Predictors of attrition in an interdisciplinary pain management program.

PURPOSE/OBJECTIVE: This study sought to investigate the extent to which demographic and clinical characteristics predict which patients drop out of an interdisciplinary pain management program (IPP). RESEARCH METHOD/DESIGN: Participants (N = 178 outpatients, 18-75 years of age) received treatment for various chronic pain conditions in an IPP (including biopsychosocial assessment, cognitive-behavioral, and physical therapies). Separate logistic regression analyses identified the demographic and clinical variables most predictive of attrition across five domains: (a) demographics, (b) number of medical and non/psychiatric diagnoses, (c) opioid use (yes versus no)/risk of misuse, (d) pain-related cognition and behavior, and (e) physical, social, and mental well-being. Significant predictors from the five domains were integrated in a final multivariable logistic regression model. RESULTS: Among patients exposed to a 4-week IPP, 34% dropped out. In the final model, significant predictors of higher odds of attrition included younger age or being unemployed. Also, patients on opioids at preintervention had higher odds of completing the IPP than patients not on opioids at preintervention. Follow-up analyses revealed 24 of 37 completers (65%) on opioids at preintervention reduced or eliminated use over the course of the IPP. CONCLUSIONS/IMPLICATIONS: Because findings are limited by sample and design characteristics, they require replication yet offer novel hypotheses for identifying patients at risk of attrition. Specifically, patients with preintervention opioid use (contrasted with opioid dependence) may particularly benefit from an IPP. Patients at highest risk for early dropout can be targeted for specific engagement interventions to promote completion and effectiveness of IPP. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk.

Beginning in the late 1990s, a movement began within the pain management field focused upon the underutilization of opioids, thought to be a potentially safe and effective class of pain medication. Concern for addiction and misuse were present at the start of this shift within pain medicine, and an emphasis was placed on developing reliable and valid methods and measures of identifying those at risk for opioid misuse. Since that time, the evidence for the safety and effectiveness of chronic opioid therapy (COT) has not been established. Rather, the harmful, dose-dependent deleterious effects have become clearer, including addiction, increased risk of injuries, respiratory depression, opioid induced hyperalgesia, and death. Still, many individuals on low doses of opioids for long periods of time appear to have good pain control and retain social and occupational functioning. Therefore, we propose that the question, "Who is at risk of opioid misuse?" should evolve to, "Who may benefit from COT?" in light of the current evidence.

Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care.

Chronic pain, a debilitating medical condition affecting approximately 15% of the US population, leads to individual suffering and costs to society in terms of health care dollars and lost productivity. To examine the effectiveness of a comprehensive pain management program, data from 108 program participants were evaluated. Preprogram, postprogram, and 6-month follow-up data were collected from 80 participants, and preprogram, postprogram, and 1-year data were collected from 46 participants. Outcomes data from several domains were assessed: pain severity, emotional distress, interference of pain on function, perceived control of pain, treatment helpfulness, and number of hours resting. Within-subject repeated-measure analyses of variance found statistically significant findings on the six outcome measures utilized in this study for both the 6-month and 1-year samples. Examination of 95% confidence intervals revealed no overlap in pretreatment scores with 6-month and 1-year outcomes in five of the six domains studied. Mean scores on emotional distress did not maintain statistical significance in the 6-month or 1-year review. Overall, this study strengthens the case for interdisciplinary care for chronic pain management and provides evidence for the long-term effectiveness of this therapy. Furthermore, this study lends support to the notion that interdisciplinary treatments are effective in targeting multiple domains affected by the pain condition.

Rapid conformational dynamics of cytochrome P450 2E1 in a natural biological membrane environment.

