Chronic Pain Management Program Research Articles

Topical Review: Pain in Survivors of Pediatric Cancer: Applying a Prevention Framework

To apply a biopsychosocial framework to understand factors influencing pain in survivors of pediatric cancer to inform pain prevention efforts and highlight the need for interdisciplinary care. This topical review draws from both pediatric cancer survivorship research and chronic noncancer pain research to illustrate how components of a preventative model can be applied to pain in survivorship. Pain is a common experience among long-term survivors of pediatric cancer. The pain experience in survivorship can be conceptualized in terms of biological disease and treatment factors, cognitive and affective factors, and social and contextual factors. We review literature pertinent to each of these biopsychosocial factors and tailor an existing public health prevention framework for pain in survivors of pediatric cancer. Classifying survivors of pediatric cancer into pain risk categories based on their daily experiences of pain, pain-related functional impairment, and distress could help guide the implementation of pain-related prevention and intervention strategies in this population. Future research is needed to establish the efficacy of screening measures to identify patients in need of psychosocial pain and pain-related fear management services, and interdisciplinary pediatric chronic pain management programs in survivors of pediatric cancer.

Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain

Background and aimsTrait behavioral inhibition represents a tendency to react with negative emotions – primarily worry – to cues which signal potential threats. This tendency has been hypothesized by a two-factor model of chronic pain to have direct effects on psychological and physical function in individuals with chronic pain, as well as to influence the associations between pain-related maladaptive cognitions and function. Our aim was to test these hypothesized associations in a sample of individuals who were being screened for possible interdisciplinary chronic pain treatment. MethodsEighty-eight patients referred to an interdisciplinary chronic pain management program were administered measures of average pain intensity, trait behavioral inhibition, kinesiophobia, pain catastrophizing, depressive symptoms, and pain interference. We then performed two linear regression analyses to evaluate the direct effects of trait behavioral inhibition on depressive symptoms and pain interference and the extent to which behavioral inhibition moderated the associations between kinesiophobia and pain catastrophizing, and the criterion variables. ResultsIn partial support of the study hypotheses, the results showed significant (and independent) direct effects of trait behavioral inhibition on depressive symptoms, and behavioral inhibition moderated the association between kinesiophobia and depression, such that there were stronger associations between kinesiophobia and depressive symptoms in those with higher dispositional sensitivity to fear-inducing stimuli. However, neither direct nor moderating effects of behavioral inhibition emerged in the prediction of pain interference. ConclusionsIf replicated in additional studies, the findings would indicate that chronic pain treatments which target both reductions in maladaptive cognitions (to decrease the direct negative effects of these on depressive symptoms) and the individual's tendency to respond to pain with worry (as a way to buffer the potential effects of maladaptive cognitions on depressive symptoms) might be more effective than treatments that targeted only one of these factors. ImplicationsAdditional research is needed to further evaluate the direct and moderating effects of pain-related behavioral inhibition on function, as well as the extent to which treatments which target behavioral inhibition responses provide benefits to individuals with chronic pain.

Beliefs About a Complementary and Alternative Therapy-Based Chronic Pain Management Program for a Medicaid Population.

Rhode Island Medicaid offers high emergency department utilizers the opportunity to take part in the Chronic Pain Program, an integrated treatment approach that includes free complementary therapies (massage, chiropractic, and acupuncture). The aim of the current analysis was to understand beliefs about the Rhode Island Chronic Pain Program from the perspective of the patient receiving services, the provider delivering services, and the administrator implementing the program. A qualitative interview-based study. Patients (N = 24), providers (N = 13), and administrators (N = 11) who were already involved, or were eligible to be involved, in the Chronic Pain Program. Semistructured interviews were conducted to elicit information about experiences with the program. Transcriptions of audio recordings were analyzed according to principles of deductive thematic analysis. Patient interviews revealed five themes: 1) relationship between stress and pain, 2) trusting patient-provider relationships, 3) increased quality of life, 4) temporary pain relief, and 5) anxiety and discomfort associated with acupuncture. Provider interviews revealed three themes: 1) a way to reach the disenfranchised, 2) not enough visits with patients, and 3) opportunity to build relationships with patients. Administrator interviews revealed two themes: 1) a means to offer a range of support services to complicated patients and 2) unanswered questions over whether the program adequately serves patients with the greatest needs. Key stakeholders in this new initiative agree that the Rhode Island Chronic Pain Program shows promise and that the holistic approach may be a good match for this hard-to-reach population.

