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Chronic Pain Patients (chronic + pain_patient)
Selected AbstractsGod Image and Happiness in Chronic Pain Patients: The Mediating Role of Disease InterpretationPAIN MEDICINE, Issue 5 2010Jessie Dezutter dra Abstract Objective., The present study explored the role of the emotional experience of God (i.e., positive and negative God images) in the happiness of chronic pain (CP) patients. Framed in the transactional model of stress, we tested a model in which God images would influence happiness partially through its influence on disease interpretation as a mediating mechanism. We expected God images to have both a direct and an indirect (through the interpretation of disease) effect on happiness. Design., A cross-sectional questionnaire design was adopted in order to measure demographics, pain condition, God images, disease interpretation, and happiness. One hundred thirty-six CP patients, all members of a national patients' association, completed the questionnaires. Results., Correlational analyses showed meaningful associations among God images, disease interpretation, and happiness. Path analyses from a structural equation modeling approach indicated that positive God images seemed to influence happiness, both directly and indirectly through the pathway of positive interpretation of the disease. Ancillary analyses showed that the negative influence of angry God images on happiness disappeared after controlling for pain severity. Conclusion., The results indicated that one's emotional experience of God has an influence on happiness in CP patients, both directly and indirectly through the pathway of positive disease interpretation. These findings can be framed within the transactional theory of stress and can stimulate further pain research investigating the possible effects of religion in the adaptation to CP. [source] Preliminary Study of the Efficacy of Radiofrequency Lesions of Stellate Ganglion in Chronic Pain PatientsPAIN MEDICINE, Issue 1 2010Shinobu Yamaguchi MD No abstract is available for this article. [source] Experience of Methadone Therapy in 100 Consecutive Chronic Pain Patients in a Multidisciplinary Pain CenterPAIN MEDICINE, Issue 7 2008FRCPC, Philip Peng MBBS ABSTRACT Objective., The objective of the study was to describe the experience of methadone use in 100 consecutive chronic pain patients managed in a single multidisciplinary center. Design., A chart review of chronic pain patients on methadone therapy initiated at the Wasser Pain Management Center from January 2001 to June 2004. Setting, Patients, and Intervention., Outpatients receiving methadone for chronic pain management in a tertiary multidisciplinary pain center. Outcome Measure., Effects on pain relief and function, conversion ratio from other opioids, side effects, and disposition were reviewed. Results., Charts of 100 methadone patients (age 45 ± 11 years old; M/F: 3/7; duration of pain 129 ± 110 months) managed by five physicians and one nurse were reviewed. The main reason for the initiation of methadone therapy was opioid rotation (72%). The average oral morphine equivalent dose was 77 mg/day before methadone therapy, and the methadone dose after initial stabilization was 42 mg with no consistent conversion ratio observed. The mean duration of methadone therapy was 11 months. Most of the patients (91%) were taking concomitant adjuvant analgesics or psychotropic agents, mostly antidepressants and anticonvulsants. The average Numeric Verbal Rating Score before and after methadone treatment was 7.2 ± 1.7 and 5.2 ± 2.5 (P < 0.0001). Thirty-five patients discontinued their methadone treatment mainly because of side effects, ineffectiveness, or both. Conclusion., From our experience, methadone is an effective alternative to conventional opioids for chronic pain management when used by experienced clinicians in a setting that allows for close monitoring and careful dose initiation and adjustment. [source] Interpreting Urine Drug Tests: Prevalence of Morphine Metabolism to Hydromorphone in Chronic Pain Patients Treated with MorphinePAIN MEDICINE, Issue 7 2008Ajay D. Wasan MD ABSTRACT Objective., Pain medicine practitioners frequently use urine drug testing (UDT) to monitor adherence to opioid therapy. It can be difficult to interpret a result as normal or abnormal in relation to which opioid compounds are expected to be found in the urine. We investigated whether hydromorphone may be a metabolite of morphine normally appearing in UDT of patients prescribed morphine. Design., This is a retrospective case-control study of urine toxicology results in pain patients taking only morphine. Inclusion criteria included urine results positive for morphine only (controls) or morphine and hydromorphone (cases). Demographic and medical history variables, and any history of aberrant drug behavior were recorded and related to the presence or absence of hydromorphone in the urine. Results., Hydromorphone was present in 21 of 32 cases (66%), none of whom had a history of aberrant drug behavior. Positive cases occurred more frequently in women, in those taking higher daily doses of morphine, and in those with higher urine morphine concentrations (P < 0.05). Only morphine urine concentration was a significant predictor of the hydromorphone metabolite in a logistic regression model (P < 0.05). Conclusions., Hydromorphone is likely a minor metabolite of morphine, normally appearing in the UDT of patients taking morphine. This finding assists in determining whether a UDT result is normal or abnormal, and subsequently whether a patient is compliant with opioid therapy. This observation should be confirmed by a prospective study in a controlled environment. Variables such as gender, morphine dose, morphine urine concentration, and genetic determinants of morphine metabolism should be investigated further. [source] Cognitive Therapy with Chronic Pain PatientsPAIN PRACTICE, Issue 1 2004Carrie Winterowd No abstract is available for this article. [source] Can the Neuropathic Pain Scale Discriminate Between Non-neuropathic and Neuropathic Pain?PAIN MEDICINE, Issue 2 2008David A. Fishbain MD, FAPA ABSTRACT Objectives., 1) To determine if the neuropathic pain scale (NPS) can be used to classify