1
|
Gerdle B, Dragioti E, Rivano Fischer M, Ringqvist Å. Acceptance and Fear-Avoidance Mediate Outcomes of Interdisciplinary Pain Rehabilitation Programs at 12-Month Follow-Up: A Clinical Registry-Based Longitudinal Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP). J Pain Res 2024; 17:83-105. [PMID: 38196970 PMCID: PMC10775695 DOI: 10.2147/jpr.s438260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/19/2023] [Indexed: 01/11/2024] Open
Abstract
Background Factors that influence outcomes of interdisciplinary pain rehabilitation programs (IPRP) are poorly known. It is unclear how outcomes are influenced by pain intensity, psychological distress, and coping strategies. Aim This clinical registry-based longitudinal cohort study has three aims: 1) to determine the relative importance of pain intensity, psychological distress, acceptance, and fear-avoidance for changes in three outcomes of IPRP at 12-month follow-up; 2) to investigate whether the effects of pain intensity and psychological distress on the three outcomes are mediated via acceptance and fear-avoidance; and 3) to determine whether sex is a moderator. Methods This study uses Patient-Reported Outcome Measures (PROMs) from specialist units reporting data (2008-2016) to the Swedish Quality Registry for Pain Rehabilitation (SQRP). Adult chronic pain patients (N = 1991) answered the PROMs (background, pain, psychological distress, coping, participation, and health-related quality of life (HRQoL)). Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to explore the aims. Results Changes in acceptance (β:0.424-0.553; all P<0.001) were the strongest predictor of the three outcomes (changes in life control, interference, and HRQoL) at 12-month follow-up. The next strongest predictor was baseline acceptance (β: 0.177-0.233; all P<0.001) and changes in fear-avoidance (β: -0.152- -0.186; all P<0.001). Baseline pain intensity and psychological distress showed weak positive associations. Their effects on the three outcomes were mediated via acceptance aspects. Sex was not a moderator. Discussion and Conclusion Acceptance aspects (baseline and changes) were important predictors of IPRP outcomes. Changes in fear-avoidance were also important although to a lesser degree. Some of the effects of pain intensity and psychological distress on outcomes were mediated via acceptance at baseline. Future PLS-SEM analysis of real-world IPRP should include more potential mediators (eg, catastrophizing and more facets of psychological flexibility and fear-avoidance) and the components of IPRP.
Collapse
Affiliation(s)
- Björn Gerdle
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Elena Dragioti
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marcelo Rivano Fischer
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Åsa Ringqvist
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
2
|
McGeary DD, Jaramillo C, Eapen B, Blount TH, Nabity PS, Moreno J, Pugh MJ, Houle TT, Potter JS, Young-McCaughan S, Peterson AL, Villarreal R, Brackins N, Sikorski Z, Johnson TR, Tapia R, Reed D, Caya CA, Bomer D, Simmonds M, McGeary CA. Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Clinical Trial. Arch Phys Med Rehabil 2022; 103:1899-1907. [DOI: 10.1016/j.apmr.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
|
3
|
Sex and gender differences in pain: past, present, and future. Pain 2022; 163:S108-S116. [PMID: 36099334 DOI: 10.1097/j.pain.0000000000002738] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/18/2022] [Indexed: 12/30/2022]
|
4
|
Bhattacharya D, Whiteside H, Tang E, Kantilal K, Loke Y, Atkins B, Hill C. A review of trial and real-world data applying elements of a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids. Br J Clin Pharmacol 2022; 88:4019-4042. [PMID: 35561033 PMCID: PMC9543530 DOI: 10.1111/bcp.15379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022] Open
Abstract
This evidence synthesis applying realist concepts and behavioural science aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid‐tapering interventions and services from a 2018 international systematic review and a 2019 England‐wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid‐tapering success. A stakeholder group (n = 23) generated draft programme theories based around the 14 domains of the Theoretical Domains Framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified 6 programme theories comprising 5 behavioural mechanisms: prescribers' knowledge about how to taper; build prescribers' beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all 6 mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive‐based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.
