to pain management in this population. The purpose of this study was to determine the feasibility and acceptability to physical therapists (PTs) and patients of a cognitive-behavioral pain self-management (CBPSM) program. METHODS Thirty-one PTs volunteered to participate, completed two 4-hour training sessions, and recruited 21 patients with activity-limited pain who consented to participate in the study. Physical therapists completed pre- and posttest assessments of CBPSM knowledge at the first training session, provided structured survey feedback after the second training session, and responded to a phone survey 3 months after training. Patients provided feedback during weekly phone interviews, while receiving the CBPSM program. Treatment sessions were audiotaped during delivery of the self-management pain protocol. Audiotapes were evaluated by independent raters for program fidelity. RESULTS Participating PTs were experienced in physical therapy (average 16.5 years) and in home health care (average 11.0 years). Analysis of pre- and posttest data showed that PTs' CBPSM knowledge increased from a pretest mean of 60.9% to a posttest mean of 85.9%. Audiotape analysis indicated 77.7% therapist adherence to the protocol. At 3-month follow-up, 24.0% of therapists continued to use the entire protocol with their patients presenting with activity-limiting pain. Patient data show high rates of patient recall of being taught protocol components, trying components at least once (ranging from 84.4% to 100.0%) and daily use of protocol components (ranging from 47.3% to 68.4%). The percentage of patients finding a technique helpful for pain management ranged from 71.4% to 81.2%. CONCLUSION This study offers preliminary data on the use of nonpharmacologic pain self-management strategies by PTs in home health setting. Positive feedback from PTs and patients suggests that the translated protocol is both feasible and acceptable.
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Affiliation(s)
- Eileen Bach
- Visiting Nurse Service of New York VNSNY Home Care, New York, NY 10001, 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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Hooten WM, Rosenberg CJ, Eldrige JS, Qu W. Knee extensor strength is associated with pressure pain thresholds in adults with fibromyalgia. PLoS One 2013; 8:e59930. [PMID: 23565175 PMCID: PMC3615122 DOI: 10.1371/journal.pone.0059930] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 02/22/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Individuals with fibromyalgia (FM) have lower muscle strength and lower pressure pain thresholds (PPT). The primary aim of this study was to determine the associations between muscle strength and PPT in adults with FM to test the hypothesis that greater measures of muscle strength would be associated with greater values of PPT. Secondary aims included determining the effects of pain severity and the peak uptake of oxygen (VO2) on the associations between muscle strength and PPT. METHODS Knee extensor and flexor strength (N = 69) was measured in the dominant leg using a dynamometer, and PPT was assessed using an electronic algometer. Pain severity was determined using the Multidimensional Pain Inventory, and peak VO2 uptake was quantified using an electronically braked cycle ergometer. RESULTS Univariable linear regression analysis demonstrated a significant association between PPT (dependent variable) and isometric knee extensor (P<.001), isokinetic (60°/s) knee extensor (P = .002), and isokinetic (60°/s) knee flexor strength (P = .043). In a multiple variable linear regression analysis adjusted for age, sex, pain severity, body mass index and peak VO2 uptake, a significant association was found between PPT and isometric knee extensor strength (P = .008). In a similar multiple variable analysis, a significant association was found between PPT and isokinetic knee extensor strength (P = .044). CONCLUSION Greater measures of isometric and isokinetic knee extensor strength were significantly associated with greater values of PPT in both univariable and multiple variable linear regression models. TRIAL REGISTRATION ClinicalTrials.gov NCT01253395.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, United States of America.
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Self-management intervention for chronic pain in older adults: a randomised controlled trial. Pain 2013; 154:824-35. [PMID: 23522927 DOI: 10.1016/j.pain.2013.02.009] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 01/23/2013] [Accepted: 02/11/2013] [Indexed: 11/20/2022]
Abstract
This study compared an outpatient pain self-management (PSM) program, using cognitive-behavioural therapy and exercises, with 2 control conditions in 141 chronic pain patients aged > 65 years. Results immediately posttreatment indicated that relative to the Exercise-Attention Control (EAC) group, the PSM group was significantly improved on measures of pain distress, disability, mood, unhelpful pain beliefs, and functional reach. The mean effect size for these gains was 0.52 (range: 0.44-0.68). By 1-month follow-up, relative to the EAC group, the PSM group remained better on most measures. At the 1-month follow-up, relative to a Waiting List (usual care) (WL) group, the PSM group was significantly improved on measures of pain distress, disability, and unhelpful pain beliefs. The mean effect size for these variables was 0.69 (range: 0.56-0.83). Relative to the WL group, the EAC group made no significant gains on any of the measured variables. At 1-month follow-up, the mean proportion of reliably improved cases (across outcome variables) was 41% (range: 16-60%) for the PSM group, twice that of those who met this criterion in the 2 control conditions (and this difference was statistically significant). Similarly, significantly more (44%) of the PSM group (vs 22% and 20% for the control groups) achieved a clinically significant improvement on pain disability. In the short term at least, cognitive-behavioural therapy-based PSM was more effective than exercises and usual care.