chronic pain patients (CPPs) as having primarily neuropathic vs non-neuropathic pain, and furthermore; 2) to determine what, if any, cut-off score can be used to reliably make this determination. Design., A total of 305 CPPs consecutive admissions to The Rosomoff Pain Center were administered the NPS and were assigned a diagnosis according to the physical examination and all available test results. CPPs with a diagnosis of chronic radiculopathy and spondylolysis/degenerative arthritis were segregated into two groups for the purposes of having a group representative of neuropathic pain (chronic radiculopathy) and non-neuropathic pain (spondylolysis/degenerative arthritis). Applying neuropathic pain criteria to each "of these two groups": a neuropathic pain "subtype" was identified within the chronic radiculopathy group; and, a non-neuropathic pain "subtype" was identified within the spondylolysis/degenerative arthritis group. This step was performed in order to assure that the CPPs selected for further analysis were truly representative of neuropathic and non-neuropathic pain. Discriminant function analysis was then employed to determine if NPS scoring could differentiate between these two "subtypes." Results from the discriminant function analysis model were utilized to derive an NPS cut-off score above which CPPs would be classified as having neuropathic pain. For the diagnoses of myofascial pain syndromes, spinal stenosis, epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome, a predicted NPS score was calculated and compared with the cut-off score. Setting., Multidisciplinary pain facility. Patients., Chronic pain patients. Results., The NPS appeared to be able to separate CPPs into neuropathic pain vs non-neuropathic pain subtypes. The derived cut-off score from the model was 5.53. Myofascial pain syndrome and spinal stenosis had predictive scores lower than this cut-off score at 3.81 and 4.26, respectively. Epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome had predictive scores higher than the cut-off score at 6.15, 6.35, 6.87, 9.34, and 7.19, respectively. Conclusions., The NPS appears to be able to discriminate between neuropathic and non-neuropathic pain. A debate is currently raging as to whether diagnoses, such as fibromyalgia and complex regional pain syndrome 1, can be classified as neuropathic. Our NPS cut-off score results suggest that these diagnoses may have a neuropathic pain component. The reliability and validity of our NPS method will need to be tested further in other neuropathic pain models, such as diabetic peripheral neuropathic pain. [source] Identifying Patients at Risk for Loss to Follow-up After Pain Center TreatmentPAIN MEDICINE, Issue 1 2001Robert B. Cutler PhD Objective., This study was designed to identify, at admission to a pain treatment facility, characteristics of patients who will be lost to follow-up after treatment completion. Method., Patients were divided into 3 groups depending on how they responded to the 12-month follow-up. The analysis was a between-subjects design using prospective data collected at a comprehensive pain treatment facility. Low back pain patients (n = 168) received 4 weeks of multidisciplinary pain treatment. The main outcome measure was response/nonresponse to follow-up questionnaires. Results. showed that patients who were later lost to follow-up, or who were reluctant to answer follow-ups, could be predicted at treatment admission by measures of pain and functioning. The prediction equation was validated by a second group of patients, treatment noncompleters (n = 55). Conclusion., Chronic pain patients who are more likely to be lost to follow-up can be identified upon admission to a pain facility. Procedures that should decrease follow-up attrition could be implemented at program admission. [source] Methadone in the Treatment of Chronic Nonmalignant Pain: A 2-Year Follow-upPAIN MEDICINE, Issue 3 2000William F. Taylor MD Objective. To examine the longitudinal use of methadone in a pain clinic. Design. Follow-up study of 40 patients initially treated with methadone and re-evaluated 2 years later, comparing those maintained on methadone with those who were switched to other opioids. Setting. Pain clinic at a university hospital. Results. The 14 patients (35%) who stayed on methadone for the duration of the study, had higher employment rates (P < .05) and higher functional ratings (P < .02) than those on other opioids. Side effects were the most common reason (33.4%) for discontinuation of methadone. Dose escalation occurred in 11 of 14 patients (78.6%). Conclusions. Chronic pain patients may be safely and effectively treated with methadone. Those not responding or tolerating methadone may be benefited by treatment with other opioids. [source] Financing the Treatment of Chronic Pain: Models for Risk-sharing among Pain Medicine Physicians, Health Care Payers, and ConsumersPAIN MEDICINE, Issue 1 2000FABPM, Richard L. Stieg MD Chronic pain patients are among a growing group of medically underserved Americans. Despite increasing public awareness about pain and widespread legislative activity that is focusing on the needs of pain patients, there remain significant roadblocks in bringing the expertise of Pain Medicine specialists to these unfortunate people. This paper explores how the managed care revolution has impacted the practice of Pain Medicine in the United States. The dissolution of many prominent multi-disciplinary pain treatment centers has been paralleled by the evolution of pain management as an area of interest by several competing medical specialty societies. Despite this fragmentation, the American Academy of Pain Medicine continues to grow and to promote the needs of Pain Medicine specialists and their patients. The advantages and disadvantages of various practice patterns for Pain Medicine specialists is explored against a backdrop of discussions about: (1) the problems currently faced by chronic pain patients; (2) the role of organized Pain Medicine in helping patients to access and finance care; and (3) the future of American health care and the new responsibilities that will bring to physicians. Finally, we have some specific recommendations for pain medicine specialists about: (1) sharing risk; (2) exerting