Among the members of the cytochrome P450 superfamily, P450 2E1 is most often associated with the production of reactive oxygen species and subsequent cellular toxicity. We sought to identify a structural basis for this distinguishing feature of P450 2E1 by examining its carbon monoxide binding kinetics as a probe of conformation/dynamics. We employed liver microsomes from wild-type and P450 2E1 knockout mice in order to characterize this P450 in a natural membrane environment. The CO binding kinetics of the P450s of wild-type microsomes had a rapid component that was absent in the knockout microsomes. Data analysis using the maximum entropy method (MEM) correspondingly identified two distinct kinetic components in the wild-type microsomes and only one component in the knockout microsomes. The rapid kinetic component in wild-type microsomes was attributed to endogenous P450 2E1, while the slower component was derived from the remaining P450s. In addition, rapid binding kinetics and a single component were also observed for human P450 2E1 in a baculovirus expression system, in the absence of other P450s. Binding kinetics of both mouse and human P450 2E1 were slowed in the presence of ethanol, a modulator of this P450. The unusually rapid CO binding kinetics of P450 2E1 indicate that it is more dynamically mobile than other P450s and thus able to more readily interconvert among alternate conformations. This suggests that conformational switching during the catalytic cycle may promote substrate release from a short-lived binding site, allowing activated oxygen to attack other targets with toxic consequences.

Examining sympathetic nerve activity with microneurography during hypnosis: untangling the effects of central command.

Using microelectrode recordings of postganglionic sympatheticaction potentials, the authors studied the effects of hypnotic suggestion on sympathetic outflow targeted to skin during static handgrip exercise. All subjects performed sustained handgrip at 33% maximal voluntary contraction (MVC) for 2 minutes during 3 consecutive trials. Two subjects randomly assigned to a hypnosis condition received suggestions that the 2nd trial was more difficult and the last trial was less difficult than the first trial. Two subjects randomly assigned to the control condition received no hypnosis or suggestions about task difficulty. In the nonhypnosis condition, skin sympathetic nerve activity (SNA) increased by 6% from baseline during the 2nd trial and 13% from baseline during the 3rd trial. In the hypnosis condition, skin SNA increased by 25% during the 2nd trial (suggestion of increased difficulty) and returned to baseline during the 3rd condition (suggestion of decreased difficulty). Therefore, the impact of central command on skin SNA is suggested by these results.

Biopsychosocial profiles of different pain diagnostic groups.

UNLABELLED: Different pain diagnoses have been examined separately in various research studies. The major aim of the present investigation was to add to the current understanding of the various groups of patients who make up the chronic pain population. This study expanded the research literature by including 7 different predominantly chronic pain syndromes (fibromyalgia, upper extremity pain, cervical pain, thoracic pain, lumbar pain, lower extremity pain, and headache). These 7 groups were examined by using a broad array of variables focusing on demographic, self-reported psychosocial, and physical/functional factors. There were 661 patients included from an interdisciplinary treatment program who had been given 1 physical pain diagnosis. Results revealed differences among the 7 groups with regard to self-reported physical/functional limitations. The headache group had less physical/functional impairment than most of the other groups. On the other hand, the lumbar, fibromyalgia, and lower extremity groups had the most physical/functional problems. On self-reported psychosocial measures, the fibromyalgia group had the most difficulties, and the lower extremity and lumbar groups had fewer problems in this area. Overall, though, besides the fibromyalgia group, there was a lack of differences among the other groups on the psychosocial measures. PERSPECTIVE: Biopsychosocial profiles were examined for different pain diagnostic groups. Seven different pain groups were compared. It was discovered that, in general, the lumbar, fibromyalgia, and lower extremity groups reported more physical/functional limitations, and the fibromyalgia and headache groups reported more psychosocial difficulties.

Molecular modeling of mammalian cytochrome P450s.

The cytochrome P450 enzymes collectively metabolize a wide range of xenobiotic and endogenous compounds. The broad substrate specificity of this superfamily derives from the multiplicity of P450s whose unique substrate specificity profiles reflect underlying differences in primary sequence. Experimental structures of P450s, where available, have provided great insight into the basis of substrate recognition. However, for those mammalian P450s whose structures have not been determined, homology modeling has become an increasingly important tool for understanding substrate specificity and mechanism. P450 modeling is often a challenging task, owing to the rather low sequence identity between target and template proteins. Although mammalian P450 models have previously been based on bacterial P450 structures, the recent advent of mammalian P450 structures holds great potential for generating more accurate homology models. Consequently, the substrate recognition properties of several mammalian P450s have been rationalized using the predicted substrate binding site of recently developed models. This review summarizes the major concepts and current approaches of molecular modeling of P450s.

Suicidal ideation, plans, and attempts in chronic pain patients: factors associated with increased risk.

