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The effects of detoxification, relaxation, and brief supportive therapy on chronic pain
Pain, 8 (1980) 319--329 © Elsevier/North-Holland Biomedical Press
319
,
THE EFFECTS OF DETOXIFICATION, RELAXATION, AND BRIEF SUPPORTIVE THERAPY ON CHRONIC PAIN **
C. BARR TAYLOR *, STEVEN I. ZLUTNICK, MICHAELJ. CORLEY and JUNE FLORA (C.B.T. and J.F.) Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Cali~ 94305, (S.LZ. and M.J.C.) Department of Rehabilitation Medicine, Pacific Medical Center, 2360 Clay Street, San Francisco, Calif.• 94115 (U.S,A.)
(Received 18 October 1979, accepted 12 March 1980)
SUMMARY Seven chronic pain patients (six with abdominal pain and one with headache pain} were detoxified from analgesic medications, taught relaxation techniques, and given an • average of 3 supportive therapy sessions. The effects of these procedures at posttreatment and at 6 months follow-up were analyzed by means of self-report diaries of pain, mood, activity and medication usage. The~e was a significant reduction in pain from pc~sthospital in 5 of 7 patients and a significant reduction in pain at 6-month follow-up for all patients, There was a significant reduction in medication use for all subjects. Mood ratings tended to improve when pain was reduced, and some patients reported increased activity levels. Detoxification combined with relaxation and supportive therapy appears to produce significant relief from pain•for these 7 patients.
INTRODUCTION Patients suffering from chronic pain with unknown etiology present a difficult management problem for the medical ~ystem. A particularly diffi-
* Reprint requests should be sent to: C. Barr Taylor, M.D., Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University Medical CenteL-Stanford, Calif. 94305, U.S.A. ** This research was supported in part by Public Health Service Research Grant No. RR-64 from the Division of Research Resources.
320
cult-to-manage subgroup of the total pain population are those patient~ suffering from the so-called chronic pain syndrome (CPS). Black [1] has characterized such patients as suffering from pain for at least 6 months and having::"intractable,~ o f t e n m u l t i p l e pain complaints which m;e usually inappropriate t o existing:somat0genic problems," ~ ~ e r , these :::patients often reveal a history of "multiple physician contacts and non-productive diagnostic procedures, excessive preoccupation with the pain problem and altered behavior patterns with some features of depression," ~ = : Another characteristic of this population is its reliance on analgesics and hypno-sedative medications. The paradoxical effect of these medications in contributing to rather than :minimizing the patient's disability is well recognized [4]. F o r many patients, increased utilization o f analgesic or:hypnosedative medications may even be accompanied by increased reports of pain. Refusing t o provide pain medications may result in behavior annoying to the patient's physician and counterproductive tc the patient's c~re: late~night phone calls, midnight visits to the hospital emergency room for intramuscular injections, and "doctor shopping" for a cure for pain as well as additional sources of drugs. These medications may compromise the patient's intellectual processes, interfere with his family relations and promp~ a shift in life priorities from work, relatior~ships and recreation, to procurement of drugs and almost total preoccupation with pain [ 1 ]. Thus, it is not surprising that the treatment of chronic pain patients often begins with detoxification. From sever~ standpoints, detoxification should produce changes in patients' report of pain. First, several investigators have argued that analgesic medicvtion used chronically may reinforce pain reports and complaints [ 3,5,7]. That is, a patient in pain takes medication which alleviates the pain, improves mood, or dulls general discomfort. The latter properties may reinforce drug use, even when the pain medication has no significant effect on alleviation of pain. Second, chronic analgesic medications may ~uppress activity and interfere with cognitive functions, all of which may affect the patients'pain and mood reports. Unfortunately, the extent of improvement in pain, mood, and activity that has been noted anecdotally subsequent to detoxification in clinical settings has not been carefully documented or systematically studied. In this paper, we uttemp~ to examine the effects of detoxification combined with brief relaxation training and supportive therapy o n 7 patient~' self-report of pain, mood, activity and drug usage immediately "after detoxification and at 6-month fellow-up. METHOD
Subjects Seven patient~ referred to t h e University 0f U t a h Pain Clinic with a diagnosis of chronic pain of unknown etiology were assigned to the inpatient detoxification protocol. All patients had exlaerienced,continuous abdominal or headache pain for at least 6 months and were using more controlled drugs
321
than prescribed by their physicians. All patients were evaluated by a faculty neurologist (for headache) or gastroenterologist (for abdominal pain) prior to admission to this program. The first 3 patients were admitted to the Clinical Research Center to guarantee rigid adherence to the experimental protocol a n d the remaining 4 patients were assigned to the inpatient unit in the Department of Psychiatry. The age, source of pain, sex, years of pain and medications at the time of admission for the 7 patients are reported in Table I. ...
Procedure Patients admitted to the hospital recorded 1 week of prehospitalization baseline diary data prior to admission. In this diary, patients rated pain, m o o d and activity and noted medication usage on an hour-by-hour basis for
TABLE I SEX, AGE, SOURCE AND YEARS OF CHRONIC PAIN AND MEDICATIONS DURING BASELINE CONDITION Patient
Sex
Age
Source of pain Years of pain
Medications during baseline
1
F
52
Abdominal
23
2
M
38
Abdominal
20
Oxycodone hydrochloride, oxycodone terephthalate, aspirin, phenacetin, caffeine, diazepam, meperidine hydro•chloride, flurazepam hydrochloride Pentazocine hydrochloride
3
F
45
Abdominal
20
4
M
30
Headache
2
M
60
7
6
F
47
Leg and abdominal Abdominal
22
7
F
71
Abdominal
15
Diazepam, codeine phosphate, aspirin, phenacetin, caffeine, diphenhydramine hydrochloride Codeine phosphate, acetaminophen, propoxyphene napsylate, phenobarbital, ergotamine tartrate, bellafoline, perphenazine Meprobamate, aspirin, propoxyphene hydrochloride Pentazocine hydrochloride, carisoprodol, phenace~;in, caffeine, ibuprofen Aspirin, diazepam, fl'jrazepam hydrochloride, iiydroxyzine pamoate, propoxyphene napsylate, acetaminophen
322 each Waking'liour. P a i n w a s r a t e d o n a scale o f 0 ( n o p a i n ) t o 5 (intolerablei~
and m o o d was also rateff on a'scale of 0 (very depressed) to 5 (good mood). AetNity Consisted of tinge spent sitting, standing and reclining and was recorded as the number' of minutes per hour spentin eadh activity, Thus, at the ~end :of each day, 'pain, mo6d and a tivity leCets Were~summed andaver: aged, produein'g a daily 'average pain, mood and activity rating. Ffg.l~ shows a sample '_n~in,diary sheet ~as 'filled~ out by a~patient, Patients continued tO rate these variables for the entire course of treatment and for 1 week post'discharge and 1 week after a 6-month follow-up interlude. tc"
"
,
•
,
Reliability :of jgain d i a r i ~ . s
.
