Inpatient Pain Management Program Research Articles

The therapeutic effect of the multidisciplinary inpatient pain management program for chronic musculoskeletal pain classified by ICD–11J

The therapeutic effect of the multidisciplinary inpatient pain management program for chronic musculoskeletal pain classified by ICD–11J

What factors predict outcome from an inpatient multidisciplinary chronic pain service? A prospective cohort study.

Objective To identify baseline factors associated with outcomes from an inpatient multidisciplinary pain management program (PMP) located in a bicultural area of Aotearoa New Zealand. Methods A prospective cohort study was undertaken involving 164 people with chronic pain who attended the PMP. Demographic, clinical, and psychosocial measures were obtained at baseline, whereas clinical and psychosocial outcome measures were also obtained at program discharge and 3-month follow up (N = 100). Multivariate analyses were used to determine baseline demographic variables that were associated with outcomes at discharge and follow up. Results Being male and working full-time were associated with poorer outcomes in select measures at discharge. At the 3-month follow up, Māori ethnicity, working full-time, being retired or unemployed, or having chronic widespread pain were associated with poorer outcomes for some measures, whereas those with rheumatoid arthritis had greater self-efficacy. Conclusions Sex, ethnicity, employment status, and patient condition impact clinical outcomes from the program and in the time from discharge to follow up. Program content and/or delivery should be altered to promote more equitable outcomes for all patients in the long term.

Multidisciplinary pain management program for patients with chronic musculoskeletal pain in Japan: a cohort study.

IntroductionMultidisciplinary pain management is a useful method for treating chronic musculoskeletal pain. Currently, few facilities in Japan offer multidisciplinary pain treatment, especially in the inpatient setting. We implemented a multidisciplinary pain management program based on International Association for the Study of Pain recommendations. This study described our initial efforts in implementing the program, and reported 3- and 6-month follow-up results.Materials and methodsOur pain management team included orthopedic surgeons, psychiatrists, nurses, physical therapists, clinical psychologists, pharmacists, and nutritionists. The 3-week inpatient pain management program comprised exercise therapy, psychotherapy, and patient education. We evaluated patients using the Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), Pain Disability-Assessment Scale (PDAS), Hospital Anxiety and Depression Scale (HADS), Pain Self-Efficacy Questionnaire (PSEQ), EuroQol Five Dimensions (EQ-5D), and physical examinations (flexibility, muscle endurance, walking ability, and physical fitness). Statistical analyses were performed using paired t-tests and Wilcoxon matched-pairs signed-rank sum tests with Bonferroni correction after the Friedman test.ResultsData for 23 patients were analyzed before and immediately after the program. Statistically significant improvements were seen in BPI, PCS, PDAS, HADS, PSEQ, EQ-5D, flexibility, muscle endurance, walking ability, and physical fitness. Eight patients were also assessed 3 and 6 months after the program. PCS (rumination and helplessness) scores and flexibility showed significant improvement at 3 and 6 months. Significant improvement was seen in PDAS and HADS (anxiety) scores and muscle endurance at 6 months, and in PSEQ scores immediately and at 3 and 6 months.ConclusionOur inpatient pain management program can improve patients’ physical function and ability to cope with chronic musculoskeletal pain, which supports improved quality of life. Our program is currently being expanded to better assist patients with chronic musculoskeletal pain.

Economic analysis of implementing virtual reality therapy for pain among hospitalized patients

Virtual reality (VR) has emerged as a novel and effective non-pharmacologic therapy for pain, and there is growing interest to use VR in the acute hospital setting. We sought to explore the cost and effectiveness thresholds VR therapy must meet to be cost-saving as an inpatient pain management program. The result is a framework for hospital administrators to evaluate the return on investment of implementing inpatient VR programs of varying effectiveness and cost. Utilizing decision analysis software, we compared adjuvant VR therapy for pain management vs. usual care among hospitalized patients. In the VR strategy, we analyzed potential cost-savings from reductions in opioid utilization and hospital length of stay (LOS), as well as increased reimbursements from higher patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The average overall hospitalization cost-savings per patient for the VR program vs. usual care was $5.39 (95% confidence interval –$11.00 to $156.17). In a probabilistic sensitivity analysis across 1000 hypothetical hospitals of varying size and staffing, VR remained cost-saving in 89.2% of trials. The VR program was cost-saving so long as it reduced LOS by ≥14.6%; the model was not sensitive to differences in opioid use or HCAHPS. We conclude that inpatient VR therapy may be cost-saving for a hospital system primarily if it reduces LOS. In isolation, cost-savings from reductions in opioid utilization and increased HCAHPS-related reimbursements are not sufficient to overcome the costs of VR.

