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Effects of opioid cessation on multidimensional outcomes following interdisciplinary chronic pain treatment
P74
The Journal of Pain
(392) Effects of opioid cessation on multidimensional outcomes following interdisciplinary chronic pain treatment J Murphy, E Banou, and M Clark; James A. Haley Veterans’ Hospital, Tampa, FL
Abstracts (394) Preliminary outcomes of an abbreviated interdisciplinary programme of Acceptance and Commitment Therapy for chronic pain
There is limited research examining the effects of opioid usage in interdisciplinary pain treatment, and even less on the lasting effects of opioid titration on treatment outcomes. The following study evaluated differences in multidomain treatment outcomes among daily opioid (n=114) and non-opioid (n=134) using veterans who participated in a three-week, interdisciplinary, inpatient chronic pain rehabilitation program at a large southeastern Veterans Affairs medical center. All participants taking opioids at admission were titrated off these medications, typically within 10 days, using a ‘‘pain cocktail’’ approach. Otherwise participants received the same treatment. Measures included a pain numeric rating scale, the Pain Outcomes Questionnaire, the Chronic Pain Coping Inventory, the Coping Skills Questionnaire, the Fears and Avoidance Behaviors Questionnaire, and the Sleep Problems Questionnaire. Instruments were administered at program admission, discharge, and three months following program completion. Baseline comparisons between groups revealed no significant differences on any dependent measures. Treatment related changes were assessed by a series of repeated measures analyses of covariance comparing baseline, discharge, and follow up scores on each outcomes variable. In each analysis, potential confounders (age, education level, and pain duration) were entered as covariates. Results revealed a significant time effect for all measures, reflecting treatment-related improvements that were mostly maintained at follow up. No main effects for group or group X time interactions were significant, indicating that both the opioid and nonopioid groups improved equally. These results indicated that opioid analgesic use had no discernable positive impact in this sample of veterans with moderate to severe chronic pain. Within the limitations of this study, results also suggest that individuals with Chronic Pain Syndromes may benefit little from daily opioid analgesic use. The clinical implications of these findings, in light of the many adverse effects associated with opioid analgesics, are discussed along with directions for further research.
K Vowles, J Ashworth, D Beachill, J Packham, G Sowden, and N Stanyer; Haywood Hospital, Stoke-on-Trent, UK
(393) Interdisciplinary pain management programs: who will successfully complete the program?
(395) Operationalizing effective functioning within a context of continuing pain in a community-based setting
S Oslund, R Robinson, J Garofalo, and M Schatman; Baylor University Medical Center, Baylor Centers for Pain Management, Dallas, TX
K Vowles, N Stanyer, G Sowden, J Packham, D Beachill, and J Ashworth; Haywood Hospital Stoke-on-Trent, UK
The complicated presentation of many of the patients being seen in interdisciplinary treatment programs necessitates increasing our understanding of factors related to treatment success. The current study aimed to build upon the current knowledge of interdisciplinary treatment programs by identifying predictors of success from a wide range of domains following completion of an intensive interdisciplinary program. The current study examined 537 participants who completed an intensive interdisciplinary pain management program to identify predictors of successful completion. Patients engaged in treatment 6-hours per day, 5-days per week, for 4 weeks, totaling 120 hours of treatment. The treatment components administered included individual cognitive behavioral therapy, physical therapy, aquatics physical therapy, occupational therapy, group education, and group relaxation. Five domains were identified in which one could achieve success: self perception of improvement, depression, physical conditioning, pain severity, and control over pain. Predictors were identified for each domain and then for success in at least three of the five domains. No single measure was found to be a significant predictor across all five domains. However, lower rates of health care utilization, higher levels of affective distress, greater perceived interference from pain, and lower levels of perceived control were predictive of successful outcomes. Perceived control over pain was the strongest predictor identified, b=-.723, c2(1)=120.885, p<.001. Health care utilization, perceived health, and perceived control were significant predictors of success in three or more domains. Overall, the findings indicate that patients with greater dysfunction at treatment entry will benefit more from treatment.