.
.
.
.
.
.
.
.
.
.
" T o de~rrniite Iif patients Were filling out pain di .~es relihbly, pai'n sheet~ were'cro~s,checked during the in,hospital'phaSe o f t he procedure in the following ways: (a) patient report of medication usage was cross-checked with nursing notes on administration of medications. Observations were scored as agreeing if they were reported within 1 h of one another, (b) patients ...report of activity was also compared with nursing observations. All, cements were scored Jf the patient noted an observable activity:as having occurred when a nurse charted such activities. For example, if the nurse reported :that a patient: was sleeping aria the patient reported that he was having pain during that time, this was scored as a non-agreement (since he couldn't be asleep and make a pain report); if the patient stated that he was with his :family and the.nurses charted this as occurring at that time, this was scored as an agreement. .
NAAM.
SAMPLE
DATE rl
'
'HOO~
BEGINNING
SITTING
,
lv~jor actMty
12 O0 ore. 1:00 2:00 3:00; 4:00 5:O0
WALKING OR STANDING
Time M.¢l.ctivity
RE(: LINING
SLEEP SLEEP SLEEP SLEEP
I:
, '
;t
EATING ' READINg,
"
TV TV
"
'"'
"5 60 60
COOKING
PAIN
:, MOOD ,~'
SLEEP SLEEP REST
REST
60
,,
234
X X X
X X X X X
T.YLENOL 4 o
EATING ,., TV RE,AE~NG ' . VISITING FRIENDS __TV EATING" TV TELEPHONE ' "' ; " •
,
W~IL ~ s ~ s 45 6O 45 30 30 45 !5'
!X i
LAUNDRY
15
WALK
15
" :
.
...
30 15 15
X X X X
iX X
REST COOKING DISFEs CLEANING.
X~ ,×
. TYLENC)L 4 1
,
.....
15
~ n
Amount01 234501
60 60 60 60 ¢;K) 60 60 30 DARVON 65mo
SIFFP
'
6: 0 0 . I 7.00, 800' 9 O0 10:00 11:00 12: 1. O0 2:00 3:O0 4:00 5 O0 6 O0 7:O0 8:00. 9:00 10:O0 11t O 0
tvEDICATIONS;
1]me A c t M t y Time Type
30
X DARVON 65rrK
REST,TV REST,TV READIN~ SLEEP
30; r ~ IVALIUM 5rob 60 60
SLEEP
60
X
X X X
X :X X
Ix
Ixi
X'
Fig. 1. Sample pain diary sheet filled out by a patient. (See text for details.)
X
5
323
Treatment contract Prior m admission, patients were asked to sign a t r e a t m e n t contract stating that ~they would abide by the ward rules and pain p r o t o c o l At the time of admission patients were ~ven a complete history a n d physical, routine and .:other. laboratory tests as needed, and a urine drug screen. Patients then underwent the following sequence of procedures" hospital baseline, detoxification,, postdetoxification, posthospitalization, and 6-month f o l l o w u p . . . .
.
-~
Hospital baseline During this baseline condition, subjects were allowed access to as much medication as they had been taking prior to admission within the limits of their prescriptions, plus 20%. The 20% figure was an attempt to correct for the underreporting o f medication use which frequently occu~.~ in these patients. Patients were: carefully observed for signs of withdrawm. Urine drug screens were obtained to cross-check self-report of medication and medications present in the urine. This baseline condition lasted until patients requested medication on a stable basis. Also at this time, any additional consultations required from other services were ordered to further insure that all possible medical a~pects of the pain had been investigated. The mean length of baseline was 3.4 :lays and ranged from 2 to 6 days.
Detoxification Following baseline, an individual withdrawal schedule was determined for each patient depending on the type and amount of medication used. Patients were checked carefully for signs and symptoms of withdrawal as well. as surreptitious drug intake during detoxification. T h e m e a n length of detoxification for all patients was 3.7 days and ranged from 1 to 6 Clays.
Postdetoxification Postdetoxification was defined as that period beginning24 h after the last analgesic a n d / o r hypno-sedative medication was adminis#;ered. The mean postdetoxification period was 3.9 days and ranged.from 2 to 8 days. During this phase, patients were taught muscular relaxation techniques using a standard procedure [2] and were given brief supportive therapy consisting of encouraging stab~ments and (if requested) discussion of other problems. During this phase patients were seen for periods of 10--2(} rain twice daily. The amount of tirv.e spent per patient in relaxation training was 1.5 h and time in supportive therapy was approximately 3 h.
Immediate posthospitalization(I week) Patients were instructed to continue recording data for 1 week immediately following hospitalization. Patients were not given any specific therapy during this period.
324
Follow-up At 6-month follow-up, all patients were instructed to provide I week of pain diary information and to report to the clinic for examination. During the examination, patients were asked to produce a urine samplewhich they were told was to detect any gross abnormalities ~in kidney function, In addition to routine urine tests, t h e urine was ~screened ~for drugs. Between the immediate posthospitalization period ~and follow-up patients were seen for an average of 3 visits each (with a range of from 2 to 5 visits) to monitor their progress.
_~ata analysis P~n, mood and activity scores were determined for the treatment phases described above. The scores were based on the hourly reports for all 7 patients, t-Tests for correlated metals were performed for each individual's pain, mood and activity reports for 7 days prior to hospitalization, the 7 d a y s immediate posthospitalization, and the 7 days of follow-up at 6 months, t-Tests for correlated means were also performed for pain, mood and activity data for the total group. ~ •
.
