Browsing by Subject "Chronic Pain"
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Item Ability of the Pain Disability Questionnaire in Predicting Healthcare Utilization(2014-09-01) Rankin, McKenna Blair; Gatchel, Robert J.; Noe, Carl; Robinson, Richard C.BACKGROUND: Chronic pain is one of the most expensive and prevalent healthcare problems in the United States. It affects not only the individual but also society as a whole. The Biopsychosocial Model of chronic pain is the standard model for understanding and treating the pain experience. As such, it is important to have accurate ways of predicting healthcare outcomes for the chronic pain population. Prior research has evaluated the predictive abilities of health outcome measures and healthcare utilization. However, only one study to our knowledge has evaluated the Pain Disability Questionnaire’s (PDQ) ability to predict healthcare utilization. SUBJECTS: The current study consisted of 50 [Mage = 54.76 (12.41) years] adult patients diagnosed with chronic pain who completed an interdisciplinary treatment program at the Eugene McDermott Center for Pain Management. METHOD: The PDQ was administered at baseline and total health care cost was obtained at three-month follow-up. Participants were placed in either the high or low health care cost group depending on how they compared to a national average estimate for chronic pain patients. Logistic and linear regression modeling, as well as receiver operator characteristic analyses were used to evaluate the predictive ability of the PDQ in determining healthcare utilization cost at a three-month follow-up time point. RESULTS: The logistic regression analysis indicated the PDQ accurately placed participants in the respective high or low healthcare cost group [X2 (1) = 10.67, p < .001]. Receiver operator characteristic analysis yielded an area under the curve of .76. A PDQ cutoff score of 96 produced the optimal sensitivity (.70) and specificity (.67) for determining whether patients fall in the high or low healthcare cost group. The linear regression established that PDQ scores at baseline statistically significantly predicted total healthcare utilization at three months following the end of their treatment program, where higher PDQ scores were related to higher healthcare cost [F (1, 48) = 11.41, p = .001]. DISCUSSION: These findings offer support for the use of the PDQ in predicting healthcare cost. Use of the PDQ in this context may help clinicians, caregivers, and patients in planning the cost of the chronic pain sufferers’ treatment. Knowing what to expect financially could help increase the patient’s quality of life.Item Association Between Health-Related Perceptions and Treatment Outcomes in an Interdisciplinary Pain Management Program(2014-12-22) Mader, Megan Denise; Gatchel, Robert J.; Robinson, Richard C.; Noe, CarlBACKGROUND: Adherence to treatment recommendations, specifically chronic pain treatment, is a particular area of importance in the elderly. It has been suggested that patient beliefs/perceptions play a role in treatment outcome, and the current study seeks to further explore this relationship in order to determine the extent to which health-related beliefs and perceptions effect treatment outcome. SUBJECTS: The study consisted of a total of 103 patients, ages 20-82, who were treated at the Eugene McDermott Center for Pain Management at University of Texas Southwestern Medical Center over the past two years. METHOD: Initial and discharge responses to Computerized Adaptive Testing (CAT) items were collected. Select measures, such as the PMQ (Pain Medication Questionnaire), BIPQ (Brief Illness Perception Questionnaire), PROMIS Global Health, Composite Pain Rating, and other PROMIS measures were analyzed via SPSS. RESULTS: Strong correlations were found between Global Health and outcomes, specifically initial Global Health and initial outcome responses. Strong correlations were also found between initial BIPQ and initial outcome measure scores. DISCUSSION: The results supported the hypotheses and showed that as health-related perceptions change, outcome measures can also change accordingly with the progression of treatment.Item Comparative Ability of the Pain Disability Questionnaire in Predicting Health Outcomes and Healthcare Costs(2013-07-03) Lippe, Ben Jonathan; Gatchel, Robert J.; Noe, Carl; Kennard, Beth D.; Deschner, Martin; Whitfill, TravisGiven the tremendous personal and societal costs of chronic pain, efforts at improving pain conceptualization via the Biopsychosocial Model have become critical in addressing pain-related health outcomes and healthcare costs. The current study consisted of 254 (Average age= 49.72, SD= 14.55) adult chronic pain patients seeking treatment through an interdisciplinary chronic pain management clinic. Participants were administered a battery of assessments including the Pain Disability Questionnaire and other established measures of health and pain-related outcomes (e.g., SF-36, PROMIS pain-related measures) at baseline and post-treatment time points. Convergent validity was observed between the Pain Disability Questionnaire and other study measures. Hierarchical regression analyses demonstrated significant associations between pain-related disability as measured by the Pain Disability Questionnaire and a range of health and psychosocial outcomes. Pain Disability Questionnaire scores, as placed in categorical severity levels, demonstrated good discriminative abilities in terms of predicting health outcomes profiles. Further, logistic regression models established that