Collapse
Affiliation(s)
- Debi Bhattacharya
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | | | - Emma Tang
- School of Pharmacy, University of East Anglia, Norwich, UK
| | - Kumud Kantilal
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Bethany Atkins
- School of Allied Health Professions, University of Leicester, Leicester, UK
| | - Caroline Hill
- School of Pharmacy, University of East Anglia, Norwich, UK
| |
Collapse
|
5
|
Flegge LG, Lake E, Truesdale C, Craner JR. Sex differences in interdisciplinary pain rehabilitation outcomes: a systematic review. Scand J Pain 2022; 22:218-231. [PMID: 35150122 DOI: 10.1515/sjpain-2021-0188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/23/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Interdisciplinary pain rehabilitation programs (IPRPs) are evidence-based treatments for chronic pain. Previous research has demonstrated that initial presentations of adult men and women admitted to IPRPs differ, but less is known about sex differences in IPRP treatment outcomes. To summarize and synthesize the current literature base on this topic, a systematic literature review was conducted that asked: are sex differences present in participant outcomes upon completion of interdisciplinary pain rehabilitation programs for cisgender patients? Four core domains of outcome measures were assessed: depression, pain catastrophizing, pain interference, and pain intensity/severity. METHODS Relevant studies meeting inclusion criteria were identified using a computer-aided search of the following electronic bibliographic databases: PubMed (MEDLINE), EMBASE, PsycINFO, CENTRAL (via Wiley Online Library), and CINAHL (via EBSCOhost). The reference list of relevant studies identified in the electronic searches was also screened to identify further studies. RESULTS This review concluded that most studies did not find any differences related to sex using the four outcome measures included in this review. This implies that specific considerations based on sex may not be needed when providing interdisciplinary pain rehabilitation. CONCLUSIONS Future research directions include comparison of additional outcome measures and exploring sex and gender issues in IPRP treatment in other formats than as a simple dichotomous variable.
Collapse
Affiliation(s)
- Lindsay G Flegge
- Pain Rehabilitation, Mary Free Bed Rehabilitation Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Eric Lake
- Pain Rehabilitation, Mary Free Bed Rehabilitation Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Carnigee Truesdale
- Pain Rehabilitation, Mary Free Bed Rehabilitation Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Julia R Craner
- Pain Rehabilitation, Mary Free Bed Rehabilitation Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| |
Collapse
|
6
|
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.
Collapse
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
| | | |
Collapse
|
7
|
Pester BD, Crouch TB, Christon L, Rodes J, Wedin S, Kilpatrick R, Pester MS, Borckardt J, Barth K. Gender differences in multidisciplinary pain rehabilitation: The mediating role of pain acceptance. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2022. [DOI: 10.1016/j.jcbs.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
8
|
Lewis GN, Bean DJ. What Influences Outcomes From Inpatient Multidisciplinary Pain Management Programs?: A Systematic Review and Meta-analysis. Clin J Pain 2021; 37:504-523. [PMID: 33883414 DOI: 10.1097/ajp.0000000000000941] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although inpatient multidisciplinary pain management programs (PMPs) are effective for chronic pain, not all patients benefit equally and there is limited evidence regarding predictors of outcome. This meta-analysis aimed to identify patient or program characteristics associated with outcomes from inpatient PMPs, and to examine the time course of effects following discharge. MATERIALS AND METHODS Medline, EBSCO, and Scopus were searched to identify articles reporting outcomes from inpatient multidisciplinary PMPs. Information was extracted on study design, participant and program characteristics, and outcomes. Effect sizes were computed for pain, physical function, depression, anxiety, and mental health outcomes. Study-level predictors of outcome were investigated with moderator analyses and meta-regression. A risk of bias assessment and sensitivity analyses were conducted and the GRADE criteria for prognostic studies were applied to assess confidence in findings. RESULTS In all, 85 studies (111 cohorts; 15,255 participants) were included. Three quarters of studies demonstrated low risk of bias. Larger effect sizes (for at least 1 outcome measure) occurred in studies where participants had more severe pain (greater intensity/longer duration), participants with alcohol or drug problems were not excluded, samples comprised mixed pain conditions, and programs included a cognitive component and/or a passive therapy component. Effect sizes for pain and physical function were maintained at follow-up, but effect sizes for depression and anxiety declined over time. DISCUSSION Inpatient multidisciplinary PMPs may be well suited to patients with severe or long-lasting pain. Programs should adopt broad patient inclusion criteria, and outcomes were similar for programs based on cognitive-behavioral versus mindfulness/acceptance-based therapies.