RESULTS
Reliability There were 218 agreements out of 237 observations for patients' use of medication yielding an agreement of 92%. On only two occasions did nurses report that a medication was given and the patient had not marked that as having occurred; the remaining 17 disagreements were around occurrence, i.e., the nurse and patients reported differences of an event by greater "than lh. With regard to activity, nursing observations agreed on 108 of 115 occasions with patients yielding an agreement of 94%. These data suggest that patients were accurately and reliably filling out their pain sheets in the hospital. On the 4 occasions when nurses charted that a patient seemed to be showing signs of pain (i.e., "the patient was clutching his belly and screaming"), the patievt reposed hi:3 highest p a i n for that 24-h period. This suggests some concordance between pain self-report and at least some kind of pain behavior.
Pain The mean pain ratings for each of the 7 patients for each of the 6 conditions are presented in Table If. As can be seen in this table, 5 patients (1, 2, 3, 6 and 7) showed a statistically significant (one-tailed t-tests) decrease in pain report from prehospital baseline to immediate posthospitalization and 6-month follow-up, T h e average reduction in pain r e p o ~ across >all patients from baseline to follow-up was 57% and ranged from 18%t089%. Patient 4 reported an increase in pain from prehospital baseline to immediate posthospitalization btxt a significant decrease at 6-month follow-up. This was
325 TABLE II PATIENTS' MEAN PAIN RATING FOR EACH OF THE 6 PHASES OF TREATMENT Patient
Prehospitalization Baseline
Hospitalization
Posthospitalization
Baseline Detoxification
Postdetoxification
Immediate (N = 7)
6-Month (N = 6)
3.~3 2.92 4.30 3.70 1.74 3.07 2.69
2.59 3.31 0.00 4.41 1.06 2.19 1.23
0.44 ** 2.11 * 0.16 ** 4.02 0.90 0.36 ** 1.18 *
1.44 ** 1.28 * 0.61 ** 2.35 * deceased 2.37 * 0.59 **
(N = 7) 1 2 3 4 5 6 7
3.09 2.96 4.84 3.18 0.99 2.88 2.27
~
3.83 3.28 1.84 3.87 2.00 2.57 3.25
*P ~ 0.05 (one-tailed~ compared with prehospitalization). P <= 0.01 (one-tailed, compared with prehospitalization).
probably due to the subsequent discovery and t r e a t m e n t of frontal sinusitis between posthospitalization and follow-up. Patient 5 reported no significant decrease in pain from prehospital baseline to 1 week immediate posthospitalization, and 6-month posthospitalization data were n o t available due to his death in an automobile accident. The within-hospital pain reports were obtained over t o o few days to allow for statistical analysis between conditions. However, there were no consist e n t trends for these patients: two patients reported progressiw~ly increased pain throughout the 3 conditions; two other patients reported progressively decreased pain and the other three varied in other ways (see Table II). When subjects' data were analyzed as a group, t-tests revealed si,~nificant changes between prehospitalization baseline and both immediate posthospitalization follow-up (t = 6.71, P ~ 0.001) and 6-month follow-up (t = 9.12, V < 0.001).
Mood Table III represents the average m o o d rath~gs for each o f the 7 patients for each of the observation phases. F o u r patients exhibited a statistically significant higher rating in m o o d between prehospitalization and immediate posthospitalization; however, this change remained significant for only two patients at 6-month follow-up. A n o t h e r patient exhibited a significant decrease in m o o d from prehospital baseline to immediate posthospitalization and at 6-month follow-up. A non-statistical examination o f trends showed 3 patient, reporting a decrease in m o o d from hospital baseline to hospital postd,~toxification; 4 p a t i e n t , ~ p o r t e d an increase in m o o d from hospitalization baseline to postdetoxification. Again, t h e r e were n o consistent trends across the 3 i n h 0 s p i t a l c o n d i t i o n s for the 7 patients.
326
T A B L E III PATIENTS' M E A N M O O D E A T I N G F O R E A C H O F T H E :6PHASES OF. T R E A T M E N T Patient:
Prehospitalization :
-
Baseline: (N --7) •
1
2 3 4 5 6 7
'
::: .
~" :
Posthospitalization
Hospitalization Baseline '
Detoxification
Postdetoxif~cation
Immediate (N = 7 ) -~
6-Month (N = 6)
0.93 2.33 3.01 ' 1.90 3.01 • 3.21 2.68
1.26 0.86 3.48 1.03 2.50 3.83 2.62
2.51 1.70 4.00 1.04 2.68 4.06 3.35
3.06 2.11 3.37 0.84 2.66 4.21 3.24
1.52 2.93 *** 3.06 0.87 *** deceased 3.23 4.34 ***
.
1.45
1.91 2.56 2.05 2.75 3.37 2.64
*** *** *** *** *
* P < 0.05 (one-tailed, c o m p a r e d w i t h p r e h o s p i t a ! baseline). ** P < 0.01 (one-tailed, c o m p a r e d w i t h prehospital baseline). *** P ~ 0.001 (one-tailed, c o m p a r e d with prehospital baseline).
Relationship b e t w e e n pain a n d m o o d
Four patients (1, 3, 6 a n d 7) who had significantly more positive ratings of mood from prehospital baseline to immediate posthospitalization period (Tabl~.s ' !I and III) also had significantly lower ratings• of pain. Pearson Product Moment correlations computed on prehospitalization pain and mood ratings for each patient revealed that only 1 of the 7 patients showed a statistically significant relationship between pain and m o o d (r =--0.83, P < 0.01). Activity •
Table I V represents the mean reclining and non-reclining time (i.e., time spent in or out of bed) for each of the 7 patients for the 3 out.of-hospital periods. Since activity levels recorded in the hospital are unlikely to reliably represent activity levels at home, they are not discussed here. Only two patients ( 1 and 7) showed a significant increase: in non-reclining time from prehospitalization to immediateposthospitalization. At 6-month follow:up, 3 patients• (1,,•2 and 7) showed a Significant increase in non-reclining time. These 3 patients w e r e among those who also reported a significant decrease in pain, . .In general, the reduction of pain and concomitant increases i n m o o d corresponded with increased non-reclining time. Medication
usage
:
"
'~,At 6'm0nth foll0W-Up 5 of the 6 remaining patients reported taking some kind; of analgesic or hypno-sedative medication. Of these-•five,t w o patients had dextropropoxyphene in their urine,one patient had dextr0propoxyphene
327
T A B L E IV-"
•
r
P A T I E N T S ' -MEAN R E C L I N I N G .AND N O N - R E C L I N I N G TIME D U R I N G EACH O F T H E 3 N O N - H O S P I T A L I Z A T I O N PHASES • Patient
Prehospitalization
(N --7) ~,~
Posthospitalizati0n
~
,
:'
Reclining ~:.
