- Email: [email protected]
(372) TelePain: improving primary care pain management
Abstracts
The Journal of Pain
S67
coding the genetic variant and disease status dichotomously. We assumed a true odds ratio (OR) of 12.0 and performed sensitivity analyses, using different proportions of contamination. Specifically, we considered contamination of remitted cases in the two groups (persistent migraine and control) in 5% increments and measured the bias for each set of misclassifications over a range of gene prevalence estimates. We found substantial bias (excess OR as a proportion of true OR) in the calculated OR’s across a range of reasonable assumptions. For example, when 20% of remitters were misclassified as persistent, the resulting bias for a range of prevalence estimates (from 5% to 25%), corresponded to OR’s ranging from 4.8–9.0. Migraine misclassification is strongly influenced by ability to distinguish between a person whose migraine is destined to remit and one whose migraine will persist. Simulations indicate even 5% misclassification results in reduction of the OR by half. In case-control studies, if migraine genes are associated with progression, contamination significantly diminishes even a sizeable odds ratio.
cords of 285 migraineurs treated with Trokendi XR (previously treated with TPM-IR, n=112). The incidence of reported cognitive effects was significantly (p=0.01) lower with Trokendi XR vs. previous TPM-IR treatment. A retrospective study using a large national medical and pharmacy claims database allowed parallel comparison of outcomes in migraineurs (n=9064) in whom TPM-IR (n=8596) or Trokendi XR (n=468) was initiated over the same 14-month period. Frequency of treatment-associated complications suggestive of cognitive effects was lower with Trokendi XR vs. TPM-IR. Trokendi XR was associated with significantly greater adherence (p<0.001), longer persistence (p<0.001) and higher continuation rates (p<0.001). In patients treated continuously $6 months, differences in monthly migraine events, migrainerelated outpatient visits, prescriptions for migraine-related drugs, and all-cause healthcare use significantly (p<0.001) favored Trokendi XR. Prospective studies and analyses of additional datasets are needed to confirm these observations of improved outcomes with Trokendi XR in migraineurs. Studies funded by Supernus Pharmaceuticals, Inc.
(369) Meta-Analysis Confirms Modality and Location Specific Alterations in Pain Thresholds in Migraine Patients
(371) PREEMPT: Prospective from complex patients in practice
H Nahman-Averbuch, T Shefi, D Li, L Ding, C King, and R Coghill; Cincinnati Children’s Hospital, Cincinnati, OH
P Flood, M Barad, J Sturgeon, M Kao, S Fish, and S Mackey; Stanford University, Stanford, CA
Quantitative sensory testing is widely used to quantify somatosensory function and indicate on impairments or interference in pain pathways of an individual in response to controlled stimuli across a variety of modalities including pressure and thermal. This metaanalysis aims to determine if there are differences in pain thresholds between migraine patients and healthy controls, and if such differences vary according to stimulus modality and stimulus location. A comprehensive search was conducted using the key words of ’migraine’ AND (’pain,’ ’threshold,’ ’pressure,’ ’electrical,’ ’warm,’ ’heat,’ ’cold,’ ’mechanical,’ ’quantitative sensory testing’). For pressure pain thresholds (PPT) 14 studies were included in the meta-analysis. No significant differences between migraine and controls were found (effect size 95% CI:-1.28 to 0.30, p=0.22). However, when subdivided by stimulus region, migraine patients demonstrated lower PPT compared to controls (effect size 95% CI:-1.5 to -0.19, P=0.01) in studies that tested PPT in the head and neck areas (local). PPT assessed outside of the head and neck region (non-local) showed no significant differences between the groups (effect size 95% CI:2.04 to 2.74, P=0.77). For heat pain thresholds (HPT) 9 studies were included. No evidence for significant differences in HPT between migraine patients and controls were found (effect size 95% CI:0.33 to 0.02, P=0.09). Similarly, no differences were evident when the data were divided to local (effect size 95% CI:-0.36 to 0.19, P=0.14) or nonlocal areas (effect size 95% CI:-0.34 to 0.08, P=0.11). This meta-analysis indicates that the alterations in nociceptive processing of migraine patients are modality and location specific. Symptoms associated with pressure sensations are often reported during migraine attack, and might explain why differences were found for PPT but not HPT. In addition, sensory abnormalities appear to be somatopically localized to the head and neck areas, and do not appear to indicate a pattern of generalized sensitization.
