Chronic Non-malignant Pain Patients Research Articles

Depersonalization, Mindfulness, and Childhood Trauma

Depersonalization (DP), i.e., feelings of being detached from one's own mental processes or body, can be considered as a form of mental escape from the full experience of reality. This mental escape is thought to be etiologically linked with maltreatment during childhood. The detached state of consciousness in DP contrasts with certain aspects of mindfulness, a state of consciousness characterized by being in touch with the present moment. Against this background, the present article investigates potential connections between DP severity, mindfulness, and childhood trauma in a mixed sample of nonpatients and chronic nonmalignant pain patients. We found a strong inverse correlation between DP severity and mindfulness in both samples, which persisted after partialing out general psychological distress. In the nonpatient sample, we additionally found significant correlations between emotional maltreatment on the one hand and DP severity (positive) and mindfulness (negative) on the other. We conclude that the results first argue for an antithetical relationship between DP and certain aspects of mindfulness and thus encourage future studies on mindfulness-based interventions for DP and second throw light on potential developmental factors contributing to mindfulness.

Home visits by specially trained nurses after discharge from multi-disciplinary pain care: A cost consequence analysis based on a randomised controlled trial

Objectives To analyse the cost consequences of a nurse follow-up intervention for chronic non-malignant pain patients discharged from multidisciplinary pain treatment. Methods The cost consequence analysis was based on a prospective, randomised controlled trial where 102 consecutive patients were randomised to either an intervention group ( n = 52) or a control group ( n = 50). During the 2-year intervention period, nurses visited patients every 4th month (7 times in total). Changes in health status were measured by the 8 SF-36 sub-scales. Intervention costs were based on prospective registrations of nurses’ time use. Data on health care cost and resource use were collected retrospectively from administrative registers. Results No statistically significant differences in health status were observed between the two groups after the 2-year intervention period. The cost of the nurse intervention programme itself was 35,000€ (2004-prices). The average cost per patient was estimated at 668€ per patient. During the observation period the average patient in the intervention group used other health care resources worth 4004€, while the average patient in the control group used 7464€. This difference (3460€, 46%) was not statistically significant. Conclusion The nurse intervention did not significantly influence patients’ health status. Patients in the intervention group tended to use fewer health care resources than those in the control group and the cost of the intervention was more than balanced out by savings in other health care resources.

(942): Examining Texas family physicians’ attitudes and beliefs toward prescribing long-acting opioids for chronic non-malignant pain

Treatment of moderate to severe chronic nonmalignant pain (CNMP) is a challenge for both the patient and health care provider. Conflicting information exists regarding the appropriate use of opioids for CNMP, and many primary care physicians (PCPs) are reluctant to prescribe long-acting opioids to CNMP patients. Further, preexisting PCP beliefs may act as barriers to prescribing long-acting opioids. This study examined PCPs’ attitudes toward prescribing long-acting opioids to patients with moderate to severe CNMP using a theoretical social cognition model (theory of planned behavior).

Efficacy of Interdisciplinary Treatment for Chronic Nonmalignant Pain Patients in Japan

Efficacy of Interdisciplinary Treatment for Chronic Nonmalignant Pain Patients in Japan

Breakthrough pain in opioid-treated chronic non-malignant pain patients referred to a multidisciplinary pain centre: a preliminary study

Breakthrough pain (BTP) has not formerly been discussed as such in chronic non-malignant pain patients referred to pain centres and clinics. The purpose of the study was to investigate the prevalence, characteristics and mechanisms of BTP in opioid-treated chronic non-malignant pain patients referred to a pain centre and to assess the short-term effects of pain treatment. Patients were assessed at referral (T(0)) and after a treatment period of 3 months (T(3)) using the visual analogue scale (VAS) of the brief pain inventory (BPI) within somatic nociceptive, neuropathic and/or visceral pain conditions, the mini mental state examination (MMSE) and the hospital anxiety and depression scale (HADS). The main treatment intervention from T(0) to T(3) was to convert short-acting oral opioids to long-acting oral opioids and to discontinue on demand and parenteral use of opioids. Thirty-three patients were assessed at T(0) and 27 at T(3). The prevalence of BTP declined significantly from T(0) (90%) to T(3) (70.4%). Worst, least, average and current pain intensities as well as duration of BTP were significantly reduced from T(0) to T(3.) The majority of BTPs were exacerbation of background pain assumed to be of the same pain mechanisms. High average pain intensity (BPI) was significantly associated with high scores for both anxiety and depression (HADS). BTP in chronic non-malignant pain patients seems to be surprisingly frequent and severe. Stabilizing the opioid regimen seems to reduce pain intensity in general as well as the intensity and duration of BTP. Average pain intensity was associated with anxiety and depression.