individual leadership; and (3) simplifying one's professional life in the new health care environment, that we hope will enable them to continue caring for as many chronic pain patients as possible. It is opined that the development of sophisticated regional specialty networks is the best model to accomplish this task in the future. [source] Daily interpersonal events in pain patients: Applying action theory to chronic illnessJOURNAL OF CLINICAL PSYCHOLOGY, Issue 9 2006Mary C. Davis Action theory proposes that individuals actively shape and then respond to their environments, highlighting the role of stable person characteristics in the development and maintenance of life's interpersonal difficulties. In this study, the authors adopt the action perspective in their examination of predictors of daily interpersonal events among chronic pain patients with rheumatoid arthritis. They probe the extent to which stable symptoms of illness explained between-person variation, and fluctuating symptoms explain day-to-day variation in both positive and negative events. Their evaluation of patients' daily diary reports indicate that between-person differences accounted for more variance in the occurrence of positive events relative to negative events (48% vs. 31%, respectively). Likewise, between-person factors accounted for more variance in appraisals of positive compared to negative events across relationship domains. Both intractable illness symptoms and disability, and daily fluctuations in pain and fatigue, were only weakly related to patients' reports of their interpersonal experiences. Consistent with action theory, these results suggest that stable person characteristics are strongly related to daily stressors and particularly daily positive events in pain patients, but still account for less than 50% of the variance in events and their appraisals. In contrast, elevations in illness-related features, both between individuals and within individuals from day-to-day, are not robust predictors of positive or negative social exchanges. These findings point to the value of capturing the experiences of individuals intensively over time, an approach that can help to elaborate the contributions of both stable factors and circumstance in shaping social contexts in chronic illness. © 2006 Wiley Periodicals, Inc. J Clin Psychol 62: 1097,1113, 2006. [source] Self-reported severity of taste disturbances correlates with dysfunctional grade of TMD painJOURNAL OF ORAL REHABILITATION, Issue 11 2009D. R. NIXDORF Summary, Altered central neural processing of sensory information may be associated with temporomandibular disorders (TMD) pain. The objectives of this study were to compare the prevalence of self-reported taste disturbances in TMD pain patients and in a control population, and to determine whether frequency of taste disturbances was correlated with dysfunctional grade of TMD pain. Subjects were 2026 people within a German population sample and 301 consecutive TMD patients diagnosed using the Research Diagnostic Criteria. Taste disturbances were measured using two questions from the Oral Health Impact Profile. Dysfunctional grade of TMD pain was measured with the Graded Chronic Pain Scale. A two-sample test of proportions revealed that TMD patients reported a greater frequency of taste disturbances, 6%, than did the general population subjects, 2% (P < 0·001). Moreover, the frequency of taste disturbances correlated with the dysfunctional grade of TMD pain. For each 1 unit increase in taste disturbance, the odds of observing a higher grade of TMD pain increased by 29% (95% CI: 3,63%, P = 0·03). Analysis by individual taste question and adjustment for age and gender did not substantially affect the results. These findings are consistent with a central neural dysfunction in TMD pain and suggest that a common neural substrate may underlie sensory disturbances of multiple modalities in chronic pain patients. Further research regarding taste disturbances and trigeminally mediated pains such as in TMD is warranted. [source] Depression levels in chronic orofacial pain patients: a pilot studyJOURNAL OF ORAL REHABILITATION, Issue 10 2004R. S. Tesch summary, The assessment of depressive behaviour in chronic pain patients is especially important, because depression is commonly associated with chronic pain. The aim of this pilot study was to compare depression levels between patients with head and neck cancer pain and temporomandibular disorders (TMD), and to determine whether there is an association between depression levels and chronic pain severity. This study was an observational and sectional study and the sample consisted of 40 patients, uniformly divided into those with chronic orofacial pain related to cancer and those with painful TMD classified with research diagnostic criteria for temporomandibular disorders (RDC/TMD) axis I. Depression levels, pain intensity and severity were assessed with RDC/TMD axis II. The study demonstrated statistically significant differences in depression levels present in the head and neck cancer pain group and the painful TMD group, with the occurrence of a moderate statistically significant correlation between depression levels and chronic pain severity. [source] Prevalence and correlates of clinical insomnia co-occurring with chronic back painJOURNAL OF SLEEP RESEARCH, Issue 1 2007NICOLE K. Y. TANG Summary Given the suggestion of a reciprocal relationship between sleep and pain and the recognition of sleep as an important parameter in determining quality of life, there is increasing research interest in sleep disturbance linked to chronic pain. The present study aimed to provide an estimate of the prevalence of ,clinical insomnia' in patients attending a specialist pain clinic and identify factors associated with it. Seventy chronic back pain patients and 70 gender- and age-matched pain-free controls completed a set of questionnaires measuring sleep (Insomnia Severity Index; ISI), pain (Short-Form McGill Pain Questionnaire) and a selection of general and specific psychological variables (Hospital Anxiety and Depression Scale, Short Health Anxiety Inventory). Scores suggestive of clinical insomnia (ISI , 15) were noted in 53% of chronic pain patients, when compared with only 3% in