Leslie Hearn

Effectiveness of psychological interventions for chronic pain on health care use and work absence: systematic review and meta-analysis

Abstract Psychological interventions for chronic pain and its consequences have been shown to improve mood, disability, pain, and catastrophic thinking, but there has been no systematic review specifically of their effects on health care use or time lost from work as treatment outcomes in mixed chronic pain. We conducted a systematic review and meta-analysis to evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults for these outcomes. We used searches from 2 previous systematic reviews and updated them. Eighteen randomized controlled trials were found that reported health care use (15 studies) and work loss (9 studies) as outcomes. Fourteen studies provided data for meta-analysis. There were moderate effects for psychological interventions compared with active controls, treatment as usual and waiting list controls in reducing health care use, with confidence in the findings. No benefits were found for medication reduction, but with less confidence in this result. Analysis of work loss showed no significant effects of psychological interventions over comparisons, but the use of many different metrics necessitated fragmenting the planned analyses, making summary difficult. The results are encouraging for the potential of routine psychological intervention to reduce posttreatment health care use, with associated cost savings, but it is likely that the range and complexity of problems affecting work necessitate additional intervention over standard group psychological intervention.

Reducing the risk of opioid misuse in persistent pain: commentary on Jamison et al.

Jamison et al. [6] describes in this issue a pilot study, the first of its kind, of psychological intervention to improve the adherence to opioid therapy in chronic pain patients at a high risk of misuse. This is an excellent initiative, a welcome alternative to using screening measures to refuse providing pain patients an adequate trial of opioids. Subjects had chronic back or neck pain, and were maintained on opioids after many unsuccessful treatment attempts. Jamison et al. opted to try to achieve the best pain management with the existing dose of opioids. Patients were assessed for the risk of misuse with a combination of self-report, physician judgement, and urine screening. High-risk patients were randomised to a psychological intervention to improve compliance or to a no-intervention control; the low risk group constituted a comparison. The intervention involved group education and worksheets on opioid risk, and individual motivational counselling, all aimed to change patterns of misuse. Patients monitored their own compliance, backed by monthly urine screens. Opioid represcription was conditional on task completion. The results are encouraging. The intervention group became low risk – comparable to the low risk comparison group – while the high risk controls were unchanged. The psychological intervention was acceptable and the dropout was low, both important findings considering that patients are often characterised as unwilling to change their pattern or the extent of opioid use. We have some reservations about the study design and conduct that affect interpretation. First, the patients took different doses of different opioids at the outset, doses that were assumed to maximize analgesia and function while minimizing the adverse effects. Yet pain control seemed less than satisfactory at the baseline: a mean of 6/10. Perhaps patients had developed tolerance. Also, the widespread use of immediate-release opioids is surprising in high-risk patients, and a suitable target for change. Second, change scores would have given a more clinically useful account than the group means [9]. Psychology is central to the intervention: changing beliefs and behaviour by a mixture of self-monitoring, education and group discussion of alternative solutions to the problems for which patients overuse opioids. Although the authors are properly cautious about reporting the significant decreases in the pain intensity and anxiety in the intervention group, since they were not targets of treatment, these changes are potentially important and worth assessing more closely in the future studies. So a third concern is that if a salient reason for opioid misuse is self-medication for anxiety and depression, as the authors propose, then psychological interventions that target those conditions directly is preferable to