Cynthia O. Townsend

A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission

Abstract Use of opioids for chronic non‐cancer pain is controversial and the efficacy of comprehensive pain rehabilitation programs (CPRPs) that incorporate opioid withdrawal requires further investigation. We test the hypothesis that patients with chronic pain and longstanding opioid use who undergo opioid withdrawal in the course of rehabilitative treatment will experience significant and sustained improvement in pain and functioning similar to patients who were not taking opioids. A longitudinal design study compared 373 consecutive patients admitted to the Mayo Clinic Pain Rehabilitation Center at admission, discharge and six‐month posttreatment by opioid status at admission. Measures of pain severity, depression, psychosocial functioning, health status, and pain catastrophizing were used to assess between‐ and within‐group differences. Treatment involved a 3‐week interdisciplinary pain rehabilitation program focused on functional restoration. Over one‐half of patients (57.1%) were taking opioids daily at admission. The majority of patients (91%) completed rehabilitation and 70% of patients who completed the program returned questionnaires six months posttreatment. On admission, patients taking low‐ and high‐dose opioids reported significantly greater pain severity (P = .001) and depression (P = .001) than the non‐opioid group. Significant improvement was found on all outcome variables following treatment (P < .001) and six‐month posttreatment (P < .001) regardless of opioid status at admission. There were no differences between the opioid and non‐opioid groups upon discharge from the program or at six months following treatment. Conclusion: Patients with longstanding CPRP on chronic opioid therapy, who choose to participate in interdisciplinary rehabilitation that incorporates opioid withdrawal, can experience significant and sustained improvement in pain severity and functioning.

Prevalence and Clinical Correlates of Vitamin D Inadequacy among Patients with Chronic Pain

OBJECTIVE Vitamin D inadequacy is associated with medication refractory musculoskeletal pain and neuromuscular dysfunction. This vitamin deficiency could subsist as an unrecognized comorbid condition among patients with chronic pain. The primary objective of this study was to determine the prevalence and clinical correlates of vitamin D inadequacy in patients seeking treatment for chronic pain. DESIGN Retrospective case series. SETTING Multidisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS The study involved 267 chronic pain patients admitted from February to December 2006. INTERVENTION Serum 25-hydroxyvitamin D (25[OH]D) was drawn at admission. OUTCOME MEASURES Patients with serum 25[OH]D levels < or=20 ng/mL were considered to have inadequate levels and those with levels >20 ng/mL were considered to have adequate levels. Upon admission, opioid intake was documented and patients completed the Short Form-36 Health Status Questionnaire. RESULTS The prevalence of vitamin D inadequacy was 26% (95% confidence interval, 20.6-31.1%). Among patients using opioids, the mean morphine equivalent dose for the inadequate vitamin D group was 133.5 mg/day compared with 70.0 mg/day for the adequate group (P = 0.001). The mean duration of opioid use for the inadequate and adequate groups were 71.1 months and 43.8 months, respectively (P = 0.023). Opioid users with inadequate levels reported worse physical functioning (P = 0.041) and health perception (P = 0.003) than opioid users with adequate levels. CONCLUSION The prevalence and clinical correlates identified in this pilot study provide the basis for the assertion that vitamin D inadequacy may represent an under-recognized source of nociception and impaired neuromuscular functioning among patients with chronic pain.

Effects of strength vs aerobic exercise on pain severity in adults with fibromyalgia: a randomized equivalence trial.