pain-free controls. Significant positive correlations with insomnia severity were detected for all six variables of interest (pain intensity, sensory pain ratings, affective pain ratings, general anxiety, general depression and health anxiety). Affective pain ratings and health anxiety were the best predictors of insomnia severity in this sample, accounting for 30% of the total variance, even when present pain intensity was controlled for. Affective pain remained as a significant predictor of insomnia severity when both the effect of pain intensity and the effects of anxiety and depression were controlled for. Future research should consider investigating the role of pain appraisal and health anxiety in the development and manifestation of insomnia concomitant to chronic pain. [source] A preliminary examination of treatment for posttraumatic stress disorder in chronic pain patients: A case studyJOURNAL OF TRAUMATIC STRESS, Issue 5 2003Jillian C. Shipherd Abstract Manualized treatments have become popular, despite concern about their use when comorbid diagnoses are present. In this report, the efficacy of manualized posttraumatic stress disorder (PTSD) treatment was examined in the presence of chronic pain. Additionally, the effect of PTSD treatment on chronic pain and additional psychiatric diagnoses was explored. Six female patients with both PTSD and chronic pain following motor vehicle accidents were treated for PTSD using a multiple baseline design. The results indicate that manualized treatment for PTSD was effective in reducing PTSD symptoms in these patients. Although there were no changes in subjective pain, there were pain-related functional improvements and reductions in other psychiatric diagnoses for the majority of patients. [source] Somatization and chronic painACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 9 2001M. Birket-Smith The experience of pain is related not only to tissue damage and physical illness, but also to mental phenomena including depression, anxiety and somatization. Somatization is common among chronic pain patients and presents special problems in management and treatment. Somatoform patients are often given inappropriate diagnoses, treated for non-existent depressive disorders, and exposed to multiple, superfluous investigations. Psychological models of chronic pain and somatization are presented, and treatment issues including psychotherapy and the use of antidepressants are discussed. [source] Longitudinal Treatment Outcomes for Geriatric Patients with Chronic Non-Cancer Pain at an Interdisciplinary Pain Rehabilitation ProgramPAIN MEDICINE, Issue 9 2010Kathleen M. Darchuk PhD Abstract Objective., This study examined depression, pain catastrophizing, psychosocial functioning, and physical and emotional health attributes for geriatric patients admitted to an interdisciplinary pain rehabilitation center compared with middle and younger age groups. Design., Quasi-experimental time series. Setting., Interdisciplinary pain rehabilitation center at a tertiary referral medical center. Patients., In total, 411 patients with chronic non-cancer pain completed the pain rehabilitation program from October 2004 to April 2006. Patients were divided into three groups based on age: older (ages 60+; n = 78); middle-age (ages 40,59; n = 230) and younger (ages 18,39; n = 141). Intervention., A 3-week outpatient interdisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates opioid withdrawal. Outcome Measures., The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Pain Catastrophizing Scale (PCS), and Center for Epidemiological Studies-Depression Scale (CES-D) were administered at admission, discharge, and 6 months following treatment. The frequency of patients using opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines at each assessment point were compared. Results., Older patients reported reduced depression, catastrophizing, pain severity, and pain interference (P < 0.001) at discharge and 6 months follow-up. Older patients also reported increased perceived control, and physical and social functioning at discharge and follow-up (P < 0.001). Improvement in older patients was comparable in magnitude to that of middle-age patients on all variables, whereas younger patients exhibited greater improvement on four variables. Significant reductions in analgesic use were observed in all groups. Conclusion., Interdisciplinary pain rehabilitation incorporating opioid withdrawal can improve long-term psychological, social and physical functioning for geriatric chronic pain patients. [source] Do Pain Patients at High Risk for Substance Misuse Experience More Pain?: A Longitudinal Outcomes StudyPAIN MEDICINE, Issue 6 2009Robert N. Jamison PhD ABSTRACT Objectives., The Screener and Opioid Assessment of Pain Patients (SOAPP v.1) has been shown to be a reliable measure of risk potential for substance misuse and to correlate with a history of substance abuse, legal problems, craving, smoking, and mood disorders among chronic pain patients. The aim of this study was to examine differences over time on a number of measures among chronic pain patients who were classified as high or low risk for opioid misuse based on scores on the SOAPP. Methods., From an initial sample of one hundred thirty-four participants (N = 134), one hundred and ten (N = 110) completed the SOAPP and were grouped as high or low risk for misuse of medication based on SOAPP scores of ,7. All subjects were asked to complete baseline measures and in-clinic monthly diaries of their pain, mood, activity interference, medication, and side effects over a 10-month study period. Results., The results showed that although those who were classified as high-risk for opioid misuse reported significantly higher levels of pain intensity, activity interference, pain catastrophizing, disability, and depressed mood at baseline (P < 0.05), only pain intensity ratings were found to differentiate groups over time (P < 0.01). These results were unrelated to perceived helpfulness of pain treatment. Conclusions., Differences in subjective pain intensity were found between those who are high risk for opioid misuse compared with those at low risk for medication misuse, implying that higher-risk patients may experience more