Prophylactic treatment with botulinum toxin for chronic migraine was approved by the FDA in 2010. While there is good evidence for treatment efficacy, there is little information from complex pain patients in a clinical environment. We evaluated the response to botulinum toxin administered via the PREEMPT protocol in 463 chronic migraine patients who presented to our pain management clinic between July, 2012 and May 2015. Patients had multiple complex pain problems with 12[6-19] (median[quartile]) regions represented on a pain body map. Individual patients had between 1 and 10 treatments with a median of 2[1-4] during the study period. The patients were 54[47-59] years old and 80% women. Their race/ethnicity was Asian (10%), Black (6%), Other (5%) and White (64%), Hispanic/Latino (4%). Mean headache free days per week increased from 1.7 before treatment to 2.5 between treatments with maximum efficacy at 180 days. The frequency of headache days/month was reduced from 22 to 15 days. There was no significant change in reported average pain severity after treatment until the 5th treatment when average numerical rating score for pain (1-10) was reduced by 1.5 points. Peak efficacy has not been reported at this late time-period. It may take up to 6 months to demonstrate efficacy in our population that suffers from migraine in addition to supplementary additional pain problems.
(370) Cognitive tolerability and health outcomes with once-daily Trokendi XRâ (extended-release topiramate) in migraineurs W O’Neal, E Hur, T Liranso, S Brittain, P Barr, H Chung, T Gu, O Tunceli, and R Turner; Supernus Pharmaceuticals, Inc., Rockville, MD In studies of immediate-release (IR) TPM dosed BID, migraineurs demonstrated greater susceptibility to TPM-related adverse events (AEs), particularly cognitive dysfunction, vs. other populations. Trokendi XRâ (extended-release topiramate, Supernus Pharmaceuticals, Inc.) is a novel, extended-release formulation producing more constant steadystate TPM plasma concentration-time profiles with QD dosing than TPM-IR BID. We report a series of studies suggesting the potential for better outcomes with Trokendi XR in migraineurs, including less cognitive impact. The initial signal emerged in a single-blind crossover study comparing relative steady-state bioavailability of TPM-IR and Trokendi XR in healthy volunteers (n=33) that included neuropsychometric testing of verbal fluency and cognitive processing speed/working memory. Both measures showed overall less impairment with Trokendi XR, with significantly less impairment in verbal fluency at 100 mg and across 50-200 mg doses. A retrospective multicenter study reviewed medical re-
Pain Management (372) TelePain: improving primary care pain management A Doorenbos, L Eaton, B Theodore, M Sullivan, J Robinson, S Rapp, and D Tauben; University of Washington, Seattle, WA Primary care providers are disadvantaged by limited access to pain medicine specialists, and inadequate pain medicine training and support. To increase access to interdisciplinary pain management guidance, a weekly video consulting session, UW TelePain was implemented. This cluster randomized control study was approved by the UW IRB. Primary care provider participants were recruited for the intervention group and nonparticipants were recruited for the control group. Each UW TelePain intervention session includes a 30-minute didactic lecture and two-to-three patient case discussions. Primary care providers were invited to present difficult chronic pain cases to our TelePain panel of specialists who made recommendations for difficult pain management issues. A summary of the recommendation was faxed to the primary health care provider. Up to 15 patients empaneled to each provider study subject were enrolled in the study. Patients completed a pain assessment and psychological (PainTracker) and quality of life (HUI-3) measures at baseline and every two-to-four weeks for 12 weeks. There were 22 providers and 116 patients in the intervention group, and 19 providers and 118 patients in the control group. Hierarchical linear modeling compared changes in patient outcomes between groups. The UW TelePain program significantly increased access to interprofessional experts who provide real-time support for the care of chronic pain patients. It also improved patient outcomes with a significant increase in quality of life for patients in the intervention group compared
S68
Abstracts
The Journal of Pain
to control (p = .02). There was also a trend in decreasing opioid doses in the intervention group compared to control without differences seen between groups in anxiety and depression. UW TelePain provides access to specialty care, support for local primary care providers, and allows patients to stay local for health care. Supported by NINR #R01NR012450 and # K24NR015340 and NIDA # N01DA-15-4424.