Summary Strengthening and aerobic exercise had equivalent effects on reducing pain severity in patients with fibromyalgia. Abstract Strength training and aerobic exercise have beneficial effects on pain in adults with fibromyalgia. However, the equivalence of strengthening and aerobic exercise has not been reported. The primary aim of this randomized equivalence trial involving patients with fibromyalgia admitted to an interdisciplinary pain treatment program was to test the hypothesis that strengthening (n = 36) and aerobic (n = 36) exercise have equivalent effects (95% confidence interval within an equivalence margin ±8) on pain, as measured by the pain severity subscale of the Multidimensional Pain Inventory. Secondary aims included determining the effects of strengthening and aerobic exercise on peak Vo2 uptake, leg strength, and pressure pain thresholds. In an intent‐to‐treat analysis, the mean (± standard deviation) pain severity scores for the strength and aerobic groups at study completion were 34.4 ± 11.5 and 37.6 ± 11.9, respectively. The group difference was −3.2 (95% confidence interval, −8.7 to 2.3), which was within the equivalence margin of Δ8. Significant improvements in pain severity (P < .001), peak Vo2 (P < .001), strength (P < .001), and pain thresholds (P < .001) were observed from baseline to week 3 in the intent‐to‐treat analysis; however, patients in the aerobic group (mean change 2.0 ± 2.6 mL/kg/min) experienced greater gains (P < .013) in peak Vo2 compared to the strength group (mean change 0.4 ± 2.6 mL/kg/min). Knowledge of the equivalence and physiological effects of exercise have important clinical implications that could allow practitioners to target exercise recommendations on the basis of comorbid medical conditions or patient preference for a particular type of exercise. This study found that strength and aerobic exercise had equivalent effects on reducing pain severity among patients with fibromyalgia.

Chronic Noncancer Pain Rehabilitation With Opioid Withdrawal: Comparison of Treatment Outcomes Based on Opioid Use Status at Admission

OBJECTIVE To study differences in treatment outcomes between patients with chronic noncancer pain taking vs those not taking maintenance opioids at admission to a pain rehabilitation program. PATIENTS AND METHODS A nonrandomized 2-group prepost design was used to compare 356 patients admitted to the Mayo Comprehensive Pain Rehabilitation Center from January 2002 to December 2002 at admission and discharge by opioid status at admission. Measures of pain severity, interference due to pain, perceived life control, affective distress, activity level, depression, and catastrophizing (an exaggerated negative mental set associated with actual or anticipated pain experiences) were used to compare opioid and nonopioid groups. The patients entered a 3-week intensive outpatient multidisciplinary pain rehabilitation program designed to improve adaptation to chronic noncancer pain. The program uses a cognitive-behavioral model and incorporates opioid withdrawal. RESULTS More than one third of patients (135/356) were taking opioids daily at admission. At completion of the program, all but 3 of the 135 patients had successfully discontinued opioid treatment. No significant pretreatment differences were found between the opioid and nonopioid group regarding demographics, pain duration, treatment completion, or all outcome variables, including pain severity. Significant improvement was noted at discharge for all outcome variables assessed regardless of opioid status at admission. CONCLUSION Patients with symptomatically severe and disabling pain while taking maintenance opioid therapy can experience significant improvement in physical and emotional functioning while participating in a pain rehabilitation program that incorporates opioid withdrawal.

The Effects of Smoking Status on Opioid Tapering Among Patients with Chronic Pain

OBJECTIVE: The primary aim of this study was to determine if smoking status affected the ability of patients with chronic pain to reduce opioid consumption during a 3-wk pain rehabilitation program. Secondary aims included determining the associations between smoking status, admission opioid use, and pain severity. METHODS: We used a retrospective, repeated measures design to assess pre- and post-treatment outcomes in a consecutive series of patients admitted to a 3-wk, outpatient pain treatment program from September 2003 through February 2007. Outcome measures included the frequency of successful opioid tapering, pain severity subscale of the Multidisciplinary Pain Inventory, and program completion status. RESULTS: The study cohort included 1241 patients (women 928); 313 (25%) smokers, 294 (24%) former smokers, and 634 (51%) never smokers. There were more smokers using opioids at admission (P < 0.001) compared to former and never smokers. Likewise, the mean morphine equivalent dose (P = 0.013) and pain severity scores (P < 0.001) of smokers were higher compared to former and never smokers. The success of opioid tapering did not depend on smoking status, and all groups experienced significant reductions in pain severity at program completion (P < 0.001). However, a higher proportion of smokers did not complete treatment (P < 0.001). CONCLUSIONS: For patients completing a pain rehabilitation program, most were able to eliminate opioid use, regardless of smoking status. However, significantly more smokers did not complete treatment. The most frequent reasons for program noncompletion included discrepant expectations of treatment, acute illness, and psychosocial stressors.