the Pain Disability Questionnaire provided good predictive validity in terms of healthcare cost categorization at three month follow-up. These findings support the clinical use of the Pain Disability Questionnaire as an equivalent, and in some cases superior, empirically supported predictor of health-related outcomes as compared with other established measures of pain and health outcomes. Additionally, initial evaluation of the Pain Disability Questionnaire’s predictive utility in terms of pain-related healthcare costs displayed significant predictive abilities. Overall, these findings suggest that the Pain Disability Questionnaire is a valuable tool in efforts to understand and manage chronic pain as well as predict associated healthcare costs for chronic pain patients.Item Computer-Administered Patient Reported Outcomes (PRO) and Psychiatric Screening in Outpatient Pain Patients: Effect of a Point-of-Care Biopsychosocial Patient Health Report on Treatment Outcomes(2012-08-13) Swanholm, Eric Neal; Gatchel, Robert J.RATIONALE: Chronic pain is a widespread health problem that carries steep costs for both individuals and society. Pain-related complaints represent one of the most common presenting symptoms across ambulatory care settings. Individuals with chronic pain often have comorbid psychiatric symptoms and/or psychosocial dysfunction. Given the related impact on treatment and health-care costs, tracking psychiatric and psychosocial outcomes is beneficial for chronic pain patients, their health care providers, and service providers. Outcome-tracking interventions that could positively affect treatment outcomes hold potential benefits for patient care. PURPOSE: The purpose of the present study was to examine the effects of the regular collection and results feedback prior to the point-of-care on multiple patient-reported outcome (PRO) domains in outpatient pain patients. Maximizing ecological validity and non-disruption of clinic flow were given significant focus in the study design and process. PATIENTS AND METHODS: This study used repeated measures and was conducted in an outpatient pain management and interdisciplinary treatment clinic (2 anesthesiologists, 1 psychiatrist, 1 psychologist, 1 counselor, 1 physical therapist). A total of 69 pain patients were randomly assigned to one of two protocol-based PRO feedback intervention groups (separate feedback to both patients and providers [Dual Feedback]; Provider-Only Feedback) or a non-intervention group (Chart-Review Only). Assessments were completed prior to the point-of-care; feedback for intervention groups was based upon a real-time, automated report generated from their PRO data. Data were gathered on touch-screen tablet-pc’s using multiple computer-adaptive-tests from the NIH-sponsored Patient Reported Outcomes Measurement Information Systems (PROMIS) Assessment Center platform; outcome domains included pain-related functioning (Pain Disability Questionnaire [PDQ]; VAS pain rating; PROMIS Physical Functioning, Pain Behavior, and Pain Interference), psychological symptoms and psychosocial variables (PROMIS Depression, Anxiety, Sleep-Related Impairment, Fatigue, Social Functioning; hypomania history screen; Pain Medication Questionnaire [PMQ; opioid misuse risk]), global HRQoL (PROMIS Mental and Physical Health domains), treatment alliance (Working Alliance Inventory [WAI]; ratings from both patients and providers]), and illness perception and optimism (Brief Illness Perception Questionnaire [BIPQ]; Life Orientation Test- Revised). Performance-based data (walking time, grip strength, range-of-motion/flexibility) were collected by the physical therapist for study patients whose treatment included a PT component (e.g. interdisciplinary pain program, individual services). Significant covariates were identified and incorporated into the primary analyses. Primary outcomes were the individual measures within each outcome domain. Analyses utilized mixed-effects modeling with random coefficients and multiple regression in comparisons of all three study groups. Secondary analysis included tabulation of completion time and comparisons between a Combined Feedback group (both intervention groups) and Chart-Review Only. RESULTS: Significant covariates included treatment type, history of psychiatric diagnosis, and a biological family history of psychiatric diagnosis. Comparing Dual Feedback vs. Chart Review Only, patients in the Dual Feedback intervention had significantly better outcomes over time for a number of domain outcomes; specifically, in pain-related functioning/symptoms (PDQ [P = .003]; PROMIS Pain Interference [P = .023]; VAS pain [P = .03]), psychological and psychosocial variables (PROMIS Anger [P = .001]; PROMIS Anxiety [P = .012]; PROMIS Depression [P = .029]; PROMIS Sleep-Related Impairment [P = .001]; PROMIS Social Functioning – Satisfaction with Discretionary Social Activities [P = .047]), PROMIS Global HrQOL (Mental Health [P = .021]; Physical Health [P = .032]), treatment alliance (WAI – Bond [patient-rated][P = .046]), illness perceptions (BIPQ – Consequence [P = .017]; BIPQ – Timeline [P = .011]; BIPQ – Treatment Control [P = .029]), and one performance-based measure (Walk Time [P = .007]). Similarly, patients in the Provider-Only group had better outcomes over time for multiple outcome domains; including, pain-related functioning/symptoms (PDQ [P = .033]; PROMIS Pain Interference [P = .031]; PROMIS Fatigue [P = .036]; PROMIS Physical Functioning [P = .049]), psychological and psychosocial variables (PMQ [opioid misuse risk][P = .041]), treatment