An intensive biopsychosocial chronic pain and recovery program shows significant reductions in opiate use along with pain reduction, researchers report.
“We have found that 63% of our chronic pain patients who come in on opiates are leaving without opiates and with a 25% reduction in pain,” lead author Bruce Singer, PsyD, director of the Chronic Pain and Recovery Center at Silver Hill Hospital, in New Canaan, Connecticut, told Medscape Medical News.
Under the residential program, patients with chronic pain who have not responded to opioid therapy enroll for a minimum of 4 weeks and take part in wide-ranging therapeutic activities for up to 12 to 14 hours per day.
The program is primarily group-based (maximum of eight patients per group), with activities focused on building self-management skills to reduce pain, improving function, and treating co-occurring mental health or addiction disorders with cognitive-behavioral and other therapies. The program also has a strong focus on reducing reliance on medication and improving patients’ quality of life.
“The program is basically about putting control of pain back in the hands of the individual,” Dr Singer explained.
A study of outcomes with the program was presented here at the American Academy of Pain Management (AAPM) 2015 Annual Meeting.
In assessing clinical outcomes of the program, which has been in operation for about 3 and a half years, the recovery center teamed up with analysts at Yale University School of Medicine and the Geisel School of Medicine at Dartmouth College, evaluating 118 of the first 136 patients admitted.
Among key findings of the analysis were declines in average pain level, according to Brief Pain Inventory (BPI) scores, from 6.6 at admission to 4.8 at discharge (P < .001), as well as declines in BPI scores on interference of pain with enjoyment (7.9 at admission to 3.7 on discharge; P < .001) and interference of pain with activities (7.0 vs 3.5; P < .001).
Anxiety, measured according to Beck Anxiety Inventory, declined significantly from 26.0 on admission to 14.2 at discharge, while depression, also measured on the Beck index, declined from 30.1 to 10.9 (bothP < .001).
Measures pertaining to the Pain Catastrophizing Scale, including rumination, magnification, and feelings of helplessness, all also declined significantly from admission to discharge (all P < .001).
Follow-up data on a small group of 18 patients who completed 6 months of aftercare showed sustained, statistically significant reductions in all measures, with small increases in depression and anxiety.
Opioid use data available for 154 patients, involving self-reported data that were corroborated with urine drug screens, meanwhile showed that among 122 (79%) of the 154 patients who were using opioids on admission, 77 (63%) no longer used the medication at discharge.
Twenty-two of the patients (18%) were transitioned to opioid agonist therapy for opioid addiction.
Twenty-three of the patients (19%) were meanwhile receiving lower-dose opioid prescriptions for pain on discharge, and most rotated to a different opioid with a mean dose reduction of greater than 75% morphine equivalents.
Follow-up data at 6 months after discharge on 19 patients in the formal aftercare program showed maintenance of the discharged opioid status among all but 1 of the patients.
The key opioid management strategies used in the program included transitioning patients to opioid agonist therapy (OAT) for addiction or taking them off of opioids and prescribing depot naltrexone if they were determined to have moderate to severe opioid use disorder.
If patients had no co-occurring opioid use disorder or were not considered to have addiction and opioids were not controlling pain, the drug dose was tapered and the patients were discharged off of the drugs without naltrexone.
Opioid treatment was continued in patients for analgesia if no opioid use disorder was identified and pain persisted after the opioid taper to the point of interfering with function despite other self-management strategies.
In addition to the opioid management efforts, key components of the integrative program include mindfulness strategies (such as meditation, body awareness, and gratitude), as well as exercise tailored to the individual condition (such as aquatic, aerobic, and stretch exercise) and important goal-setting activities.
Patients also participate in 12-step groups including Chronic Pain Anonymous, Alcoholics Anonymous, and Narcotics Anonymous.
“From day 1, patients are put on a 14-hour-a-day schedule, and even if they’ve been previously lying in bed for 20 hours a day, there’s a behavioral activation right away,” Dr Singer said.
“We have found that the people who do well in our program are unattaching their physical pain level from their wellness level and shifting their focus to how well they are as people in spite of pain,” Dr Singer said. “The ones who make that shift are the ones who succeed.”
Importantly, patients are provided with tools to sustain the motivation for recovery on their own.
“Rather than us telling patients to do this and get better, they begin to see that they can do this themselves and generate their own self-talk for encouragement.”
Dr Singer noted that several former patients have gone on to become volunteers and help lead groups at the center, helping to share their experiences to support others going through similar experiences.
Thomas Watson, PT, a chronic pain specialist, physical therapist, and diplomate of the AAPM, said the research offers important evidence documenting the benefits of the center’s integrative approach to chronic pain.
“The trend in pain management is for opioid reduction and to use the best therapeutic dose with the least side effects, or to try to get patients off altogether, and what this study shows is clear benefits from that approach,” he told Medscape Medical News.
“I would say the 25% reduction in pain they saw is equal to or better than most programs,” he added. “This emphasizes that you can’t treat pain with just one modality or with pharmacology alone — you really have to have other measures, such as music, yoga, physical therapy, or acupuncture. That way you’re treating the whole person.”
American Academy of Pain Management (AAPM) 2015 Annual Meeting. Presented September 19, 2015.