Chronic Non-malignant Pain Patients Research Articles

Screening for problematic prescription opioid use.

The proper medicinal use of opioids, in light of their notorious history and current relation to social ills, continues to be debated and remains unclear in several areas of medicine. This article will review several areas and points of controversy related to screening for potential problematic opioid behavior in chronic nonmalignant pain patients. Controversy over the prescription of opioids for chronic nonmalignant pain continues, despite the growing acceptance of this practice. Indeed, past research supports the beneficial use of opioids for noncancer pain. Unfortunately, traditional definitions of abuse and dependence, with their emphasis on tolerance and withdrawal, are inappropriate for chronic pain patients prescribed opioids. The component of traditional definitions of abuse and dependence that appears most applicable to chronic pain patients centers on the criterion that the patient continue to take the drug (in this case, the opioid) despite negative and harmful effects or despite any decrease in pain level. Although clinical observations exist about risk factors for opioid misuse in chronic pain patients, there is limited research. Further, the area of prescreening for problematic drug behavior is in its infancy. However, researchers have begun to delve into this challenging area and the application of rigorous empirical research will bring us closer to identifying those patients at risk so that their pain is managed without destructive outcomes in other areas of their life.

PPN4: UTILITY ASSESSMENTS OF OPIOID TREATMENT IN THE US, CANADA AND AUSTRALIA FOR PATIENTS WITH CHRONIC NON-MALIGNANT PAIN

BACKGROUND: Optimal treatment for chronic non-malignant pain (CNMP) is largely a function of patient preferences in balancing pain control with treatment tolerability. OBJECTIVE: To estimate utilities for health states associated with CNMP and its treatment with opioids. METHODS: 96 CNMP patients (31 Canadian, 33 US, 32 Australian) completed the SF-36TM and assessed health state descriptions and their own current health using the visual analog scale and computer-assisted adaptive conjoint analysis (ACA). The health state descriptions included combinations of: presence/absence of 7 side effects (3 severity levels for each); pain control (5 severity levels); and 2 opioid administration routes. RESULTS: On average, subjects were 47 (±13) years, white (95%), female (63%), not living alone (74%), and unemployed (74%). Approximately 75% of subjects in each country were currently experiencing mild to moderate pain; most had arthritic or low back pain. All SF-36TM subscale scores by country were significantly lower than US age- and gender-equivalent norms (p < 0.05). Mean utilities did not vary substantially between oral vs. transdermal opioid administration. Overall, mean (±SE) utilities ranged from a maximum of 0.87 ± 0.02 (no pain or side effects) to a minimum of 0.18 ± 0.02 (uncontrolled pain with severe respiratory depression or severe vomiting). Mean utilities for controlled pain with moderate side effects ranged from 0.62 ± 0.02 (mood changes, vomiting, or respiratory depression) to 0.74 ± 0.02 (sweating). Uncontrolled pain without side effects (0.64 ± 0.02) was preferred to well-controlled pain with severe side effects (range: 0.41 ± 0.03 [mood changes, vomiting, or respiratory depression] to 0.54 ± 0.03 [sweating]). CONCLUSIONS: Results indicate a patient preference for opioid therapy that causes fewer side effects. Although pain may be extremely debilitating, tolerating pain to avoid opioid side effects may be preferable to controlling pain and experiencing certain opioid side effects. Opioid side effects combined with poorly-controlled pain may result in very low health utility.

Multidisciplinary treatment of chronic pain patients: Its efficacy in changing patient locus of control

Coughlin AM, Badura AS, Fleischer TD, Guck TP. Multidisciplinary treatment of chronic pain patients: its efficacy in changing patient locus of control. Arch Phys Med Rehabil 2000;81:739-40.Objective: To assess the efficacy of multidisciplinary treatment in altering chronic pain patient locus of control beliefs.Design: A before-and-after treatment design including demographics.Participants: Seventy-three chronic nonmalignant pain patients who completed study questionnaires both before and after treatment.Setting: Comprehensive, outpatient, multidisciplinary pain management program at a large Midwestern university medical center.Main Outcome Measures: Pain Locus of Control Scale and Survey of Pain Attitudes Control subscale.Results: Patients' perception of personal control over pain increased from pretreatment to posttreatment, and patients' perceptions of external control over pain, such as fate or powerful others, decreased from pretreatment to posttreatment.Conclusions: This study supports the efficacy of chronic pain management centers in altering patient beliefs about pain. The ability to increase patients' self-efficacy in their control over pain and to decrease external attributions are essential to successful pain management.