In tertiary settings, factors that contribute to problematic functioning with chronic pain have long been identified, including concepts such as catastrophizing or ‘‘maladaptive’’ beliefs. Recent work has concentrated on identifying factors involved in successful adaptation to continuing pain. Results indicate that as one is less caught up in the struggle to control pain and more engaged in activities that bring meaning and quality to living, pain-related limitations diminish. It is not clear, however, whether these results hold true in other settings, particularly those that operate at the interface between primary and secondary care, where the circumstances influencing patient functioning, including pain duration or treatment history, may differ from patients presenting to tertiary settings. The present analysis evaluated whether factors of known importance in tertiary settings remain relevant in a non-tertiary, community-based setting. In particular, we sought to examine whether processes of acceptance of chronic pain, or willingness to have chronic pain fully and without defense, and values-based action, or engagement in activities that bring meaning and fulfillment to one’s life, are related to indices of emotional and physical functioning in a sample of 185 individuals presenting for treatment. In addition to measures of pain acceptance and values-based action, patients completed measures of pain intensity and impact, and emotional and physical functioning. After controlling for pain intensity and demographic variables, the results of linear regression analyses indicated that acceptance and values-based action accounted for a significant variance in measures of pain-related distress, depression, pain-related anxiety, disability, and healthcare use (r2 range = .14 to .40). These results replicated those observed within tertiary care settings were replicated and suggest that treatment methods to improve flexibility in responding to aversive and painful experiences are also relevant at the interface between primary and secondary care.
Over the past decade, Acceptance and Commitment Therapy (ACT), a form of Cognitive-Behavioral Therapy concentrating on the facilitation of effective and meaningful functioning within a context of continued pain and pain-related distress and disability, has achieved promising results. The majority of this work has occurred within tertiary care settings, with some treatments including treatment five days per week for a period of three to four weeks (e.g., Vowles & McCracken, 2008). Obviously, it can be difficult for some clinical facilities to offer interventions of that intensity, due to cost and resource implications. The present study evaluated the results following a briefer interdisciplinary treatment, which occurred on two days per week for a period of four weeks, in a sample of 60 patients with chronic pain. Each patient completed measures of physical and psychosocial functioning, as well as a walking and sit-to-stand task, at the onset and conclusion of treatment, as well as at a three month follow-up. Results indicated significant improvements in all measures through to follow-up. Within subjects effect sizes at the three month followup ranged from 0.76 for disability to 1.0 for depression and pain-related fear. Treatment process variables, including acceptance of pain and success in values-based activity, also improved significantly, with effect sizes of 1.8 and 1.2, respectively. These results provide initial support for the substantial effects of an interdisciplinary programme of rehabilitation for pain based on an ACT model offered for a total of eight days over the course of a month. Further, the positive maintenance of outcomes through at least a short-term followup appointment suggests these gains may be durable. Future study will need to examine the effectiveness of treatment within larger samples and relative to alternate interventions or treatment as usual. (Vowles & McCracken, Journal Cons Clin Psych, 2008).
The Journal of Pain
(392) Effects of opioid cessation on multidimensional outcomes following interdisciplinary chronic pain treatment J Murphy, E Banou, and M Clark; James A. Haley Veterans’ Hospital, Tampa, FL
Abstracts (394) Preliminary outcomes of an abbreviated interdisciplinary programme of Acceptance and Commitment Therapy for chronic pain
There is limited research examining the effects of opioid usage in interdisciplinary pain treatment, and even less on the lasting effects of opioid titration on treatment outcomes. The following study evaluated differences in multidomain treatment outcomes among daily opioid (n=114) and non-opioid (n=134) using veterans who participated in a three-week, interdisciplinary, inpatient chronic pain rehabilitation program at a large southeastern Veterans Affairs medical center. All participants taking opioids at admission were titrated off these medications, typically within 10 days, using a ‘‘pain cocktail’’ approach. Otherwise participants received the same treatment. Measures included a pain numeric rating scale, the Pain Outcomes Questionnaire, the Chronic Pain Coping Inventory, the Coping Skills Questionnaire, the Fears and Avoidance Behaviors Questionnaire, and the Sleep Problems Questionnaire. Instruments were administered at program admission, discharge, and three months following program completion. Baseline comparisons between groups revealed no significant differences on any dependent measures. Treatment related changes were assessed by a series of repeated measures analyses of covariance comparing baseline, discharge, and follow up scores on each outcomes variable. In each analysis, potential confounders (age, education level, and pain duration) were entered as covariates. Results revealed a significant time effect for all measures, reflecting treatment-related improvements that were mostly maintained at follow up. No main effects for group or group X time interactions were significant, indicating that both the opioid and nonopioid groups improved equally. These results indicated that opioid analgesic use had no discernable positive impact in this sample of veterans with moderate to severe chronic pain. Within the limitations of this study, results also suggest that individuals with Chronic Pain Syndromes may benefit little from daily opioid analgesic use. The clinical implications of these findings, in light of the many adverse effects associated with opioid analgesics, are discussed along with directions for further research.
K Vowles, J Ashworth, D Beachill, J Packham, G Sowden, and N Stanyer; Haywood Hospital, Stoke-on-Trent, UK
(393) Interdisciplinary pain management programs: who will successfully complete the program?