6_
7
2O.OO
...
6-Month (N = 6)
.
reclining
Reclining
Nonreclining
Reclining
Nonreclining
9.35 9.94 15.61 8.73 10.29 13.56 4.00
10.76 * 14.46 9.46
]:3.24 9.54 14.54
8.71 *~; 10.61 ** 9.56 14.77 Deceased 7.76 17.11 *
15.29 13:39 14.44 9.23 Deceased 16.24 6.89
~
. ?
14.65 14.06 8.39 15.27 13.71 10.44
2: 3 4: 5,
I m m e d i a t e (N - 7) Noll
13.14 8'73 • 15.62 **
10.86 15..27 8.38
* P ~ 0.05 (one-tailed, compared with prehospital baseline). **P ~ 0.01 (one-tailed, compared with prehospital baseline).
IJ :~
.
ands.aspirin, one p~_tient had .secoba~bital, and one patient had diazepmn. No p a t i e ~ ' a s taking the drugs which they had been at the time of admission to hospil~. The reported use of medication was in agreement with. the urine screen for 3 of the 6 patients. DIscussION
The results 0f.this study demonstrate that for some patients a treatment program comprised of rapid detoxification plus relaxation and brief supportive: therapy is ~sociated with significant changes in the self-report of pain, both f011owhg treatment and at 6-month follow-up. The average improvement in pain ratings across subjects from prehospitalization to 6-month foUowiup was 57%, with a range Of improvement from 18 to 89%. improvement in mood and activity as a function of the treatment regimen was less consistent than that noted for pain; 4 subjects reported improvement in mood posthospitalization, whereas three were reporting increased activity at 6 months, While the decrease in pain does seem to be associated at 6-month f011ow-up with some improvement in mood, the correlation between pain and mood self-reports for individual patierits is not significant. Whus~ the greatest overall change as a f~ncti0n of detoxification; relaxation and supportive therapy was Clearly in self-reported pain. These data lend support to suggestions by other investigators [3,4,7] that medication may be a contributing factor inpatients' ongoing disability. • Unfortunately, the specific,contribution of detoxificati0n in producing these .changes Was confounded by, the use of relaxation training and brief •.
~ •
..
•
328 supportive therapy during the postdetoxification and 6-month follow-up. However, since the postdetoxification phase lasted a mean of 3.7 days mid patients had, at most, 3 sessions of relaxation and 3 h of therapist contact, it is unlikely that either procedure had a major impact on the patipnts' follow-up course. Further, a number of studies have shown that relaxation has minimal effects on pain tolerance and then mostly in patients who are reporting anxiety [6]. Since patients were seer: for only 2--5 supportive therapy visits following discharge, it is also unlikely that such minireal therapist contact could make a major difference in their outcome. Nevertheless, the specific contribution of detoxification to producing improvement in pain report is not certain. A more serious problem in the evaluation of these data is the lack of control groups. In this study, each subject served as his own control. Although maximum precision and generality ultimately require demonstration through the use of control groups, thi~ report systematically monitors pain, mood and activity at baseline, treatment, and follow-up throughout what have now become standard procedvres for the treatment of chro~c pain. The individual variation in the relationship between pain and mood in these patients is strikin[i:. For some patients pain and mood covaried; for others there was no-'~pparent relationship. For those who exhibited improved mood with decreased pain, their mood may have been reactive to the pain. Patients who continued to report low mood ratings in spite of improvement in pain report may suffer endogenous depression and may require more aggressive treatment of their depression. Further studies are needed to determine if changes in mood following detoxification might discriminate between reactive and endogenous depression in chronic pain patients. Changes in activity with decreased pain were more consistent than changes in mood. Those patients who initially spent most of their waking hours reclining showed a significant increase in the time spent sitting or standing after detoxification. However, analysis of the total group data of these patients showed no significant relationship between changes in activity prehospitalization to 6-month follow-up. These data also suggest that for some patients a time-consuming and costly hospitalization in order to increase activity may be v nnecessazy, at least for patients with abdominal or headache pain. For other patients, however, increases of activity must be carefully monitored a~d reinforced. Activity has be,~ome a popular and, at times, a primary outcome measure for pain programs. However, these data suggest that it is too early to abandon the self-report of pain as an outcome measure, since some patients will report a significant pain reduction with no change in activity and vice versa. Urine drug screens should also be included in an assessment outcome package for chror, ic pain patients, since 3 of 5 patients taking hypno-sedatives or mild analgesics at 6-month follow-up failed to report their usage on the pain diaries, These data also point to t h e need for at least a 6-month
329
follow-up to determine treatment outcome for a chronic pain program. The treatment of chronic pain accounts for a significant part of the health-care dollar. It behooves researchers in this area to begin to parcel out the specific effects of treatment with the goal of developing cost-effective programs. A reasonable start is to determine if simple procedures, like detoxification with relaxation and brief supportive therapy, may be as useful for some patients as more complex and expensive procedures and longer hospitalizations. REFERENCES 1 Black, R.G., The chronic pain syndrome, Surg. Clin. N. Amer., 55 (1975) 4. 2 Ferguson, J.M., Marquis, J. and Taylor, C.B., .~_ script for deep muscle relaxation, Dis. nerv. Syst., 38 (1977) 703--708. 3 Fordyce, W.F., Behavioral Methods for Chronic Pain and Illness, Mosby, St. Louis, Mo., 1975. 4 Halpern, L.M., Psychotropic drugs and the management of chronic pain. In: J.J. Bonica (Ed.), Advances in Neurology: International Symposium on Pain, Raven Press, New York, 1974, pp. 539--545. 5 Sternbach, R.A., Pain Patients: Traits and Treatment, Academic Press, New York, 1974. 6 Weisenberg, M., Pain and pain control, Psychol. BulL, 84 (1977) 1008--1044. 7 Ziesat, H.A., Angle, H.V., Gentry, D. and Ellinwood, E.H., Drug use and misuse in operant pain patients, Addict. Behav., 4 (1979) 263--266.