(642) The Impact of Depression on Health Resource Utilization for Chronic Nonmalignant Pain Patients

(642) The Impact of Depression on Health Resource Utilization for Chronic Nonmalignant Pain Patients

Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: a randomised controlled trial

This randomised controlled study investigated the effect of outpatient multidisciplinary pain centre treatment (MPT) compared with treatment by a general practitioner after initial supervision by a pain specialist (GP-group) and with a group of patients waiting for 6 months before treatment was initiated (WL-group). One-hundred-and-eighty-nine chronic non-malignant pain patients were studied. At referral, and after 3 and 6 months patients filled in questionnaires evaluating pain intensity, health related quality of life (HRQL) and use of analgesics. HRQL was evaluated using the Medical Outcome Study-Short Form (SF-36), the Hospital Anxiety and Depression scale (HAD) and the Psychological General Well-being Scale (PGWB). After 6 months patients allocated to MPT (n=63) reported statistically significant reduction in pain intensity (VAS-score, P<0.001), improvement in psychological well-being (PGWB, P<0.001), quality of sleep (P<0.05) and physical functioning (SF-36-Phycical Functioning, P<0.05). No improvements were seen in the GP-group (n=63). In the WL-group (n=63) a statistically significant deterioration was observed in PGWB-scores, HAD-scores and in 6 of 8 SF-36-subscores (P ≤ 0.05). A reduction in use of opioids administered on demand was obtained in the group receiving MPT (P<0.001). In the MPT- and GP-groups a decrease in the use of short acting opioids was observed (P<0.01). No change in use of analgesics was seen in the WL-group. The study showed that (i) in the MPT-group there was a significant reduction in pain intensity and improvement of HRQL compared to the WL-group, and (ii) the mere establishment of a pain diagnosis and a pain management plan by a pain specialist was not sufficient to enable the referring GP to manage severely chronic pain patients.

Impaired Neuropsychological Performance in Chronic Nonmalignant Pain Patients Receiving Long-Term Oral Opioid Therapy

The study investigated neuropsychological performance in chronic nonmalignant pain patients receiving long-term oral opioid therapy. Forty patients treated solely with regular and stable doses of an oral opioid were compared with 40 healthy volunteers. The patients received daily opioid doses of 15–300 mg of oral morphine (median: 60 mg) or equianalgesic doses of other opioids. The neuropsychological tests consisted of continuous reaction time (CRT), which measured vigilance/attention; finger tapping test (FTT), which measured psychomotor speed; and paced auditory serial addition task (PASAT), which measured working memory. Three months after the study had been carried out, 14 of the controls were retested in order to determine the reliability of the three tests. The patients performed statistically significantly poorer than the controls in all the tests. Significantly positive correlations were found between the PASAT and pain visual analogue scales (VAS). In the retesting of 14 controls, it was found that the tests showed high reliability. Vigilance/attention, psychomotor speed, and working memory were significantly impaired in chronic nonmalignant pain patients. The present study cannot determine which factors influenced the test results, but pain itself seemed to have an arousal effect on working memory.

The Medication Quantification Scale: measurement of medication usage at a multidisciplinary pain center

Program evaluation standards require pain centers to assess medication use as one of an array of outcome criteria. The Medication Quantification Scale (MQS) has been introduced as a continuous method for quantifying medication use in chronic nonmalignant pain patients that overcomes methodological concerns inherent in previous pain medication measures. The reliability and sensitivity to program effects of the MQS was demonstrated by the original authors. The present study reexamined the reliability and sensitivity, and provided evidence for the validity of the MQS in an effort to determine whether use of the MQS can be generalized to other pain centers. Interrater reliability between two nurses on 40 pretreatment and 40 6-month follow-up MQS scores were .958 (p < .0001) and .968 (p < .0001) respectively. Six month follow-up MQS scores were significantly lower than pretreatment MQS scores (t = 5.40, p < .0001) for 106 chronic nonmalignant pain patients treated at a multidisciplinary pain center. Convergent and divergent validity of the MQS were demonstrated by higher correlations between the MQS and conceptually similar rather than dissimilar outcome measures. The reliability, sensitivity, and validity of the MQS was demonstrated suggesting it can be generalized for program evaluation purposes to other pain centers.

