Jennifer L. Kerkvliet

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.

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.

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

Intervention for Erythromelalgia, a Chronic Pain Syndrome: Comprehensive Pain Rehabilitation Center, Mayo Clinic

9.31 (

(763): Pain rehabilitation with opioid withdrawal: Longitudinal study of treatment outcomes for chronic noncancer pain

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

318) Using electronic diaries to monitor intervention compliance in chronic pain

6.68 (

(316) Psychological and physiological correlates of a brief intervention to enhance self-regulation in chronic pain

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.

(303) Psychological, social and physical treatment outcomes for geriatric patients with chronic non-cancer pain at a multidisciplinary pain rehabilitation center

OBJECTIVE To describe the response in patients with erythromelalgia to the pain rehabilitation program at Mayo Clinic, Rochester, Minnesota. DESIGN Retrospective case series. SETTING Comprehensive Pain Rehabilitation Center at a tertiary referral medical center. Patients Eight patients with erythromelalgia admitted to the pain rehabilitation program from January 1, 2002, through June 30, 2007. MAIN OUTCOME MEASURES The Multidimensional Pain Inventory, the 36-Item Short Form Health Survey, the Pain Catastrophizing Scale, and the Center for Epidemiologic Studies Depression Scale were administered at admission and dismissal from the program. Mean differences in scores were compared using 2-sided paired t tests. RESULTS Scores for the life interference, life control, and general activity subscales of the Multidimensional Pain Inventory showed significant improvement from admission to dismissal (all P < .05). Similarly, the scores of the Pain Catastrophizing Scale, the Center for Epidemiologic Studies Depression Scale, and the physical functioning and emotional role limitation subscales of the 36-Item Short Form Health Survey were significantly improved after intervention (all P < .01). Conclusion The results of our study indicate that pain rehabilitation is a useful method for managing pain-related impairment in physical and emotional functioning in patients with erythromelalgia.