319
,
THE EFFECTS OF DETOXIFICATION, RELAXATION, AND BRIEF SUPPORTIVE THERAPY ON CHRONIC PAIN **
C. BARR TAYLOR *, STEVEN I. ZLUTNICK, MICHAELJ. CORLEY and JUNE FLORA (C.B.T. and J.F.) Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Cali~ 94305, (S.LZ. and M.J.C.) Department of Rehabilitation Medicine, Pacific Medical Center, 2360 Clay Street, San Francisco, Calif.• 94115 (U.S,A.)
(Received 18 October 1979, accepted 12 March 1980)
SUMMARY Seven chronic pain patients (six with abdominal pain and one with headache pain} were detoxified from analgesic medications, taught relaxation techniques, and given an • average of 3 supportive therapy sessions. The effects of these procedures at posttreatment and at 6 months follow-up were analyzed by means of self-report diaries of pain, mood, activity and medication usage. The~e was a significant reduction in pain from pc~sthospital in 5 of 7 patients and a significant reduction in pain at 6-month follow-up for all patients, There was a significant reduction in medication use for all subjects. Mood ratings tended to improve when pain was reduced, and some patients reported increased activity levels. Detoxification combined with relaxation and supportive therapy appears to produce significant relief from pain•for these 7 patients.
INTRODUCTION Patients suffering from chronic pain with unknown etiology present a difficult management problem for the medical ~ystem. A particularly diffi-
* Reprint requests should be sent to: C. Barr Taylor, M.D., Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University Medical CenteL-Stanford, Calif. 94305, U.S.A. ** This research was supported in part by Public Health Service Research Grant No. RR-64 from the Division of Research Resources.
320
cult-to-manage subgroup of the total pain population are those patient~ suffering from the so-called chronic pain syndrome (CPS). Black [1] has characterized such patients as suffering from pain for at least 6 months and having::"intractable,~ o f t e n m u l t i p l e pain complaints which m;e usually inappropriate t o existing:somat0genic problems," ~ ~ e r , these :::patients often reveal a history of "multiple physician contacts and non-productive diagnostic procedures, excessive preoccupation with the pain problem and altered behavior patterns with some features of depression," ~ = : Another characteristic of this population is its reliance on analgesics and hypno-sedative medications. The paradoxical effect of these medications in contributing to rather than :minimizing the patient's disability is well recognized [4]. F o r many patients, increased utilization o f analgesic or:hypnosedative medications may even be accompanied by increased reports of pain. Refusing t o provide pain medications may result in behavior annoying to the patient's physician and counterproductive tc the patient's c~re: late~night phone calls, midnight visits to the hospital emergency room for intramuscular injections, and "doctor shopping" for a cure for pain as well as additional sources of drugs. These medications may compromise the patient's intellectual processes, interfere with his family relations and promp~ a shift in life priorities from work, relatior~ships and recreation, to procurement of drugs and almost total preoccupation with pain [ 1 ]. Thus, it is not surprising that the treatment of chronic pain patients often begins with detoxification. From sever~ standpoints, detoxification should produce changes in patients' report of pain. First, several investigators have argued that analgesic medicvtion used chronically may reinforce pain reports and complaints [ 3,5,7]. That is, a patient in pain takes medication which alleviates the pain, improves mood, or dulls general discomfort. The latter properties may reinforce drug use, even when the pain medication has no significant effect on alleviation of pain. Second, chronic analgesic medications may ~uppress activity and interfere with cognitive functions, all of which may affect the patients'pain and mood reports. Unfortunately, the extent of improvement in pain, mood, and activity that has been noted anecdotally subsequent to detoxification in clinical settings has not been carefully documented or systematically studied. In this paper, we uttemp~ to examine the effects of detoxification combined with brief relaxation training and supportive therapy o n 7 patient~' self-report of pain, mood, activity and drug usage immediately "after detoxification and at 6-month fellow-up. METHOD
Subjects Seven patient~ referred to t h e University 0f U t a h Pain Clinic with a diagnosis of chronic pain of unknown etiology were assigned to the inpatient detoxification protocol. All patients had exlaerienced,continuous abdominal or headache pain for at least 6 months and were using more controlled drugs
321
than prescribed by their physicians. All patients were evaluated by a faculty neurologist (for headache) or gastroenterologist (for abdominal pain) prior to admission to this program. The first 3 patients were admitted to the Clinical Research Center to guarantee rigid adherence to the experimental protocol a n d the remaining 4 patients were assigned to the inpatient unit in the Department of Psychiatry. The age, source of pain, sex, years of pain and medications at the time of admission for the 7 patients are reported in Table I. ...
Procedure Patients admitted to the hospital recorded 1 week of prehospitalization baseline diary data prior to admission. In this diary, patients rated pain, m o o d and activity and noted medication usage on an hour-by-hour basis for
TABLE I SEX, AGE, SOURCE AND YEARS OF CHRONIC PAIN AND MEDICATIONS DURING BASELINE CONDITION Patient
Sex
Age
Source of pain Years of pain
Medications during baseline
1
F
52
Abdominal
23
2
M
38
Abdominal
20
Oxycodone hydrochloride, oxycodone terephthalate, aspirin, phenacetin, caffeine, diazepam, meperidine hydro•chloride, flurazepam hydrochloride Pentazocine hydrochloride
3
F
45
Abdominal
20
4
M
30
Headache
2
M
60
7
6
F
47
Leg and abdominal Abdominal
22
7
F
71
Abdominal
15
Diazepam, codeine phosphate, aspirin, phenacetin, caffeine, diphenhydramine hydrochloride Codeine phosphate, acetaminophen, propoxyphene napsylate, phenobarbital, ergotamine tartrate, bellafoline, perphenazine Meprobamate, aspirin, propoxyphene hydrochloride Pentazocine hydrochloride, carisoprodol, phenace~;in, caffeine, ibuprofen Aspirin, diazepam, fl'jrazepam hydrochloride, iiydroxyzine pamoate, propoxyphene napsylate, acetaminophen
322 each Waking'liour. P a i n w a s r a t e d o n a scale o f 0 ( n o p a i n ) t o 5 (intolerablei~
and m o o d was also rateff on a'scale of 0 (very depressed) to 5 (good mood). AetNity Consisted of tinge spent sitting, standing and reclining and was recorded as the number' of minutes per hour spentin eadh activity, Thus, at the ~end :of each day, 'pain, mo6d and a tivity leCets Were~summed andaver: aged, produein'g a daily 'average pain, mood and activity rating. Ffg.l~ shows a sample '_n~in,diary sheet ~as 'filled~ out by a~patient, Patients continued tO rate these variables for the entire course of treatment and for 1 week post'discharge and 1 week after a 6-month follow-up interlude. tc"
"
,
•
,
Reliability :of jgain d i a r i ~ . s
.