(373) Sustained participation in the VA SCAN ECHO Pain Management Telementoring Program enhances pain care quality B Moore, A Lee, P Mutalik, and R Kerns; VA Connecticut Healthcare System, West Haven, CT
VA SCAN ECHO, a telementoring program for primary care providers (PCPs) based on the ECHO project was launched in 2011 at seven national sites including VA Connecticut Healthcare System. SCAN ECHO Pain Management (PM) uses video-teleconferencing to provide PCPs with case-based specialist consultation and didactic education. Previous research has shown that PCPs who submitted consults to SCAN ECHO PM had better medication practices and used physical medicine services more frequently than those who did not. This study examines the effect of degree of attendance at SCAN ECHO sessions (i.e., ‘‘SCAN ECHO dose’’: not quantified in previous studies) on pain care quality (PCQ) measures by evaluating 3 attendance groups: non-attendees (0 sessions, n=30), infrequent attendees (1 to 5 sessions, n=14), or frequent attendees (>5 sessions, n=11) of 20 sessions of Pain SCAN ECHO offered during 2012. All patients with pain intensity ratings of $4 seen by these PCP’s in six-month time windows prior to implementation (n=3258), and after implementation (Jan-June 2013, n=3660) were identified using administrative VHA data. PCQ measures were 1) referral to comprehensive pain care alternatives, including mental health services, physical and occupational therapy, chiropractic, health psychology, and specialty pain management, and 2) prescription of opioid and non-opioid medications for pain. Outcomes were evaluated using General Estimating Equations with patient as a random factor nested within provider. Frequent attendees were more likely to be from community-based outpatient centers rather than two large VA medical centers. Findings indicated that the proportion of patients who received specialty care and who received prescriptions for non-opioid medications increased significantly for frequent attendees, but not for infrequent and non-attendees. Results extend prior findings by documenting an effect of extent of participation in SCAN ECHO PM sessions and encourages efforts to promote sustained participation.
(374) Ketamine infusion as an analgesic adjunct in the management of severe pain in patients with sickle cell disease K Hassell, W Ngongo, R Montgomery, and L Hornick; University of Colorado Denver, Aurora, CO
One of the major and most encumbering complications of sickle cell disease (SCD) are recurrent episodes of acute pain crises, which are often superimposed on chronic pain and managed with high opiate dosages. Consequently, recurrent acute painful episodes may lead to opioid tolerance, transition to chronic pain, and in some cases, opioid-induced hyperalgesia (OIH). A review of the literature reveals anecdotal case reports of ketamine infusion for patients whose SCD pain crises were refractory to opioids, resulting in reduced pain scores and opioid use, and suggesting that ketamine may serve as a useful adjunct in the management of severe SCD-induced pain. We present our experience with 10 opioid-tolerant adult patients with SCD who were admitted to the University of Colorado Hospital for acute exacerbation of pain refractory to opioid therapy. These patients received a total of 72 continuous ketamine infusions, representing the largest reported experience to date. Sixty-six (91.7%) of the administrations led to reduced pain intensity scores (from an average of 7.88 to 4.25 out of 10) and reduced opioid intake. Only a total of 8 administrations (11.1%) caused side effects, including hallucinations and vomiting, that led to discontinuation. Ongoing analysis will determine if there is a subsequent sustained reduction in chronic opioid dosing. These data suggest ketamine infusion may be beneficial as an analgesic adjunct in the management of severe acute pain in patients with SCD. However, a randomized trial will be necessary to cultivate an evidence-based protocol for the use of ketamine infusion as a therapeutic option for patients with SCD whose pain become severe and refractory to opioids.