The pain course: a randomised controlled trial comparing a remote-delivered chronic pain management program when provided in online and workbook formats

This study compared a remote-delivered pain management program, the Pain Course, when delivered in online and workbook formats. Participants (n = 178) were randomised into 2 groups: (1) an Internet Group (n = 84) who were provided with secure accounts to the program in an online format; or (2) a Workbook Group (n = 94) who were mailed workbook versions of the program. The content of both programs was identical and comprised 5 core lessons, which participants were encouraged to work through over an 8-week period, according to a prescribed timetable. All participants were provided with weekly contact with a clinical psychologist through email and telephone throughout the program. The overall findings suggest that the workbook format was no less effective or acceptable than the validated online format. Significant improvements (avg. improvement; Internet Group vs Workbook Group) in levels of disability (PDI: 16% vs 24%; RMDQ: 12% vs 15%), anxiety (GAD-7: 36% vs 26%), and depression (PHQ-9: 36% vs 36%) were observed in both groups immediately posttreatment. Further improvements were observed in disability levels to 3-month follow-up, and improvements across the other primary outcomes were maintained until 12-month follow-up. High treatment completion rates and levels of satisfaction were reported in both groups, and both groups required a similarly small amount of clinician contact per participant (M = 74.85 minutes; SD = 41.03). These results highlight the public health potential of remote-delivered pain management programs, delivered in either workbook or online formats, as methods of increasing access to pain management.

Falsely Low Urine Δ9-Tetrahydrocannabinol COOH Levels from Metal Lid Specimen Containers with a Low-Density Polyethylene Lining.

To the Editor: Our laboratory offers a multianalyte LC-MS/MS urine drug testing panel to assist with compliance monitoring for patients enrolled in chronic pain management programs (1). Recently, we investigated switching from a plastic-only urine collection container (Globe Scientific; item number: 6220) to a metal lid type (Covidien; item number: 2200SA). Both of the containers, not including the lids, were composed of polypropylene. Low-density polyethylene (LDPE)1 lined the inside of the metal lid to ensure a secure fit when closed. The plastic-only container did not have a liner. The quantitative influence of the specimen container was originally investigated by splitting spiked urine specimens and inverting the metal lid container …

The suffering of chronic pain patients on a wait list: Are they amenable to narrative therapy?

ABSTRACTBackground: Chronic pain affects one in five Canadians. People with chronic pain frequently experience loss in their lives related to work, relationships, and their independence. They may be referred to a chronic pain program, which aims to strengthen coping through medical intervention and self-management skills. Data suggest that, even when individuals begin their pain program, many feel overwhelmed and do not continue.Aims: The aim of this study was to conduct a needs assessment to explore the acceptability and feasibility of developing a psychosocial intervention, narrative therapy (NT), to address loss for chronic pain patients on the wait list of a chronic pain program.Methods: Two focus groups were conducted with ten patients who had experienced being on a wait list for a provincial chronic pain management program (CPMP). Transcribed interviews were subjected to thematic and interpretive analysis.Results: Two major themes emerged from the analysis: loss of identity and sharing a story of chronic pain. All patients were enthusiastic toward an NT intervention, although individual preferences differed regarding mode of delivery.Conclusions: Loss is a significant part of the chronic pain experience. NT seems to be an acceptable intervention to address loss for patients on the wait list for a chronic pain program.

The effect of involving significant others in chronic pain programs for adult patients with chronic non-malignant pain: a systematic review protocol.

The objective of this review is to identify the effect of the involvement of significant others in chronic pain management programs for adult patients with chronic non-malignant pain on function, self-efficacy and pain.More specifically, the objectives are to identify the effect of involving significant others in chronic management programs for adults with chronic non-malignant pain in primary, secondary or tertiary health care. This is compared to those receiving usual care or other self-management interventions.

Comprehensive care of pain: Developing systems and tools to improve patient care and resident education.

Chronic non-cancer pain is a common condition associated with tremendous risk for morbidity and mortality. In many settings, the management of chronic non-cancer pain by primary care providers, although customary, can be difficult due to inadequate training and conflicts between patient expectations and best practices. Resident physicians, faculty, and staff of this family medicine residency program developed a comprehensive chronic pain management program to address these issues while improving patient outcomes. The program was aligned with evidence-based chronic non-cancer pain management strategies yet tailored to the needs of the providers and patients and the strengths of the clinic. In the end, the societal demand for improved chronic non-cancer pain management resulted in a massive curricular and clinical practice overhaul for this residency program.

