Assessment and patient selection process for a pain management programme: a case study in specialty care.

INTRODUCTION: The present study audited the process of assessing and selecting patients for a pain management programme with the aim of reviewing best practice in the light of the latest British Pain Society guidelines for pain management programmes for adults. The guidelines include defined inclusion/exclusion criteria and it was explored how they are used by clinicians providing a pain management service. METHOD: The records of 200 consecutive patients who attended a multidisciplinary assessment for a central London specialist Pain Management Service from September 2014 to December 2014 were audited. The proportions of patients who were offered a programme, were discharged or referred for a different service were calculated. Clinic letters were reviewed to collect information on assessment outcomes, recommendations and inclusion/exclusion criteria used. RESULTS: About half the patients (53%) seen for assessment were offered treatment within the service, most frequently the intensive residential programme (30.5%, with an additional 11.6% offered case management first), followed by the five session outpatient programme (8.1%) and a minority was offered individual treatment (2.5%); 44.7% of the patients were discharged following the assessment. The three most frequently used reasons for exclusion were: not ready to engage with the pain management approach (35%), complex psychological or other needs needing to be prioritised (29.5%) and the patient declining a programme (19.3%). CONCLUSION: Reviewing the use of inclusion/exclusion criteria revealed some challenges regarding patient selection. For example, a sizable proportion of patients were still seeking pain reduction and were not open to a self-management approach when this was the recommended treatment for them. Complex patients might need other treatment approaches before they can be considered for a programme. Having a range of pain management options of varying intensities available seems helpful in meeting individual patient need.

Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change.

Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.

Assessing physical functioning on pain management programmes: the unique contribution of directly assessed physical performance measures and their relationship to self-reports.

Physical functioning is a recommended outcome domain for pain management programmes. It can be assessed by self-report and by direct assessment of performance. Although physical performance measures may provide unique and useful information about patient functioning over and above self-report measures, it is not entirely clear which of the many possible performances to assess. This study investigated a battery of three directly assessed physical performance measures and their relationship to three currently used self-report measures of general health and functioning. The three performance measures were sensitive to treatment; patients performed significantly better on all three measures following completion of the pain management programme. The three performance measures were shown to represent a single underlying dimension, and there was a significant degree of overlap between them. The performance measures were shown to be relevant in explaining variation in the self-report measures, as well as to offer a clinically relevant different dimension of assessment to self-report. Future research could focus on developing performance-based measures that capture quality of movement and that are sensitive to relevant processes of therapeutic change.

Changes in Sleep Problems and Psychological Flexibility following Interdisciplinary Acceptance and Commitment Therapy for Chronic Pain: An Observational Cohort Study.

AIMS: Cognitive and behavioral treatments (CBT) for sleep problems and chronic pain have shown good results, although these results could improve. More recent developments based on the psychological flexibility model, the model underlying Acceptance and Commitment Therapy (ACT) may offer a useful addition to traditional CBT. The aim of this study was to examine whether an ACT-based treatment for chronic pain is associated with improved sleep. Secondly, we examined the associations between changes on measures of psychological flexibility and sleep-related outcomes. METHODS: The study used an observational cohort methodology. Participants were 252 patients (73.8% female) attending a 4-week, interdisciplinary, pain management program in London, United Kingdom. Participants completed standard self-report measures of pain and functioning, sleep outcomes, and processes of psychological flexibility. Pre- to post-treatment, and pre-treatment to follow-up measures were examined for statistically significant differences using paired samples t-tests. Secondarily, hierarchical multiple regression analyses were conducted to examine change in process measures in relation to change in treatment outcome. RESULTS: Participants showed statistically significant improvements (all p < 0.001) at post-treatment on measures of insomnia severity (d = 0.45), sleep interference (d = 0.61), and sleep efficiency (d = 0.32). Significant improvements in insomnia severity and sleep interference were also observed at 9-month follow up. Small to medium effect sizes were observed across the sleep outcomes. Statistically significant changes were also observed on measures of psychological flexibility, and these improvements were significantly associated with improvements on sleep-related outcomes, independently contributing up to 19% of unique variance. CONCLUSION: This study supports the potential usefulness of ACT-based treatments for chronic pain for addressing co-occurring sleep difficulties. Further research is needed to determine how to improve the impact of this treatment for co-morbid pain and sleep difficulties, possibly using a randomized-controlled trial design.