(375) The relationship of absorption and relaxation training with biofeedback in the management of chronic pain C Gagnon, F Laevksy, and S Hoye; Rehabilitation Institute of Chicago, Chicago, IL
The role of absorption has been implicated in the use of mind - body therapies for the past forty years with many studies showing relationships between absorption and treatment efficacy. There are few studies pertaining to the construct of absorption with mind-body therapies, such as guided imagery and hypnosis and even less so with biofeedback. Biofeedback combined with relaxation training is a mind-body therapy which utilizes relaxation and visualization techniques similar to hypnosis and other mind-body modalities with the addition of physiological monitoring. This was a prospective study including 101 chronic pain patients designed to examine relationships among absorption and outcomes from biofeedback and relaxation training. Subjects’ level of absorption was assessed using a modified, nine-item version of the Tellegen Absorption Scale (9TAS). Outcomes in biofeedback were assessed using a modified version of the Chronic Pain Self-Efficacy Scale (CPSS and CPSS-bio) and physiological measures (muscle tension- sEMG, respiration- RSP, skin conductance- GSR, and temperature -Temp). It was hypothesized that absorption would be associated with biofeedback outcomes following completion of an interdisciplinary pain program. Treatment efficacy was assessed using pair-samples t-tests. Results showed significant improvements in overall self-efficacy and biofeedback self-efficacy as well as improvements in sEMG, RSP, and GSR (P’s < .05), but no improvement in Temp. Pearson correlations assessed the relationships of the TAS with the biofeedback outcomes. The total TAS correlated significantly with reductions in respiration; specifically, lower TAS scores were associated with greater reductions in respiration (r = -.201, p = .035). The TAS was not significantly associated with any other outcome measures (CPSS, CPSS-bio, Temp, sEMG, GSR), P’s >.05. Patients demonstrated improvements on all but one treatment outcome. However, most of the improvements were not significantly associated with pre-treatment levels of absorption. The results suggest little connection between absorption and relaxation training and biofeedback outcome.
(376) Impact of the Harborview Chronic Pain Self-Management Program on participants’ quality of life, confidence and pain experience D Gordon, A Meins, J Noar, A Doorenbos, D and I Lesnik; Harborview Medical Center, Seattle, WA
Tauben,
The Chronic Pain Self-Management Program (CPSMP) is as an evidenced-based model that helps sufferers of chronic pain conditions learn how to better manage their pain symptoms and overall health status. The CPSMP involves a six-week long workshop that is designed for adults with chronic pain conditions to work together and build off of each other’s strengths and knowledge regarding pain management. The program is adapted from the well-researched Chronic Disease Self-Management Program developed at Stanford that followed more than 1000 people with heart disease, lung disease, stroke or arthritis in a three-year randomized, controlled trial demonstrating improvements in many areas of health status, health care utilization, self-efficacy and self-management behaviors. Little to no evidence exists on the program effects for persons with chronic pain. The purpose of this study is to assess how effective the Harborview CPSMP workshops are at improving participants’ ability to manage their pain and overall health status. Participants completed pre and post course surveys including the PROMIS Scale v1.2 – Global Health, Stanford program items for confidence about doing things and medical care, and the UW PainTrackerÔ that includes the PHQ-4 and items about pain interference in past week. We report on results of six courses held between October 2015 and March 2017. Preliminary analysis of 19 individuals to date reveals improvements in confidence keeping fatigue, physical discomfort and emotional distress from interfering with things they want to do in life. An increased percentage of participants at the end of the course report confidence to do things other than see a doctor or take medication to reduce how much pain affects everyday life most or all of the time.