Learning to Manage Chronic Pain: The Patients' Perspective.

IntroductionThe objective of the present study was to gain insight into patients’ experiences in a 4-week interdisciplinary chronic pain management program by determining major themes from patients’ written comments on exit questionnaires.MethodsUpon completion of the program at the Chronic Pain Management Unit (CPMU), patients fill out program satisfaction (Pain Program Satisfaction Questionnaire) and evaluation of goal accomplishment (Self-Evaluation Scale) forms, sections of which are open-ended. Questionnaire data from 50 patients, admitted into the CPMU between May 2013 and December 2014, were randomly selected for this study. Written responses to open-ended sections were obtained. Comments were stratified by gender and coded using an inductive approach. Codes were grouped into categories which were further combined into several major themes.ResultsSix main themes extracted from comments were (1) impact of a strong interdisciplinary team, (2) learning to adapt in order to manage, (3) the Program as a stepping stone, (4) positive effects of a group effort, (5) improved mental health, and (6) benefits of the program.ConclusionThe results of this analysis reinforce the effectiveness of the interdisciplinary CPMU program at improving patients’ quality of life. Findings may assist in the promotion of the program to stakeholders such as referral sources. The outcomes may also assist in the development of future programs that have similar goals. Concerns that arise within patients’ comments may assist clinicians in this program to make adjustments such that all unique needs are met.Electronic supplementary materialThe online version of this article (doi:10.1007/s40122-016-0047-0) contains supplementary material, which is available to authorized users.

Narrative Approach for Identifying Movements of Change and the Value of Therapeutic Writing Related to Chronic Pain Management

In this study, we examined extensive narratives prepared by participants who attended a chronic pain management programme where therapeutic writing was included. The aim was to explore how narrators experience the contexts in which their lives unfold following a cognitive behavioural programme. The analysis was based on a three-sphere model for context analysis, which referred to the contexts in which the narrators located their life stories: their immediate inter-subjective relationships, the collective social field, and broad cultural meaning. We identified important change processes related to adaptation. Our examination of the experience of therapeutic writing clearly indicated that therapeutic writing is helpful. We suggest that obtaining a better understanding of living with chronic pain through storytelling as part of therapeutic writing and using a three-sphere model for context analysis could improve understanding and approaches to nursing. Health carers should organize care around the experience of illness and its inter-subjective, social, and cultural consequences, which may provide a deeper understanding of identity and the core themes embedded in life stories.

The American chronic pain crisis and the media: about time to get it right?

The American chronic pain crisis and the media: about time to get it right?

The Continuing and Growing Epidemic of Chronic Low Back Pain.

Because of the great prevalence of chronic pain, it is not surprising that there have been a number of influential reports by the Institute of Medicine, National Institutes of Health, and the World Health Organization that have documented the medical, social and economic problems caused by it, and the need for better pain-management programs. The present article briefly reviews these reports, and then focuses on three important areas that need to be considered when addressing the continuing and growing epidemic of one of the most prevalent types of chronic pain [chronic low back pain (CLBP)]: the biopsychosocial model of chronic pain; the paradigm shift in medicine from a disease model to an illness model of CLBP; and a review of the treatment- and cost-effectiveness of interdisciplinary chronic pain management programs. This overview will serve as an important prelude to other topics related to low back pain included in this Special Issue of Healthcare. Topics covered will range from assessment and treatment approaches, to important psychosocial mediators/moderators such as coping and pain beliefs.

Basal Pain Sensitivity does not Predict the Outcome of Multidisciplinary Chronic Pain Treatment.