Effects of smoking status on immediate treatment outcomes of multidisciplinary pain rehabilitation

OBJECTIVE The primary aim of this study was to determine the effects of smoking on treatment outcomes following multidisciplinary pain rehabilitation. A secondary aim was to assess the tobacco use characteristics of smokers with chronic pain. DESIGN A prospective, nonrandomized, repeated measures design. SETTING Multidisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS All patients (N = 193) consecutively admitted from August 2005 through February 2006. INTERVENTIONS A 3-week outpatient multidisciplinary pain rehabilitation program. OUTCOME MEASURES The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Center for Epidemiologic Studies-Depression scale (CES-D), Pain Anxiety Symptom Scale (PASS-20) and Pain Catastrophizing Scale (PCS) were administered at admission and dismissal. RESULTS The study involved 49 (83% women) smokers and 144 (83% women) nonsmokers. The mean number of cigarettes smoked daily was 17.5 (SD 11.1) and the mean duration of smoking was 21.5 years (SD 12.1). After adjusting for demographic differences, repeated measures of analysis of covariance showed a main effect of smoking status for MPI affective distress (P = 0.008), CES-D (P = 0.001) and PCS (P = 0.011). An interaction of smoking status and time was found for the PASS-20 (P = 0.028), MPI affective distress (P = 0.033), MPI life control (P = 0.003) and SF-36 role-emotional (P = 0.004) subscale. While the majority of smokers were ready to consider smoking abstinence, 43% declined a brief smoking cessation intervention. CONCLUSIONS In this series of patients undergoing multidisciplinary treatment for chronic pain, immediate treatment effects for a variety of outcome measures were similar or significantly better in smokers compared with nonsmokers.

Associations between Heat Pain Perception and Opioid Dose among Patients with Chronic Pain Undergoing Opioid Tapering

OBJECTIVE The purpose of this study was to investigate the associations between morphine equivalent dose and heat pain (HP) perception in patients with chronic pain undergoing opioid tapering in the context of a multidisciplinary rehabilitation program. DESIGN Prospective design. SETTING Multidisciplinary pain rehabilitation center. PATIENTS The cohort included 109 patients using opioids (female 52%) who met inclusion criteria, and were consecutively admitted from March 2007 to June 2008. INTERVENTION Three-week outpatient multidisciplinary rehabilitation program that incorporates opioid tapering. OUTCOME MEASURES Using a standardized quantitative sensory test (QST) method of levels, standardized values of HP perception were obtained one day following program admission and following completion of the opioid taper at program dismissal. RESULTS At admission, the mean morphine equivalent dose was 192 mg/day. Univariate linear regression analysis showed that greater baseline morphine equivalent dose was associated (P = 0.040) with lower, or more hyperalgesic, values of HP 5-0.5, which is a standardized measure of HP perception. The dose dependent association retained significance (P = 0.029) after adjusting for pain severity, pain duration and pain diagnosis. Tapering of greater morphine equivalent dosages was associated (P = 0.001) with lower values of HP 5-0.5. The association retained significance (P = 0.001) after adjusting for pain severity, pain duration, pain diagnosis, opioid withdrawal symptoms, and time between completion of the taper and performance of the dismissal QST. CONCLUSION The use of a validated QST method of levels and standardized values of HP 5-0.5 may expand the methodological approaches available for investigating the clinical effects of opioids on HP perception.

Withdrawal of analgesic medication for chronic low-back pain patients: improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history.