subjective pain. Consequently, these patients may be more challenging to treat. [source] Nausea and Vomiting Side Effects with Opioid Analgesics during Treatment of Chronic Pain: Mechanisms, Implications, and Management OptionsPAIN MEDICINE, Issue 4 2009Frank Porreca PhD ABSTRACT Objectives., Gastrointestinal (GI) side effects such as nausea and vomiting are common following opioid analgesia and represent a significant cause of patient discomfort and treatment dissatisfaction. This review examines the mechanisms that produce these side effects, their impact on treatment outcomes in chronic pain patients, and counteractive strategies. Results., A number of mechanisms by which opioids produce nausea and vomiting have been identified. These involve both central and peripheral sites including the vomiting center, chemoreceptor trigger zones, cerebral cortex, and the vestibular apparatus of the brain, as well as the GI tract itself. Nausea and vomiting have a negative impact on treatment efficacy and successful patient management because they limit the effective analgesic dosage that can be achieved and are frequently reported as the reason for discontinuation of opioid pain medication or missed doses. While various strategies such as antiemetic agents or opioid switching can be employed to control these side effects, neither option is ideal because they are not always effective and incur additional costs and inconvenience. Opioid-sparing analgesic agents may provide a further alternative to avoid nausea and vomiting due to their reduced reliance on mu-opioid signalling pathways to induce analgesia. Conclusions., Nausea and vomiting side effects limit the analgesic efficiency of current opioid therapies. There is a clear need for the development of improved opioid-based analgesics that mitigate these intolerable effects. [source] Reduced Cold Pain Tolerance in Chronic Pain Patients Following Opioid DetoxificationPAIN MEDICINE, Issue 8 2008Jarred Younger PhD ABSTRACT Objective., One potential consequence of chronic opioid analgesic administration is a paradoxical increase of pain sensitivity over time. Little scientific attention has been given to how cessation of opioid medication affects the hyperalgesic state. In this study, we examined the effects of opioid tapering on pain sensitivity in chronic pain patients. Design., Twelve chronic pain patients on long-term opioid analgesic treatment were observed in a 7- to 14-day inpatient pain rehabilitation program, with cold pain tolerance assessed at admission and discharge. The majority of participants were completely withdrawn from their opioids during their stay. Outcome Measures., We hypothesized that those patients with the greatest reduction in daily opioid use would show the greatest increases in pain tolerance, as assessed by a cold pressor task. Results., A linear regression revealed that the amount of opioid medication withdrawn was a significant predictor of pain tolerance changes, but not in the direction hypothesized. Greater opioid reduction was associated with decreased pain tolerance. This reduction of pain tolerance was not associated with opioid withdrawal symptoms or changes in general pain. Conclusions., These findings suggest that the withdrawal of opioids in a chronic pain sample leads to an acute increase in pain sensitivity. [source] Experience of Methadone Therapy in 100 Consecutive Chronic Pain Patients in a Multidisciplinary Pain CenterPAIN MEDICINE, Issue 7 2008FRCPC, Philip Peng MBBS ABSTRACT Objective., The objective of the study was to describe the experience of methadone use in 100 consecutive chronic pain patients managed in a single multidisciplinary center. Design., A chart review of chronic pain patients on methadone therapy initiated at the Wasser Pain Management Center from January 2001 to June 2004. Setting, Patients, and Intervention., Outpatients receiving methadone for chronic pain management in a tertiary multidisciplinary pain center. Outcome Measure., Effects on pain relief and function, conversion ratio from other opioids, side effects, and disposition were reviewed. Results., Charts of 100 methadone patients (age 45 ± 11 years old; M/F: 3/7; duration of pain 129 ± 110 months) managed by five physicians and one nurse were reviewed. The main reason for the initiation of methadone therapy was opioid rotation (72%). The average oral morphine equivalent dose was 77 mg/day before methadone therapy, and the methadone dose after initial stabilization was 42 mg with no consistent conversion ratio observed. The mean duration of methadone therapy was 11 months. Most of the patients (91%) were taking concomitant adjuvant analgesics or psychotropic agents, mostly antidepressants and anticonvulsants. The average Numeric Verbal Rating Score before and after methadone treatment was 7.2 ± 1.7 and 5.2 ± 2.5 (P < 0.0001). Thirty-five patients discontinued their methadone treatment mainly because of side effects, ineffectiveness, or both. Conclusion., From our experience, methadone is an effective alternative to conventional opioids for chronic pain management when used by experienced clinicians in a setting that allows for close monitoring and careful dose initiation and adjustment. [source] Addiction-Related Assessment Tools and Pain Management: Instruments for Screening, Treatment Planning, and Monitoring CompliancePAIN MEDICINE, Issue 2008Steven D. Passik PhD ABSTRACT Objective., To review and critique the various assessment tools currently available to pain clinicians for assessing opioid use and abuse in patients with chronic noncancer pain to allow pain clinicians to make informed selections for their practices. Methods., A literature search on PubMed was conducted in June 2006 using the search terms opioid plus screening or assessment with or without the additional term risk, and opioid-related disorders/prevention and control in order to identify clinical studies published in English over the previous 10 years. Additional studies were identified using the PubMed link feature and Google. When abstracts described or referred to a tool for opioid abuse screening, the corresponding publication was acquired and reviewed for relevance to the pain treatment setting. Results., Forty-three publications were selected for review