Bruce Singer, PsyD presented this poster at the American Academy of Pain Management’s 26th Annual Meeting: No Life Limited By Pain 2015. See the other poster winner.
Diverse Opioid Pathways in Chronic Pain Recovery
Presenter: Bruce Singer, PsyD
Authors: Seddon Savage, MD; Brent Moore PhD; Bruce Singer PsyD; Seth Resnick, MD; Michael Brennan, MD; Michael Fortin, DPT; Tiffany Nienstedt, MS; and Sigurd Ackerman, MD
Background: While some patients with chronic pain experience effective analgesia with opioid therapy, over time other patients experience loss of analgesia, declining function, persistent side effects, mood changes, increasing pain, escalating dose requirements, and/or diverse types of opioid misuse that ultimately result in declining well-being. A patient’s distress in such contexts may reflect diverse issues including:
- Ineffective pain management due to tolerance, hyperalgesia, opioid non-responsiveness, or inappropriate dosing
- The presence of unaddressed, co-occurring symptoms that facilitate pain such as depression, anxiety, intrusive memories, sleep disturbance, or others
- Opioid-induced distress related to active opioid misuse or addiction
- A combination of these
Objective: To address chronic pain in patients who have not responded favorably to opioid therapy, the Chronic Pain & Recovery Center (CPRC) at Silver Hill Hospital (SHH) is guided by the following understandings:
- Chronic pain, like other chronic medical conditions, often has complex biopsychosocial contributors and benefits from a strong foundation in self-management.
- Distress occurring in the treatment of chronic pain with opioids can reflect diverse drivers, therefore opioid management must be tailored to the individual and the causes of distress; no single approach is effective in addressing the needs of all patients.
- Outcomes of treatment based on these guidelines are presented.
Admission criteria and process
All patients have one or more pain diagnoses. Many have co-occurring psychiatric or addictive disorders. Treatment costs are covered by the individual, workers compensation, the Veterans Administration, or through SHH scholarships covering 75% of cost.
Patients are admitted to the program by two routes:
- On an non-urgent, elective basis following outpatient evaluation by the CPRC team.
- On transfer from inpatient psychiatric admission for acute mental health or addiction issues with chronic pain; evaluated by the CPRC team once stable.
Table 1 indicates the numbers of common pain diagnoses and psychiatric and substance abuse disorders in the first 154 patients admitted to the program.
Pain Diagnoses *
Musculoskeletal- Axial 95
Neuropathic (non-facial) 18
Psychiatric and Substance Abuse Diagnoses*
Depressive disorder or state 114 *
Anxiety disorder or state 79
Bipolar disorder 4
Opioid use disorder 72
Sedative hypnotic use disorder 45
Alcohol use disorder 35
*Patients could be diagnosed with more than one pain or psychiatric disorder
Payer sources were 54% self-pay, 30% workers compensation, 2% Veterans Administration, and 14% scholarship.
Program format and goals
The CPRC is a minimum four-week, residential program with a maximum census of eight patients. The program focuses on acquisition of self-management skills with goals to reduce pain, improve coping with residual pain, increase function, effectively treat co-occurring disorders (mental health or addiction), reduce medication reliance, and enhance overall quality of life. Patients engage in therapeutic activities 12 to 14 hours a day. Treatment is primarily group-based with individual counseling sessions with a psychologist a minimum of twice weekly and medical/psychiatric appointments from one to five times a week as indicated.
Core treatment approaches include:
- Cognitive behavioral therapy (CBT) integrated with acceptance and commitment therapy (ACT) tailored to comprehensively address pain, mood, and substance disorders
- Mindfulness strategies including meditation, body awareness, gratefulness
- Physical therapy tailored to individual condition
- Land-based exercise (aerobic, stretch, strengthening)
- Aquatic exercise
- Goal setting and process groups
- Education on pain, mood, substance use, sleep hygiene, nutrition, and related topics
Patients also participate in
- 12-step groups including Chronic Pain Anonymous, AA, NA
- Movement groups including yoga, Tai Chi, Chi Gong
- Art therapy
- Family program
- 12-month step down aftercare and telephone support follow-up is offered
All patients using opioids without favorable response or with negative consequences are educated about ways in which opioids can contribute to distress and are encouraged to taper off on a trial basis. Decisions regarding ongoing management of opioids are made with the patient based on their response to taper.