Development and implementation of an inpatient multidisciplinary pain management program for patients with intractable chronic musculoskeletal pain in Japan: preliminary report.

IntroductionMultidisciplinary pain management is a useful method to treat chronic musculoskeletal pain. Few facilities in Japan administer a multidisciplinary pain management program, especially an inpatient program. Therefore, we implemented a multidisciplinary pain management program in our hospital based on biopsychosocial factors guided by the recommendations of the International Association for the Study of Pain. The purpose of this study is to describe our inpatient pain management program for Japanese patients, which uses the biopsychosocial method of pain self-management.Materials and methodsFourteen patients with intractable chronic musculoskeletal pain, who were implemented a multidisciplinary pain management program in our hospital, were studied using the evaluation of the pain and associated factors and physical function.ResultsSignificant improvement in outcomes were seen in the brief pain inventory, the pain catastrophizing scale (rumination, magnification, and helplessness), the pain disability assessment scale, the hospital anxiety and depression scale (anxiety and depression), the pain self-efficacy questionnaire, the EuroQol five dimensions questionnaire, and muscle endurance and physical fitness. We found no statistically significant differences in static flexibility or walking ability.ConclusionWe developed an inpatient chronic pain management program for Japanese patients. Our results suggest that our program improves chronic musculoskeletal pain coping mechanisms, and that the program can improve patients’ quality of life and some physical function. This inpatient pain management program is being expanded to better help intractable chronic musculoskeletal pain patients.

Interdisciplinary rehabilitation after whiplash injury: An observational prospective 5 years outcome study.

Whiplash injury associated disorders (WAD) cause high costs for public health care. Neck pain is number 16 on the global prevalence lists for the 50 most common sequelae. It is of importance to obtain long-term data on disability and working capacity outcomes after rehabilitation. Long-term prospective data of the outcome course of whiplash are sparse. The aim of this study was to quantify improvements of pain, function/role performance, vitality, and working capacity 5 years after whiplash injury and to compare the state of health to normative values at 5 years after rehabilitation.In this naturalistic, observational, prospective cohort study, 115 patients were assessed 5 years (60 months) after a multidisciplinary rehabilitation program. The assessment set consisted of the Short Form 36 (SF-36), parts of the North American Spine Society's cervical spine assessment questionnaire (NASS) and the coping strategies questionnaire (CSQ). The effects were quantified by effect size (ES) and standardized response mean (SRM). Score differences over the course were tested by the Wilcoxon–Mann–Whitney U test for significance.Comparing data between entry and 60 months after rehabilitation 8 of 15 parameters improved with large ES/SRM. Outcome between 6 and 60 months showed small to moderate ES/SRM. Working capacity increased from 0 at entry to rehabilitation to 21 h/wk at 6 months and to 30 h/wk at 60 months follow-up.After large improvements in health and working capacity in the mid-term, further important improvements were observed in the long-term course. It can be hypothesized that part of those can be attributed to the interventions during inpatient rehabilitation, for example, due to better coping strategies.