.
.
.
.
.
.
.
.
.
.
" T o de~rrniite Iif patients Were filling out pain di .~es relihbly, pai'n sheet~ were'cro~s,checked during the in,hospital'phaSe o f t he procedure in the following ways: (a) patient report of medication usage was cross-checked with nursing notes on administration of medications. Observations were scored as agreeing if they were reported within 1 h of one another, (b) patients ...report of activity was also compared with nursing observations. All, cements were scored Jf the patient noted an observable activity:as having occurred when a nurse charted such activities. For example, if the nurse reported :that a patient: was sleeping aria the patient reported that he was having pain during that time, this was scored as a non-agreement (since he couldn't be asleep and make a pain report); if the patient stated that he was with his :family and the.nurses charted this as occurring at that time, this was scored as an agreement. .
NAAM.
SAMPLE
DATE rl
'
'HOO~
BEGINNING
SITTING
,
lv~jor actMty
12 O0 ore. 1:00 2:00 3:00; 4:00 5:O0
WALKING OR STANDING
Time M.¢l.ctivity
RE(: LINING
SLEEP SLEEP SLEEP SLEEP
I:
, '
;t
EATING ' READINg,
"
TV TV
"
'"'
"5 60 60
COOKING
PAIN
:, MOOD ,~'
SLEEP SLEEP REST
REST
60
,,
234
X X X
X X X X X
T.YLENOL 4 o
EATING ,., TV RE,AE~NG ' . VISITING FRIENDS __TV EATING" TV TELEPHONE ' "' ; " •
,
W~IL ~ s ~ s 45 6O 45 30 30 45 !5'
!X i
LAUNDRY
15
WALK
15
" :
.
...
30 15 15
X X X X
iX X
REST COOKING DISFEs CLEANING.
X~ ,×
. TYLENC)L 4 1
,
.....
15
~ n
Amount01 234501
60 60 60 60 ¢;K) 60 60 30 DARVON 65mo
SIFFP
'
6: 0 0 . I 7.00, 800' 9 O0 10:00 11:00 12: 1. O0 2:00 3:O0 4:00 5 O0 6 O0 7:O0 8:00. 9:00 10:O0 11t O 0
tvEDICATIONS;
1]me A c t M t y Time Type
30
X DARVON 65rrK
REST,TV REST,TV READIN~ SLEEP
30; r ~ IVALIUM 5rob 60 60
SLEEP
60
X
X X X
X :X X
Ix
Ixi
X'
Fig. 1. Sample pain diary sheet filled out by a patient. (See text for details.)
X
5
323
Treatment contract Prior m admission, patients were asked to sign a t r e a t m e n t contract stating that ~they would abide by the ward rules and pain p r o t o c o l At the time of admission patients were ~ven a complete history a n d physical, routine and .:other. laboratory tests as needed, and a urine drug screen. Patients then underwent the following sequence of procedures" hospital baseline, detoxification,, postdetoxification, posthospitalization, and 6-month f o l l o w u p . . . .
.
-~
Hospital baseline During this baseline condition, subjects were allowed access to as much medication as they had been taking prior to admission within the limits of their prescriptions, plus 20%. The 20% figure was an attempt to correct for the underreporting o f medication use which frequently occu~.~ in these patients. Patients were: carefully observed for signs of withdrawm. Urine drug screens were obtained to cross-check self-report of medication and medications present in the urine. This baseline condition lasted until patients requested medication on a stable basis. Also at this time, any additional consultations required from other services were ordered to further insure that all possible medical a~pects of the pain had been investigated. The mean length of baseline was 3.4 :lays and ranged from 2 to 6 days.
Detoxification Following baseline, an individual withdrawal schedule was determined for each patient depending on the type and amount of medication used. Patients were checked carefully for signs and symptoms of withdrawal as well. as surreptitious drug intake during detoxification. T h e m e a n length of detoxification for all patients was 3.7 days and ranged from 1 to 6 Clays.
Postdetoxification Postdetoxification was defined as that period beginning24 h after the last analgesic a n d / o r hypno-sedative medication was adminis#;ered. The mean postdetoxification period was 3.9 days and ranged.from 2 to 8 days. During this phase, patients were taught muscular relaxation techniques using a standard procedure [2] and were given brief supportive therapy consisting of encouraging stab~ments and (if requested) discussion of other problems. During this phase patients were seen for periods of 10--2(} rain twice daily. The amount of tirv.e spent per patient in relaxation training was 1.5 h and time in supportive therapy was approximately 3 h.
Immediate posthospitalization(I week) Patients were instructed to continue recording data for 1 week immediately following hospitalization. Patients were not given any specific therapy during this period.
324
Follow-up At 6-month follow-up, all patients were instructed to provide I week of pain diary information and to report to the clinic for examination. During the examination, patients were asked to produce a urine samplewhich they were told was to detect any gross abnormalities ~in kidney function, In addition to routine urine tests, t h e urine was ~screened ~for drugs. Between the immediate posthospitalization period ~and follow-up patients were seen for an average of 3 visits each (with a range of from 2 to 5 visits) to monitor their progress.
_~ata analysis P~n, mood and activity scores were determined for the treatment phases described above. The scores were based on the hourly reports for all 7 patients, t-Tests for correlated metals were performed for each individual's pain, mood and activity reports for 7 days prior to hospitalization, the 7 d a y s immediate posthospitalization, and the 7 days of follow-up at 6 months, t-Tests for correlated means were also performed for pain, mood and activity data for the total group. ~ •
.