The Journal of Pain
S67
coding the genetic variant and disease status dichotomously. We assumed a true odds ratio (OR) of 12.0 and performed sensitivity analyses, using different proportions of contamination. Specifically, we considered contamination of remitted cases in the two groups (persistent migraine and control) in 5% increments and measured the bias for each set of misclassifications over a range of gene prevalence estimates. We found substantial bias (excess OR as a proportion of true OR) in the calculated OR’s across a range of reasonable assumptions. For example, when 20% of remitters were misclassified as persistent, the resulting bias for a range of prevalence estimates (from 5% to 25%), corresponded to OR’s ranging from 4.8–9.0. Migraine misclassification is strongly influenced by ability to distinguish between a person whose migraine is destined to remit and one whose migraine will persist. Simulations indicate even 5% misclassification results in reduction of the OR by half. In case-control studies, if migraine genes are associated with progression, contamination significantly diminishes even a sizeable odds ratio.
cords of 285 migraineurs treated with Trokendi XR (previously treated with TPM-IR, n=112). The incidence of reported cognitive effects was significantly (p=0.01) lower with Trokendi XR vs. previous TPM-IR treatment. A retrospective study using a large national medical and pharmacy claims database allowed parallel comparison of outcomes in migraineurs (n=9064) in whom TPM-IR (n=8596) or Trokendi XR (n=468) was initiated over the same 14-month period. Frequency of treatment-associated complications suggestive of cognitive effects was lower with Trokendi XR vs. TPM-IR. Trokendi XR was associated with significantly greater adherence (p<0.001), longer persistence (p<0.001) and higher continuation rates (p<0.001). In patients treated continuously $6 months, differences in monthly migraine events, migrainerelated outpatient visits, prescriptions for migraine-related drugs, and all-cause healthcare use significantly (p<0.001) favored Trokendi XR. Prospective studies and analyses of additional datasets are needed to confirm these observations of improved outcomes with Trokendi XR in migraineurs. Studies funded by Supernus Pharmaceuticals, Inc.
(369) Meta-Analysis Confirms Modality and Location Specific Alterations in Pain Thresholds in Migraine Patients
(371) PREEMPT: Prospective from complex patients in practice
H Nahman-Averbuch, T Shefi, D Li, L Ding, C King, and R Coghill; Cincinnati Children’s Hospital, Cincinnati, OH
P Flood, M Barad, J Sturgeon, M Kao, S Fish, and S Mackey; Stanford University, Stanford, CA
Quantitative sensory testing is widely used to quantify somatosensory function and indicate on impairments or interference in pain pathways of an individual in response to controlled stimuli across a variety of modalities including pressure and thermal. This metaanalysis aims to determine if there are differences in pain thresholds between migraine patients and healthy controls, and if such differences vary according to stimulus modality and stimulus location. A comprehensive search was conducted using the key words of ’migraine’ AND (’pain,’ ’threshold,’ ’pressure,’ ’electrical,’ ’warm,’ ’heat,’ ’cold,’ ’mechanical,’ ’quantitative sensory testing’). For pressure pain thresholds (PPT) 14 studies were included in the meta-analysis. No significant differences between migraine and controls were found (effect size 95% CI:-1.28 to 0.30, p=0.22). However, when subdivided by stimulus region, migraine patients demonstrated lower PPT compared to controls (effect size 95% CI:-1.5 to -0.19, P=0.01) in studies that tested PPT in the head and neck areas (local). PPT assessed outside of the head and neck region (non-local) showed no significant differences between the groups (effect size 95% CI:2.04 to 2.74, P=0.77). For heat pain thresholds (HPT) 9 studies were included. No evidence for significant differences in HPT between migraine patients and controls were found (effect size 95% CI:0.33 to 0.02, P=0.09). Similarly, no differences were evident when the data were divided to local (effect size 95% CI:-0.36 to 0.19, P=0.14) or nonlocal areas (effect size 95% CI:-0.34 to 0.08, P=0.11). This meta-analysis indicates that the alterations in nociceptive processing of migraine patients are modality and location specific. Symptoms associated with pressure sensations are often reported during migraine attack, and might explain why differences were found for PPT but not HPT. In addition, sensory abnormalities appear to be somatopically localized to the head and neck areas, and do not appear to indicate a pattern of generalized sensitization.