Efficacy of Interdisciplinary Treatment for Chronic Nonmalignant Pain Patients in Japan

The implementation of interdisciplinary pain management is a relatively new concept in Japan. Although there are more than 4200 pain specialists in Japan at present, no multidisciplinary pain center has yet to be established. This prospective study is, to our knowledge, the first published evaluation of the effectiveness of multidisciplinary/interdisciplinary pain treatment in Japanese patients with chronic noncancer pain. Ninety-nine patients with chronic noncancer pain were treated by an interdisciplinary approach in a Japanese outpatient pain clinic. Treatment was on the basis of the biopsychosocial model of pain and consisted of the following components: (1) education; (2) exercise and stretch; (3) long-term and short-term goal setting; (4) medication management; and (5) cognitive and behavioral techniques for problem solving and changing maladaptive behaviors. Each treatment session was 30 minutes and was held once every 1 to 3 weeks for 8 to 12 times according to the patients' progress and availability. The patients were assessed before and 2 to 4 weeks after the treatment. Results showed (1) 68.9% of patients reported a significant decrease in pain, (2) 92.0% stopped using inappropriate medication including nonsteroidal anti-inflammation drugs, benzodiazepines and muscle relaxants, (3) 51.4% underwent their usual daily activities without being disturbed by pain, and (4) 75.0% who had been unemployed because of pain returned to work. Overall, the treatment succeeded in 56.8% of the patients. Our results suggest that an interdisciplinary treatment based upon the biopsychosocial model of pain was associated with significant improvement in multiple outcomes in this sample of Japanese patients with chronic pain.

Opioid Switching from Morphine to Methadone Causes a Minor But Not Clinically Significant Increase in QTc Time: A Prospective 9-Month Follow-Up Study

Case reports and retrospective studies suggest that methadone causes an increase in QTc (QT time corrected for heart rate) time and risk of torsades de pointes arrhythmia. No prospective studies in pain patients have been conducted, and data on whether a methadone-induced increase in QTc time persists during long-term treatment have not been reported. Eight chronic nonmalignant pain patients experiencing insufficient pain control or intolerable side effects during treatment with oral morphine switched to oral methadone and were included in this study. Electrocardiograms were obtained at baseline and at follow-up 2 weeks, and 3 and 9 months after the opioid switch. Start of methadone caused a minor but statistically significant increase in QTc time, while fluctuations in QTc during treatment with stable doses of methadone were neither clinically nor statistically significant. We observed no episodes of arrhythmias.

The Influence of Discordance in Pain Assessment on the Functional Status of Patients with Chronic Nonmalignant Pain

Chronic pain is a frequent cause of suffering and disability that seriously affects patients' quality of life and imposes a staggering socioeconomic toll on society. Little is known about the impact of patient-physician disagreement (discordance) regarding the assessment of chronic pain on patients' quality of life in primary care settings. This study evaluates the role of discordance and other potentially modifiable factors that affect the quality of life and functional status of chronic pain patients. We evaluated 436 patient-physician encounters at 12 academic medical centers in the United States. We surveyed chronic nonmalignant pain patients to understand their pain perceptions. We concurrently surveyed their physicians about their perceptions of their patient's pain in primary care settings. More than 50% of physicians disagreed with their patient's pain. Thirty-nine percent of primary care physicians underestimated their patient's pain. In the multivariate analysis, this discordance was associated with poor physical functioning and worse bodily pain (P < 0.018 and P < 0.001 respectively). Patients with chronic, nonmalignant pain have reductions in physical function and bodily pain domains of the SF-36 compared to age-matched populations. Depression and obesity represented other associations. Patients with chronic nonmalignant pain have poor physical functioning and worse bodily pain. Discordance, obesity, and depression are other modifiable factors. Prospective studies are needed to design interventions. However, a multifaceted approach appears to represent the best opportunity to reduce the pain and suffering of this challenging population.

