Effect of cognitive behavioural therapy on sleep and opioid medication use in adults with fibromyalgia and insomnia

The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review

Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.

Opioids and fibromyalgia: frequency of use and factors associated with increased consumption in patients remitted to a tertiary care center

BACKGROUND

Opioids are not recommended for fibromyalgia.

OBJECTIVE

To investigate the frequency of opioid use in a large cohort of fibromyalgia patients and to identify factors associated with opioid consumption.

METHODS

A retrospective, observational study of a large fibromyalgia cohort in a tertiary care center. We assessed fibromyalgia severity, functional capacity, anxiety, depression, drugs consumption and the patient's impression of change. We compared strong opioid consumers (SOC) and non-SOC. Inferential statistical and logistic regression analysis were used to identify factors associated with opioid consumption, and ANOVA for repeated measurements.

RESULTS

We found a prevalence of 9.2% of SOC (100 patients) among 1087 patients in the cohort. During the last four years there was a significant increase on the incidence of SOC up to 12.8% (p = 0.004). There were no differences in demographic variables between SOC and non-SOC. Clinical variables were significantly more severe in SOC, and they consumed more non-opioid drugs (p < 0.0001). Opioid consumption was independently associated with other non-opioid drugs (Odds ratio 1.25, CI: 1.13-1.38), but not with the fibromyalgia severity. At three months, 62% of the patients had opioid withdrawal. There were no statistical differences in the fibromyalgia severity at the initial evaluation, or the patient's impression of change compared with those patients who continued opioids. Coping strategies were better in those patients who withdrew opioids (p = 0.044).

CONCLUSIONS

We observed an increase in opioid prescriptions during the last four years. Opioid consumption was associated with concomitant use of non-opioid drugs, but it was not associated with fibromyalgia severity.

Acupuncture improves certain aspects of sleep in hematopoietic stem cell transplantation patients: a secondary analysis of a randomized controlled trial

BACKGROUND

High-dose chemotherapy followed by hematopoietic stem cell transplantation (HSCT) is associated with a high symptom burden including sleep disturbance. Here we present the results of a secondary analysis of a randomized, sham-controlled trial assessing the effect of acupuncture on sleep quality during HSCT.

METHODS

Adult multiple myeloma patients undergoing inpatient and outpatient autologous HSCT were randomized and blinded to receive either true or sham acupuncture (by licensed acupuncturists) once daily for 5 days starting the day after chemotherapy. Sleep onset, total sleep time, sleep efficiency percentage and sleep-onset latency time were assessed using an actigraphy-based sleep monitor. A multivariate regression analysis was conducted to compare the average area-under-the-curve of five acupuncture intervention days for each sleep outcome between groups, adjusted by baseline score and inpatient or outpatient chemotherapy stratum.

RESULTS

Over 32 months, 63 patients were enrolled. Participants undergoing true acupuncture experienced a significant improvement in sleep efficiency when compared to sham (-6.70, 95% CI -13.15, -0.25, p = 0.042). Subgroup analysis showed that the improvement was more prominent in the inpatient setting (-9.62, 95% CI -18.76, -0.47; p = 0.040). True acupuncture tended to improve wake time after sleep onset (WASO; -10.95, p = 0.054). Between-group differences in other sleep related variables were not statistically significant.

CONCLUSION

Our data suggest that true acupuncture may improve certain aspects of sleep, including sleep efficiency and possibly WASO, in multiple myeloma patients undergoing HSCT. By studying patient reported outcomes in future larger scale studies, acupuncture's role in improving sleep quality during HSCT treatment could be further elucidated.

TRIAL REGISTRATION NUMBER

NCT01811862 (ClinicalTrials.gov).

Acupuncture in hematologic malignancies and hematopoietic cell transplantation

Acupuncture is an integrative medicine modality that has been used historically and studied recently for managing various symptoms and diseases. Patients with hematological malignancies often experience a high symptom burden including pain, fatigue, nausea, vomiting, and insomnia. Pharmacological interventions are the mainstay of managing these symptoms, although they may not provide adequate control or are not well tolerated due to side effects. There have been many randomized controlled trials of acupuncture on reduction of these symptoms. In this review, we will summarize the current evidence on the effect of acupuncture on the management of common symptoms experienced by patients with hematological malignancies and the current understanding of acupuncture's mechanism of action. The evidence is the strongest for reducing pain and nausea vomiting, less strong for symptoms such as peripheral neuropathy, fatigue, constipation, insomnia, night sweat, and pruritus.