Prophylactic treatment with botulinum toxin for chronic migraine was approved by the FDA in 2010. While there is good evidence for treatment efficacy, there is little information from complex pain patients in a clinical environment. We evaluated the response to botulinum toxin administered via the PREEMPT protocol in 463 chronic migraine patients who presented to our pain management clinic between July, 2012 and May 2015. Patients had multiple complex pain problems with 12[6-19] (median[quartile]) regions represented on a pain body map. Individual patients had between 1 and 10 treatments with a median of 2[1-4] during the study period. The patients were 54[47-59] years old and 80% women. Their race/ethnicity was Asian (10%), Black (6%), Other (5%) and White (64%), Hispanic/Latino (4%). Mean headache free days per week increased from 1.7 before treatment to 2.5 between treatments with maximum efficacy at 180 days. The frequency of headache days/month was reduced from 22 to 15 days. There was no significant change in reported average pain severity after treatment until the 5th treatment when average numerical rating score for pain (1-10) was reduced by 1.5 points. Peak efficacy has not been reported at this late time-period. It may take up to 6 months to demonstrate efficacy in our population that suffers from migraine in addition to supplementary additional pain problems.
(370) Cognitive tolerability and health outcomes with once-daily Trokendi XRâ (extended-release topiramate) in migraineurs W O’Neal, E Hur, T Liranso, S Brittain, P Barr, H Chung, T Gu, O Tunceli, and R Turner; Supernus Pharmaceuticals, Inc., Rockville, MD In studies of immediate-release (IR) TPM dosed BID, migraineurs demonstrated greater susceptibility to TPM-related adverse events (AEs), particularly cognitive dysfunction, vs. other populations. Trokendi XRâ (extended-release topiramate, Supernus Pharmaceuticals, Inc.) is a novel, extended-release formulation producing more constant steadystate TPM plasma concentration-time profiles with QD dosing than TPM-IR BID. We report a series of studies suggesting the potential for better outcomes with Trokendi XR in migraineurs, including less cognitive impact. The initial signal emerged in a single-blind crossover study comparing relative steady-state bioavailability of TPM-IR and Trokendi XR in healthy volunteers (n=33) that included neuropsychometric testing of verbal fluency and cognitive processing speed/working memory. Both measures showed overall less impairment with Trokendi XR, with significantly less impairment in verbal fluency at 100 mg and across 50-200 mg doses. A retrospective multicenter study reviewed medical re-
Pain Management (372) TelePain: improving primary care pain management A Doorenbos, L Eaton, B Theodore, M Sullivan, J Robinson, S Rapp, and D Tauben; University of Washington, Seattle, WA Primary care providers are disadvantaged by limited access to pain medicine specialists, and inadequate pain medicine training and support. To increase access to interdisciplinary pain management guidance, a weekly video consulting session, UW TelePain was implemented. This cluster randomized control study was approved by the UW IRB. Primary care provider participants were recruited for the intervention group and nonparticipants were recruited for the control group. Each UW TelePain intervention session includes a 30-minute didactic lecture and two-to-three patient case discussions. Primary care providers were invited to present difficult chronic pain cases to our TelePain panel of specialists who made recommendations for difficult pain management issues. A summary of the recommendation was faxed to the primary health care provider. Up to 15 patients empaneled to each provider study subject were enrolled in the study. Patients completed a pain assessment and psychological (PainTracker) and quality of life (HUI-3) measures at baseline and every two-to-four weeks for 12 weeks. There were 22 providers and 116 patients in the intervention group, and 19 providers and 118 patients in the control group. Hierarchical linear modeling compared changes in patient outcomes between groups. The UW TelePain program significantly increased access to interprofessional experts who provide real-time support for the care of chronic pain patients. It also improved patient outcomes with a significant increase in quality of life for patients in the intervention group compared
S68
Abstracts
The Journal of Pain
to control (p = .02). There was also a trend in decreasing opioid doses in the intervention group compared to control without differences seen between groups in anxiety and depression. UW TelePain provides access to specialty care, support for local primary care providers, and allows patients to stay local for health care. Supported by NINR #R01NR012450 and # K24NR015340 and NIDA # N01DA-15-4424.