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Wood BM, Nicholas MK, Blyth F, Asghari A, Gibson S. Catastrophizing mediates the relationship between pain intensity and depressed mood in older adults with persistent pain. THE JOURNAL OF PAIN 2012; 14:149-57. [PMID: 23265846 DOI: 10.1016/j.jpain.2012.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 09/29/2012] [Accepted: 10/21/2012] [Indexed: 12/30/2022]
Abstract
UNLABELLED This study examined the role of catastrophizing in mediating the relationship between pain intensity and depressed mood in older adults with persistent pain using reliable and valid measures for this population. A convenience sample of 669 patients 61 years and over attending a tertiary-level referral pain center completed questionnaires measuring pain intensity, depressed mood, and catastrophizing as part of a clinical assessment process. The catastrophizing subscale of the Pain-Related Self-Statements scale (PRSS-Catastrophizing) was examined for internal consistency and factor structure. Mediation was tested for each factor from the optimal model of the PRSS-Catastrophizing scale using regression analyses, which included measures of pain intensity and depressed mood. The PRSS-Catastrophizing scale was found to be a reliable measure of pain-related catastrophizing. A 2-factor solution (magnification, helplessness) was identified. Both factors partially and significantly mediated the relationship between pain intensity and depressed mood. This study highlights the importance of cognitive factors-in this case catastrophizing-in the persistent pain experience of older adults. It also demonstrates that pain-related catastrophizing can be reliably measured in this population. These findings have important clinical implications. They emphasize the importance of using interventions to reduce catastrophizing to modify the pain experience of older adults with persistent pain. PERSPECTIVE This study confirms the mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain using psychometrically sound measures. These findings indicate that clinicians should address catastrophizing to improve treatment outcomes with this population.
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Affiliation(s)
- Bradley M Wood
- Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia.
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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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McCracken LM, Jones R. Treatment for Chronic Pain for Adults in the Seventh and Eighth Decades of Life: A Preliminary Study of Acceptance and Commitment Therapy (ACT). PAIN MEDICINE 2012; 13:860-7. [DOI: 10.1111/j.1526-4637.2012.01407.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Hooten MW, Qu W, Townsend CO, Judd JW. Effects of strength vs aerobic exercise on pain severity in adults with fibromyalgia: a randomized equivalence trial. Pain 2012; 153:915-923. [PMID: 22341565 DOI: 10.1016/j.pain.2012.01.020] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 12/22/2011] [Accepted: 01/18/2012] [Indexed: 12/20/2022]
Abstract
Strength training and aerobic exercise have beneficial effects on pain in adults with fibromyalgia. However, the equivalence of strengthening and aerobic exercise has not been reported. The primary aim of this randomized equivalence trial involving patients with fibromyalgia admitted to an interdisciplinary pain treatment program was to test the hypothesis that strengthening (n=36) and aerobic (n=36) exercise have equivalent effects (95% confidence interval within an equivalence margin ± 8) on pain, as measured by the pain severity subscale of the Multidimensional Pain Inventory. Secondary aims included determining the effects of strengthening and aerobic exercise on peak Vo(2) uptake, leg strength, and pressure pain thresholds. In an intent-to-treat analysis, the mean (± standard deviation) pain severity scores for the strength and aerobic groups at study completion were 34.4 ± 11.5 and 37.6 ± 11.9, respectively. The group difference was -3.2 (95% confidence interval, -8.7 to 2.3), which was within the equivalence margin of Δ8. Significant improvements in pain severity (P<.001), peak Vo(2) (P<.001), strength (P<.001), and pain thresholds (P<.001) were observed from baseline to week 3 in the intent-to-treat analysis; however, patients in the aerobic group (mean change 2.0 ± 2.6 mL/kg/min) experienced greater gains (P<.013) in peak Vo(2) compared to the strength group (mean change 0.4 ± 2.6 mL/kg/min). Knowledge of the equivalence and physiological effects of exercise have important clinical implications that could allow practitioners to target exercise recommendations on the basis of comorbid medical conditions or patient preference for a particular type of exercise. This study found that strength and aerobic exercise had equivalent effects on reducing pain severity among patients with fibromyalgia.
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Affiliation(s)
- Michael W Hooten
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN, USA Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA Department of Physical Medicine and Rehabilitation, Mayo Graduate School of Medicine, Rochester, MN, USA
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Current world literature. Curr Opin Support Palliat Care 2011; 5:174-83. [PMID: 21521986 DOI: 10.1097/spc.0b013e3283473351] [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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