星総合病院での入院型ペインマネジメントプログラム

A biopsychosocial model of well–being is a very important concept in the multidisciplinary pain clinic. This model is a general model or approach stating that biological, psychological, and social factors play a significant role in human functioning in the context of disease or illness. There are few facilities in Japan that administer a multidisciplinary pain clinic, especially an inpatient pain management program. In Hoshi General Hospital we are implementing a multi disciplinary pain management program based on the biopsychosocial model, guided by IASP recommendations. The aim of this report is to describe our initial efforts in creating an inpatient pain management program using the biopsychosocial method of self–pain management. The pain management center started with a team consisting of orthopaedic surgeons, psychiatrists,physical therapists, clinical psychologists, nurses, pharmacists, and nutritionists. Our 3–week inpatient pain management program is indicated for patients who find it hard to work or go to school due to chronic pain, and/or are confined to life at home but want to return to work or school. The program consists of 1) measurements of physical fitness, and training with a physical therapist, 2) assertion and relaxation training, role–playing to increase healthy behavior and to decrease painful behavior led by a psychologist, and 3) a lecture ⁄ discussion by each specialist. The goals of the program are to return to a functional daily life habit, education to acquire coping methods for chronic pain, and to get into the habit of exercise. Finally, participation in lectures and psychotherapy programs is to include not only patients but also their family members or significant others. Using this program, our inpatients with chronic pain were evaluated using a numerical rating scale, a pain catastrophizing scale (rumination, magnification, and helplessness), a pain disability assessment scale, a hospital anxiety and depression scale, a pain self–efficacy questionnaire, the EQ–5D, and assessment of physical functions before and after treatment. Three patients have been treated during the first 8 months. The average change of outcomes among these patients before and after 3–week program were: 7.0 to 6.8 in numerical rating scale; 16.7 to 8.0, 15.7 to 10.3, 7.3 to 3.3 in each pain catastro phizing scale (rumination, magnification, and helplessness); 12.0 to 7.0, 14.3 to 8.3in the hospital anxiety and depression scale (anxiety and depression); 31.0 to 21.3 in the pain disability assessment scale; 16.0 to 32.0 in the pain self–efficacy questionnaire; 0.399 to 0.612 in the EQ–5D; and 25.3 cm to 33.7 cm in the static flexibility test. Thus, most outcomes were improved after the 3–week inpatient program. The results suggest that we may be able to improve the coping mechanisms of our patients for dealing with chronic pain, and that the program can improve their quality of life and flexibility. Our inpatient pain management program may be expanded to better serve chronic pain patients.

A study protocol for a single-blind, randomized controlled trial of adjunctive transcranial direct current stimulation (tDCS) for chronic pain among patients receiving specialized, inpatient multimodal pain management

BackgroundAvailable treatments for chronic pain (CP) are modestly effective or associated with iatrogenic harm. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that may be an effective, adjunctive treatment to non-opioid therapies. In this randomized control trial (RCT), we compare adjunctive active versus sham tDCS among patients in a multimodal inpatient pain management program. The primary objectives of the RCT are to improve pain tolerance and subjective pain experience. Methods and designPatients admitted to the Pain Management Program at The Menninger Clinic in Houston, Texas are eligible for this trial. Eighty-four participants will be randomized (1:1) into a single-blind, 2×12 (group×time) controlled trial. A battery-powered direct and constant current stimulator (Soterix Medical Inc. 2014) delivers anodal stimulation over the left dorsolateral prefrontal cortex (DLPFC) and cathodal stimulation over the right DLPFC. Active tDCS is applied by supplying a 2mA current for 20min/session over 10 sessions. Participants complete self-report and performance-based assessments on a weekly basis just prior to brain stimulation. Self-report assessments are collected via Chronic Pain Tracker version 3.6, an iPad interfaced application. The performance-based pain tolerance task is completed through the cold presser task. DiscussionInterventions with cross-symptomatic therapeutic potential are absolutely essential in the context of CP, in which psychiatric comorbidity is the norm. Modalities that can be used in tandem with evidence-based, non-opioid therapies have the potential to have a synergistic effect, resulting in increased effectiveness of what have been modestly effective treatments to date.

Responsiveness of the cervical Northern American Spine Society questionnaire (NASS) and the Short Form 36 (SF-36) in chronic whiplash

Objective: To determine and compare the sensitivity to change of the condition-specific cervical Northern American Spine Society (NASS) and the generic Short Form 36 (SF-36). Design: Prospective cohort study. Subjects: One hundred and seventy five patients after whiplash injury. Interventions: Four-week inpatient interdisciplinary pain management programme. Main measures, analysis: Responsiveness of the NASS and the SF-36 was quantified by effect size and standardized response mean and compared within the same construct by the modified Jacknife test. Ability to detect improvement was compared using sensitivities determined from receiver operating characteristics curves. Results: In pain, the NASS was comparable responsive to the SF-36 at the one-month follow-up (n = 175): effect sizes: 0.62 (NASS) versus 0.61 (SF-36), P = 0.914. The NASS was less responsive than the SF-36 in function: 0.23 versus 0.63, P < 0.001 and in pain+function: 0.35 versus 0.58 (P = 0.001). These relationships remained consistent using standardized response means, at the six-month follow-up (n = 103), and in the comparison of the sensitivities. Sensitivities at one month, pain: 70% (NASS) versus 62% (SF-36), P = 0.234; function: 65% versus 80%, P = 0.002; pain+function: 68% versus 78%, P = 0.035. The six-month data were similar. Conclusions: The generic SF-36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF-36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.