Effect of chronic nonmalignant pain on highway driving performance

Most pain patients are treated in an outpatient setting and are engaged in daily activities including driving. Since several studies showed that cognitive functioning may be impaired in chronic nonmalignant pain, the question arises whether or not chronic nonmalignant pain affects driving performance. Therefore, the objective of the present study was to determine the effects of chronic nonmalignant pain on actual highway driving performance during normal traffic. Fourteen patients with chronic nonmalignant pain and 14 healthy controls, matched on age, educational level, and driving experience, participated in the study. Participants performed a standardized on-the-road driving test during normal traffic, on a primary highway. The primary parameter of the driving test is the Standard Deviation of Lateral Position (SDLP). In addition, driving-related skills (tracking, divided attention, and memory) were examined in the laboratory. Subjective assessments, such as pain intensity, and subjective driving quality, were rated on visual analogue scales. The results demonstrated that a subset of chronic nonmalignant pain patients had SDLPs that were higher than the matched healthy controls, indicating worse highway driving performance. Overall, there was a statistically significant difference in highway driving performance between the groups. Further, chronic nonmalignant pain patients rated their subjective driving quality to be normal, although their ratings were significantly lower than those of the healthy controls. No significant effects were found on the laboratory tests.

10-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life and health care utilization

Background In Denmark, opioids have been used liberally for many years in the treatment of non-malignant pain, but long-term consequences as tolerance and influence on health related quality of life remain unknown. Aim Adherence to medical treatment, opioid dose escalation, health related quality of life, anxiety, depression, coping strategies and health care utilization were evaluated in chronic pain patients 10 years after treatment in a multidisciplinary pain centre. Methods Information was gathered from medical records, postal questionnaires and a central hospital register. Results Opioid dose escalation occurred in only a few patients. Increase and decrease in opioid dose were almost equally frequent. Sixty percent of those discharged on long acting opioids were still on that treatment at follow-up. Twenty-eight percent of the patients initiated opioid treatment after discharge from the pain centre. Occupational status was identified as a determining factor for future opioid use. Opioid users had a lower health related quality of life, higher occurrence of depression and more frequent use of coping strategies like ‘Catastrophizing’ and ‘Hoping and Praying’. Adjuvant analgesics were highly discontinued. Multidisciplinary pain treatment reduced the number of hospital admissions and in-hospital days. Conclusion We recommend that future research on opioid treatment does not only focus on biological issues. The effect of opioids needs to be viewed in a much more complex context where consequences like health related quality of life, depression and the role of various coping strategies are included.

Exploratory principle components analysis of the Pain Medication Attitudes Questionnaire

The Pain Medication Attitudes Questionnaire (PMAQ) is composed of seven scales assessing attitudes and beliefs of chronic non-malignant pain patients towards their use of pain medications. Scale development integrated items derived from the literature, pain clinicians, and patient focus groups. Item and scale analyses resulted in a 47-item measure assessing 7 pain medication attitudes: addiction, unfavourable scrutiny, side effects, tolerance, withdrawal, perceived need, and mistrust of doctors.

Neuropsychological assessment of chronic non-malignant pain patients treated in a multidisciplinary pain centre

The aim of the study was to investigate the influence of pain, sedation, pain medications and socio-demographics on cognitive functioning in chronic non-malignant pain patients. Chronic non-malignant pain patients ( N = 91) treated in a multidisciplinary pain centre were compared with age and sex matched healthy volunteers ( N = 64). Furthermore four subgroups of patients were examined: Group 1 ( N = 21) received no pain medications, group 2 ( N = 19) were in long-term oral opioid treatment, group 3 ( N = 18) were treated with antidepressants and/or anticonvulsants and group 4 ( N = 33) were treated with a combination of long-term oral opioids and antidepressants and/or anticonvulsants. Assessments comprised pain (PVAS) and sedation (SVAS), Continuous Reaction Time (CRT) testing for sustained attention, Finger Tapping Test (FTT) testing for psychomotor speed, Paced Auditory Serial Addition Task (PASAT) testing for information processing and working memory and Mini Mental State Examination (MMSE). CRT and FTT were impaired in the total patient sample. Treatment with opioids was associated with poorer performance of PASAT. High scores of PVAS and SVAS were associated with poor performance of PASAT and CRT, respectively. MMSE seems to be too insensitive for detecting the milder forms of cognitive impairment found in chronic non-malignant patients.

