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The critical role of nursing in successful opioid withdrawal in chronic non-cancer pain
Abstracts
S55
(787) Fear of (re)injury as a predictor of chronic pain, disability and distress: A validation and age analysis using structural equation modeling
(789) Efficacy of operant- and cognitive-behavioral pain treatment in psychosocial subgroups of FibromyalgiaSyndrome
A. Cook, P. Brawer; University of Virginia Health Sciences Center, Charlottesville, VA The fear-avoidance (FA) model postulates that fear of movement/(re)injury represents a response to pain that is influenced by catastrophizing. This fear contributes to avoidance behaviors, and subsequently disuse, depression and increased disability. Although components of this model have been tested and supported, the full multivariate FA model has not been empirically validated. Possible age differences in the FA model also have not been investigated. We employed structural equation modeling (SEM) for confirmatory analyses of the model in a sample of 474 (54% female) chronic pain patients undergoing initial evaluations in an interdisciplinary university-based pain management center. Participants completed a comprehensive evaluation, including measures of catastrophizing, fear of (re)injury, pain disability, depression, and pain severity. To evaluate potential age differences, the sample was divided into three groups: young ⬍40 (n⫽155), middle-aged 41-54 (n⫽199), older ⬎55 (n⫽120). Fear of (re)injury was assessed with the Tampa Scale of Kinesiophobia (TSK). Confirmatory factor analyses supported the 2-factor structure of the TSK (Avoidance, Somatic Focus) within all age groups. Using SEM, the multivariate fear-avoidance model was found to provide a strong fit to the data (AGFI⫽.96, CFI⫽.95, RMSEA⫽.04), and to be invariant across the 3 age groups. Older adults had significantly lower TSK scores, though clinical significance of these differences was modest. Results provide empirical confirmation of the fear-avoidance model, and its applicability across age groups of chronic pain patients. Findings of lower fear of (re)injury among older adults are contrary to stereotypical assumptions based on increased frailty or physical vulnerability. Implications for treatment and future research are discussed.
K. Thieme, H. Flor, D. Turk; University of Washington, Seattle, WA The present study focused on the evaluation of the effects of operantbehavioral (OB) and of cognitive-behavioral treatment (CBT) for psychosocial subgroups in fibromyalgia syndrome (FMS). One hundred patients who fulfilled the ACR-criteria for FMS were randomly assigned to OB (N⫽40), a CBT, (N⫽40), or an attention placebo (social discussion, AP, N⫽20). The assessments of pain intensity, cognitive, stress, affective, and behavioral variables were performed pre, post, 6, and 12 months after treatment. Twenty nine percent of patients were classified as Dysfunctional (DYS), 29% percent as Interpersonally Distressed (ID), and 42% as Adaptive Copers (AC) based on responses to the Multidimensional Pain Inventory (MPI). Post-treatment, patients receiving both the OB and CBT reported a significant reduction in pain intensity, interference (all Fs ⬎ 3.35, all p ⬍ 0.04). The OB treatment reduced the percentage of DYS patients significantly from 33.3% to 22.2% (Chi-square (1) ⫽ 6.84, p ⫽ 0.01) in contrast the CBT did not produce a significant reduction of DYS. However, the CBT treatment reduced the numbers of ID from 50.0% to 31.6 % (Chi-square (1) ⫽ 4.39, p ⫽ 0.03) after 12 months in contrast to OB that did not achieve a significant reduction in the number of ID patients. The percentage of AC patients increased after OB from 55.6% to 66.7% (Chi-square (1) ⫽ 4.21, p ⫽ 0.04) and after CBT from 28.9% to 42.1% (Chi-square (1) ⫽ 5.21, p ⫽ 0.02). These results suggest that the OB treatment was significantly more effective than the CBT for DYS whereas the CBT was significantly more for ID-patients with FMS. The results suggest that different treatments for FMS subgroups might be useful.