(373) Sustained participation in the VA SCAN ECHO Pain Management Telementoring Program enhances pain care quality B Moore, A Lee, P Mutalik, and R Kerns; VA Connecticut Healthcare System, West Haven, CT
VA SCAN ECHO, a telementoring program for primary care providers (PCPs) based on the ECHO project was launched in 2011 at seven national sites including VA Connecticut Healthcare System. SCAN ECHO Pain Management (PM) uses video-teleconferencing to provide PCPs with case-based specialist consultation and didactic education. Previous research has shown that PCPs who submitted consults to SCAN ECHO PM had better medication practices and used physical medicine services more frequently than those who did not. This study examines the effect of degree of attendance at SCAN ECHO sessions (i.e., ‘‘SCAN ECHO dose’’: not quantified in previous studies) on pain care quality (PCQ) measures by evaluating 3 attendance groups: non-attendees (0 sessions, n=30), infrequent attendees (1 to 5 sessions, n=14), or frequent attendees (>5 sessions, n=11) of 20 sessions of Pain SCAN ECHO offered during 2012. All patients with pain intensity ratings of $4 seen by these PCP’s in six-month time windows prior to implementation (n=3258), and after implementation (Jan-June 2013, n=3660) were identified using administrative VHA data. PCQ measures were 1) referral to comprehensive pain care alternatives, including mental health services, physical and occupational therapy, chiropractic, health psychology, and specialty pain management, and 2) prescription of opioid and non-opioid medications for pain. Outcomes were evaluated using General Estimating Equations with patient as a random factor nested within provider. Frequent attendees were more likely to be from community-based outpatient centers rather than two large VA medical centers. Findings indicated that the proportion of patients who received specialty care and who received prescriptions for non-opioid medications increased significantly for frequent attendees, but not for infrequent and non-attendees. Results extend prior findings by documenting an effect of extent of participation in SCAN ECHO PM sessions and encourages efforts to promote sustained participation.
(374) Ketamine infusion as an analgesic adjunct in the management of severe pain in patients with sickle cell disease K Hassell, W Ngongo, R Montgomery, and L Hornick; University of Colorado Denver, Aurora, CO
One of the major and most encumbering complications of sickle cell disease (SCD) are recurrent episodes of acute pain crises, which are often superimposed on chronic pain and managed with high opiate dosages. Consequently, recurrent acute painful episodes may lead to opioid tolerance, transition to chronic pain, and in some cases, opioid-induced hyperalgesia (OIH). A review of the literature reveals anecdotal case reports of ketamine infusion for patients whose SCD pain crises were refractory to opioids, resulting in reduced pain scores and opioid use, and suggesting that ketamine may serve as a useful adjunct in the management of severe SCD-induced pain. We present our experience with 10 opioid-tolerant adult patients with SCD who were admitted to the University of Colorado Hospital for acute exacerbation of pain refractory to opioid therapy. These patients received a total of 72 continuous ketamine infusions, representing the largest reported experience to date. Sixty-six (91.7%) of the administrations led to reduced pain intensity scores (from an average of 7.88 to 4.25 out of 10) and reduced opioid intake. Only a total of 8 administrations (11.1%) caused side effects, including hallucinations and vomiting, that led to discontinuation. Ongoing analysis will determine if there is a subsequent sustained reduction in chronic opioid dosing. These data suggest ketamine infusion may be beneficial as an analgesic adjunct in the management of severe acute pain in patients with SCD. However, a randomized trial will be necessary to cultivate an evidence-based protocol for the use of ketamine infusion as a therapeutic option for patients with SCD whose pain become severe and refractory to opioids.