Intrathecal opioid treatment for chronic non-malignant pain: a 3-year prospective study

Intrathecal (IT) opioid therapy is a treatment alternative for patients with severe chronic non-malignant pain. Several uncontrolled retrospective and prospective outcome studies have suggested a benefit in chronic non-malignant pain patients, but uncertainties about patient selection in these studies weaken the results. This study evaluated long-term outcome of IT opioid therapy in chronic non-malignant pain prospectively, and included two comparative groups to improve understanding of selection criteria and relative severity of intrathecal pump recipients (PRs). The study subjects included 38 PRs while the comparative groups included 31 intrathecal candidates who either had an unsuccessful trial, or declined the IT therapy, and another group of 41 newly referred patients. The following data were analyzed at study entry, and at 6 monthly intervals for a 3-year period: Symptom Check List 90 (SLC-90), SF-36 Health survey, Beck Depression Inventory, McGill Pain Questionnaire (short form), Oswestry Disability Index, Pain Drawings and Pain rating on visual analogue scale. Data analysis suggests the study group of PRs had improvements in pain, mood, and function from baseline to 36 months. These same parameters improved among new referrals (less severe patients receiving conservative pain management) while non-recipients significantly worsened. Although PRs improved, they were still worse off at 36 months than new referrals were at baseline. The study showed that when patients with extremely severe pain problems are selected as pump candidates, they will likely improve with the therapy, but their overall severity of pain and symptoms still remains high.

Intrathecal opioid treatment for chronic non-malignant pain: a 3-year prospective study

Intrathecal (IT) opioid therapy is a treatment alternative for patients with severe chronic non-malignant pain. Several uncontrolled retrospective and prospective outcome studies have suggested a benefit in chronic non-malignant pain patients, but uncertainties about patient selection in these studies weaken the results. This study evaluated long-term outcome of IT opioid therapy in chronic non-malignant pain prospectively, and included two comparative groups to improve understanding of selection criteria and relative severity of intrathecal pump recipients (PRs). The study subjects included 38 PRs while the comparative groups included 31 intrathecal candidates who either had an unsuccessful trial, or declined the IT therapy, and another group of 41 newly referred patients. The following data were analyzed at study entry, and at 6 monthly intervals for a 3-year period: Symptom Check List 90 (SLC-90), SF-36 Health survey, Beck Depression Inventory, McGill Pain Questionnaire (short form), Oswestry Disability Index, Pain Drawings and Pain rating on visual analogue scale. Data analysis suggests the study group of PRs had improvements in pain, mood, and function from baseline to 36 months. These same parameters improved among new referrals (less severe patients receiving conservative pain management) while non-recipients significantly worsened. Although PRs improved, they were still worse off at 36 months than new referrals were at baseline. The study showed that when patients with extremely severe pain problems are selected as pump candidates, they will likely improve with the therapy, but their overall severity of pain and symptoms still remains high.

Other: Opioid-induced bowel dysfunction: a survey of prevalence and risk factors in chronic non-malignant pain patients

Other: Opioid-induced bowel dysfunction: a survey of prevalence and risk factors in chronic non-malignant pain patients

Opioids in non-cancer pain: Impact of a medication management program on the functionality of individuals with severe chronic non-malignant pain

A medication management program was designed to treat complex chronic non-malignant pain patients. All patients were referred by General Practitioners and treated under a publicly funded health care system. GP referral was accepted if there were concerns regarding level of functioning, medication dose, safety or addiction. The referral source agreed to reaccept patient care once concerns were adequately addressed and medications stabilized. A multidisciplinary pain clinic in Edmonton, Canada. The study period was from March 2000 to April 2003. There were no exclusion criteria except patients must be ≥18 years of age. Patients with co-morbid conditions such as addiction and psychiatric illness were included. Following physician assessment a treatment plan was developed by the management team. The team consisted of an addiction medicine consultant, internist, pharmacist, and registered nurse. All patients were managed with substitution or institution of long acting or continuous release opioids. Medication was titrated to function. Short acting opioids for break through pain were minimized. When addiction and psychiatric screening identified co-morbidities, additional appropriate therapies were started. Urine screens were done on each patient and monitored according to risk factors. A 15 dimensional HRQOL instrument (15D) measured the functional outcome of the program. Emergency Room (ER) utilization was assessed via faxed updates from local ER’s. Of 58 patients, 57 had complete answers to the 15D. Functional improvement was statistically and clinically significant as measured. ER utilization was controlled or reduced. Patients were successfully transferred back to the referral source 71.5% of the time. The specific pain program significantly improved functionality as measured by the 15D. The functional improvement measured by the 15D was greater than that obtained by a patient undergoing a knee replacement.