Collapse
Affiliation(s)
- Gwyn N Lewis
- Health & Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology
| | - Debbie J Bean
- Health & Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology
- Chronic Pain Service, Department of Anaesthesiology & Perioperative Medicine, Waitemata District Health Board, Auckland, New Zealand
| |
Collapse
|
9
|
Brown-Taylor L, Beckner A, Scaff KE, Fritz JM, Buys MJ, Patel S, Bayless K, Brooke BS. Relationships between physical therapy intervention and opioid use: A scoping review. PM R 2021; 14:837-854. [PMID: 34153178 DOI: 10.1002/pmrj.12654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To synthesize available evidence that has examined the relationship between physical therapy (PT) and opioid use. TYPE: Scoping Review LITERATURE SURVEY: Data sources including Google Scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to October 24, 2019 using terms ("physical therapy"[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]). METHODOLOGY Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design. SYNTHESIS Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) of using opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopedic surgery was also associated with lower odds of using opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT. CONCLUSIONS The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes because of heterogeneity between studies.
Collapse
Affiliation(s)
- Lindsey Brown-Taylor
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Medpace Inc., Cincinnati, Ohio, USA
| | - Aaron Beckner
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Ochsner Health System, New Orleans, Louisiana, USA
| | - Katie E Scaff
- Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington, USA
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
| | - Michael J Buys
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Department of Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Shardool Patel
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Kim Bayless
- Department of Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Benjamin S Brooke
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
10
|
Covington EC, Argoff CE, Ballantyne JC, Cowan P, Gazelka HM, Hooten WM, Kertesz SG, Manhapra A, Murphy JL, Stanos SP, Sullivan MD. Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations. Mayo Clin Proc 2020; 95:2155-2171. [PMID: 33012347 DOI: 10.1016/j.mayocp.2020.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022]
Abstract
Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.
Collapse
Affiliation(s)
- Edward C Covington
- Neurological Center for Pain (Emeritus), Cleveland Clinic, Cleveland, OH.
| | | | - Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | | | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Stefan G Kertesz
- Birmingham Veterans Affairs Medical Center and Division of Preventive Medicine, University of Alabama School of Medicine, Birmingham, AL
| | - Ajay Manhapra
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT; New England Mental Illness Research and Education Center, West Haven, CT; Advanced Pain Clinic, Hampton VA Medical Center, Hampton, VA
| | - Jennifer L Murphy
- James A. Haley Veterans Hospital and Department of Neurology, University of South Florida Morsani College of Medicine, Tampa
| | | | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, Department of Anesthesiology and Pain Medicine, and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Influences of Sex, Education, and Country of Birth on Clinical Presentations and Overall Outcomes of Interdisciplinary Pain Rehabilitation in Chronic Pain Patients: A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP). J Clin Med 2020; 9:jcm9082374. [PMID: 32722367 PMCID: PMC7466148 DOI: 10.3390/jcm9082374] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 12/31/2022] Open
Abstract
This study investigates the effects of sex, education, and country of birth on clinical presentations and outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRPs). A multivariate improvement score (MIS) and two retrospective estimations of changes in pain and ability to handle life situations were used as the three overall outcomes of IMMRPs. The study population consisted of chronic pain patients within specialist care in the Swedish Quality Registry for Pain Rehabilitation (SQRP) between 2008 and 2016 at baseline (n = 39,916), and for the subset participating in IMMRPs (n = 14,666). A cluster analysis based on sex, education, and country of origin revealed significant differences in the following aspects: best baseline clinical situation was for European women with university educations and the worst baseline clinical situation was for all patients born outside Europe of both sexes and different educations (i.e., moderate-large effect sizes). In addition, European women with university educations also had the most favorable overall outcomes in response to IMMRPs (small effect sizes). These results raise important questions concerning fairness and equality and need to be considered when optimizing assessments and content and delivery of IMMRPs for patients with chronic pain.
Collapse
|
13
|
Fowler CA, Ballistrea LM, Mazzone KE, Martin AM, Kaplan H, Kip KE, Murphy JL, Winkler SL. A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study. Pilot Feasibility Stud 2019; 5:146. [PMID: 31890259 PMCID: PMC6907328 DOI: 10.1186/s40814-019-0501-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements. METHODS This study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes. DISCUSSION This study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans' own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.