Individual differences in underlying, "basal" pain sensitivity are large and have clinical implications. Some studies have suggested that basal pain sensitivity may also predict the outcome of pain treatment. Multidisciplinary chronic pain management programs are effective, but treatment success is individually very different. Therefore, identification of predictors of treatment success is important. This study investigated if basal pain sensitivity predicted the outcome of a 4-week outpatient multidisciplinary pain management program. Cohort study. Chronic pain outpatient clinic at the Department of Anesthesiology, Intensive Care Medicine and Pain Therapy of the University of Münster. Basal pain sensitivity was measured at treatment onset, using comprehensive experimental pain testing (thermal, pressure, and pinprick pain) and the pain sensitivity questionnaire. Primary (clinical pain intensity) and secondary (depression, anxiety, pain-related disability) outcome parameters were assessed at treatment start, at discharge and 6 months later. Sixty five adult chronic pain patients with mixed pain diagnoses. There were significant improvements in clinical pain intensity (from 6.1 ± 2.0 to 5.1 ± 1.8 [0-10]), depression and anxiety at discharge (all P < 0.001) and of clinical pain intensity (to 5.3 ± 2.3 [0-10]) and pain-related disability at 6 months (all P < 0.05). However, treatment outcome was not predicted by any of the basal pain sensitivity measures. Results show that basal pain sensitivity is not a reliable predictor of treatment outcome in mixed diagnosis multidisciplinary pain management programs, possibly due to the heterogeneity of patients enrolled in such programs. Clinically useful predictors of treatment success in this setting remain to be identified.

Addressing Item-Level Missing Data: A Comparison of Proration and Full Information Maximum Likelihood Estimation

Often when participants have missing scores on one or more of the items comprising a scale, researchers compute prorated scale scores by averaging the available items. Methodologists have cautioned that proration may make strict assumptions about the mean and covariance structures of the items comprising the scale (Schafer & Graham, 2002; Graham, 2009; Enders, 2010). We investigated proration empirically and found that it resulted in bias even under a missing completely at random (MCAR) mechanism. To encourage researchers to forgo proration, we describe a full information maximum likelihood (FIML) approach to item-level missing data handling that mitigates the loss in power due to missing scale scores and utilizes the available item-level data without altering the substantive analysis. Specifically, we propose treating the scale score as missing whenever one or more of the items are missing and incorporating items as auxiliary variables. Our simulations suggest that item-level missing data handling drastically increases power relative to scale-level missing data handling. These results have important practical implications, especially when recruiting more participants is prohibitively difficult or expensive. Finally, we illustrate the proposed method with data from an online chronic pain management program.

Empowering Patients with Persistent Pain Using an Internet-based Self-Management Program

New strategies are needed to improve access to cognitive and behavioral therapies for patients with persistent pain. The purpose of this randomized, controlled trial was to determine the effectiveness of the Chronic Pain Management Program, an 8-week online intervention targeting cognitive, emotional, behavioral, and social pain determinants. Program efficacy and engagement was evaluated for 92 individuals with a diagnosis of chronic noncancer pain who had a current opioid prescription. Participants were recruited from primary care practices and Internet sites, then randomly assigned to receive access to the intervention either immediately (treatment group) or after an 8-week delay (wait-list comparison). Biweekly self-report measurements were collected using online surveys on pain, depressive symptoms, pain self-management behaviors, and health care utilization during the 8-week trial. Additional measurements of opioid misuse behaviors, pain self-efficacy, and medicine regimens were completed at baseline and week 8. Engagement was evaluated by examining completion of program learning modules. The results from analysis of variance showed that at week 8, the treatment group had significantly greater improvements on pain self-efficacy and opioid misuse measures than the wait-list comparison group. Engagement level was positively associated with improvements in pain intensity, pain interference, and pain self-efficacy. In conclusion, patients on opioids were able to engage and demonstrate positive outcomes using an Internet-based self-management program. Future efforts toward heightening engagement could further maximize impacts.

The development and delivery of a female chronic pelvic pain management programme: a specialised interdisciplinary approach.

Chronic pelvic pain (CPP) is a physically and psychologically debilitating condition. European Association of Urology (EAU) Guidelines (2013) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (2012) place strong emphasis upon multi-speciality assessment and liaison, as well as interdisciplinary assessment and intervention in reference to the management of CPP. The aim was to introduce and describe the development and delivery of an interdisciplinary pain management programme (PMP), at a Specialised Pain Management Centre in Liverpool, United Kingdom, for women diagnosed with CPP. The format and content of the CPP PMP at The Walton Centre, Liverpool, is described and the preliminary results from the CPP PMP are presented. Preliminary data suggest that outcomes on the specialised CPP PMP indicate that patients are able to make clinically important change across a range of outcome measures. Moreover, these results compare favourably to the established PMP for generalised chronic pain when comparing clinically significant outcomes with the Walton Centre's (a tertiary-level pain management centre) 2013 PMP Audit document. Patients attending the CPP PMP positively appraised the PMP and felt it was useful and supportive to be in a group dedicated to CPP. This article presents some preliminary results that suggest there is value in delivering a specialised multidisciplinary PMP for this group. There is a clear need for further clinical research into the effectiveness of similar interventions for CPP, including the early identification of those CPP patients who may benefit from both multi-specialty and interdisciplinary management.