Diagnostic subgroups and psychosocial characteristics in chronic non-malignant pain patients referred to an out-patient pain center

The purpose of this study is to describe an out-patient Pain Center population on the basis of IASP Classification of Chronic Pain. Furthermore, the study investigates the relationship between diagnostic subgroups of chronic non-malignant pain patients and psychosocial parameters. The average age of the patients was 42 and the mean age at the onset of pain was 34.2. In the present study about x of all the patients had severe pain with a duration of 48 months (median value), patients with dysfunctional pain, one of three diagnostic subgroups, had a significantly longer pain duration (80 months). Nearly (1/3) of all patients are not able to work regularly and 85 % felt impaired in their daily work activities. Nearly (1/3) of the patients without any somatic pathological findings had at least one invasive intervention, just like the patients in the other diagnostic subgroups, and the need-controlled pain medication reached its highest level in this group (45 %). Only 19 % of the 323 patients investigated had nociceptive-neuropathic pain complaint, whereas 53 % were suffering from dysfunctional, and 28 % had a somatoform pain disorder. So, in patients suffering from chronic pain, simultaneous somatic and psychic or psychosomatic diagnostics are indispensable due to the relevance of psychic and psychosocial factors to pain genesis, modulation and persistence. For patients in each of the described subgroups additional psychological factors such as attitudes, beliefs, self-efficacy, fear-avoidance beliefs and motivational factors always have a significant influence on the persistence of chronic pain syndromes. So, as a rule, to make a reliable diagnosis and to give a profound prognosis for the course of treatment, a close interdisciplinary cooperation is required.

Chronic non-malignant pain patients and health economic consequences

A prospective cohort study on chronic non-malignant pain patients was performed to describe health consequences and changes in use of health care resources and social transfers following multidisciplinary pain treatment. Patients, referred to a Danish Multidisciplinary Pain Center (MPC), were evaluated during four periods: six months prior to referral, waiting list period, intervention, nine months follow-up. Outcome measures: pain intensity (VAS), The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), The Psychological General Well-Being Index (PGWB), The Hospital Anxiety and Depression Scale (HAD). Use of health care resources and social transfers were retrieved from public registers. Statistically significant improvements were obtained in pain intensity, SF-36 bodily pain, PGWB index and subscores vitality, and general health at discharge and follow-up. Intervention costs amounted to EUR 1102 (SD 721). Health care costs were not significantly reduced, but significant reductions in social transfers were seen.

Chronic non-malignant pain patients and health economic consequences

Chronic non-malignant pain patients and health economic consequences

Individual choice of opioids and formulations: strategies to achieve the optimum for the patient.

The role of opioid therapy in chronic musculoskeletal disease continues to be controversial. However, recent years have seen a gradual shift towards the use of opioid therapy in chronic non-malignant pain (CNMP) following recognition that at least a subpopulation of such patients appears to benefit from long-term opioid treatment. Misconceptions about opioids and the associated risk of dependence stemmed from older research that was fundamentally flawed. More recent, rigorous research has yielded clearer statistics on opioid dependence and has highlighted the need for screening to identify individuals who may require closer monitoring during long-term opioid therapy. Controlled-release formulations (oral and transdermal) for the management of steady pain, in conjunction with fast-acting, immediate-release formulations for the management of breakthrough pain, may be available for a wide range of opioid analgesics, providing comprehensive therapy systems for use in CNMP. However, there are no universal criteria that can be confidently used to select CNMP patients who might profit from or be responsive to opioid therapy. Opioid treatment must therefore be individualised for each patient, based on a clear understanding of drug absorption, metabolism, toxicity and binding characteristics, using opioid switching strategies where appropriate. Practical guidelines for opioid therapy in CNMP include regular and systematic checks of treatment results to adjust therapy for each individual patient and to ensure optimum benefit.