Differences in pain, function and coping in Multidimensional Pain Inventory subgroups of chronic back pain: a one-group pretest-posttest study

BackgroundPatients with non-specific back pain are not a homogeneous group but heterogeneous with regard to their bio-psycho-social impairments. This study examined a sample of 173 highly disabled patients with chronic back pain to find out how the three subgroups based on the Multidimensional Pain Inventory (MPI) differed in their response to an inpatient pain management program.MethodsSubgroup classification was conducted by cluster analysis using MPI subscale scores at entry into the program. At program entry and at discharge after four weeks, participants completed the MPI, the MOS Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Coping Strategies Questionnaire (CSQ). Pairwise analyses of the score changes of the mentioned outcomes of the three MPI subgroups were performed using the Mann-Whitney-U-test for significance.ResultsCluster analysis identified three MPI subgroups in this highly disabled sample: a dysfunctional, interpersonally distressed and an adaptive copers subgroup. The dysfunctional subgroup (29% of the sample) showed the highest level of depression in SF-36 mental health (33.4 ± 13.9), the interpersonally distressed subgroup (35% of the sample) a modest level of depression (46.8 ± 20.4), and the adaptive copers subgroup (32% of the sample) the lowest level of depression (57.8 ± 19.1). Significant differences in pain reduction and improvement of mental health and coping were observed across the three MPI subgroups, i.e. the effect sizes for MPI pain reduction were: 0.84 (0.44 - 1.24) for the dysfunctional subgroup, 1.22 (0.86 - 1.58) for the adaptive copers subgroup, and 0.53 (0.24 - 0.81) for the interpersonally distressed subgroup (p = 0.006 for pairwise comparison). Significant score changes between subgroups concerning activities and physical functioning could not be identified.ConclusionsMPI subgroup classification showed significant differences in score changes for pain, mental health and coping. These findings underscore the importance of assessing individual differences to understand how patients adjust to chronic back pain.

Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: Evaluation of a CBT informed pain management programme

Randomized controlled trials and meta-analyses provide evidence for the efficacy of cognitive-behaviourally informed treatment (CBT) programmes for chronic pain. The current study aims to provide practice-based evidence for the effectiveness of CBT in routine clinical settings. Over a 10-year period 1013 pain patients were accepted into a 4 week in-patient pain management programme. Data from more than 800 patients was available at pre-treatment and at one month post-treatment and for around 600 patients at pre-treatment and at 9 months follow-up. Measures reported in this analysis were pain experience and interference, psychological distress (depression and anxiety), self-efficacy, catastrophizing, and walking. Change from pre-treatment to post-treatment and follow-up was assessed with conventional statistical tests, the computation of effect sizes and by the reliable change index (RCI) and clinically significant change (CSC) methodology. These analyses provide evidence of statistical improvement at post-treatment and follow-up and the RCI/CSC methodology suggested that between 1 in 3 and 1 in 7 (depending on the outcome measure) achieved clinically significant gains. There was also evidence that a small percentage of patients (1–2%) reliably deteriorated during the period of treatment. The limitations in the inferences that can be drawn from this study and of the methodology are discussed. A case is made for the application of benchmarking methods using data from RCTs in order to more fully evaluate practice and to generate better quality practice based evidence.

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 – 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.

Psychometric characteristics of the Pain Treatment Satisfaction Scale

Treatment satisfaction is an important domain of pain treatment outcomes. The current study was designed to evaluate the psychometric characteristics of a previously developed patient treatment satisfaction measure using a large sample of individuals with chronic pain. Participants included patients enrolled in a nineteen-day inpatient interdisciplinary cognitive-behavioral pain management program. At program discharge patient satisfaction ratings were obtained, including ratings for overall program satisfaction, staff warmth, staff skill level, ease of scheduling appointments, and recommendation of the program to other patients.

