Chronic noncancer pain rehabilitation with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

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.

Psychological Flexibility, Pain Characteristics and Risk of Opioid Misuse in Noncancerous Chronic Pain Patients

Chronic pain has an estimated annual prevalence rate between 10 and 35%. In the US, first-line treatment for chronic pain is often opioids.

OBJECTIVE

To our knowledge, this is the first study exploring psychological flexibility and its association with pain severity, pain interference and risk of opioid misuse in chronic pain patients.

METHODS

Data were collected at two outpatient pain clinics in the northeastern United States. Adults (N = 99) completed a cross-sectional survey with validated measures. Pain severity and pain interference were hypothesized to uniquely predict the risk of opioid misuse. Pain severity was hypothesized to predict pain interference. Finally, psychological flexibility was hypothesized as an indirect effect in these relationships.

RESULTS

Main findings suggest that pain severity predicts risk of opioid misuse, mediated by psychological flexibly. Pain interference also predicts risk of opioid misuse, mediated by psychological flexibility. Finally, results suggest pain severity predicts pain interference, mediated by psychological flexibility.

DISCUSSION

Implications of findings are discussed in terms of future psychological and medical assessments and interventions for chronic pain patients seeking prescription opioids.

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

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.

A Novel Approach to Assessing and Treating Musculoskeletal-Mediated Atypical Abdominal Pain: A Case Study

Abdominal pain is a common and functionally limiting complaint within the healthcare system linked to impaired quality of life and increased health care utilization. This chief complaint is associated with an extensive differential diagnosis leading to high utilization of diagnostic testing, increased healthcare cost, and delayed access to care. In patients presenting with acute or chronic abdominal pain, musculoskeletal pain often requires expensive testing, thereby delaying definitive care. An improved triage process is warranted. Performing a musculoskeletal examination to determine if pain patterns can be mechanically reproduced at the site of origin, or remote to the site of pain, warrants referral to a musculoskeletal specialist. In our young and healthy population, once the musculoskeletal mediated abdominal pain origin is determined, we see significant success in the application of a treatment approach consisting of manipulative therapy, exercise, and instrument-assisted soft tissue mobilization. A multimodal treatment approach for musculoskeletal-mediated abdominal pain has not been previously described. This case study outlines a novel management approach for musculoskeletal-mediated abdominal pain and provides an alternative diagnostic technique, when implemented early in the evaluation and management process of atypical abdominal pain, that improves the quality of life.

Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review

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.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review

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.

Opioid Medications in the Management of Chronic Abdominal Pain

PURPOSE OF REVIEW

Chronic abdominal pain is a complex medical condition. The causes of chronic abdominal pain are extremely diverse ranging from chronic pancreatitis, Crohn's disease, to chronic pain with no clear etiology. Treatment of chronic abdominal pain remains a challenge in our clinical practice. While current interventions with celiac plexus blocks and pain medications provide some relief for these patients, but these treatments are typically less efficacious and limited by various adverse effects. Opioid medications are commonly used to manage chronic pain syndromes that are refectory to other pain management interventions. The potential problems related to opioids include misuse, abuse, constipation, nausea pruritus, et al. Moreover, according to the recent centers for disease (CDC) control report, opioid abuse has reached epidemic proportions in the USA (LJ P. Centers for Disease Control and Prevention. 2016) and accounted for 28,000 deaths in 2014. Rudd et al. (MMWR Morb Mortal Wkly Rep 64(50-51):1378-82, 2016) Given this current situation, it is apparent that a careful review of clinical evidences supporting the use of opioid medications is necessary to guide our treatment approaches in the management of complex chronic abdominal pain patients. This review is set out to analyze efficacy of opioid medications for chronic abdominal pain.

RECENT FINDINGS

The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline, and EMbase. The search terms used included Opioid, Oxycodone, Buprenorphine, Morphine, Fentanyl, Oxymorphone, Hydromorphone, chronic abdominal pain, Crohn's disease, and pancreatitis. All studies were considered eligible for inclusion if they were clinical studies evaluating the efficacy of opioid medications for chronic abdominal pain. Two studies were found according to these criteria. Chronic abdominal pain is a challenging medical condition in our daily practice. This condition often requires opioid medications when other treatments fail. This review provided very limited clinical evidence to support long-term opioid use for chronic abdominal pain. Given recent CDC report of opioid epidemic, it is prudent to use the best medical practice with appropriate evaluation of psychological comorbidities, urine drug screening, prescription drug monitor, and opioid treatment agreements to minimize adverse side effects related to opioids. Furthermore, well-designed clinical trials are needed to evaluate the effectiveness of long-term use of opioid medications, and more clinical research on which opioid medication is more effective for chronic abdominal pain.

Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment

Significant functional impairment and psychological distress have been observed in adolescent patients with postural orthostatic tachycardia syndrome (POTS). Interdisciplinary rehabilitation programs have been shown to be beneficial in the treatment of chronic pain in adults and adolescents. Only preliminary data have examined interdisciplinary rehabilitation efforts in patients with POTS. This study evaluated the impact of an interdisciplinary rehabilitation program on the functional impairment and psychological distress in 33 adolescents diagnosed with POTS. Patients included in the study were adolescents ages 11 to 18 diagnosed with POTS. Measures completed at admission and discharge from the program included the Functional Disability Index, Center for Epidemiological Studies-Depression-Child scale, and the Pain Catastrophizing Scale for Children. After participation in the 3-week program, adolescents with POTS demonstrated a significant increase in overall functional ability and significant reductions in depression and catastrophizing.

Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial

Patients receiving long-term opioid therapy for chronic pain and interested in tapering their opioid dose were randomly assigned to a 22-week taper support intervention (psychiatric consultation, opioid dose tapering, and 18 weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills) or usual care (N = 35). Assessments were conducted at baseline and 22 and 34 weeks after randomization. Using an intention to treat approach, we constructed linear regression models to compare groups at each follow-up. At 22 weeks, adjusted mean daily morphine-equivalent opioid dose in the past week (primary outcome) was lower in the taper support group, but this difference was not statistically significant (adjusted mean difference = -42.9 mg; 95% confidence interval, -92.42 to 6.62; P = .09). Pain severity ratings (0-10 numeric rating scale) decreased in both groups at 22 weeks, with no significant difference between groups (adjusted mean difference = -.68; 95% confidence interval, -2.01 to .64; P = .30). The taper support group improved significantly more than the usual care group in self-reported pain interference, pain self-efficacy, and prescription opioid problems at 22 weeks (all P-values < .05). This taper support intervention is feasible and shows promise in reducing opioid dose while not increasing pain severity or interference.

PERSPECTIVE

In a pilot randomized trial comparing a prescription opioid taper support intervention to usual care, lower opioid doses and pain severity ratings were observed at 22 weeks in both groups. The groups did not differ significantly at 22 weeks in opioid dose or pain severity, but the taper support group improved significantly more in pain interference, pain self-efficacy, and perceived opioid problems. These results support the feasibility and promise of this opioid taper support intervention.

Anorectal and Pelvic Pain

Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.

Common Functional Gastroenterological Disorders Associated With Abdominal Pain

Although abdominal pain is a symptom of several structural gastrointestinal disorders (eg, peptic ulcer disease), this comprehensive review will focus on the 4 most common nonstructural, or functional, disorders associated with abdominal pain: functional dyspepsia, constipation-predominant and diarrhea-predominant irritable bowel syndrome, and functional abdominal pain syndrome. Together, these conditions affect approximately 1 in 4 people in the United States. They are associated with comorbid conditions (eg, fibromyalgia and depression), impaired quality of life, and increased health care utilization. Symptoms are explained by disordered gastrointestinal motility and sensation, which are implicated in various peripheral (eg, postinfectious inflammation and luminal irritants) and/or central (eg, stress and anxiety) factors. These disorders are defined and can generally be diagnosed by symptoms alone. Often prompted by alarm features, selected testing is useful to exclude structural disease. Identifying the specific diagnosis (eg, differentiating between functional abdominal pain and irritable bowel syndrome) and establishing an effective patient-physician relationship are the cornerstones of therapy. Many patients with mild symptoms can be effectively managed with limited tests, sensible dietary modifications, and over-the-counter medications tailored to symptoms. If these measures are not sufficient, pharmacotherapy should be considered for bowel symptoms (constipation or diarrhea) and/or abdominal pain; opioids should not be used. Behavioral and psychological approaches (eg, cognitive behavioral therapy) can be helpful, particularly in patients with chronic abdominal pain who require a multidisciplinary pain management program without opioids.

The Efficacy of Interdisciplinary Rehabilitation for Improving Function in People with Chronic Pain

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.

Dependence on Prescription Opioids

BACKGROUND

The incidence of initial prescriptions of opioids for chronic non-cancer pain rose by 37% in Germany from 2000 to 2010. Prescribing practice does not always conform with the recommendations of current guidelines. In the USA, 8-12% of patients with chronic non-cancer pain are opioid-dependent.

METHODS

This review is based on publications retrieved by a selective PubMed search and on the German S3 guideline on the long-term use of opioids in non-cancer pain.