Collapse
Affiliation(s)
- Christopher A. Fowler
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| | - Lisa M. Ballistrea
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| | - Kerry E. Mazzone
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Aaron M. Martin
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Howard Kaplan
- Advanced Visualization Center, University of South Florida – Information Technology, 4202 E. Fowler Avenue, CMC147, Tampa, FL 33620 USA
| | - Kevin E. Kip
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL 33612 USA
| | - Jennifer L. Murphy
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
- Department of Neurology, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Sandra L. Winkler
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| |
Collapse
|
14
|
Naylor JC, Wagner HR, Johnston C, Elbogen EE, Brancu M, Marx CE, Strauss JL. Pain Intensity and Pain Interference in Male and Female Iraq/Afghanistan-era Veterans. Womens Health Issues 2019; 29 Suppl 1:S24-S31. [PMID: 31253239 DOI: 10.1016/j.whi.2019.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic pain conditions are common among both male and female Iraq/Afghanistan-era veterans and can have substantial negative impacts on quality of life and function. Although in general women tend to report higher levels of pain intensity than men, findings remain mixed on whether gender differences in pain exist in Iraq/Afghanistan-era veterans. Additionally, the relationships between functional impairment, pain intensity, and gender remain unknown. METHODS This project examined gender differences in pain intensity and pain interference in 875 male and female Iraq/Afghanistan-era veterans. Nonparametric Wilcoxon rank-tests examined gender differences in pain scores. Multivariable generalized linear regression modeling was used to evaluate the magnitude of pain intensity and interference across levels of chronicity and gender, and to evaluate the role of chronicity in gender effects in measures of pain and function. RESULTS Pain intensity and interference scores were significantly greater among both male and female veterans reporting chronic pain relative to acute pain. Women veterans endorsed higher levels of pain intensity and pain interference compared with men. Results derived from multivariable analyses implicated pain intensity as a factor underlying gender differences in functional impairment among chronic pain sufferers, indicating that gender differences in functional measures were eliminated after controlling statistically for pain intensity. CONCLUSIONS Results demonstrate that the effects of functional impairment are impacted by pain intensity, and not by gender.
Collapse
Affiliation(s)
- Jennifer C Naylor
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina.
| | - H Ryan Wagner
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina
| | - Cynthia Johnston
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Pharmacy Practice Department, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, North Carolina
| | - Eric E Elbogen
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina
| | - Mira Brancu
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina
| | - Christine E Marx
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina
| | -
- VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina
| | -
- VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC), Durham, North Carolina
| | - Jennifer L Strauss
- Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, District of Columbia
| |
Collapse
|
15
|
Fowler CA, Ballistrea LM, Mazzone KE, Martin AM, Kaplan H, Kip KE, Ralston K, Murphy JL, Winkler SL. Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study. JMIR Form Res 2019; 3:e11266. [PMID: 31670696 PMCID: PMC6914277 DOI: 10.2196/11266] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 12/15/2022] Open
Abstract
Background Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management. Objective The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy. Methods Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described. Results Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=−0.35). The confidence interval (95% CI −0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI −0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=−0.56, 95% CI −0.96 to −0.16), and small for pain intensity (Cohen d=−0.40, 95% CI −0.69 to −0.12) and catastrophizing (Cohen d=−0.41, 95% CI −0.79 to −0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI −0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI −0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported. Conclusions Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection.
