Biopsychosocial Program Provides Long-Term Pain Relief to Patients Not Responding to Opioids

(Pain Medicine News – March 2, 2016) — Chronic pain patients who have not benefited from the use of opioids may experience positive outcomes—and may even be tapered off opioids—from a biopsychosocial program that focuses on self-management, a study suggests.

Opioids may be ineffective for these patients due to a combination of factors, such as inappropriate dosing, undiagnosed symptoms that facilitate pain (e.g., depression, anxiety and sleep disturbances), and opioid misuse or addiction, according to researchers from the Chronic Pain and Recovery Center (CPRC) at Silver Hill Hospital, in New Canaan, Conn. They noted that long-term opioid therapy can lead to a “declining well-being” (i.e., increased pain, escalating dose requirements, persistent side effects and mood changes) in some patients, which results in a chronic pain syndrome that “often has complex biopsychosocial contributors” and this syndrome “benefits from a strong foundation in self-management.”

They analyzed data from 154 patients to determine the efficacy of a new biopsychosocial program developed at the CPRC for addressing chronic pain in this patient population. The program centers on helping patients acquire and retain skills they can use to reduce pain, cope with residual pain, increase function, reduce medication reliance, enhance quality of life and treat reoccurring disorders, such as mental health or addiction.

“I think people come to the Chronic Pain and Recovery Center often in a position of being very passive, dependent on what we would call external cure seeking: ‘This pill is going to make me feel better; this operation is going to help me; this intervention; this doctor is going to help me,’” said Bruce Singer, PsyD, study author and the CPRC program director. “They’ve lost a sense that they can help heal themselves.”

The 28-day minimum residential program (eight patients maximum) consists of 12 to 14 hours of daily groupbased therapeutic activities. Patients receive cognitive-behavioral therapy, acceptance and commitment therapy, physical therapy/exercise tailored to their individual needs, and education on topics such as pain, substance abuse and nutrition. Patients also have a minimum of two weekly individual counseling sessions with a psychologist, and weekly medical/psychiatric appointments.

Each patient in the study had at least one pain diagnosis—the majority was for axial musculoskeletal pain (n=95). Some patients also had a diagnosis of one or more psychiatric and substance abuse disorders (predominantly depression, n=114). All patients were given psychological, opiate misuse and personality testing before admission, and were retested at 28 days as well as three, six and nine months after the end of the program. Primary measures were pain scores, pain interference, mood and opioid use. The final analysis included data from the first 118 patients who were admitted to and completed the program, and opioid data for 154 patients who completed the program.

The researchers found that average pain scores decreased from 6.5 to 4.5, and 77 of 122 (63%) patients on opioids at admission no longer used opioids at discharge. Dr. Singer said these findings are consistent with other biopsychosocial programs, but he was surprised that some patients exhibited pain relief months after the end of the program. “The pain interference with enjoyment or with general activities can be sustained beyond six months,” he said. “If someone continues to use the skills that we teach them, we can see long-term changes that maintain themselves.”

Dr. Singer said the program’s approach to opioid-assisted treatment is what sets it apart from others.

“Most pain programs traditionally have been abstinence based. You come in on an opiate; you have to get off it and then you go home. But the problem is people relapse,” he said.

Patients were transitioned to opioid agonist therapy or were taken off opioids and prescribed depot naltrexone if they were considered to have moderate to severe opioid use disorder. Patients were discharged/tapered off opioids without naltrexone if they misused opioids or if they declined opioid agonist therapy. Twenty patients transitioned to opioid agonist therapy, 22 on buprenorphine-naloxone (Suboxone, Indivior) and two on methadone. The researchers also found that 23 patients ended with a lower opioid dose by the end of the program; most rotated to a different opioid with a mean dose reduction of greater than 75% morphine equivalents.

The study authors wrote that more research is needed to validate these findings in other patient populations and to determine long-term opioid management options. The study was presented at the 2015 annual meeting of the American Academy of Pain Management, where it was received an award for best poster abstract.