PALM SPRINGS, CALIF. – An intensive interdisciplinary outpatient program successfully treated 246 patients at high risk of substance abuse, alongside 230 low-risk patients, for their debilitating chronic pain.

At the start of the 3-week pain rehabilitation program, the two groups did not differ significantly in their duration of pain (nearly 12 years on average) or duration of opioid use (6 years on average). They reported similar levels of pain severity.

The high-risk patients, however, had significantly worse scores on measures of depression, pain interference with life, pain catastrophizing, and perceived control of life and pain. Despite comparable pain severity and duration, they were taking significantly greater morphine-equivalent doses of pain medications, compared with doses taken by low-risk patients (124 vs. 60 mg/day).

By the end of the program, which incorporated substance abuse education and support, both the high-risk and low-risk groups had improved in all these measures, and there was no longer any significant difference in scores between the two groups, Sarah E. Hayes reported in an award-winning poster and plenary session at the annual meeting of the American Academy of Pain Medicine.

Dr. W. Michael Hooten (left) and Sarah E. Hayes discuss their study with an attendee at the American Association of Pain Medicine meeting.

The intensive program at the Mayo Clinic, Rochester, Minn. provides more than can be offered in a typical ambulatory setting, coinvestigator Dr. Michael Hooten said in an interview. The results suggest that high-risk patients can be included in pain rehabilitation programs without affecting treatment outcomes, said Dr. Hooten of the Mayo Clinic.

Patients attend sessions 8 hours per day, 5 days per week, focused on functional restoration, withdrawal from opioids, and reduced polypharmacy rather than on attempted cures or interventional procedures for their chronic pain. Approximately 97% completely taper off of opioids, said Ms. Hayes, who conducted the study while she was a research associate at the Mayo Clinic and is now a student at New York University.

The interdisciplinary staff includes physicians, psychologists, pharmacists, nurses, physical therapists, and occupational therapists. The foundation of treatment is a cognitive-behavioral model that includes biofeedback, relaxation training, and stress management. Patients receive education in "chemical health" and in "wellness" topics such as sleep hygiene and healthy diets. Pain management training covers activity moderation and eliminating behaviors that cause pain. Family education and after-care assistance are provided.

Patients were identified as high risk if they had a history of using mood-altering substances, used pain medications in ways other than those prescribed, showed aberrant drug-related behaviors, had family members or health care providers who expressed concern, had a family history of substance abuse, or had other health risks (such as polypharmacy and high-dose opioid use).

At entry, they were significantly more likely than the low-risk group to have used opioids (75% vs. 46%), benzodiazepines (51% vs. 34%), or a combination of opioids, benzodiazepines, and sedative hypnotics (18% vs. 7%), and they were significantly more likely to be dependent on nicotine (37% vs. 10%), to have a history of heavy alcohol use (27% vs. 6%), and to be currently using cannabis (13% vs. 0.4%).

For the high-risk group, approximately 18 of the 120 hours in the program were devoted to a substance use curriculum that covered the physical and medical aspects of substance abuse, the cycle of pain and how substance use has become a part of that cycle, and how to manage high-risk situations and triggers for substance abuse. Patients explored their personal substance use patterns, family aspects, the effects of substance use on relationships, and their life goals.

"We’re increasingly noticing that chronic pain patients often have comorbid chemical dependency issues," Ms. Hayes said. Both chronic pain and substance abuse need to be addressed at the same time, she suggested.

The investigators plan to conduct longitudinal studies to identify how best to support high-risk patients after they complete the pain rehabilitation program.

The study included consecutive patients treated from February 2010 to May 2011. Patients averaged 45 years in age, ranging from 18 to 90 years. Back pain, fibromyalgia, and headache were the most common types of pain. Patients in the high-risk group were significantly more likely than those in the low-risk group to be living with back pain (27% vs. 21%) and significantly less likely to be living with fibromyalgia (15% vs. 21%).

Significantly fewer high-risk patients completed the 3-week program compared with low-risk patients (87% vs. 94%).

Functional status was assessed at the start and the end of the program using multiple tools including the Multidimensional Pain Inventory, the Center for Epidemiological Studies Depression Scale, the Pain Self-Efficacy Questionnaire, and the Pain Catastrophizing Scale.

A physician in the audience urged the investigators to mass market the tools to help chronic pain patients who are at high risk of substance abuse. "In the private setting, we don’t have the tools to provide the kind of program that you do," he said.

The investigators reported having no relevant financial disclosures.

Substance Abusers in Pain Tapered Off Opioids