VOSviewer-Based Bibliometric Network Analysis for Evaluating Research on Juvenile Primary Fibromyalgia Syndrome (JPFS)

Background: Juvenile primary fibromyalgia syndrome (JPFS) is a chronic musculoskeletal pain syndrome that affects children and adolescents. Methods: A VOSviewer-based bibliometric network analysis was performed by scanning the global literature on JPFS in the Web of Science (WOS) online database. The search string applied to identify the closest matching articles was “juvenile primary fibromyalgia syndrome (all field)”. Results: A total of 67 articles on JPFS were published from 1985 to March 2022, in the WOS. Regarding article types, 39 were research manuscripts, 16 reviews, 8 meeting abstracts, 2 letters, 1 book chapter, 1 correction, and 1 proceeding paper. The Quartile analysis demonstrated that 44% of papers were published in Q1, 37% in Q2, 8% in Q3, and 11% in Q4. Conclusions: Our analysis highlights that more efforts are warranted to increase the production of quality papers and enhance the connections between the various research groups. JFPS represents a research field still to be explored and which deserves greater investments to obtain quality scientific evidence.

Past-year use or misuse of an opioid is associated with use of a sedative-hypnotic medication: a US National Survey on Drug Use and Health (NSDUH) study

STUDY OBJECTIVES

Prescription use and misuse of opioids are linked to greater sleep disturbance. However, there are limited data on the prevalence of sedative-hypnotic medication use among persons who use opioids. Therefore, this study examined whether past-year sedative-hypnotic use among persons who used/misused opioids was higher than among individuals who did not use opioids.

METHODS

Data were acquired from the US National Survey on Drug Use and Health for 2015-2018. Use of a sedative benzodiazepine (temazepam, flurazepam, triazolam) or a Z-drug (eszopiclone, zaleplon, zolpidem) was examined in relation to use/misuse of an opioid within the past year. Logistic regression models estimated the associations between opioids and sedative-hypnotics using inverse probability of treatment weighting. A secondary machine learning analysis tested 6 binary classifiers to predict sedative-hypnotic use based on opioid use/misuse and other covariates.

RESULTS

Of 171,766 respondents, 24% used a prescription opioid whereas 3.6% misused an opioid in the past year. Among those who used a prescription opioid, 1.9% received a sedative benzodiazepine and 9% received a Z-drug during the same time frame. Use of an opioid was associated with greater odds of sedative benzodiazepine use (odds ratio, 4.4; 95% confidence interval, 3.61-5.4) and Z-drug use (odds ratio, 3.8; 95% confidence interval, 3.51-4.09), and stronger associations were noted for misuse of an opioid. Machine learning models accurately classified sedative-hypnotic medication use for > 70% of respondents based on opioid use/misuse.

CONCLUSIONS

Sedative-hypnotic use is common among persons who use opioids, which is of concern given the elevated mortality risk with concurrent use of these substances.

CITATION

Tubbs AS, Ghani SB, Naps M, Grandner MA, Stein MD, Chakravorty S. Past-year use or misuse of an opiod is associated with use of a sedative-hypnotic medication: a US National Survey on Drug Use and Health (NSDUH) study. J Clin Sleep Med. 2022;18(3):809-816.

Role of Rehabilitation in Opioid Tapering: A Scoping Review

Purpose: Among industrialized countries, Canada has the second-highest opioid prescribing rate for pain management. Physiotherapy and occupational therapy interventions are potential non-pharmacological alternatives. We undertook a scoping review to explore and summarize the current evidence describing the interventions included or used in physiotherapy and occupational therapy in opioid tapering for individuals with chronic pain. Method: A systematic search of the peer-reviewed health databases was conducted, with data synthesis guided by Arksey and O'Malley's scoping review methodology. Articles were included in the narrative synthesis if (1) interventions within the scope of practice for physiotherapists or occupational therapists were described or these professionals were part of interdisciplinary care and (2) opioid tapering or reduction was addressed. Results: The 39 articles identified included 2 systematic reviews, 9 narrative reviews or commentaries, 2 case reports, 11 uncontrolled cohort studies, 1 cross-sectional study, 5 randomized controlled trials, 4 programme evaluations, and 4 qualitative studies. Of the 28 studies reporting specific outcomes, 25 reported positive outcomes of rehabilitation interventions for opioid tapering. There was greater representation of interventions from physiotherapy than from occupational therapy: few articles contained substantive descriptions (e.g., dosage and duration). Conclusions: The evidence to guide therapists in supporting opioid tapering for people with chronic pain seems to be limited. Further research is needed to establish effectiveness for stand-alone interventions and as part of a comprehensive rehabilitation approach.

Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia

OBJECTIVE

To analyze opioid intake interference with psychological, well-being, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Pain Rehabilitation Program (MCPRP) in Florida.

PATIENTS AND METHODS

A retrospective study on MCPRP outcomes was conducted. We reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to fill out a survey at admission to and dismissal from the program. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Center for Epidemiological Studies-Depression Scale, Pain Catastrophizing Scale, 36-Item Short-Form Health Status Survey (general health perceptions subscale), and Pain Self-Efficacy Questionnaire. A medical record review identified categories and number of medications at program admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did not include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group).

RESULTS

By dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a significant (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially higher percentage in the opioids group.

CONCLUSION

Benefit of the comprehensive pain rehabilitation program in patients with fibromyalgia was indicated by clinical improvements in pain severity, physical and emotional health, and functional capacity while successfully tapering medication. Opioid intake at admission may modify the program outcomes.

The effects of mindfulness-based intervention on sleep disturbance and benzodiazepine hypnotics use in patients hospitalized with cancer: A systematic review and meta-analysis

Previous studies have reported discrepant outcomes for mindfulness-based intervention (MBI) to improve sleep quality or reduce the benzodiazepines (BZDs) use in cancer patients; therefore, a meta-analysis was required to examine the relationships. The MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials et al. were searched by independent reviewers from date of inception to January 2020 to examine the associations between MBI and sleep disturbance or BZDs use among cancer patients. Randomized controlled studies that reported the effect of MBI on sleep disturbance or BZDs use in cancer patients aged over 18 years were included. Standardized mean differences with 95% CIs were calculated to estimate effect size. If P ≥ 0.1, I² < 50%, the fixed effect model was used for meta-analysis, while if P < 0.1, I² ≥ 50%, the random effects model was used. Fourteen studies of 1659 participant were identified in the meta-analysis. Overall, sleep disturbance was significantly relieved in MBI group (SMD = 0.37, 95% CI 0.19 to 0.55, P < 0.001), and the effect could sustain to follow up duration (SMD = 0.35, 95% CI 0.02 to 0.69, P < 0.001). Only three studies reported that MBI could decrease the BZDs use in hospitalized cancer patients. Our findings indicate that MBI were effective in alleviating sleep disturbance in a short time, and may be associated with therapeutic benefits for BZDs use. Further randomized controlled studies are needed to examine the effectiveness of MBI for BZDs use in cancer patients.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

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.

Use of Complementary and Alternative Medicine in Fibromyalgia: Results of an Online Survey

BACKGROUND

Fibromyalgia is a chronic condition which may negatively impact various aspects of patients' lives. Many people with fibromyalgia look to complementary and alternative medicine treatments for symptom relief.

AIMS

The three main objectives of this study were to examine self-reported complementary and alternative medicine use in patients with fibromyalgia, to determine associations between the use of complementary and alternative medicine treatments and patients' self-reported quality of live and self-reported pain levels.

DESIGN

Cross-sectional survey.

SETTING

Web-based.

PARTICIPANTS/SUBJECTS

Adults over the age of 18 years who had been diagnosed with fibromyalgia.

METHODS

Patients with fibromyalgia responded to an online questionnaire regarding the following: treatments (complementary and alternative medicine, prescription and over-the-counter medications), quality of life (Quality of Life Scale-16), assessment of current pain (visual analog scale), and demographic information.

RESULTS

Approximately 66% of the respondents used complementary and alternative treatments. Vitamins, massage therapy, and meditation were the most commonly used complementary and alternative therapies. Results indicated respondents using a combination of complementary and alternative medicine and pharmacologic treatments (prescription or over-the-counter) had significantly higher quality of life versus those using pharmacologic treatments alone, p = .011. Similarly, respondents using only complementary and alternative medicine treatment reported significantly lower pain levels versus those using pharmacologic treatment alone, p = .046.

CONCLUSIONS

The study suggests that a large proportion of fibromyalgia patients use complementary and alternative medicine, and these treatments may offer beneficial effects to these patients. Integration of complementary and alternative medicine into conventional treatment regimens may provide opportunities for a holistic treatment approach and greater symptom relief for fibromyalgia patients. This approach is timely, as controlled substances are increasingly difficult for patients with fibromyalgia to access.