Collapse
Affiliation(s)
- Christopher A Fowler
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Lisa M Ballistrea
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Kerry E Mazzone
- Chronic Pain Rehabilitation Program, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Aaron M Martin
- Chronic Pain Rehabilitation Program, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Howard Kaplan
- Advanced Visualization Center, Information Technology, University of South Florida, Tampa, FL, United States
| | - Kevin E Kip
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States.,College of Public Health, University of South Florida, Tampa, FL, United States
| | - Katherine Ralston
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| | - Jennifer L Murphy
- Chronic Pain Rehabilitation Program, James A Haley Veterans Hospital, Tampa, FL, United States.,Department of Neurology, College of Medicine, University of South Florida, Tampa, FL, United States
| | - Sandra L Winkler
- Research and Development Service, James A Haley Veterans Hospital, Tampa, FL, United States
| |
Collapse
|
16
|
Pisanu C, Franconi F, Gessa GL, Mameli S, Pisanu GM, Campesi I, Leggio L, Agabio R. Sex differences in the response to opioids for pain relief: A systematic review and meta-analysis. Pharmacol Res 2019; 148:104447. [DOI: 10.1016/j.phrs.2019.104447] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/21/2022]
|
17
|
Takahashi N, Takatsuki K, Kasahara S, Yabuki S. Multidisciplinary pain management program for patients with chronic musculoskeletal pain in Japan: a cohort study. J Pain Res 2019; 12:2563-2576. [PMID: 31686898 PMCID: PMC6708881 DOI: 10.2147/jpr.s212205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/02/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Multidisciplinary pain management is a useful method for treating chronic musculoskeletal pain. Currently, few facilities in Japan offer multidisciplinary pain treatment, especially in the inpatient setting. We implemented a multidisciplinary pain management program based on International Association for the Study of Pain recommendations. This study described our initial efforts in implementing the program, and reported 3- and 6-month follow-up results. Materials and methods Our pain management team included orthopedic surgeons, psychiatrists, nurses, physical therapists, clinical psychologists, pharmacists, and nutritionists. The 3-week inpatient pain management program comprised exercise therapy, psychotherapy, and patient education. We evaluated patients using the Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), Pain Disability-Assessment Scale (PDAS), Hospital Anxiety and Depression Scale (HADS), Pain Self-Efficacy Questionnaire (PSEQ), EuroQol Five Dimensions (EQ-5D), and physical examinations (flexibility, muscle endurance, walking ability, and physical fitness). Statistical analyses were performed using paired t-tests and Wilcoxon matched-pairs signed-rank sum tests with Bonferroni correction after the Friedman test. Results Data for 23 patients were analyzed before and immediately after the program. Statistically significant improvements were seen in BPI, PCS, PDAS, HADS, PSEQ, EQ-5D, flexibility, muscle endurance, walking ability, and physical fitness. Eight patients were also assessed 3 and 6 months after the program. PCS (rumination and helplessness) scores and flexibility showed significant improvement at 3 and 6 months. Significant improvement was seen in PDAS and HADS (anxiety) scores and muscle endurance at 6 months, and in PSEQ scores immediately and at 3 and 6 months. Conclusion Our inpatient pain management program can improve patients' physical function and ability to cope with chronic musculoskeletal pain, which supports improved quality of life. Our program is currently being expanded to better assist patients with chronic musculoskeletal pain.
Collapse
Affiliation(s)
- Naoto Takahashi
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima 9601295, Japan.,Pain Management Center, Hoshi General Hospital, Koriyama 963-8501, Japan
| | - Kozue Takatsuki
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima 9601295, Japan
| | - Satoshi Kasahara
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima 9601295, Japan.,Pain Management Center, Hoshi General Hospital, Koriyama 963-8501, Japan
| | - Shoji Yabuki
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima 9601295, Japan.,Pain Management Center, Hoshi General Hospital, Koriyama 963-8501, Japan
| |
Collapse
|
18
|
Racine M, Solé E, Sánchez-Rodríguez E, Tomé-Pires C, Roy R, Jensen MP, Miró J, Moulin DE, Cane D. An Evaluation of Sex Differences in Patients With Chronic Pain Undergoing an Interdisciplinary Pain Treatment Program. Pain Pract 2019; 20:62-74. [PMID: 31376331 DOI: 10.1111/papr.12827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/02/2019] [Accepted: 07/27/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine if there are sex differences in a sample of patients participating in a 4-week interdisciplinary pain treatment program in (1) pretreatment pain intensity, physical function, psychological function, pain beliefs, kinesiophobia, pain catastrophizing, and activity management patterns; and (2) treatment response. METHODS Seventy-two men and 130 women with chronic pain completed study measures. Analyses of covariance (ANCOVAs) were performed to compare men and women on pretreatment measures. Repeated-measures ANCOVAs were used to compare both sexes on 3 treatment outcomes (pain intensity, physical function, and depressive symptoms). RESULTS Before treatment, compared to women, men reported higher levels of kinesiophobia, were more likely to view their pain as being harmful, and used more activity pacing when doing daily activities. Women were more likely to use an overdoing activity pattern than men. No sex differences emerged for pretreatment pain intensity, physical function, psychological function, catastrophizing, activity avoidance, or measures of other pain-related beliefs. At posttreatment, women reported more improvements in pain intensity and physical function compared to men, while both sexes reported similar reductions in depressive symptoms. All effect sizes for statistically significant findings were of small to moderate magnitude. DISCUSSION The results of this study suggest that men and women have a comparable profile with respect to the overall burden of chronic pain. Nevertheless, sex differences were found for certain pain beliefs and coping styles. Women appear to reap more benefits from the interdisciplinary pain management program than men. These findings indicate that further research to develop sex-specific assessment procedures and tailored pain treatments may be warranted.