Common management approaches include:
- Opioid taper with continued cessation (with or without naltrexone)
- Transition to opioid agonist maintenance therapy for opioid addiction (buprenorphine/naloxone or methadone maintenance)
- Rotation to an alternative opioid at lower doses for analgesia
- Lower dose therapy using the admission opioid for analgesia
Psychiatric medications are adjusted as indicated to treat co-occurring psychiatric issues. Non-opioid medications for pain are introduced or adjusted as indicated.
Results: One hundred eighteen of the first 136 patients admitted completed treatment and had assessment data analyzed. Clinical outcomes for pain, pain interference, mood, catastrophizing are indicated in the adjacent graphs. Data indicates significant reductions in mean pain and pain interference with enjoyment of life and with activity. Anxiety and depression scores significantly reduced, as did scores from the pain catastrophizing measures. Data available at three and six months after initiation of treatment on a smaller group of 18 patients who participated in aftercare suggest that these improvements persisted.
Opioid use data is available on 154 patients who completed treatment and indicates the following:
- 79% of 154 (122) patients admitted to CPRC were using opioids on admission.
- 63% of those admitted on opioids (77) no longer used opioids at discharge
- 3 of these were on the depot naltrexone to support recovery from opioid addiction.
- 18% (22) were transitioned to opioid agonist therapy (OAT) for treatment of opioid addiction.
- 20 on buprenorphine/naloxone
- 2 on methadone with referral to methadone maintenance
- 19% (23) were on lower dose opioid prescriptions for pain, most rotated to a different opioid with a mean dose reduction of greater than 75% morphine equivalents.
- One patient with history overuse of prescribed opioids and relapsing alcoholism (in part driven by pain) who was not on opioids at admission, was prescribed buprenorphine/nx for pain.
- One patient’s admission opioids were unchanged on discharge.
Opioid use data at six months post discharge based on self report and urine drug screens on 19 patients in aftercare (see Table 2) indicate maintenance of discharge opioid status for all but one patient.
Conclusions: From treatment intake to discharge, all measures of pain, pain interference, and measures of psychiatric functioning (anxiety and depression) showed significant clinical improvement. For participants in the aftercare program, improvements appear to be retained for the pain measures. There is some indication that anxiety and depression scores at later follow-up may be returning toward baseline.
Importantly, these clinical improvements occurred in the context of reduction or elimination of opioid use for pain. Opioid management generally followed these principles:
- Patients were transitioned to OAT for addiction or taken off opioids and prescribed depot naltrexone if they were determined to have moderate to severe opioid use disorder (OUD).
- OAT was prescribed to patients with histories of relapsing opioid addiction, high levels of craving or other variables indicating strong potential for relapse or opioid-associated harm.
- Naltrexone was considered in patients with recent onset addiction, no history of prior addiction or addiction treatment, and/or those who declined OAT.
- Patients were tapered and discharged off opioids without naltrexone if
- Opioids were ineffective for pain but they had no co-occurring opioid use disorder
- They had misused opioids targeting relief of pain or other symptoms/distress but were not judged to have triggered addiction (absent craving, history of relapses, past opioid addiction, or other indicators) or
- They were identified as having moderate to severe OUD but declined OAT or naltrexone.
- Opioids were continued or resumed for analgesia if no major OUD was identified and impairing pain persisted during or after opioid taper and interfered with function and/or program engagement despite introduction of self-management strategies and use of non-opioid analgesic approaches
- In this treatment population for whom opioid analgesic therapy was previously unsuccessful or associated with misuse or harm, upward titration of opioids for pain was not identified as useful.
Limitations and further study:
The study is limited to patients in residential treatment for chronic pain, and may not generalize to other populations. In addition, although standardized assessment measures were used, all assessments were based on self-report. Finally, both clinical and opioid use follow-up data is limited to patients who actively participated in an aftercare program, so the persistence of clinical improvement in patients with less support following discharge is unknown.
Future evaluations will include:
- Analysis of the relationship of opioid management strategies implemented and their association with different pain types, mental health diagnoses, and other patient variables.
- How opioid use changes over time post-treatment to determine the long-term effectiveness of different opioid management options for different patients.
- Examination of which ongoing self-management practices (exercise, cognitive awareness, meditation, etc.) at what intensity of practice are associated with best clinical outcomes.
These outcomes suggest that intensive residential engagement in self-management can improve chronic pain, function, and quality of life at the same time reliance on opioids is reduced. Opioid management strategies associated with positive pain treatment outcomes vary according to patient clinical variables and may include:
- Opioid cessation (with or without naltrexone)
- Transition to opioid agonist treatment for opioid addiction
- Opioid rotation and reduction in equivalent opioid dose
- Reduction in dose of current opioid