Crisostomo RA, Schmidt JE, Hooten WM, Kerkvliet JL, Townsend CO, Bruce BK: Withdrawal of analgesic medication for chronic low-back pain patients: improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history. Am J Phys Med Rehabil 2008;87:527–536. Objective:To determine the posttreatment outcomes of multidisciplinary pain rehabilitation that incorporates analgesic medication withdrawal for chronic low-back pain patients on the basis of lumbar spine surgical history. Design:This is a retrospective analysis of 383 consecutive chronic low-back pain patients participating in a 3-wk, outpatient, intensive, multidisciplinary pain rehabilitation program. The study sample was divided into three groups based on history of spine surgery: 196 patients without previous lumbar spine surgery, 125 with history of lumbar fusion, and 62 with history of nonfusion lumbar spine surgery. Patients were assessed at admission and dismissal for medication use, pain severity and affective characteristics, physical functioning, depression, and pain catastrophizing. Results:At admission, patients in both the fusion and nonfusion surgery groups were using more opioids compared with the no-surgery group. Reported pain severity and duration was highest in the fusion group compared with the other groups. Admission to dismissal comparisons showed significant and nearly equal improvements for all groups in health and medication measures. Conclusions:Study results demonstrate that multidisciplinary pain rehabilitation treatment incorporating analgesic medication withdrawal is associated with significant clinical improvements in physical and emotional functioning, regardless of lumbar spine surgical history.

Sex Differences in Characteristics of Smokers with Chronic Pain Undergoing Multidisciplinary Pain Rehabilitation

OBJECTIVE The primary aim of this study was to determine the influence of sex and the interactions between sex and smoking status on the immediate treatment outcomes of patients undergoing multidisciplinary pain treatment. DESIGN A retrospective, repeated measures design. Setting. Multidisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS The cohort (N = 1,241) included 928 women and 313 men of whom 313 were current smokers, 294 were former smokers and 634 were never smokers consecutively admitted from September 2003 through February 2007. Interventions. A 3-week outpatient multidisciplinary pain rehabilitation program. OUTCOME MEASURES The Multidimensional Pain Inventory, Short Form-36 Health Status Questionnaire, Center for Epidemiologic Studies-Depression scale, Pain Anxiety Symptom Scale, and Pain Catastrophizing Scale were administered at admission and dismissal. RESULTS Women experienced significantly greater improvement in depressive symptoms compared with men (P = 0.023). Smokers experienced significantly greater improvements in depression (P = 0.039), pain catastrophizing (P = 0.010), and anxiety (P = 0.037) compared with former and never smokers. No significant interaction effects between treatment by sex by smoking status were observed. A significant sex by smoking status interaction was observed for daily morphine equivalent dose (mg/d) where male smokers consumed greater quantities of opioids compared with female smokers at program admission (P < 0.001). CONCLUSIONS The effects of smoking status on the immediate treatment outcomes of multidisciplinary pain treatment are not modified by sex. However, women experienced significantly greater improvement in depression than men and male smokers consumed significantly greater quantities of opioids compared with female smokers at admission.

Smoking Cessation and Chronic Pain: Patient and Pain Medicine Physician Attitudes

Although previous studies suggest that the clinical setting of an interdisciplinary pain treatment program may provide an optimal environment to promote smoking cessation, currently available smoking cessation interventions may be less effective for adults with chronic pain due, in part, to unrecognized clinical factors related to chronic pain. The specific aim of this qualitative study was to solicit information from adult smokers with chronic pain participating in an interdisciplinary pain treatment program regarding their perceptions of how smoking affects pain symptoms, and how these beliefs, cognitions, and emotions may either impede or facilitate smoking cessation. Similar information was solicited from a group of pain specialty physicians. The study involved 18 smokers with chronic pain, and seven physicians. Patients reported that smoking was an important coping strategy for pain and distress, primarily by offering an opportunity for distraction and avoidance, respectively. The majority of patients using opioids reported that opioid consumption stimulated smoking. Important barriers were identified toward making a quit attempt during pain treatment including quitting smoking while making changes in opioid use, and perceived difficulty managing multiple treatment‐related stressors. Several pain‐related benefits of smoking cessation were identified by physicians, but important barriers to providing smoking cessation services were recognized including lack of time and knowledge about how to help patients quit smoking. The findings of this study identified several novel and important clinical factors that should be incorporated into a targeted smoking cessation intervention for adults with chronic pain.