Stanley L. Chapman

The effect of opioids on driving and psychomotor performance in patients with chronic pain

Objectives:This study compared the psychomotor performance and driving ability of patients with chronic pain managed with stable regimens of opioid analgesics with that of normal healthy volunteers. The hypothesis was that patients with chronic pain on stable opioid analgesic regimens operate their automobiles safely with proficiency equal to normal volunteer controls. Methods:Patients were evaluated for errors while driving their own automobile through a predetermined route in the community, including variable residential and highway conditions, and for speed and accuracy on repeated trials through a 5-station obstacle course that evaluated forward and reverse driving, turning, and parallel parking. Patients also completed the Test of Variables of Attention and the Digit Symbol Substitution Test. Results:No significant differences were observed among groups in driving performance in the community and on the obstacle course or on the Test of Variables of Attention. Results on dependent measures within the opioid group generally were not correlated with morphine equivalent daily opioid doses, which averaged 118 mg (median 40 mg). Conclusions:Many patients with chronic pain, even if treated with potent analgesics such as morphine and hydromorphone, show comparable driving ability as normals.

A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches

&NA; A comprehensive survey of EMG and thermal biofeedback for chronic muscle contraction and migraine headaches is presented. The studies done to date suggest a high degree of short‐term efficacy of biofeedback, which has been maintained on long‐term follow‐ups. While comparisons of biofeedback with relaxation generally have shown approximately equivalent effectiveness, the two forms of therapy may be differentially effective with different subjects. Attempts to correlate EMG and/or thermal parameters with headache parameters generally have failed to produce significant results, particularly in more recent and better‐controlled studies; however, numerous technical and procedural difficulties have obscured meaningful interpretation of physiological data. Results with pseudofeedback do suggest a likely specific contribution of frontalis EMG to muscle contraction headaches, at least for some subjects. Comparable evidence for a specific contribution of thermal parameters to migraines is almost totally lacking. Clinical outcome research suggests that biofeedback in general may be more effective in younger anxious subjects who show no chronic habituation to drugs, and that there is little apparent benefit from repeating biofeedback for more than about 12 sessions maximum. Three broad areas for subsequent research are suggested: longitudinal study of EMG and thermal parameters in a naturalistic setting, specification of processes critically involved in biofeedback, and clinically relevant comparative outcome research with biofeedback and alternative therapies.

Effects of intermediate- and long-term use of opioids on cognition in patients with chronic pain.

The authors review research on the intermediate- and long-term effects of taking opioid medication on cognitive functioning in patients with chronic cancer and non-cancer pain. Opioids seem to be more likely to worsen cognitive performance during the first few days of use and during the first few hours after a given dose, particularly on timed performance in psychomotor tasks. Results have been inconsistent regarding what decrements in cognitive performance are observed when patients with chronic pain who have been using opioids for more than three days are compared with healthy volunteers. Relatively few differences have been found when cognitive performance in these patients is compared with their performance before taking opioids, or with the performance of a comparable pain population not taking opioids. Major unresolved questions remain regarding such important issues as effects of different types of opioids, dose effects, interactions with other medications, and subject variables.

Chronic back pain: Electromyographic, motion and behavioral assessments following sympathetic nerve blocks and placebos

&NA; Twenty patients with chronic low back pain received 12 lumbar sympathetic injections, in a series of 6 with bupivacaine and a series of 6 with saline. Changes in subjective pain intensity, EMG from paravertebral muscles, joint ranges of mobility, and daily activity levels were measured at multiple intervals throughout treatment and at 3 monthly follow‐up intervals. The MMPI was administered before treatment, after treatment and at 3‐month follow‐up. Results revealed significant reductions in subjective pain intensity lasting 1 month after treatment which were not significantly different during bupivacaine and saline injection periods. Patients MMPI profiles were indicative of reduced depression and an increase in ability to manage their lives. No significant changes were recorded with respect to EMG, joint range of mobility, or daily activity levels. Results were discussed in terms of a massive placebo effect and analgesia obtained through hyperstimulation of various tissue structures. They are consistent with the hypothesis that central postsynaptic mechanisms were predominant in these patients chronic back pain states. Because subjective pain relief did not independently produce increasing function, it was recommended that deep analgesic injections or other pain relieving techniques be matched with behavior modification leading to functional rehabilitation.

Treatment outcome in a chronic pain rehabilitation program

One hundred patients were selected who had completed an outpatient rehabilitation program designed to teach competent coping with chronic pain. Data at follow-up periods averaging 21 months posttreatment indicated statistically significant decreases in subjective pain intensity and increases in activities of daily living with substantial reductions in use of medications for pain. Changes from pretreatment to follow-up were not significantly different among groups of patients with pending, current, or no disability. Eight of 19 unemployed persons who had pending disability claims had returned to work at follow-up. It was concluded that considerable changes in function can occur with relatively brief outpatient pain rehabilitation and that pending or current disability is not necessarily an indication of likely treatment failure.

