Jeffrey D. Rome

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.

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.

Reduction in Medication Costs for Patients with Chronic Nonmalignant Pain Completing a Pain Rehabilitation Program: A Prospective Analysis of Admission, Discharge, and 6‐Month Follow‐Up Medication Costs

OBJECTIVE Chronic nonmalignant pain (CNMP) is both a prevalent and a costly health problem in our society. Pain rehabilitation programs have been shown to provide cost-effective treatment. A treatment goal for some rehabilitation programs is reduction in the use of pain-related medication. Medication costs savings from pain rehabilitation programs have not been analyzed in previous studies. DESIGN This prospective cohort study of 186 patients with CNMP addresses the costs of medications at admission to a 3-week outpatient pain rehabilitation program, at discharge, and at 6-month follow-up. Medication use was determined through a detailed pharmacist interview with patients at admission and discharge. Patients were sent questionnaires 6 months after program completion, which obtained current medication information. RESULTS Statistically significant medication cost savings were seen for program completers at discharge and at 6-month follow-up (P < 0.05). The mean (standard deviation) daily prescription medication cost reduction from admission to discharge was

Longitudinal Treatment Outcomes for Geriatric Patients with Chronic Non‐Cancer Pain at an Interdisciplinary Pain Rehabilitation Program

9.31 (

Congenital idiopathic inability to perceive pain: a new syndrome of insensitivity to pain and itch with preserved small fibers.

12.70) using the average wholesale price of medications. From the original study cohort, 121 patients completed the 6-month follow-up survey. The mean daily prescription medication cost savings from admission to 6-month follow-up was

Effect of inpatient psychiatry training on internal medicine residents: Results of a survey

6.68 (

A rehabilitation approach to chronic pain in rheumatologic practice.

14.40). CONCLUSION Patients benefited from significant medication cost savings at the completion of the 3-week outpatient pain rehabilitation program and maintained significant savings after 6 months. This study adds to the current literature on the economic value of comprehensive pain rehabilitation programs.

Limbically Augmented Pain Syndrome (LAPS): Kindling, Corticolimbic Sensitization, and the Convergence of Affective and Sensory Symptoms in Chronic Pain Disorders

OBJECTIVE This study examined depression, pain catastrophizing, psychosocial functioning, and physical and emotional health attributes for geriatric patients admitted to an interdisciplinary pain rehabilitation center compared with middle and younger age groups. DESIGN Quasi-experimental time series. SETTING Interdisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS In total, 411 patients with chronic non-cancer pain completed the pain rehabilitation program from October 2004 to April 2006. Patients were divided into three groups based on age: older (ages 60+; n = 78); middle-age (ages 40-59; n = 230) and younger (ages 18-39; n = 141). INTERVENTION A 3-week outpatient interdisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates opioid withdrawal. OUTCOME MEASURES The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Pain Catastrophizing Scale (PCS), and Center for Epidemiological Studies-Depression Scale (CES-D) were administered at admission, discharge, and 6 months following treatment. The frequency of patients using opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines at each assessment point were compared. RESULTS Older patients reported reduced depression, catastrophizing, pain severity, and pain interference (P < 0.001) at discharge and 6 months follow-up. Older patients also reported increased perceived control, and physical and social functioning at discharge and follow-up (P < 0.001). Improvement in older patients was comparable in magnitude to that of middle-age patients on all variables, whereas younger patients exhibited greater improvement on four variables. Significant reductions in analgesic use were observed in all groups. CONCLUSION Interdisciplinary pain rehabilitation incorporating opioid withdrawal can improve long-term psychological, social and physical functioning for geriatric chronic pain patients.

Slow-Frequency rTMS Reduces Fibromyalgia Pain

Individuals vary widely in their sensitivity to painful stimuli. Some exhibit heightened reactions to pain (hyperpathia), while others show relative indifference. Although multiple factors may be responsible for these differences, varying sensitivities to pain also can be due to underlying differences in nociceptive neurophysiology. We present here the case of an individual with an apparent congenital inability to perceive pain. This patient appears to be different from other reported cases of insensitivity to pain described in the medical literature. He exhibited no evidence of an abnormality of the peripheral or autonomic nervous system and no apparent abnormality of the central nervous system other than isolated deficits in pain and temperature perception. Since pain is a subjective phenomenon, there is no definitive way to assess this patients reported inability to perceive painful somatic stimulation, but available evidence suggests he has a defect in the supraspinal processing of nociceptive stimuli which renders him insensitive to pain. This raises the possibility of either deficient central nociceptive functioning or aberrant endogenous anti-nociceptive functioning.

Treatment Outcomes after Multidisciplinary Pain Rehabilitation with Analgesic Medication Withdrawal for Patients with Fibromyalgia

Forty-two residents in internal medicine completed an attitudinal survey at the beginning and end of a 2-month inpatient psychiatry rotation. Residents noted a significant increase in their confidence regarding the management of various psychiatric problems and personality problems, the conducting of supportive counseling, the making of psychiatric referrals, the usefulness of psychotherapy, and the ability to discuss emotionally difficult subjects with patients. The rotation was perceived as being worthwhile and enjoyable. Areas of uncertainty that remained included concern regarding the time demands, the perception that psychiatric patients are anxiety-provoking and difficult to treat, and that psychiatric knowledge was an extension of common sense.