from the abstracts identified, and 19 were rejected because they did not describe a specific tool or provide adequate information regarding the screening tool used. The remaining 24 publications described relevant screening tools for opioid abuse risk and were reviewed. Conclusions., A variety of self-administered and physician-administered tools differing in their psychometrics and intended uses have been developed, but not all have been validated for use in chronic pain patients seen in a clinical practice setting. Some tools assess abuse potential in patients being considered for opioid therapy, whereas other tools screen for the presence of substance abuse. By recognizing the psychometrics of each tool, clinicians can select the ones most appropriate for their patient population and screening needs. [source] Sleep-Disordered Breathing and Chronic Opioid TherapyPAIN MEDICINE, Issue 4 2008Lynn R. Webster MD ABSTRACT Objective., To assess the relation between medications prescribed for chronic pain and sleep apnea. Design., An observational study of chronic pain patients on opioid therapy who received overnight polysomnographies. Generalized linear models determined whether a dose relation exists between methadone, nonmethadone opioids, and benzodiazepines and the indices measuring sleep apnea. Setting., A private clinic specializing in the treatment of chronic pain. Patients., Polysomnography was sought for all consecutive (392) patients on around-the-clock opioid therapy for at least 6 months with a stable dose for at least 4 weeks. Of these, 147 polysomnographies were completed (189 patients declined, 56 were directed to other sleep laboratories by insurance companies, and data were incomplete for seven patients). Available data were analyzed on 140 patients. Outcome Measures., The apnea,hypopnea index to assess overall severity of sleep apnea and the central apnea index to assess central sleep apnea. Results., The apnea,hypopnea index was abnormal (,5 per hour) in 75% of patients (39% had obstructive sleep apnea, 4% had sleep apnea of indeterminate type, 24% had central sleep apnea, and 8% had both central and obstructive sleep apnea); 25% had no sleep apnea. We found a direct relation between the apnea,hypopnea index and the daily dosage of methadone (P = 0.002) but not to other around-the-clock opioids. We found a direct relation between the central apnea index and the daily dosage of methadone (P = 0.008) and also with benzodiazepines (P = 0.004). Conclusions., Sleep-disordered breathing was common in chronic pain patients on opioids. The dose,response relation of sleep apnea to methadone and benzodiazepines calls for increased vigilance. [source] Can the Neuropathic Pain Scale Discriminate Between Non-neuropathic and Neuropathic Pain?PAIN MEDICINE, Issue 2 2008David A. Fishbain MD, FAPA ABSTRACT Objectives., 1) To determine if the neuropathic pain scale (NPS) can be used to classify chronic pain patients (CPPs) as having primarily neuropathic vs non-neuropathic pain, and furthermore; 2) to determine what, if any, cut-off score can be used to reliably make this determination. Design., A total of 305 CPPs consecutive admissions to The Rosomoff Pain Center were administered the NPS and were assigned a diagnosis according to the physical examination and all available test results. CPPs with a diagnosis of chronic radiculopathy and spondylolysis/degenerative arthritis were segregated into two groups for the purposes of having a group representative of neuropathic pain (chronic radiculopathy) and non-neuropathic pain (spondylolysis/degenerative arthritis). Applying neuropathic pain criteria to each "of these two groups": a neuropathic pain "subtype" was identified within the chronic radiculopathy group; and, a non-neuropathic pain "subtype" was identified within the spondylolysis/degenerative arthritis group. This step was performed in order to assure that the CPPs selected for further analysis were truly representative of neuropathic and non-neuropathic pain. Discriminant function analysis was then employed to determine if NPS scoring could differentiate between these two "subtypes." Results from the discriminant function analysis model were utilized to derive an NPS cut-off score above which CPPs would be classified as having neuropathic pain. For the diagnoses of myofascial pain syndromes, spinal stenosis, epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome, a predicted NPS score was calculated and compared with the cut-off score. Setting., Multidisciplinary pain facility. Patients., Chronic pain patients. Results., The NPS appeared to be able to separate CPPs into neuropathic pain vs non-neuropathic pain subtypes. The derived cut-off score from the model was 5.53. Myofascial pain syndrome and spinal stenosis had predictive scores lower than this cut-off score at 3.81 and 4.26, respectively. Epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome had predictive scores higher than the cut-off score at 6.15, 6.35, 6.87, 9.34, and 7.19, respectively. Conclusions., The NPS appears to be able to discriminate between neuropathic and non-neuropathic pain. A debate is currently raging as to whether diagnoses, such as fibromyalgia and complex regional pain syndrome 1, can be classified as neuropathic. Our NPS cut-off score results suggest that these diagnoses may have a neuropathic pain component. The reliability and validity of our NPS method will need to be tested further in other neuropathic pain models, such as diabetic peripheral neuropathic pain. [source] Chronic Pain and Violent Ideation: Testing a Model of Patient ViolencePAIN MEDICINE, Issue 3 2007Daniel Bruns PsyD ABSTRACT Objective., Physicians are at risk of patient-perpetrated violence. The objective of this study was to test a clinical model of patient violence, which had been developed previously by Fishbain and colleagues. The developers of this model believed that it would be associated with increased risk of violence in pain patients. Design., Hypotheses generated by the model were tested using manova and chi-square procedures. Setting., A total of 527 subjects for this study were patients obtained from 90 medical facilities in 30 U.S. states. Patients., All subjects were patients being treated for injury and nonmalignant