RESULTS

Patients must be informed and counseled about the effects and risks of opioids before these drugs are prescribed. All opioid prescriptions for patients with chronic non-cancer pain should be regularly reviewed. The risk of abuse is high in young adults (odds ratio [OR] = 6.74) and in those with a history of substance abuse (OR = 2.34). Any unusual medication-related behavior, e.g., loss of prescriptions or increasing the dose without prior discussion with the physician, calls for further assessment by the physician in conversation with the patient. Urine testing for drugs and their metabolites is helpful as well. The goal of treatment of opioid abuse is opioid abstinence by gradual reduction of the dose. If this is not possible on an outpatient basis, hospitalization for drug withdrawal or substitution-based addiction therapy can be offered.

CONCLUSION

Physicians who know the indications and risks of opioid therapy and the typical behavior of drug-dependent patients will be better able to identify patients at risk and to prevent dependence. Studies on the prevalence of opioid abuse and dependence in German patients with chronic pain can help provide better estimates of the current extent and implications of this problem in Germany.

Associations between Neuroticism and Depression in Relation to Catastrophizing and Pain-Related Anxiety in Chronic Pain Patients

Several cognitive-affective constructs, including pain catastrophizing and pain-related anxiety, have been implicated in the onset and progression of chronic pain, and both constructs have been identified as key targets for multidisciplinary pain treatment. Both neuroticism and depression have been linked to these constructs (and to each other), but how each may contribute to the pain experience is unknown. This study tested associations between neuroticism, depression, and indices of catastrophizing and pain-related anxiety among persons seeking treatment for chronic non-malignant pain. We hypothesized, as a higher-order personality trait, neuroticism would remain uniquely associated with both pain catastrophizing and pain-related anxiety, even after accounting for current symptoms of depression. A retrospective study design assessed depression (as measured by the Centers for Epidemiologic Studies-Depression scale), neuroticism (measured with the Neuroticism-Extraversion-Openness Personality Inventory), the Pain Catastrophizing Scale, and the Pain Anxiety Symptom Score in a consecutive series of patients (n=595) admitted to a 3-week outpatient pain treatment program from March 2009 through January 2011. Hierarchical regression indicated that neuroticism was independently associated with greater pain catastrophizing and pain-related anxiety, above-and-beyond the contributions of sociodemographic characteristics, pain severity, and depression. A depression by neuroticism interaction was not observed, suggesting that associations between neuroticism and cognitive-affective pain constructs remained stable across varying levels of current depression. These findings represent an early but important step towards the clarification of complex associations between trait neuroticism, current depression, and tendencies toward catastrophic and anxiety-provoking appraisals of pain among persons seeking treatment for chronic pain.

Influence of clonidine and ketamine on m-RNA expression in a model of opioid-induced hyperalgesia in mice

Background

We investigated the influence of morphine and ketamine or clonidine in mice on the expression of genes that may mediate pronociceptive opioid effects.

Material and Methods

C57BL/6 mice received morphine injections thrice daily using increasing doses (5-20mg∙kg^-1) for 3 days (sub-acute, n=6) or 14 days (chronic, n=6) and additionally either s-ketamine (5mg∙kg^-1, n=6) or clonidine (0.1mg∙kg^-1, n=6). Tail flick test and the assessment of the mechanical withdrawal threshold of the hindpaw was performed during and 4 days after cessation of opioid treatment. Upon completion of the behavioural testing the mRNA-concentration of the NMDA receptor (NMDAR1) and β-arrestin 2 (Arrb2) were measured by PCR.

Results

Chronic opioid treatment resulted in a delay of the tail flick latency with a rapid on- and offset. Simultaneously the mice developed a static mechanical hyperalgesia with a delayed onset that that outlasted the morphine treatment. Sub-acute morphine administration resulted in a decrease of NMDAR1 and Arrb2 whereas during longer opioid treatment the expression NMDAR1 and Arrb2 mRNA increased again to baseline values. Coadministration of s-ketamine or clonidine resulted in a reversal of the mechanical hyperalgesia and inhibited the normalization of NMDAR1 mRNA expression but had no effect on the expression of Arrb2 mRNA.

Conclusion

In the model of chronic morphine therapy the antinociceptive effects of morphine are represented by the thermal analgesia while the proniceptive effects are represented by the mechanical hyperalgesia. The results indicate that the regulation of the expression of NMDAR1 and Arrb2 may be associated to the development of OIH in mice.

Perspective

The results indicate that co-administration of clonidine or ketamine may influence the underlying mechanisms of OIH.

Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders

BACKGROUND

Opioids are frequently used for the postoperative treatment of chronic disabling occupational musculoskeletal disorders. In many such cases, long-term opioid use persists because of patient requests for ongoing pain relief. Little is known about the relationship between chronic opioid use and functional recovery in these patients.