Suffering and transition strategies in adult patients attending a chronic pain management programme

To develop a deeper understanding of suffering and useful transition strategies in patients after participation in a chronic pain management programme. Chronic pain is a complex, multifaceted, individual experience. Limitations in patients' ability to perform their usual activities, as well as social isolation, are frequently reported. This condition may include a state of suffering that leads to challenges with transitions, for which support, guidance and achievement of useful strategies are needed. Qualitative study with a descriptive and explorative design from a phenomenological perspective. A phenomenological-hermeneutic approach was used to analyse interviews with 12 participants in a group-based cognitive-behavioural therapy management programme. Suffering from chronic pain means handling difficult thoughts and feelings. Expression of these thoughts and feelings through group support and therapeutic writing alleviates suffering. In addition, new perspectives through active involvement in the cognitive-behavioural therapy programme indicate a transition towards adaptation to the chronic pain situation. Qualitative analysis of participation in a cognitive-behavioural therapy programme deepens our understanding of both patient suffering and helpful transition strategies towards adaptation. Group participation in the programme appeared to be useful in improving patients' ability to handle challenging experiences with transitions. It is essential that the patients play an active role in adaptive transitions by developing new perspectives and insight. It is an important activity for nurses or other healthcare workers to assist in the transition process so that the patient can take an active role to achieve alleviation. Focus on transition conditions seems to be helpful because it considers the factors that might facilitate successful transitions towards optimal adaptation.

Change in Suicidal Ideation After Interdisciplinary Treatment of Chronic Pain

To examine suicidal ideation (SI) in individuals with chronic pain, especially change in suicidal thinking after interdisciplinary treatment. Consecutive patients (n=250) admitted to a 4-week, group-based chronic pain management program completed measures of pain intensity, functional limitations, depressive symptoms, overall distress, pain catastrophizing, self-perceived burden, and SI at pretreatment and posttreatment. Before treatment, 30 (12.0%) participants were classified as having a high level of SI, 56 (22.4%) had a low level of SI, and 164 (65.6%) reported none. After treatment, there was a significant reduction in SI and improvements in all other outcomes, but there were still some individuals with high (n=22, 8.8%) or low (n=28, 11.2%) levels at discharge. Patients with high SI at baseline differed from those with no suicidal thinking on pretreatment and posttreatment measures of depression, distress, catastrophizing, and self-perceived burden, but not on pain intensity or functional limitations. Patients high in SI endorsed greater pain catastrophizing and self-perceived burden than those low in suicidal thinking. Sustained SI after treatment was associated with higher baseline levels of suicidal thinking and self-perceived burden to others, as well as a more limited overall response to treatment. SI was common in individuals with chronic pain, although mostly at a low level. Interdisciplinary treatment may result in reduced suicidal thinking; however, some patients continue to express thoughts of self-harm. Future studies could examine processes of change and interventions for treatment-resistant suicidal concerns.

(538) Efficacy of an outpatient, multidisciplinary VA pain management clinic: findings from a one-year outcome study

Meta-analyses offer clear evidence that multidisciplinary chronic pain management programs offer patients the greatest opportunity for relief. However, according to the Committee for the Accreditation of Rehabilitation Facilities (CARF), the number of accredited programs in the U.S. has decreased in the last decade or specific practices have been

Interdisciplinary chronic pain management: Past, present, and future.

Chronic pain is a significant and costly problem in the United States as well as throughout the industrialized world. Unfortunately, there have been concerns about the effectiveness of traditional medical interventions, suggesting the need for alternative chronic pain treatment strategies. However, the introduction of the biopsychosocial model of pain during the past decade stimulated the development of more therapeutically effective and cost-effective interdisciplinary chronic pain management programs. In the present article we briefly review the history of pain management, discuss the major components of a "true" interdisciplinary pain management program, focus on the evidence-based outcomes that have documented the effectiveness of such interdisciplinary pain management programs, and note the barriers that have blocked the wider use of such programs. Finally, we discuss future directions in interdisciplinary pain management.