RESULTS
Reliability There were 218 agreements out of 237 observations for patients' use of medication yielding an agreement of 92%. On only two occasions did nurses report that a medication was given and the patient had not marked that as having occurred; the remaining 17 disagreements were around occurrence, i.e., the nurse and patients reported differences of an event by greater "than lh. With regard to activity, nursing observations agreed on 108 of 115 occasions with patients yielding an agreement of 94%. These data suggest that patients were accurately and reliably filling out their pain sheets in the hospital. On the 4 occasions when nurses charted that a patient seemed to be showing signs of pain (i.e., "the patient was clutching his belly and screaming"), the patievt reposed hi:3 highest p a i n for that 24-h period. This suggests some concordance between pain self-report and at least some kind of pain behavior.
Pain The mean pain ratings for each of the 7 patients for each of the 6 conditions are presented in Table If. As can be seen in this table, 5 patients (1, 2, 3, 6 and 7) showed a statistically significant (one-tailed t-tests) decrease in pain report from prehospital baseline to immediate posthospitalization and 6-month follow-up, T h e average reduction in pain r e p o ~ across >all patients from baseline to follow-up was 57% and ranged from 18%t089%. Patient 4 reported an increase in pain from prehospital baseline to immediate posthospitalization btxt a significant decrease at 6-month follow-up. This was
325 TABLE II PATIENTS' MEAN PAIN RATING FOR EACH OF THE 6 PHASES OF TREATMENT Patient
Prehospitalization Baseline
Hospitalization
Posthospitalization
Baseline Detoxification
Postdetoxification
Immediate (N = 7)
6-Month (N = 6)
3.~3 2.92 4.30 3.70 1.74 3.07 2.69
2.59 3.31 0.00 4.41 1.06 2.19 1.23
0.44 ** 2.11 * 0.16 ** 4.02 0.90 0.36 ** 1.18 *
1.44 ** 1.28 * 0.61 ** 2.35 * deceased 2.37 * 0.59 **
(N = 7) 1 2 3 4 5 6 7
3.09 2.96 4.84 3.18 0.99 2.88 2.27
~
3.83 3.28 1.84 3.87 2.00 2.57 3.25
*P ~ 0.05 (one-tailed~ compared with prehospitalization). P <= 0.01 (one-tailed, compared with prehospitalization).
probably due to the subsequent discovery and t r e a t m e n t of frontal sinusitis between posthospitalization and follow-up. Patient 5 reported no significant decrease in pain from prehospital baseline to 1 week immediate posthospitalization, and 6-month posthospitalization data were n o t available due to his death in an automobile accident. The within-hospital pain reports were obtained over t o o few days to allow for statistical analysis between conditions. However, there were no consist e n t trends for these patients: two patients reported progressiw~ly increased pain throughout the 3 conditions; two other patients reported progressively decreased pain and the other three varied in other ways (see Table II). When subjects' data were analyzed as a group, t-tests revealed si,~nificant changes between prehospitalization baseline and both immediate posthospitalization follow-up (t = 6.71, P ~ 0.001) and 6-month follow-up (t = 9.12, V < 0.001).
Mood Table III represents the average m o o d rath~gs for each o f the 7 patients for each of the observation phases. F o u r patients exhibited a statistically significant higher rating in m o o d between prehospitalization and immediate posthospitalization; however, this change remained significant for only two patients at 6-month follow-up. A n o t h e r patient exhibited a significant decrease in m o o d from prehospital baseline to immediate posthospitalization and at 6-month follow-up. A non-statistical examination o f trends showed 3 patient, reporting a decrease in m o o d from hospital baseline to hospital postd,~toxification; 4 p a t i e n t , ~ p o r t e d an increase in m o o d from hospitalization baseline to postdetoxification. Again, t h e r e were n o consistent trends across the 3 i n h 0 s p i t a l c o n d i t i o n s for the 7 patients.
326
T A B L E III PATIENTS' M E A N M O O D E A T I N G F O R E A C H O F T H E :6PHASES OF. T R E A T M E N T Patient:
Prehospitalization :
-
Baseline: (N --7) •
1
2 3 4 5 6 7
'
::: .
~" :
Posthospitalization
Hospitalization Baseline '
Detoxification
Postdetoxif~cation
Immediate (N = 7 ) -~
6-Month (N = 6)
0.93 2.33 3.01 ' 1.90 3.01 • 3.21 2.68
1.26 0.86 3.48 1.03 2.50 3.83 2.62
2.51 1.70 4.00 1.04 2.68 4.06 3.35
3.06 2.11 3.37 0.84 2.66 4.21 3.24
1.52 2.93 *** 3.06 0.87 *** deceased 3.23 4.34 ***
.
1.45
1.91 2.56 2.05 2.75 3.37 2.64
*** *** *** *** *
* P < 0.05 (one-tailed, c o m p a r e d w i t h p r e h o s p i t a ! baseline). ** P < 0.01 (one-tailed, c o m p a r e d w i t h prehospital baseline). *** P ~ 0.001 (one-tailed, c o m p a r e d with prehospital baseline).
Relationship b e t w e e n pain a n d m o o d
Four patients (1, 3, 6 a n d 7) who had significantly more positive ratings of mood from prehospital baseline to immediate posthospitalization period (Tabl~.s ' !I and III) also had significantly lower ratings• of pain. Pearson Product Moment correlations computed on prehospitalization pain and mood ratings for each patient revealed that only 1 of the 7 patients showed a statistically significant relationship between pain and m o o d (r =--0.83, P < 0.01). Activity •
Table I V represents the mean reclining and non-reclining time (i.e., time spent in or out of bed) for each of the 7 patients for the 3 out.of-hospital periods. Since activity levels recorded in the hospital are unlikely to reliably represent activity levels at home, they are not discussed here. Only two patients ( 1 and 7) showed a significant increase: in non-reclining time from prehospitalization to immediateposthospitalization. At 6-month follow:up, 3 patients• (1,,•2 and 7) showed a Significant increase in non-reclining time. These 3 patients w e r e among those who also reported a significant decrease in pain, . .In general, the reduction of pain and concomitant increases i n m o o d corresponded with increased non-reclining time. Medication
usage
:
"
'~,At 6'm0nth foll0W-Up 5 of the 6 remaining patients reported taking some kind; of analgesic or hypno-sedative medication. Of these-•five,t w o patients had dextropropoxyphene in their urine,one patient had dextr0propoxyphene
327
T A B L E IV-"
•
r
P A T I E N T S ' -MEAN R E C L I N I N G .AND N O N - R E C L I N I N G TIME D U R I N G EACH O F T H E 3 N O N - H O S P I T A L I Z A T I O N PHASES • Patient
Prehospitalization
(N --7) ~,~
Posthospitalizati0n
~
,
:'
Reclining ~:.