Collapse
Affiliation(s)
- Mélanie Racine
- Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Ester Solé
- Unit for the Study and Treatment of Pain-ALGOS, Department of Psychology, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Catalonia, Spain.,Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Catalonia, Spain
| | - Elisabet Sánchez-Rodríguez
- Unit for the Study and Treatment of Pain-ALGOS, Department of Psychology, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Catalonia, Spain.,Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Catalonia, Spain
| | - Catarina Tomé-Pires
- Unit for the Study and Treatment of Pain-ALGOS, Department of Psychology, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Catalonia, Spain.,Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Catalonia, Spain
| | - Rubén Roy
- Unit for the Study and Treatment of Pain-ALGOS, Department of Psychology, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Catalonia, Spain.,Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Catalonia, Spain
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Jordi Miró
- Unit for the Study and Treatment of Pain-ALGOS, Department of Psychology, Research Center for Behavior Assessment (CRAMC), Universitat Rovira i Virgili, Catalonia, Spain.,Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Catalonia, Spain
| | - Dwight E Moulin
- Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Douglas Cane
- Pain Management Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| |
Collapse
|
19
|
Lewis GN, Bean D, Mowat R. How Have Chronic Pain Management Programs Progressed? A Mapping Review. Pain Pract 2019; 19:767-784. [DOI: 10.1111/papr.12805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/09/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Gwyn N. Lewis
- Health and Rehabilitation Research Institute Auckland University of Technology AucklandNew Zealand
| | - Debbie Bean
- Department of Psychological Medicine University of Auckland AucklandNew Zealand
- The Auckland Regional Pain Service Auckland District Health Board AucklandNew Zealand
| | - Rebecca Mowat
- Toi Ohomai Institute of Technology Tauranga New Zealand
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
An Interdisciplinary Pain Rehabilitation Program for Veterans with Chronic Pain: Description and Initial Evaluation of Outcomes. Pain Res Manag 2018; 2018:3941682. [PMID: 29849842 PMCID: PMC5932417 DOI: 10.1155/2018/3941682] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/13/2018] [Accepted: 03/18/2018] [Indexed: 12/02/2022]
Abstract
Objective Chronic pain conditions are prominent among Veterans. To leverage the biopsychosocial model of pain and comprehensively serve Veterans with chronic pain, the San Francisco Veterans Affairs Healthcare System has implemented the interdisciplinary pain rehabilitation program (IPRP). This study aims to (1) understand initial changes in treatment outcomes following IPRP, (2) investigate relationships between psychological factors and pain outcomes, and (3) explore whether changes in psychological factors predict changes in pain outcomes. Methods A retrospective study evaluated relationships between clinical pain outcomes (pain intensity, pain disability, and opioid use) and psychological factors (depressive symptoms, catastrophizing, and “acceptable” level of pain) and changes in these outcomes following treatment. Multiple regression analysis explored whether changes in psychological variables significantly predicted changes in pain disability. Results Catastrophizing and depressive symptoms were positively related to pain disability, while “acceptable” level of pain was idiosyncratically related to pain intensity. Pain disability and psychological variables showed significant changes in their expected directions. Regression analysis indicated that only changes in depressive symptoms significantly predicted changes in pain disability. Conclusion Our results are consistent with evidence-based clinical practice guidelines for the management of chronic pain in Veterans. Further investigation of interdisciplinary treatment programs in Veterans is warranted.
