Kate Johnson

February 29, 2012

February 29, 2012 (Palm Springs, California) — Patients with chronic pain who are at high risk for substance abuse can be treated in an intensive pain rehabilitation program and achieve the same outcomes as low-risk patients, according to a study presented here at the American Academy of Pain Medicine (AAPM) 28th Annual Meeting.

"On discharge, with the curriculum aimed at substance abuse, there was improvement on all outcome measures for all patients, but the striking thing was there was no difference between the high- and low-risk patients," reported Sarah Hayes, an undergraduate research associate at Mayo Clinic Pain Rehabilitation Clinic in Rochester, Minnesota.

Sarah Hayes

She said the program has a 97% taper rate. "The goal of the program is not to decrease pain, although we do seem some pain decrease. It is functional restoration and discontinuation of opioids and polypharmacy."

The study was ranked among the top 6 at the AAPM meeting.

Investigators retrospectively analyzed 476 consecutive patients with chronic pain entering the 3-week interdisciplinary pain rehabilitation program between February 2010 and May 2011.

A total of 246 patients were considered high risk for substance abuse, with the remaining 230 at low risk. High risk was defined as having current or a history of substance abuse, or clinical dependency on high-dose opioids or mood-altering substances, said Hayes.

At baseline, the 2 groups did not differ for duration of pain (approximately 11 to 12 years), or duration of opioid use (between 5 and 7 years). However, compared with low-risk patients, high-risk patients used opioids, benzodiazepines, marijuana, tobacco, and alcohol at higher frequencies (P ≤ .001); had significantly greater daily morphine equivalence doses (124 vs 60 mg/day; P < .001); and reported greater depression, pain catastrophizing, pain interference, and poorer pain self-efficacy (P ≤ .001).

All patients were treated for 3 weeks in an all-day program that included cognitive-behavioral therapy (CBT), physical therapy, occupational therapy, biofeedback and relaxation training, stress management, wellness instruction (eg, sleep hygiene, healthy diet), chemical health education, and pain management training (eg, activity moderation, elimination of pain behaviors), Hayes explained.

The high-risk curriculum, taught by an advanced nurse specialist, replaced a few hours of the CBT and focused on "the cycle of pain and substance abuse," she said. "We are really giving these patients the psychoeducation, the tools that they need to manage high-risk situations in the future."

At the end of the program, despite more severe baseline levels, high-risk patients were similar to low-risk patients in terms of pain severity, pain catastrophizing and pain interference, depression, and perceived control of life and pain, she reported.

"So the take-home point is there was significant functional improvement for all," she announced. "We can treat these patients that have that mysterious, sometimes very difficult to understand, overlap between addiction and chronic pain."

During the question period, Kelvin Gorrell, MD, a pain physician in private practice in Spring Hill, Florida, questioned the program's "ridiculously high" success rate. "I didn't get any pearl or secret of why the Mayo Clinic program is so successful when everybody else is failing," he said. "I don't understand what you guys are doing different. Is there something in the water?"

Michael Hooten, MD, senior author on the study, replied, "This particular program has been in continuous operation since 1974. It is a very robust intervention, very intensive. Patients are exposed to more than 140 hours of really intense cognitive-behavioral therapy, but it's also coupled with physical exercise and retraining. There is no magic. It's just really kind of grass roots."

"It gets billed as just all cognitive-behavioral therapy, but I think it's more than that," said session moderator James Watson, MD, who also works at the Mayo Clinic in Rochester but is not involved with the program.

"There are a lot of other things that go into it," he told Medscape Medical News. "It's a multidisciplinary approach from the educational side of things, from the physical therapy side of things, from simplifying polypharmacy to the sleep and mood issues and all those other things that go along with the pain."

Asked about his doubts, Dr. Gorrell softened his criticism after speaking to Dr. Hooten. "Cognitive-behavioral therapy is a basic and common modality in psychotherapy, but it's never had this success rate before," he said in an interview with Medscape Medical News.

"What they underemphasized and maybe don't fully appreciate is that theirs is actually an integrative approach using a mind-body connection, if you will. They're probably doing about 3 to 4 hours of physical movement combined with about 4 hours of other psychotherapeutic effects. So while taking the patient off the synthetic manmade opiates, they are also simultaneously being replaced with the body's upregulation and increased production of endogenous opiates."

None of the speakers have disclosed any relevant financial relationships.

American Academy of Pain Medicine (AAPM) 28th Annual Meeting: Abstract #195. Presented February 24, 2012.

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