This study describes suicidal behavior in a cross-sectional sample of chronic pain patients and evaluates factors associated with increased risk for suicidal ideation. One hundred-fifty-three adults with nonmalignant pain (42% back pain) who were consecutively referred to a tertiary care pain center completed a Structured Clinical Interview for Suicide History, the McGill Pain Questionnaire, and the Beck Depression Inventory. Nineteen-percent reported current passive suicidal ideation (PSI), 13% had active thoughts of committing suicide (ASI), 5% had a current suicide plan, and 5% reported a previous suicide attempt. Drug overdose was the most commonly reported plan and method of attempt (75%). Thirteen-percent reported a family history of suicide attempt/completion. Pain-specific and traditional suicide risk factors were evaluated as predictors of current PSI and ASI. Logistic regression analyses revealed that a family history of suicide attempts/completions was associated with a 7.5 fold increase in risk of PSI (P=0.001) and a 6.6 fold increase in ASI (P=0.003), after adjusting for significant covariates. Having abdominal pain was associated with an adjusted 5.5 fold increase in PSI (P=0.05) and a 4.2 fold increase in ASI (P=0.10). Neuropathic pain significantly reduced risk for both PSI (P=0.002) and ASI (P=0.01). Demographics, pain severity, and depression severity were not associated with suicidal ideation in multivariate analyses. These findings highlight the need for routine evaluation and monitoring of suicidal behavior in chronic pain, especially for patients with family histories of suicide, those taking potentially lethal medications, and patients with abdominal pain.

Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients.

This study constituted the first step in the psychometric development of a self-report screening instrument for risk of opioid medication misuse among chronic pain patients. A 26-item instrument, the Pain Medication Questionnaire (PMQ), was constructed based on suspected behavioral correlates of opioid medication misuse, which heretofore have received limited empirical investigation. The PMQ was administered to 184 patients at an interdisciplinary pain treatment center. Reliability coefficients for the PMQ were found to be of moderate but acceptable strength. Construct and concurrent validity were examined through correlation of PMQ scores to measures of substance abuse, physical and psychological functioning, and physicians' risk assessments. To explore high and low cutoff points for misuse risk, subgroups were formed according to the upper and lower thirds of PMQ scores and compared on validity measures. Higher PMQ scores were associated with history of substance abuse, higher levels of psychosocial distress, and poorer functioning. Future psychometric analyses will consider predictive validity and examine shortened versions of the instrument.

Improvement in postoperative and nonoperative spinal patients on a self-report measure of disability: the Spinal Function Sort (SFS).

The present study was designed to evaluate the clinical utility of the Spinal Function Sort (SFS), in a group of postoperative and nonoperative low back pain patients who completed a functional restoration program. The SFS was administered to 38 spinal pain patients (16 nonoperative and 21 postoperative), before and after completing a functional restoration program. Results revealed that the SFS detected a significant improvement in Ratings of Perceived Capacity scores, and that the postoperative patients appeared to improve more than nonoperative patients. These findings demonstrate the clinical utility of the SFS as an effective assessment tool of functional capacity in both postoperative and nonoperative spinal disorder patients. It provides a time-efficient method for evaluating a patient's functional status.

Challenges to early prevention and intervention: personal experiences with adherence.

OBJECTIVE: To describe potential adherence-related difficulties encountered in the implementation of a secondary prevention, early intervention study with acute low back pain patients. An additional goal is to provide recommendations, based on the authors' experience, on how best to overcome these potential obstacles for future research. DESIGN: The study used a predictive algorithm, identified through previous research, to identify which patients presenting with acute low back pain were at risk for developing chronic problems. These subjects were then treated prophylactically with an interdisciplinary intervention. Specific difficulties initially encountered during the pilot stage of implementation of this intervention included securing adequate physician referrals to the study and helping patients to progress through treatment in the most efficient manner. CONCLUSIONS: Potential difficulties are discussed in the contextual framework of treatment adherence and factors affecting it, including the impact of personality factors, satisfaction, comprehension, side effects, financial issues, length of treatment, type of regimen, social issues, patient beliefs, and biologic factors. It is hoped that the present authors' experience will enable future investigators to anticipate these common problems, and structure their research endeavors accordingly.