Sociodemographic predictors of treatment outcome in chronic non-malignant pain patients. Do patients receiving or applying for Disability Pension benefit from multidisciplinary pain treatment?

The present study investigated the ability of sociodemographic variables to predict the short-term effect of multidisciplinary pain treatment in 286 chronic non-malignant pain patients consecutively referred to a Danish multidisciplinary pain centre. At inclusion and 3 and 6 months later the patients' pain and health related quality of life (HRQL) was assessed using self-administered questionnaires. Sociodemographic variables measured were: age, gender, educational level, civil status, employment status and disability pension (DP) status. Intensity of pain was measured using a VAS scale. HRQL was evaluated using the Medical Outcome Study-Short Form (SF-36) and the Psychological General Well-Being Scale (PGWB). Drop out was 30% after 6 months, leaving 170 patients for the study of treatment effects. Among the sociodemographic variables evaluated only retirement pension (RP) and DP-status seemed to be significant outcome predictors: six months after inclusion, patients on RP (patients >68 years, n=40) reported larger pain reduction (30 mm on the VAS scale) than patients ≤68 years (8 mm on the VAS scale)( P=0.001). Patients applying for DP-pension ( n=26) did not improve. Patients on DP ( n=54) and patients not receiving DP ( n=50) obtained moderate improvements, but the improvements were significantly larger than the improvements observed in the ApplyDP-group ( P=0.05). The same pattern was seen for changes in psychological well-being (PGWB) and social functioning (SF36-SFA). No improvements were obtained in SF36-Physical functioning scores. DP-status predicted improvement in pain and social functioning even when controlling for the effect of other demographic variables, pain intensity and HRQL at referral. The present study indicates that the multidimensional problems experienced by patients applying for DP are dominated by socioeconomic factors. Focus on solving these socioeconomic problems is important if chronic pain patients are to benefit from multidisciplinary pain treatment.

Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center

This paper presents the results of a detailed study of the pain epidemiology and health related quality of life (HRQL) in 150 chronic non-malignant pain patients consecutively referred to a Danish multidisciplinary pain center. Mean pain severity was 71.6 (SD=18.5) on the VAS scale. Forty-two percent reported poor quality of sleep. HRQL was evaluated with the Medical Outcome Study-Short Form (SF-36), the Hospital Anxiety and Depression scale (HAD) and the Psychological General Well-Being Scale (PGWB). Compared with the normal population (NP) both SF-36 scores and PGWB scores were significantly reduced ( P<0.001) indicating that physical, psychological and social well-being were severely reduced. On the HAD scale 58% were found to have a depressive or anxiety disorder. Statistically significant but modest correlations were found between pain severity and HRQL. Psychological and social well-being was closely correlated. Sixty-three percent of the referred patients had neurogenic pain conditions. Of these, only 25% were treated with antidepressants or anticonvulsants at referral. Seventy-three percent were treated with opioids at referral. Mean opioid consumption was 64 mg of morphine per day (range 1–280 mg). Compared with the NP the chronic pain patients had used the health care system five times more often in the years prior to referral ( P<0.001). The study confirms the severe multidimensional impact of chronic pain and demonstrates that HRQL of chronic non-malignant pain patients is among the lowest observed for any medical condition.

Intraspinal opioid therapy for chronic nonmalignant pain: Current practice and clinical guidelines

The multidimensional nature of chronic nonmalignant pain lends itself to numerous treatment options, which vary in cost and invasiveness. Based on the principle that use invasive and less costly interventions for pain treatment should be attempted first, a continuum of interventions for chronic pain states is presented. Although intraspinal opioid therapy is a relatively invasive and costly modality for pain treatment, it has a rational place in the treatment continuum for some chronic nonmalignant pain patients. A through review of the literature, supplemented by clinical experience, provides a foundation for the development of management guidelines.

Survey of Opioid Use in Chronic Non-Malignant Pain Patients

Survey of Opioid Use in Chronic Non-Malignant Pain Patients