(375) The relationship of absorption and relaxation training with biofeedback in the management of chronic pain C Gagnon, F Laevksy, and S Hoye; Rehabilitation Institute of Chicago, Chicago, IL
The role of absorption has been implicated in the use of mind - body therapies for the past forty years with many studies showing relationships between absorption and treatment efficacy. There are few studies pertaining to the construct of absorption with mind-body therapies, such as guided imagery and hypnosis and even less so with biofeedback. Biofeedback combined with relaxation training is a mind-body therapy which utilizes relaxation and visualization techniques similar to hypnosis and other mind-body modalities with the addition of physiological monitoring. This was a prospective study including 101 chronic pain patients designed to examine relationships among absorption and outcomes from biofeedback and relaxation training. Subjects’ level of absorption was assessed using a modified, nine-item version of the Tellegen Absorption Scale (9TAS). Outcomes in biofeedback were assessed using a modified version of the Chronic Pain Self-Efficacy Scale (CPSS and CPSS-bio) and physiological measures (muscle tension- sEMG, respiration- RSP, skin conductance- GSR, and temperature -Temp). It was hypothesized that absorption would be associated with biofeedback outcomes following completion of an interdisciplinary pain program. Treatment efficacy was assessed using pair-samples t-tests. Results showed significant improvements in overall self-efficacy and biofeedback self-efficacy as well as improvements in sEMG, RSP, and GSR (P’s < .05), but no improvement in Temp. Pearson correlations assessed the relationships of the TAS with the biofeedback outcomes. The total TAS correlated significantly with reductions in respiration; specifically, lower TAS scores were associated with greater reductions in respiration (r = -.201, p = .035). The TAS was not significantly associated with any other outcome measures (CPSS, CPSS-bio, Temp, sEMG, GSR), P’s >.05. Patients demonstrated improvements on all but one treatment outcome. However, most of the improvements were not significantly associated with pre-treatment levels of absorption. The results suggest little connection between absorption and relaxation training and biofeedback outcome.
(376) Impact of the Harborview Chronic Pain Self-Management Program on participants’ quality of life, confidence and pain experience D Gordon, A Meins, J Noar, A Doorenbos, D and I Lesnik; Harborview Medical Center, Seattle, WA
Tauben,
The Chronic Pain Self-Management Program (CPSMP) is as an evidenced-based model that helps sufferers of chronic pain conditions learn how to better manage their pain symptoms and overall health status. The CPSMP involves a six-week long workshop that is designed for adults with chronic pain conditions to work together and build off of each other’s strengths and knowledge regarding pain management. The program is adapted from the well-researched Chronic Disease Self-Management Program developed at Stanford that followed more than 1000 people with heart disease, lung disease, stroke or arthritis in a three-year randomized, controlled trial demonstrating improvements in many areas of health status, health care utilization, self-efficacy and self-management behaviors. Little to no evidence exists on the program effects for persons with chronic pain. The purpose of this study is to assess how effective the Harborview CPSMP workshops are at improving participants’ ability to manage their pain and overall health status. Participants completed pre and post course surveys including the PROMIS Scale v1.2 – Global Health, Stanford program items for confidence about doing things and medical care, and the UW PainTrackerÔ that includes the PHQ-4 and items about pain interference in past week. We report on results of six courses held between October 2015 and March 2017. Preliminary analysis of 19 individuals to date reveals improvements in confidence keeping fatigue, physical discomfort and emotional distress from interfering with things they want to do in life. An increased percentage of participants at the end of the course report confidence to do things other than see a doctor or take medication to reduce how much pain affects everyday life most or all of the time.