Problem-Solving Appraisal and Psychological Adjustment of Persons with Chronic Low-Back Pain

To examine the role of self-appraised problem-solving ability in the prediction of psychosocial impairment, depression, hopelessness, average pain unpleasantness, and current pain ratings among persons with chronic low-back pain. A second purpose was to enhance theoretical understanding of the mechanisms by which problem-solving appraisal influences adjustment. Correlational and regression procedures were used to test the hypothesized relations procedures between elements of self-appraised problem-solving ability and each criterion variable. Seventy-eight persons enrolled in an inpatient multidisciplinary chronic pain management program. The psychosocial subscale of the Sickness Impact Profile, the Beck Depression Inventory, the Beck Hopelessness Scale, the McGill Pain Questionnaire, and Visual Analogue Scales of Pain Sensory Intensity and Affective Response were the main outcome measures. After first controlling demographic characteristics, elements of self-appraised problem-solving ability assessed by the Problem-Solving Inventory were significantly predictive of depression, hopelessness, psychosocial impairment, and average pain unpleasantness (accounting for 20, 26, 29, and 11% of the respective variance in these constructs). Results indicate complex relations among the elements of problem-solving appraisal, suggesting that the Approach–Avoidance link to psychological adjustment was mediated by Problem-Solving Confidence. Comprehensive problem-solving interventions may be beneficial to persons with chronic pain

Does cognitive change predict the outcome of cognitive-behavioural pain management?

Does cognitive change predict the outcome of cognitive-behavioural pain management? The psychometric properties of the Pain Cognitions Questionnaire (PCQ: Boston et al. , 1990), a brief self-rated measure of spontaneously occurring pain-related cognitions, were examined in a sample of 833 severely impaired chronic pain patients who completed it prior to and at several points following discharge from an inpatient cognitive-behavioural pain management programme. Principal components analysis allowed the identification of a two-factor structure which remained stable in this population across all points of assessment. The first factor (11 items) was labelled 'positive self statements'; the second (12 items), 'lack of mastery over pain'. Both factors showed adequate reliability (test-retest and internal consistency) and sensitivity to treatment-induced change; and preliminary support was obtained for criterion-related validity. The PCQ was then used to examine an underlying assumption of cognitive-behavioural therapies (CBT), viz that cognitive change mediates successful treatment outcome. Regression modelling was used to examine the extent to which change in PCQ scores from pre- to post-treatment was predictive of a range of outcomes including pain, depression, medication use and general functioning (Sickness Impact Profile scores) at one-month follow-up after controlling for pre-treatment levels of relevant variables. Results were broadly, though weakly, supportive of the cognitive hypothesis, with cognitive change accounting for up to 15% of outcome variance.

Computerized version of the pain experience scale: a study of equivalence

Comprehensive diagnosis of pain comprises assessment of subjectively felt pain as one necessary component. Modern approaches are multidimensional (differentiation between sensory and affective parts; multiple sub-aspects of sensory pain) and go far beyond single-item-methods, whose utility remain questionable not only regarding the contents but for measurement purposes as well. One of these modern instruments of pain assessment, the Pain Experience Scale (German: Schmerzempfindungsskala, SES), served as original for the development of a computerized version. The study aimed to establish whether this computer version is equivalent to the paper-pencil original. Fifty-eight pain patients were recruited on admission to an in-patient pain management program. Half of them filled out the paper-pencil scale first, then worked on the computerized version. The others did so in reverse order. Analyses of means revealed nearly identical scores for both versions. Correlational analyses (computation of reliabilities for parallel tests) showed excellent correspondence. Analyses of order of presentation showed no effect. The two test versions are almost completely equivalent and can be used as a reliable tool in the practice of pain measurement. Moreover, validation data and questionnaire norms of the original version are completely applicable to the computerized version.