6_
7
2O.OO
...
6-Month (N = 6)
.
reclining
Reclining
Nonreclining
Reclining
Nonreclining
9.35 9.94 15.61 8.73 10.29 13.56 4.00
10.76 * 14.46 9.46
]:3.24 9.54 14.54
8.71 *~; 10.61 ** 9.56 14.77 Deceased 7.76 17.11 *
15.29 13:39 14.44 9.23 Deceased 16.24 6.89
~
. ?
14.65 14.06 8.39 15.27 13.71 10.44
2: 3 4: 5,
I m m e d i a t e (N - 7) Noll
13.14 8'73 • 15.62 **
10.86 15..27 8.38
* P ~ 0.05 (one-tailed, compared with prehospital baseline). **P ~ 0.01 (one-tailed, compared with prehospital baseline).
IJ :~
.
ands.aspirin, one p~_tient had .secoba~bital, and one patient had diazepmn. No p a t i e ~ ' a s taking the drugs which they had been at the time of admission to hospil~. The reported use of medication was in agreement with. the urine screen for 3 of the 6 patients. DIscussION
The results 0f.this study demonstrate that for some patients a treatment program comprised of rapid detoxification plus relaxation and brief supportive: therapy is ~sociated with significant changes in the self-report of pain, both f011owhg treatment and at 6-month follow-up. The average improvement in pain ratings across subjects from prehospitalization to 6-month foUowiup was 57%, with a range Of improvement from 18 to 89%. improvement in mood and activity as a function of the treatment regimen was less consistent than that noted for pain; 4 subjects reported improvement in mood posthospitalization, whereas three were reporting increased activity at 6 months, While the decrease in pain does seem to be associated at 6-month f011ow-up with some improvement in mood, the correlation between pain and mood self-reports for individual patierits is not significant. Whus~ the greatest overall change as a f~ncti0n of detoxification; relaxation and supportive therapy was Clearly in self-reported pain. These data lend support to suggestions by other investigators [3,4,7] that medication may be a contributing factor inpatients' ongoing disability. • Unfortunately, the specific,contribution of detoxificati0n in producing these .changes Was confounded by, the use of relaxation training and brief •.
~ •
..
•
328 supportive therapy during the postdetoxification and 6-month follow-up. However, since the postdetoxification phase lasted a mean of 3.7 days mid patients had, at most, 3 sessions of relaxation and 3 h of therapist contact, it is unlikely that either procedure had a major impact on the patipnts' follow-up course. Further, a number of studies have shown that relaxation has minimal effects on pain tolerance and then mostly in patients who are reporting anxiety [6]. Since patients were seer: for only 2--5 supportive therapy visits following discharge, it is also unlikely that such minireal therapist contact could make a major difference in their outcome. Nevertheless, the specific contribution of detoxification to producing improvement in pain report is not certain. A more serious problem in the evaluation of these data is the lack of control groups. In this study, each subject served as his own control. Although maximum precision and generality ultimately require demonstration through the use of control groups, thi~ report systematically monitors pain, mood and activity at baseline, treatment, and follow-up throughout what have now become standard procedvres for the treatment of chro~c pain. The individual variation in the relationship between pain and mood in these patients is strikin[i:. For some patients pain and mood covaried; for others there was no-'~pparent relationship. For those who exhibited improved mood with decreased pain, their mood may have been reactive to the pain. Patients who continued to report low mood ratings in spite of improvement in pain report may suffer endogenous depression and may require more aggressive treatment of their depression. Further studies are needed to determine if changes in mood following detoxification might discriminate between reactive and endogenous depression in chronic pain patients. Changes in activity with decreased pain were more consistent than changes in mood. Those patients who initially spent most of their waking hours reclining showed a significant increase in the time spent sitting or standing after detoxification. However, analysis of the total group data of these patients showed no significant relationship between changes in activity prehospitalization to 6-month follow-up. These data also suggest that for some patients a time-consuming and costly hospitalization in order to increase activity may be v nnecessazy, at least for patients with abdominal or headache pain. For other patients, however, increases of activity must be carefully monitored a~d reinforced. Activity has be,~ome a popular and, at times, a primary outcome measure for pain programs. However, these data suggest that it is too early to abandon the self-report of pain as an outcome measure, since some patients will report a significant pain reduction with no change in activity and vice versa. Urine drug screens should also be included in an assessment outcome package for chror, ic pain patients, since 3 of 5 patients taking hypno-sedatives or mild analgesics at 6-month follow-up failed to report their usage on the pain diaries, These data also point to t h e need for at least a 6-month
329
follow-up to determine treatment outcome for a chronic pain program. The treatment of chronic pain accounts for a significant part of the health-care dollar. It behooves researchers in this area to begin to parcel out the specific effects of treatment with the goal of developing cost-effective programs. A reasonable start is to determine if simple procedures, like detoxification with relaxation and brief supportive therapy, may be as useful for some patients as more complex and expensive procedures and longer hospitalizations. REFERENCES 1 Black, R.G., The chronic pain syndrome, Surg. Clin. N. Amer., 55 (1975) 4. 2 Ferguson, J.M., Marquis, J. and Taylor, C.B., .~_ script for deep muscle relaxation, Dis. nerv. Syst., 38 (1977) 703--708. 3 Fordyce, W.F., Behavioral Methods for Chronic Pain and Illness, Mosby, St. Louis, Mo., 1975. 4 Halpern, L.M., Psychotropic drugs and the management of chronic pain. In: J.J. Bonica (Ed.), Advances in Neurology: International Symposium on Pain, Raven Press, New York, 1974, pp. 539--545. 5 Sternbach, R.A., Pain Patients: Traits and Treatment, Academic Press, New York, 1974. 6 Weisenberg, M., Pain and pain control, Psychol. BulL, 84 (1977) 1008--1044. 7 Ziesat, H.A., Angle, H.V., Gentry, D. and Ellinwood, E.H., Drug use and misuse in operant pain patients, Addict. Behav., 4 (1979) 263--266.