Treatment helpfulness questionnaire: a measure of patient satisfaction with treatment modalities provided in chronic pain management programs

&NA; The Treatment Helpfulness Questionnaire (THQ) is presented as a reliable and valid measure for assessing patient perceptions of the helpfulness of treatment modalities offered at multidisciplinary pain centers. It is easy to administer and score and shows good interscorer and test‐retest reliability without order effects and with good internal consistency. Patients give diverse responses to items that fall into four factors, three of which represent identifiable components of multidisciplinary treatment for chronic pain. Findings that similar THQ items are positively correlated and that many items show positive correlations with treatment outcome support the validity of the instrument. The latter finding also suggests the potential of patient satisfaction measurement for improving treatment outcomes at pain centers.

Management of patients with chronic pain

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Learned helplessness and responses to nerve blocks in chronic low back pain patients.

Abstract In a double‐blind study, 67 chronic low back pain patients received 4 lumbar sympathetic nerve blocks, two given with bupivacaine and two given with saline. It was hypothesized that patients showing evidence of ‘learned helplessness,’ as measured by dependence on habit‐forming medications for the pain, low activity levels, and elevated MMFI scores on Hypochondriasis, Depression and Hysteria would show the least reduction in subjective pain intensity following injections with both bupivacaine and saline. It also was hypothesized that placebo responses would be greatest in patients who had a high educational level, were divorced, and had no pending disability claims. Responses 30 min following nerve blocks failed to correlate with these variables. However, decreases in subjective pain intensity 24 h following both types of nerve blocks were greater in patients who showed low levels of pain behavior, who were divorced, and who had no pending disability claims. Decreased pain 24 h following saline injections was significantly related to low scores on the Lie, Defensiveness, Hypochondriasis, and Hysteria scales of the MMPI and to reduced subjective pain intensity following a 6 week comprehensive outpatient pain rehabilitation program. It was concluded that chronic pain patients who are fixed in their focus on pain, high in pain‐related behaviors, and low in responsibilities are less likely to respond favorably to nerve blocks and that medical treatment for them needs to be paired with therapies designed to reduce their helplessness.

Patterns of conscious failure to provide accurate self-report data in patients with low back pain.

Assessment and treatment responses were compared in 17 subjects with chronic low back pain assessed as showing at least one clear consciously produced inconsistency in statements and/or behaviors during their participation in an interdisciplinary treatment program and 143 subjects assessed as showing no such inconsistency. Numerous statistically significant differences emerged: Inconsistent subjects were more likely to have pending litigation and to be assessed by staff as showing a higher degree of focus on pain and more dramatized complaints, lower levels of medical findings and attention and interest in treatment, and poor compliance with treatment and assessment procedures. In addition, these subjects reported lower levels of physical activity and generally more inconsistent or negative responses to lumbar sympathetic injections with fewer expected changes in physical sensations. Though not definitive, these results suggested a syndrome of characteristics among such subjects which are similar to those proposed as likely characterizing malingerers. The need for a particularly careful validation of self-report data in patients showing many of these characteristics was emphasized.

Prediction of treatment outcome from clinically derived MMPI clusters in rehabilitation for chronic low back pain.

OBJECTIVE The aim of this study was to assess the ability of specific and clinically relevant Minnesota Multiphasic Personality Inventory (MMPI) profile types to predict outcomes in a structured interdisciplinary pain-management program for patients with low back pain. DESIGN Subjects were divided into clusters representing MMPI profiles yielding similar clinical interpretation. Analyses of variance and chi-square testing assessed the effect of cluster group on a variety of outcome measures at pretreatment, posttreatment, and 6- to 66-month follow-up. Fishers Least Significant Difference Test assessed the significance of differences between pairs of cluster groups. SETTING A university-based comprehensive interdisciplinary pain-management program serving both inpatients and outpatients. PATIENTS 122 subjects with chronic low back pain who completed the program, provided follow-up data, and fit into the definition of one of seven clusters. MAJOR OUTCOME MEASURES Self-reports of subjective pain intensity, pain-related medication intake, and activity level at pretreatment, posttreatment, and follow-up; employment status at pretreatment and follow-up. RESULTS Cluster groups did not differ significantly at any time on activity level and medication intake and differed on employment status only at pretreatment. There was a significant (p < 0.05) effect of cluster group on subjective pain intensity, but only two pairwise group comparisons were significant: subjects with a normal MMPI profile and those with no elevations except T = 71-80 on Hypochondriasis and Hysteria reported less pain at follow-up than did subjects with extreme elevations (T > 80) on both Hypochondriasis and Hysteria. CONCLUSION Even when subjects with chronic pain are divided into cluster groups associated with highly similar clinical interpretations, the MMPI for the most part fails to predict self-reported outcomes in an interdisciplinary pain-management program.