Incorporating Cognitive-Behavioral Therapy with Occupational Therapy: A Comparative Study with Patients with Low Back Pain

This paper reports on the implementation of a psychoeducational program utilizing cognitive-behavioral principles. The efficacy of this psychoeducational treatment program in modifying dysfunctional attitudes in patients with chronic low back pain was examined using a two-group pretest posttest design with a follow-up at 3 months. Thirty patients (average age = 44,37, SD = 13.71) participated in the study, with 15 in the psychoeducational treatment group and 15 in the placebo control group. These two conditions were added on to an existing eclectic inpatient pain management program. After assessment on the IPAM (The Integrated Psychosocial Assessment Model), scores were reduced to multivariate composite scores on the factors of “illness behavior,” “depressed and negative cognitions,” and “acute pain strategies.” Results of a group × time repeated measures analysis of variance for the three pain factors revealed a significant main effect for group(F(23,1) = 5.00, p > .04), tempered by a significant interaction between group and time on the ‘depressed and negative’ pain factor(F(23,1) = 4.77, p > .04). Patients in the treatment group improved significantly over time and significantly more than the placebo control group patients at posttreatment. Results provide support for the program in increasing patients' feelings of control over their pain and the use of positive coping strategies, while reducing perceived helplessness, depression, disability, and pain intensity.

Attrition from a pain management programme

Drop-out from treatment and attrition from follow-up present problems for generalizing results from pain management programmes. Predictors of drop-out and of attrition were sought from a range of psychological and physical variables. Of 239 patients admitted to an in-patient pain management programme, 24 (10 percent) dropped out, 12 (5 percent) did not attend one month follow-up and 65 (26 percent) did not attend six month follow-up. Comparisons were made of personal, medical, psychological, physical and pain measures, taken before admission, on discharge and at one month follow-up. Drop-out was best predicted by the combination of low self-efficacy and poor physical performance. Before treatment, future non-attenders at six month follow-up reported more distress due to pain and more frequent catastrophic thinking. Although they improved during treatment, at one month follow-up future non-attenders at six month follow-up scored significantly worse on almost all physical and psychological measures. Frequency of catastrophic thoughts at one month follow-up was the best predictor of attrition at six month follow-up.

Interpretive Limitations of the MMPI-2 Anger and Cynicism Content Scales

Relationships between the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tetlegen, & Kaemmer, 1989) anger (ANG) and cynicism (CYN) content scales and concurrent measures of anger and subjective distress were examined among 97 men admitted to an inpatient chronic pain management program. Subjects completed the MMPI-2, StateTrait Anger Expression Inventory (Spielberger, 1988), State-Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), and Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) on the day of admission. Regression analyses indicated that Trait Anger was the best single predictor of ANG. CYN elevation was best predicted by BDI scores. Factor analyses revealed associations between ANG and anger externalization and between CYN and anger internalization. The results suggest that ANG is a reliable index of predispositions to the external expression of anger, whereas CYN is more difficult to characterize, perhaps be...

Opiate reduction in chronic pain patients: A comparison of patient-controlled reduction and staff controlled cocktail methods

This study compares the effectiveness of two methods of opiate reduction in 108 chronic pain patients during a 4 week inpatient pain management programme, and at 1-month and 6-month follow-up. Patients chose either the patient-controlled reduction (PCR) or cocktail reduction method, aiming to complete withdrawal by discharge. Use of opiates and other drugs was recorded, and psychological measures taken, at admission, at discharge, and at follow-ups. Patients who opted for the cocktail reduction method started at higher morphine equivalents ( P < 0.001), were less confident in their ability to cope without medication ( P < 0.05), and rated their everyday activities as more disrupted by pain ( P < 0.05). At discharge, 89% of the cocktail group were abstinent from opiates compared with 68% of the PCR group ( P < 0.05). By 1-month follow-up, the advantage of the cocktail method had disappeared, with no significant differences between the two groups in mean opiate dose, nor in the proportion of abstinent patients. This was the result of a greater return to opiate use in the cocktail group, with abstinence rates remaining unchanged in the PCR group. By 6-month follow-up, abstinence rates for the groups were equivalent, with 55% of patients remaining off opiates. By this stage, however, non-abstinent cocktail group patients were taking significantly larger doses of opiates than PCR patients ( P < 0.05), although in both groups, the dose was well below admission level. Admission opiate dose level was the best predictor both of abstinence at discharge and of subsequent opiate dose level in non-abstinent patients. This study demonstrates that both reduction methods can produce substantial reduction in opiate use by severely impaired chronic pain patients with long medication histories.