(395) Operationalizing effective functioning within a context of continuing pain in a community-based setting
S Oslund, R Robinson, J Garofalo, and M Schatman; Baylor University Medical Center, Baylor Centers for Pain Management, Dallas, TX
K Vowles, N Stanyer, G Sowden, J Packham, D Beachill, and J Ashworth; Haywood Hospital Stoke-on-Trent, UK
The complicated presentation of many of the patients being seen in interdisciplinary treatment programs necessitates increasing our understanding of factors related to treatment success. The current study aimed to build upon the current knowledge of interdisciplinary treatment programs by identifying predictors of success from a wide range of domains following completion of an intensive interdisciplinary program. The current study examined 537 participants who completed an intensive interdisciplinary pain management program to identify predictors of successful completion. Patients engaged in treatment 6-hours per day, 5-days per week, for 4 weeks, totaling 120 hours of treatment. The treatment components administered included individual cognitive behavioral therapy, physical therapy, aquatics physical therapy, occupational therapy, group education, and group relaxation. Five domains were identified in which one could achieve success: self perception of improvement, depression, physical conditioning, pain severity, and control over pain. Predictors were identified for each domain and then for success in at least three of the five domains. No single measure was found to be a significant predictor across all five domains. However, lower rates of health care utilization, higher levels of affective distress, greater perceived interference from pain, and lower levels of perceived control were predictive of successful outcomes. Perceived control over pain was the strongest predictor identified, b=-.723, c2(1)=120.885, p<.001. Health care utilization, perceived health, and perceived control were significant predictors of success in three or more domains. Overall, the findings indicate that patients with greater dysfunction at treatment entry will benefit more from treatment.
In tertiary settings, factors that contribute to problematic functioning with chronic pain have long been identified, including concepts such as catastrophizing or ‘‘maladaptive’’ beliefs. Recent work has concentrated on identifying factors involved in successful adaptation to continuing pain. Results indicate that as one is less caught up in the struggle to control pain and more engaged in activities that bring meaning and quality to living, pain-related limitations diminish. It is not clear, however, whether these results hold true in other settings, particularly those that operate at the interface between primary and secondary care, where the circumstances influencing patient functioning, including pain duration or treatment history, may differ from patients presenting to tertiary settings. The present analysis evaluated whether factors of known importance in tertiary settings remain relevant in a non-tertiary, community-based setting. In particular, we sought to examine whether processes of acceptance of chronic pain, or willingness to have chronic pain fully and without defense, and values-based action, or engagement in activities that bring meaning and fulfillment to one’s life, are related to indices of emotional and physical functioning in a sample of 185 individuals presenting for treatment. In addition to measures of pain acceptance and values-based action, patients completed measures of pain intensity and impact, and emotional and physical functioning. After controlling for pain intensity and demographic variables, the results of linear regression analyses indicated that acceptance and values-based action accounted for a significant variance in measures of pain-related distress, depression, pain-related anxiety, disability, and healthcare use (r2 range = .14 to .40). These results replicated those observed within tertiary care settings were replicated and suggest that treatment methods to improve flexibility in responding to aversive and painful experiences are also relevant at the interface between primary and secondary care.
Over the past decade, Acceptance and Commitment Therapy (ACT), a form of Cognitive-Behavioral Therapy concentrating on the facilitation of effective and meaningful functioning within a context of continued pain and pain-related distress and disability, has achieved promising results. The majority of this work has occurred within tertiary care settings, with some treatments including treatment five days per week for a period of three to four weeks (e.g., Vowles & McCracken, 2008). Obviously, it can be difficult for some clinical facilities to offer interventions of that intensity, due to cost and resource implications. The present study evaluated the results following a briefer interdisciplinary treatment, which occurred on two days per week for a period of four weeks, in a sample of 60 patients with chronic pain. Each patient completed measures of physical and psychosocial functioning, as well as a walking and sit-to-stand task, at the onset and conclusion of treatment, as well as at a three month follow-up. Results indicated significant improvements in all measures through to follow-up. Within subjects effect sizes at the three month followup ranged from 0.76 for disability to 1.0 for depression and pain-related fear. Treatment process variables, including acceptance of pain and success in values-based activity, also improved significantly, with effect sizes of 1.8 and 1.2, respectively. These results provide initial support for the substantial effects of an interdisciplinary programme of rehabilitation for pain based on an ACT model offered for a total of eight days over the course of a month. Further, the positive maintenance of outcomes through at least a short-term followup appointment suggests these gains may be durable. Future study will need to examine the effectiveness of treatment within larger samples and relative to alternate interventions or treatment as usual. (Vowles & McCracken, Journal Cons Clin Psych, 2008).