pain. All of the subjects were adults, ranging in age from 18 to 65 years, and were able to read at the sixth-grade level. The demographics of the sample approximated U.S. Census data for race, education, age, and gender. Results., The results included findings that violent ideation was associated with higher levels of physical difficulties, including pain (P = 0.01), problems with functioning (P = 0.0003), and somatic complaints (P = 0.0001). Significant psychosocial variables included hostility (P < 0.0001), dependency (P < 0.0001), substance abuse (P < 0.0001), litigation (P < 0.001), and a lack of trust in the physician (P < 0.001). Conclusions., Using the Battery for Health Improvement 2 as a measure, the findings of this study consistently supported the Fishbain Model of violence risk, and also reinforced the need for psychological assessment and management when working with chronic pain patients. Suggestions for intervention were also offered, but further research will be necessary to see whether these interventions are effective in decreasing patient violence. [source] Treating Pain Patients at Risk: Evaluation of a Screening Tool in Opioid-Treated Pain Patients With and Without AddictionPAIN MEDICINE, Issue 2 2003FACP, Robert Friedman MD ABSTRACT Patients receiving opioid treatment for chronic pain, many of whom were hospitalized with medical complications of substance abuse, were asked to complete a screening questionnaire to help validate a simple self-administered survey. Questions relating to tobacco abuse and prior treatment for drug and alcohol abuse distinguished patients with addiction and pain from opioid-treated chronic pain patients. [source] UNINTENTIONAL OVERDOSE WITH INTRATHECAL ZICONOTIDEPAIN MEDICINE, Issue 2 2002Article first published online: 4 JUL 200 Steven G. Charapata MD, Research Medical Center, Kansas City, MO; David Ellis MD, PhD, Elan Pharmaceuticals, South San Francisco, CA Ziconotide is a novel, N-type, voltage-sensitive calcium channel (VSCC) blocker, with well-documented efficacy as an intrathecal (IT) analgesic. Ziconotide has been administered to over 1000 chronic pain patients in nine clinical trials. Over 350 patients have been on ziconotide IT therapy for more than three months in a long-term safety and tolerability study. Common adverse events for ziconotide include dizziness, nausea, nystagmus, abnormal gait, constipation, urinary retention, somnolence, postural hypotension, vomiting, confusion and abnormal vision. Ziconotide adverse events are recognizable, reversible and manageable, by dose adjustment and slow dose titration. Case reports of unintentional overdose in six chronic pain patients treated with IT ziconotide are presented. These unintentional overdoses were attributable to pump programming or dilution errors; none were lethal. The patient who received the highest overdose was administered 31 mcg/hr over 24 hours, or nearly 750 mcg ziconotide, total. This hourly dose rate is 300-fold the current recommended initial dose rate of 0.1 mcg/hr. This patient was sedated, but arousable; vital signs were stable and patient had no change in blood pressure. His symptoms resolved within 24 hours. His Visual Analog Score of Pain Intensity (VASPI) was reduced from 82 at baseline to 2.5 at the end of the titration period. The patient elected to continue in the long-term IT ziconotide study. The other 5 cases of inadvertent overdose were less severe, with dose rate at 5 mcg/hr or less. Associated adverse events also resolved within 24-hours of discontinuing ziconotide infusion. Unlike an unintentional overdose with IT morphine, which slows respiration and could potentially lead to hypoxia, coma or death; ziconotide does not produce respiratory depression. No tolerance to the analgesic effect of ziconotide, or withdrawal symptoms after discontinuation of the drug have been reported. Ziconotide has a wide margin of safety as an IT analgesic. [source] Millon Behavioral Health Inventory Scores of Patients With Chronic Pain Associated with Myofascial Pain SyndromePAIN MEDICINE, Issue 4 2001David A. Fishbain MSc, FAPA Objectives., Normative data for the coping styles and psychogenic attitudes of the Millon Behavioral Health Inventory (MBHI) for male and female chronic pain patients (CPPs) with mixed pain diagnoses have previously been reported and compared with normative MBHI manual data. However, results from other studies have suggested that CPPs with myofascial pain syndrome (MPS) may need to be considered as a distinct group in psychiatric/psychological studies. The purpose of the present study was then to provide normative data for each MBHI scale for male and female CPPs with MPS and to compare these data with MBHI manual norms for similarities and differences. Setting.,Multidisciplinary pain facility. Patients.,CPPs with an associated diagnosis of MPS. Outcome Measure.,MBHI base rate scores. Methods. CPPs with an associated diagnosis of MPS were first broken down into two groups: males and females. Analyses were then performed using the MBHI base rate scores of these two groups. For each group, the percentages of CPPs who had a base rate of 75 or above were calculated for each individual coping style and psychogenic attitude. These percentages were then compared by chi square with percentages of patients with base rate scores of 75 or above for each coping style and psychogenic attitude to the MBHI Manual normative sample. Results., Female CPPs with MPS differed from MBHI Manual normative counterparts on two of the six psychogenic attitude scales (future despair and somatic anxiety); no differences were found in any of the eight coping style scales. Male CPPs with MPS differed from MBHI Manual normative counterparts on one coping style scale (sociable) and three psychogenic attitude scales (premorbid pessimism, future despair, and somatic anxiety). Conclusions., The pattern of the results indicated that CPPs with MPS, especially males, differ from the MBHI Manual normative data counterparts. These differences appear to be greater than those for CPPs with mixed pain diagnoses. Differences in MBHI scale scores between CPPs with MPS and MBHI Manual normative data counterparts may be related to a number of issues, such as whether differences in state factors reflecting depression and anxiety might affect trait factors purportedly measured by the MBHI. [source] (216) Pain and Addiction: Screening Patients at RiskPAIN MEDICINE, Issue 3 2001Victor Li Introduction: Addictive disease is a common co-morbidity in chronic pain patients [1]. 