Collapse
|
22
|
Rahman QA, Janmohamed T, Pirbaglou M, Ritvo P, Heffernan JM, Clarke H, Katz J. Patterns of User Engagement With the Mobile App, Manage My Pain: Results of a Data Mining Investigation. JMIR Mhealth Uhealth 2017; 5:e96. [PMID: 28701291 PMCID: PMC5529741 DOI: 10.2196/mhealth.7871] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 06/07/2017] [Accepted: 06/28/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pain is one of the most prevalent health-related concerns and is among the top 3 most common reasons for seeking medical help. Scientific publications of data collected from pain tracking and monitoring apps are important to help consumers and healthcare professionals select the right app for their use. OBJECTIVE The main objectives of this paper were to (1) discover user engagement patterns of the pain management app, Manage My Pain, using data mining methods; and (2) identify the association between several attributes characterizing individual users and their levels of engagement. METHODS User engagement was defined by 2 key features of the app: longevity (number of days between the first and last pain record) and number of records. Users were divided into 5 user engagement clusters employing the k-means clustering algorithm. Each cluster was characterized by 6 attributes: gender, age, number of pain conditions, number of medications, pain severity, and opioid use. Z tests and chi-square tests were used for analyzing categorical attributes. Effects of gender and cluster on numerical attributes were analyzed using 2-way analysis of variances (ANOVAs) followed up by pairwise comparisons using Tukey honest significant difference (HSD). RESULTS The clustering process produced 5 clusters representing different levels of user engagement. The proportion of males and females was significantly different in 4 of the 5 clusters (all P ≤.03). The proportion of males was higher than females in users with relatively high longevity. Mean ages of users in 2 clusters with high longevity were higher than users from other 3 clusters (all P <.001). Overall, males were significantly older than females (P <.001). Across clusters, females reported more pain conditions than males (all P <.001). Users from highly engaged clusters reported taking more medication than less engaged users (all P <.001). Females reported taking a greater number of medications than males (P =.04). In 4 of 5 clusters, the percentage of males taking an opioid was significantly greater (all P ≤.05) than that of females. The proportion of males with mild pain was significantly higher than that of females in 3 clusters (all P ≤.008). CONCLUSIONS Although most users of the app reported being female, male users were more likely to be highly engaged in the app. Users in the most engaged clusters self-reported a higher number of pain conditions, a higher number of current medications, and a higher incidence of opioid usage. The high engagement by males in these clusters does not appear to be driven by pain severity which may, in part, be the case for females. Use of a mobile pain app may be relatively more attractive to highly-engaged males than highly-engaged females, and to those with relatively more complex chronic pain problems.
Collapse
Affiliation(s)
- Quazi Abidur Rahman
- Centre for Disease Modelling, Department of Mathematics and Statistics, York University, Toronto, ON, Canada
| | | | - Meysam Pirbaglou
- School of Kinesiology & Health Science, York University, Toronto, ON, Canada
| | - Paul Ritvo
- School of Kinesiology & Health Science, York University, Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | - Jane M Heffernan
- Centre for Disease Modelling, Department of Mathematics and Statistics, York University, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Joel Katz
- School of Kinesiology & Health Science, York University, Toronto, ON, Canada
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| |
Collapse
|
23
|
Gender Differences in Demographic and Clinical Correlates among Veterans with Musculoskeletal Disorders. Womens Health Issues 2017; 27:463-470. [PMID: 28325585 DOI: 10.1016/j.whi.2017.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies suggest that women may be at greater risk for developing chronic pain and pain-related disability. METHODS Because musculoskeletal disorders (MSD) are the most frequently endorsed painful conditions among veterans, we sought to characterize gender differences in sociodemographic and clinical correlates among veterans upon entry into Veterans Health Administration's Musculoskeletal Disorders Cohort (n = 4,128,008). RESULTS Women were more likely to be younger, Black, unmarried, and veterans of recent conflicts. In analyses adjusted for gender differences in sociodemographics, women were more likely to have diagnoses of fibromyalgia, temporomandibular disorders, and neck pain. Almost one in five women (19.4%) had more than one MSD diagnosis, compared with 15.7% of men; this higher risk of MSD multimorbidity remained in adjusted analyses. Adjusting for sociodemographics, women with MSD were more likely to have migraine headache and depressive, anxiety, and bipolar disorders. Women had lower odds of cardiovascular diseases, substance use disorders, and several MSDs, including back pain conditions. Men were more likely to report "no pain" on the pain intensity Numeric Rating Scale, whereas more women (41%) than men (34%) reported moderate to severe pain (Numeric Rating Scale 4+). CONCLUSIONS Because women veterans are more likely to have conditions such as fibromyalgia and mental health conditions, along with greater pain intensity in the setting of MSD, women-specific pain services may be needed.
Collapse
|
24
|
|