(788) The effects of psychological pain treatment in Fibromyalgia Syndrome on psychophysiological parameters
(790) The critical role of nursing in successful opioid withdrawal in chronic non-cancer pain
K. Thieme, H. Flor, D. Turk; University of Washington, Seattle, WA Although psychological treatments are effective in treating fibromyalgia syndrome (FMS) patients, little attention has been given to the impact of these treatments on physiological parameters. The present study was the evaluation of the effects of operant behavioral (OB) and cognitive-behavioral therapy (CBT) for FMS on the cardiovascular, autonomic, and muscular systems. Pain intensity, baseline levels, and stress reactivity measures were assessed in 100 patients with FMS randomly assigning to OB (N⫽40), CBT (N⫽40), and an attention placebo (social discussion, AP, N⫽20) treatment groups. In addition, 30 age- and sex-matched Healthy controls (HC) were included for comparison. Surface electromyography (EMG) recorded from the trapezius muscle, blood pressure (BP), heart rate (HR), and skin conductance levels (SCL) were continuously recorded during adaptation and baseline, social conflict, mental arithmetic, and relaxation tasks. Additionally, pain and activity score by Multidimensional Pain Inventory (MPI) were recorded. Assessments were performed pre, post, 6 and 12 months following treatment. The OB and CBT groups reported significant and stable reductions in pain intensity (F(4;102) ⫽ 3.51, p⬍0.01). FMS showed significant lower EMG and elevated HR and SCL compared to the HC prior to treatment (Fs(4,130) ⬎ 5.51, ps⬍0.01) as an expression of lowered physical performance capability. Only, the OB group showed significant changes in EMG and HR at 6 month and 12 month after the treatment. Additionally the activity score was increased 12 month after the operant treatment (t (99) ⫽ ⫺2.1, p⬍0.03 ). The enhanced muscle tension and decreased HR as well as the increased activity after the operant pain treatment suggest an enhancement of physical performance capability in FMS. Supported by grants of Deutsche Forschungsgemeinschaft to KT (Th 988-1/2), HF (FL 156/26, Clinical Research Unit 107) the Max-Planck-Award for International Cooperation, and from the National Institute of Arthritis and Musculoskeletal and Skin Diseases to DCT (AR44724)
J. Cronin, P. Dokken, L. Newell; Mayo Clinic, Rochester, MN Maintenance opioid use in chronic non-cancer pain treatment is widespread and controversial. A recent article in Mayo Clinic Proceedings examined this issue and concluded that, “patients who have symptomatically severe and functionally disabling pain, while receiving maintenance opioid therapy, can obtain significant benefit from rehabilitative treatment that incorporates opioid withdrawal.”1 The purpose of the present study is to describe the process of opioid withdrawal undertaken in a multidisciplinary pain rehabilitation program with the emphasis on the specific roles nurses play in the success of this intervention. A multidisciplinary approach is utilized, with two levels of nursing care, aimed at improving patient’s emotional and physical functioning and quality of life. A key component in this pain rehabilitation effort is a conservative philosophy of analgesic use for chronic non-cancer pain. Opioid medications are discontinued, while self-management strategies are implemented including exercise, relaxation skills, moderation and healthy lifestyle changes. The masters prepared Clinical Nurse Specialist (CNS) and baccalaureate prepared RN, supervised by the MD, assist patients with medication changes using a systematic, gradual method of reducing and discontinuing opioids for chronic pain management. The CNS structures opioid tapers utilizing prescriptive privileges, advanced assessment, and education/interventions focusing on chemical health and wellness. The RN monitors daily opioid tapers including monitoring patient self-administration of medications, assessing withdrawal symptoms, and reinforcing alternative coping techniques for pain management. Measures of pain severity, interference due to pain, activity level, perceived life control, affective distress, depression and catastrophizing have been used to compare opioid and nonopioid groups within this pain rehabilitation center. This paper will illustrate specific interventions utilized by pain rehabilitation nurses that directly contribute to successful opioid withdrawal and improvement in emotional and physical functioning for patients with chronic pain. (1. Rome, J.D. et al., Mayo Clinic Proceedings, 2004).
