Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder

Recent data suggest that comorbid substance use disorders (SUDs) are common among chronic non-cancer pain (CNCP) patients; however, prevalence rates vary across studies and findings are limited regarding treatment options for CNCP patients with comorbid SUD. The purpose of this systematic review is to assess the prevalence, associated demographic and clinical characteristics, and treatment outcomes for CNCP patients with comorbid SUD. We conducted searches from Ovid MEDLINE, PsychINFO, and PubMED from 1950 through February 2010 and retrieved the references. Thirty-eight studies met inclusion criteria and provided data that addressed our key questions. Three to forty-eight percent of CNCP patients have a current SUD. There are no demographic or clinical factors that consistently differentiate CNCP patients with comorbid SUD from patients without SUD, though SUD patients appear to be at greater risk for aberrant medication-related behaviors. CNCP patients with SUD are more likely to be prescribed opioid medications and at higher doses than CNCP patients without a history of SUD. CNCP patients with comorbid SUD do not significantly differ in their responses to treatment compared to CNCP patients without SUD, though the quality of this evidence is low. Limited data are available to identify predictors of treatment outcome. Although clinical experience and research suggests that SUDs are common among CNCP patients, only limited data are available to guide clinicians who treat this population. Research is needed to increase understanding of the prevalence, correlates, and responses to treatment of CNCP patients with comorbid SUDs.     

Acupuncture and relaxation response for substance use disorder recovery

Background & Aims: Substance abuse is a major health problem in the US population, particularly among veterans. Current treatments for substance abuse in the form of pharmacologic, behavioural, or psychosocial therapy can be effective in limited instances. We investigated the effect of using two complementary and alternative approaches, acupuncture and the relaxation response, to treat veterans who are recovering from substance use disorders.

Methods: We conducted a controlled trial at a US Veterans Administration homeless residential rehabilitation programme. Study participants were randomly assigned to acupuncture, relaxation response or usual care groups.

Results: Both acupuncture and the relaxation response interventions were well received by the veterans with high intervention attendance rates (75% and 80%, respectively). The acupuncture group had significantly greater reductions in craving and anxiety levels and greater improvements in the spirituality dimension of quality of life, while the relaxation response group had significantly greater reductions in anxiety level and greater improvements in mental health and spirituality dimensions of quality of life than usual care. The two intervention groups had no significant difference in any outcome measures.

Conclusions: This trial provided promising pilot data for larger studies to validate the effects of acupuncture and the relaxation response for relapse prevention.     

How enough becomes enough: Processes of change prior to treatment for substance use disorder

Aim: Explore patient’s perceptions of change processes occurring prior to inpatient treatment for substance use disorder, forming the basis for treatment entry. Method: Four single focus-group interviews including a total of 14 patients (11 men and 3 women) were conducted in accordance with a brief interview guide. Interviews focused on patient’s perceptions of change processes prior to treatment entry, associated factors, decision-making and implications for their way forward. A content analysis was conducted to identify code and subcategorize meaning units. Results: Patients describe complex processes of change involving a new perception of life situation enabled by accumulation and escalation of negative consequences, especially related to loss and health, along with an external pressure or trigger. The transition to treatment entry is either based on a deliberate and active decision or a result of spontaneous action and less deliberate decision to initiate in treatment. Conclusions: Patient’s perceptions of treatment entry as a result of a more or less deliberate decision challenges patient’s readiness at treatment entry, constituting an important clinical challenge of relevance for clarifying treatment goals and interventions which in turn may affect the course of treatment applied to the patient.     

The beliefs of people with chronic pain in relation to 'important' treatment components.

BACKGROUND: The beliefs of people with chronic pain (service users) about the importance of treatment components offered through both multidisciplinary and other types of chronic pain programmes are not widely examined in the literature. AIM AND METHOD: As part of a wider research study of the congruence between what service providers and service users believe to be important treatments for chronic pain, members of three chronic pain support groups located in the North-West region of England were surveyed. The survey asked service users' opinion about whether specific treatment components are important or not important for people with chronic pain. The survey also included Skevington's Beliefs About Pain Control Questionnaire (BPCQ) that measures beliefs in the internal or personal control of pain, beliefs that powerful others (doctors) control pain and beliefs that pain is controlled by chance events. RESULTS AND CONCLUSION: Findings show that no treatment components were endorsed as important by more that 67% of the participants. Endorsements clustered around treatments that focused on self-management and biomedical interventions. A statistically significant relationship emerged between certain treatment components and BPCQ scores. These findings contribute to the growing cautions regarding standardised, 'one-size-fits all' treatment programs and the mistake of assuming people with pain form a homogenous group.     

Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

Abstract

Purpose: The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems. Methods: A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors. Results: Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain. Conclusions: No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly.

• Implications for Rehabilitation

• It remains challenging to correctly predict the outcome of treatment from patients’ baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome.

• Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation.

• Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning.

• Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program.

• Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

     

Development and feasibility testing of a Pain Neuroscience Education program for children with chronic pain: treatment protocol

Background

Current treatment for adults with chronic pain often includes Pain Neuroscience Education (PNE) to make people understand the nature underlying their pain and thus provides a clear rational for a biopsychosocial approach. Despite recommendations to use Pain Neuroscience Education as well in children with chronic pain, a specific program, tailored to children aged 6–12 years is lacking.

Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain

The relationship between persistent pain and self-directed, non-reactive awareness of present-moment experience (i.e., mindfulness) was explored in one of the dominant psychological theories of chronic pain – the fear-avoidance model [53]. A heterogeneous sample of 104 chronic pain outpatients at a multidisciplinary pain clinic in Australia completed psychometrically sound self-report measures of major variables in this model: Pain intensity, negative affect, pain catastrophizing, pain-related fear, pain hypervigilance, and functional disability. Two measures of mindfulness were also used, the Mindful Attention Awareness Scale [4] and the Five-Factor Mindfulness Questionnaire [1]. Results showed that mindfulness significantly negatively predicts each of these variables, accounting for 17–41% of their variance. Hierarchical multiple regression analysis showed that mindfulness uniquely predicts pain catastrophizing when other variables are controlled, and moderates the relationship between pain intensity and pain catastrophizing. This is the first clear evidence substantiating the strong link between mindfulness and pain catastrophizing, and suggests mindfulness might be added to the fear-avoidance model. Implications for the clinical use of mindfulness in screening and intervention are discussed.     

Adaptations to pain rehabilitation programmes for non-native patients with chronic pain

Purpose.?(i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place.

Subjects.?Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme.

Method.?A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ² tests or Fischer's exact tests and logistic regression analysis.

Results.?Twelve institutes (44.4%%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9%% of the institutes); longer consultations (25.9%%) and education for employees regarding cultural competency (11.1%%). Institutes which treated a high percentage (≥11%%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p == 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees.

Conclusion.?Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.     

Validation of the Pain Sensitivity Questionnaire in chronic pain patients

Recently, a self-rating measure for pain perception based on imagined painful daily life situations, the Pain Sensitivity Questionnaire (PSQ), has been developed and shown to correlate with experimentally obtained pain intensity ratings in healthy subjects. Here, we assessed the validity of the PSQ for investigation of general pain perception (ie, pain perception outside the site of clinical pain) in chronic pain patients. PSQ scores were obtained in 134 chronic pain patients and compared to those of 185 healthy control subjects. In a subgroup of 46 chronic pain patients, we performed experimental pain testing outside the clinical pain site, including different modalities (heat, cold, pressure, and pinprick) and different measures (pain thresholds, pain intensity ratings). Results show that PSQ scores were significantly correlated with both experimental pain intensity ratings (Pearson's r=0.71, P<.001) and experimental pain thresholds (r=-0.52, P<.001). In addition, chronic pain patients exhibited significantly elevated PSQ scores as compared to healthy controls, consistent with the generalized increase of experimentally determined pain perception that has repeatedly been reported in chronic pain patients. These results demonstrate that the PSQ constitutes a valid self-rating measure of pain perception outside the clinical pain site in chronic pain patients and might serve as an alternative to experimental assessment of pain perception outside the clinical pain site in situations where experimental pain testing is not feasible.     

慢性疼痛的综合评估与治疗

慢性疼痛成为 2 1世纪最普遍、花费最高的健康问题之一 ,严重或持久的疼痛能影响身体的各个系统 ,引起潜在的、严重的健康问题。医护人员应从身体状况、情感因素、精神以及社会关系方面对慢性疼痛病人给予正确而全面地评估 ,并给予综合治疗。     

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 - 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.     

A pilot study into the problematic use of opioid analgesics in chronic non-cancer pain patients.

Controversy surrounds the use of strong opioid analgesic drugs for chronic non-cancer pain. Specialists have concluded that fears of problematic drug use are often unfounded. In contrast, others claim the existence of significant problems.'Problematic drug use' includes the following definitions; addiction, abuse, physiological dependence and tolerance.We present a case study and the results of a pilot, longitudinal, cohort study, via a pilot questionnaire, of 22 chronic pain clinic patients following a trial of opioid drugs.The results suggest that chronic non-cancer pain patients can be maintained on opioids with few problems, and likewise can withdraw with minimal adverse effects, other than a return of pain.     

Effectiveness of a multimodal inpatient treatment for pediatric chronic pain: A comparison between children and adolescents

Objectives To evaluate short and long‐term treatment outcome of children (7–10 years) in comparison to adolescents (11–18 years) with disabling chronic pain following multimodal inpatient pain treatment. Patients and methods: Thirty‐three children and 167 adolescents underwent multimodal inpatient pain treatment. Standardized assessment of pain‐related variables, disability, coping, and use of analgesics was performed at admission, 3‐ and 12‐month follow‐up. Results: Children and adolescents displayed similar pain‐characteristics at admission. Adolescents demonstrated significantly higher disability and passive pain coping. Children relied more on others when in pain. All core variables (i.e., pain intensity, pain‐related disability, school absence and pain‐related coping) decreased significantly in both children and adolescents after 3 months. Both groups maintained this decline 12 months later. More than half of the children and adolescents demonstrated a 50%‐reduction in pain intensity after 3 months, and almost 60% after 12 months. Use of analgesics was significantly reduced at 3‐month follow‐up with no additional changes after 12 months. While age did not exert any impact on results, there were significant gender differences in pain intensity and school absence. Girls demonstrated higher pain intensity and higher school absence 1 year following treatment. Conclusions: Children display similar pain‐characteristics to adolescents when entering inpatient treatment. A multimodal inpatient program appears to stop the the long‐term vicious cycle of disability and pain for both children and adolescents. The demonstrated gender differences raise issues for further research and the possiblity of additional pain management strategies for girls.     

Pain in critically ill patients with substance use disorder or long-term opioid use for chronic pain

Opioid tolerance resulting from long-term opioid consumption for chronic pain or from substance use disorder adds a layer of complexity to managing pain in the critical care setting. This article discusses similarities and differences of these 2 conditions. The phenomenon of tolerance and opioid-induced hyperalgesia are presented. Prevention of opioid withdrawal, when patients are on methadone or buprenorphine, is described. An overview of the neurophysiology of pain and substance use disorder is presented. Practical clinical suggestions are given to assist the critical care nurse in caring for these complex patients.