26% of patients on methadone treatment believed that prescribed opioids led to their addiction [2]. We report initial validation of a Screening Tool for Addiction Risk (STAR). Methods: Questions based on prior studies of pain and addiction, addiction-screening tools [3,4], discussions with clinicians experienced in pain medicine and addiction, and our clinical experience were used to develop the STAR. After obtaining IRB approval, chronic pain patients completed the 14-item STAR questionnaire. 14 patients with chronic pain and history of drug addiction (DSM-IV Criteria) and 34 additional chronic pain patients completed the survey as part of their initial clinical evaluation. Patient responses were compared to determine which were questions accounted for statistically significant differences. Results: Questions related to respondent classification of addict based on chi-square analysis and Fisher's exact test were: prior treatment in a drug rehabilitation facility (p < 0.00001), nicotine use (p < 0.0032), feeling of excessive nicotine use (p < 0.0007), and treatment in another pain clinic (p < 0.018). A factor analysis linked addiction to first three questions mentioned above. Question: "Have you ever been treated in a drug or alcohol rehabilitation facility?" had a positive predictive value of 93% for addiction. Responses to recreational substance use, alcohol abuse, recent anxiety or depression, unemployment, emergency room visits, family history of drug or alcohol abuse, multiple physicians prescribing pain medication, or a prior history of physical or emotional abuse were not different between either patient group. Discussion: Screening for addiction is an important part of management of chronic pain patients. A history of treatment in drug or alcohol rehabilitation facility and questions related to cigarette smoking may be useful to screen for potential risk of addiction. Further investigations needed to validate results of this study. [source] (229) Serum Cortisol Concentrations and Adrenal Reserve May Be Altered by Severe Chronic PainPAIN MEDICINE, Issue 3 2001Forest Tennant It has been postulated that chronic pain over-stimulates the hypothalamus-pituitary-adrenal axis to produce an extended stress response. If this assumption is true, patients with severe, chronic pain should demonstrate abnormalities of the pituitary-adrenal axis. To evaluate this premise, we screened 40 adult, chronic pain patients in the first week of treatment with serum cortisol concentrations taken between 8:00 and 10:00 AM. Criteria for inclusion in this study required that pain be present for at least one year and be constant, incurable, interfere with sleep, and cause the patient to be bed or house-bound without opioid treatment. Sixteen (16) of the subjects were challenged with cosyntropin, 0.25mg, given intramuscularly immediately after blood was drawn for determination of baseline serum cortisol concentration. Normal serum cortisol concentrations was considered to range from 5.0 to 25.0 ug/dl at baseline, and normal cortisol reserve was considered to be at least a doubling of the baseline concentration determined one hour after cosyntropin administration. Ten (25%) of the patients had evaluated serum cortisol concentrations above 25ug/dl with the highest being 54.4 ug/dl. Nine (20%) demonstrated low serum cortisol concentrations under 5 ug/dl, and 5 of 16 (31.25%) given cosyntropin challenge demonstrated inadequate adrenal reserve by failing to double their baseline cortisol concentration. All patients with high or low serum cortisol concentration demonstrated a normal cortisol concentration following pain control with a long-acting opioid including methadone, extended-length morphine or oxycodone, or transdermal fentanyl. This study suggests that severe, chronic pain may produce profound abnormalities of serum cortisol and cortisol reserve, and normalization of these alterations may require pain treatment with long-acting opioids. [source] (231) Use of Transmucosal Fentanyl in Non-Malignant, Chronic PainPAIN MEDICINE, Issue 3 2001Forest Tennant Transmucosal fentanyl (TF) has recently become available for treatment of breakthrough pain in cancer patients who are already tolerant to opioids. In addition to cancer patients, there is a growing number of chronic pain patients who regularly use and are tolerant to opioids and require a breakthrough opioid for adequate pain control. This pilot study was done to determine if TF is effective and acceptable to non-malignant, chronic pain patients who are opioid tolerant and require a breakthrough opioid(s) for pain control. Sixty patients with chronic, non-malignant pain who were maintained on a long-acting opioid and who required breakthrough pain control were given TF in an initial dose of 400 or 600 mcg per single, transmuscosal administration. Among the study group 35 (58.3%) experienced chronic pain due to injuries to the spine and 25 (41.7%) were due to medical conditions other than cancer. After at least three months of usage, patients were asked if they desired to continue TF and the reason(s) why they believed it to be effective. Fifty-eight (96.7%) of these subjects perceived that TF was an effective breakthrough opioid and desired to continue it. The single, effective dosage ranged from 800 to 1600 mcg per administration, and the number of separate monthly dosages ranged from 2 to 360. The majority of patients used TF only for emergency, pain purposes but others preferred TF as their major breakthrough opioid and ceased use of other short-acting opioids including injectable meperidine. Reported reasons for widespread patient acceptance included TF's fast action, fewer bed-bound days, increased energy, decreased use of other opioids, less depression, and fewer emergency room visits. This pilot study indicates that TF is effective and desired as a preferential opioid for breakthrough pain by a high percentage of chronic, non-malignant pain patients. [source] | |||||||||||||