S55
(787) Fear of (re)injury as a predictor of chronic pain, disability and distress: A validation and age analysis using structural equation modeling
(789) Efficacy of operant- and cognitive-behavioral pain treatment in psychosocial subgroups of FibromyalgiaSyndrome
A. Cook, P. Brawer; University of Virginia Health Sciences Center, Charlottesville, VA The fear-avoidance (FA) model postulates that fear of movement/(re)injury represents a response to pain that is influenced by catastrophizing. This fear contributes to avoidance behaviors, and subsequently disuse, depression and increased disability. Although components of this model have been tested and supported, the full multivariate FA model has not been empirically validated. Possible age differences in the FA model also have not been investigated. We employed structural equation modeling (SEM) for confirmatory analyses of the model in a sample of 474 (54% female) chronic pain patients undergoing initial evaluations in an interdisciplinary university-based pain management center. Participants completed a comprehensive evaluation, including measures of catastrophizing, fear of (re)injury, pain disability, depression, and pain severity. To evaluate potential age differences, the sample was divided into three groups: young ⬍40 (n⫽155), middle-aged 41-54 (n⫽199), older ⬎55 (n⫽120). Fear of (re)injury was assessed with the Tampa Scale of Kinesiophobia (TSK). Confirmatory factor analyses supported the 2-factor structure of the TSK (Avoidance, Somatic Focus) within all age groups. Using SEM, the multivariate fear-avoidance model was found to provide a strong fit to the data (AGFI⫽.96, CFI⫽.95, RMSEA⫽.04), and to be invariant across the 3 age groups. Older adults had significantly lower TSK scores, though clinical significance of these differences was modest. Results provide empirical confirmation of the fear-avoidance model, and its applicability across age groups of chronic pain patients. Findings of lower fear of (re)injury among older adults are contrary to stereotypical assumptions based on increased frailty or physical vulnerability. Implications for treatment and future research are discussed.
K. Thieme, H. Flor, D. Turk; University of Washington, Seattle, WA The present study focused on the evaluation of the effects of operantbehavioral (OB) and of cognitive-behavioral treatment (CBT) for psychosocial subgroups in fibromyalgia syndrome (FMS). One hundred patients who fulfilled the ACR-criteria for FMS were randomly assigned to OB (N⫽40), a CBT, (N⫽40), or an attention placebo (social discussion, AP, N⫽20). The assessments of pain intensity, cognitive, stress, affective, and behavioral variables were performed pre, post, 6, and 12 months after treatment. Twenty nine percent of patients were classified as Dysfunctional (DYS), 29% percent as Interpersonally Distressed (ID), and 42% as Adaptive Copers (AC) based on responses to the Multidimensional Pain Inventory (MPI). Post-treatment, patients receiving both the OB and CBT reported a significant reduction in pain intensity, interference (all Fs ⬎ 3.35, all p ⬍ 0.04). The OB treatment reduced the percentage of DYS patients significantly from 33.3% to 22.2% (Chi-square (1) ⫽ 6.84, p ⫽ 0.01) in contrast the CBT did not produce a significant reduction of DYS. However, the CBT treatment reduced the numbers of ID from 50.0% to 31.6 % (Chi-square (1) ⫽ 4.39, p ⫽ 0.03) after 12 months in contrast to OB that did not achieve a significant reduction in the number of ID patients. The percentage of AC patients increased after OB from 55.6% to 66.7% (Chi-square (1) ⫽ 4.21, p ⫽ 0.04) and after CBT from 28.9% to 42.1% (Chi-square (1) ⫽ 5.21, p ⫽ 0.02). These results suggest that the OB treatment was significantly more effective than the CBT for DYS whereas the CBT was significantly more for ID-patients with FMS. The results suggest that different treatments for FMS subgroups might be useful.