METHODS

A total of 1226 patients with a chronic disabling occupational musculoskeletal disorder were consecutively admitted into an interdisciplinary functional restoration program. They were divided into two groups: 630 patients who reported no opioid use at the time of admission (No group) and 596 patients who reported some opioid use at the time of admission (Yes group). The 516 patients for whom daily opioid doses could be determined were further divided into four subgroups: Low (<30 mg, n=267), Medium (31 to 60 mg, n=112), High (61 to 120 mg, n=78), and Very High (>120 mg, n=59). During the initial weeks of treatment, patients consented to be weaned from all opioid medications. In addition, the patients were assessed before and after rehabilitation with regard to self-reported measures of pain, function, and depression and were analyzed for change. One year after the termination of treatment, socioeconomic outcomes were assessed to measure work and financial status, healthcare utilization, and recurrent injury-associated pain.

RESULTS

A higher post-injury opioid dose was associated with a greater risk of program noncompletion, which was anticipated because of the requirement that patients taper opioids. High opioid use was significantly related to important socioeconomic outcomes, such as lower rates of return to work and work retention as well as higher healthcare utilization (p<or=0.05 for all). Moreover, at one year after treatment, the group reporting the highest opioid use was 11.6 times as likely to be receiving Social Security Disability Income/Supplemental Security Income as compared with the group reporting no opioid use at the time of admission into the program.

CONCLUSIONS

Chronic opioid use beginning after a work-related injury is a predictor of less successful outcomes for patients whose final treatment intervention is an interdisciplinary functional restoration program. Higher dose levels are associated with progressively greater indemnity and medical costs for ongoing disability. Physicians involved in the treatment of chronic disabling occupational musculoskeletal disorders should be aware of problems associated with permitting long-term opioid use in patients with a disabling occupational disorder.

Documentation and potential tools in long-term opioid therapy for pain

The field of pain medicine is experiencing increased pressure from regulatory agencies and other sources regarding the continuation, or even initial use, of opioids in pain patients. Therefore, it is essential that pain clinicians provide rationale for engaging in this modality of treatment and provide ample documentation in this regard. Thus, assessment and documentation are cornerstones for both protecting your practice and obtaining optimal patient outcomes while on opioid therapy. Several potential tools and documentation strategies are discussed that will aid clinicians in providing evidence for the continuation of this type of treatment for their patients.

Chronic pain management in spine disorders

Chronic nonmalignant pain is less a symptom of a disease than a disease in itself. Accordingly, successful treatments rely less on identifying underlying pathology than on treating neural causes of pain amplification, psychologic causes of disability, and the sequelae of deconditioning and psychiatric illness. The outcome, when such treatment is provided, is remarkably favorable.

Documentation and potential tools in long-term opioid therapy for pain

The field of pain medicine is experiencing increased pressure from regulatory agencies and other sources regarding the continuation, or even initial use, of opioids in pain patients. Therefore, it is essential that pain clinicians provide rationale for engaging in this modality of treatment and provide ample documentation in this regard. Thus, assessment and documentation are cornerstones for both protecting your practice and obtaining optimal patient outcomes while on opioid therapy. Several potential tools and documentation strategies re discussed that will aid clinicians in providing evidence for the continuation of this type of treatment for their patients.

Treatment Outcomes after Multidisciplinary Pain Rehabilitation with Analgesic Medication Withdrawal for Patients with Fibromyalgia

OBJECTIVE

This study of patients with a diagnosis of fibromyalgia (FM) was conducted to test the hypothesis that immediate posttreatment measures of psychosocial functioning, health attributes, negative pain-related emotions, and depressive symptoms improve significantly during multidisciplinary pain rehabilitation while concurrently withdrawing analgesic medications.

DESIGN

Prospective case series.

SETTING

Multidisciplinary pain rehabilitation center at a tertiary referral medical center.

PATIENTS

In total, 159 consecutive patients with a diagnosis of FM admitted to the pain rehabilitation program from January 2002 to December 2003.

INTERVENTIONS

A 3-week outpatient multidisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates analgesic medication withdrawal.

OUTCOME MEASURES

Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Coping Strategies Questionnaire-Catastrophizing subscale (CSQ-C), and the Center for Epidemiologic Studies-Depression scale (CES-D) were administered at admission and dismissal and the mean differences in scores were compared using paired t-tests. The number of patients using opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, and muscle relaxants at admission and dismissal were compared using chi-squared analyses.

RESULTS

The difference in admission and dismissal scores from the MPI, SF-36, CSQ-C, and CES-D demonstrated a favorable response to treatment (P < 0.001). Compared with admission, the number of patients using opioids (P < 0.001), NSAIDs (P < 0.001), benzodiazepines (P < 0.001), and muscle relaxants (P < 0.01) at program dismissal was significantly reduced.

CONCLUSION

The results of this study support the hypothesis that immediate posttreatment measures of physical and emotional functioning are favorable for patients with FM following multidisciplinary pain rehabilitation that incorporates withdrawal of analgesic medications.