(788) The effects of psychological pain treatment in Fibromyalgia Syndrome on psychophysiological parameters
(790) The critical role of nursing in successful opioid withdrawal in chronic non-cancer pain
K. Thieme, H. Flor, D. Turk; University of Washington, Seattle, WA Although psychological treatments are effective in treating fibromyalgia syndrome (FMS) patients, little attention has been given to the impact of these treatments on physiological parameters. The present study was the evaluation of the effects of operant behavioral (OB) and cognitive-behavioral therapy (CBT) for FMS on the cardiovascular, autonomic, and muscular systems. Pain intensity, baseline levels, and stress reactivity measures were assessed in 100 patients with FMS randomly assigning to OB (N⫽40), CBT (N⫽40), and an attention placebo (social discussion, AP, N⫽20) treatment groups. In addition, 30 age- and sex-matched Healthy controls (HC) were included for comparison. Surface electromyography (EMG) recorded from the trapezius muscle, blood pressure (BP), heart rate (HR), and skin conductance levels (SCL) were continuously recorded during adaptation and baseline, social conflict, mental arithmetic, and relaxation tasks. Additionally, pain and activity score by Multidimensional Pain Inventory (MPI) were recorded. Assessments were performed pre, post, 6 and 12 months following treatment. The OB and CBT groups reported significant and stable reductions in pain intensity (F(4;102) ⫽ 3.51, p⬍0.01). FMS showed significant lower EMG and elevated HR and SCL compared to the HC prior to treatment (Fs(4,130) ⬎ 5.51, ps⬍0.01) as an expression of lowered physical performance capability. Only, the OB group showed significant changes in EMG and HR at 6 month and 12 month after the treatment. Additionally the activity score was increased 12 month after the operant treatment (t (99) ⫽ ⫺2.1, p⬍0.03 ). The enhanced muscle tension and decreased HR as well as the increased activity after the operant pain treatment suggest an enhancement of physical performance capability in FMS. Supported by grants of Deutsche Forschungsgemeinschaft to KT (Th 988-1/2), HF (FL 156/26, Clinical Research Unit 107) the Max-Planck-Award for International Cooperation, and from the National Institute of Arthritis and Musculoskeletal and Skin Diseases to DCT (AR44724)
J. Cronin, P. Dokken, L. Newell; Mayo Clinic, Rochester, MN Maintenance opioid use in chronic non-cancer pain treatment is widespread and controversial. A recent article in Mayo Clinic Proceedings examined this issue and concluded that, “patients who have symptomatically severe and functionally disabling pain, while receiving maintenance opioid therapy, can obtain significant benefit from rehabilitative treatment that incorporates opioid withdrawal.”1 The purpose of the present study is to describe the process of opioid withdrawal undertaken in a multidisciplinary pain rehabilitation program with the emphasis on the specific roles nurses play in the success of this intervention. A multidisciplinary approach is utilized, with two levels of nursing care, aimed at improving patient’s emotional and physical functioning and quality of life. A key component in this pain rehabilitation effort is a conservative philosophy of analgesic use for chronic non-cancer pain. Opioid medications are discontinued, while self-management strategies are implemented including exercise, relaxation skills, moderation and healthy lifestyle changes. The masters prepared Clinical Nurse Specialist (CNS) and baccalaureate prepared RN, supervised by the MD, assist patients with medication changes using a systematic, gradual method of reducing and discontinuing opioids for chronic pain management. The CNS structures opioid tapers utilizing prescriptive privileges, advanced assessment, and education/interventions focusing on chemical health and wellness. The RN monitors daily opioid tapers including monitoring patient self-administration of medications, assessing withdrawal symptoms, and reinforcing alternative coping techniques for pain management. Measures of pain severity, interference due to pain, activity level, perceived life control, affective distress, depression and catastrophizing have been used to compare opioid and nonopioid groups within this pain rehabilitation center. This paper will illustrate specific interventions utilized by pain rehabilitation nurses that directly contribute to successful opioid withdrawal and improvement in emotional and physical functioning for patients with chronic pain. (1. Rome, J.D. et al., Mayo Clinic Proceedings, 2004).