alliance (WAI – Bond [patient-rated][P = .076]; WAI – Bond [provider-rated][P = .008]), illness perceptions (BIPQ – Timeline [P = .048]; BIPQ – Personal Control [P = .027]), and one performance-based measure (Walk Time [P = .035]). Comparisons between patients in the Dual Feedback and Provider-Only Feedback groups were significant for a few domain outcomes. Compared to Provider-Only Feedback, Dual Feedback had better outcomes over time for multiple domain measures; including, the PDQ (P = .085), PROMIS Anger (P = .000), PROMIS Anxiety (P = .018), and BIPQ – Treatment Control (P = .015). Conversely, the Provider-Only group had better outcome scores over time for PROMIS Global HrQOL (Mental Health (P = .032); Physical Health (P = .074). Analyses of process variables showed a mean completion time of 15.8 minutes for the entire assessment; completion-time statistics were also calculated for the 11 PROMIS computer-adaptive-tests (M = 7.57 minutes [all PROMIS CAT’s]; M = 41.3 second per measure, SD = 9.3 seconds) and other primary outcomes (PDQ, PMQ, BIPQ) (M = 8.23 minutes total; M = 2.74 minutes per measure, SD = .99 minutes). CONCLUSION: The provision of dual feedback (patient and providers) from PRO data collected prior to the point-of-care had an impact on several outcomes from multiple domains (pain-related functioning, psychological symptoms, psychosocial variables, illness perception, walking performance) over time, compared to patients who received no point-of-care feedback. To a lesser extent, group by time effects were also observed in comparisons between patients receiving provider-only feedback and those with no feedback. Brought together, high ecological validity was maintained with minimal disruption of clinic flow; likely contributing factors include the use of a set framework for outcome-tracking, protocol-based delivery of feedback, and efficiency of administration. This is the first study to show the potential benefits of providing PRO data feedback to both patients and providers prior to the point-of-care.Item Decision Fatigue in Primary Care Opioid Prescribing(2020-05-01T05:00:00.000Z) Hughes, Jordan Gregory; Kandil, Enas; Reed, W. Gary; Greilich, PhilipBACKGROUND: Decision fatigue -- a psychological phenomenon describing the depletion of mental resources as one makes a series of decisions -- affects primary care physicians as they treat patients and prescribe medications throughout the course of the clinical day. This results in more inappropriate treatments being ordered as the day goes on. Because the United States faces an unprecedented epidemic of opioid abuse, we must understand the extent to which decision fatigue affects opioid prescribing, as the prescription of these drugs has been associated with both long-term use and overdose deaths. Additionally, we are unaware of the effect various national interventions to stem the tide of the opioid epidemic have had on decision fatigue in opioid prescribing. LOCAL PROBLEM: We are unaware of whether decision fatigue is playing a role in opioid prescribing, and if it is, how great the variation in prescription likelihood is throughout the clinical day in UT Southwestern's primary care clinics. The aim of this study is to measure PCPs' varying likelihoods of prescribing opioids throughout the clinical day, before and after major interventions were implemented to combat the epidemic, as this can serve as an indication of both the presence of decision fatigue and the impact of concerted interventions. METHODS: We used the years 2014 and 2017 to represent the pre- and post-intervention periods for study, as many major interventions to combat the opioid epidemic took place in 2016. Next, we analyzed the percentage of appointments in which opioids were prescribed in each hour of physicians' clinical days, at three exclusively primary care clinics at UT Southwestern. Scheduled appointment times were used as substitutes for visit times. We then excluded patients with cancer and those who had surgery within six weeks of an appointment, in order to minimize the number of appointments in which opioids may be prescribed by clear clinical indication. Finally, we employed logistic regression analysis to determine the predictive relationship between appointment time and opioid prescriptions, using physicians' prescription rates in their first clinic hour as the reference for calculating hourly odds ratios in each year. INTERVENTIONS: New legislation, updated healthcare guidelines, and national media coverage in 2016, including: the CDC's "Guideline for Prescribing Opioids for Chronic Pain—United States", the FDA's "General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drug Products: Guidance for Industry, 2016", the Comprehensive Addiction and Recovery Act of 2016, the Surgeon General's call to providers to end the opioid crisis, and the opioid crisis becoming top health news story of 2016. RESULTS: 34,972 clinic visits in 2014 and 42,313 clinic visits in 2017 met our inclusion criteria. In 2014, patients were prescribed an opioid at 5.34% of all primary care appointments, while in 2017, they were prescribed at a rate of 4.34% (2014 vs 2017 OR=1.290; 95% CI, 1.217-1.367). While the overall rates of opioids decreased from 2014 to 2017, the hourly likelihoods of patients being prescribed opioids steadily increased throughout the clinical day in both years (p<0.01 in 2014 and 2017). In fact, each year had hours in which physicians' opioid prescription odds ratio was over 1.6, when compared to their first clinical hour. DISCUSSION: While there was a significant decrease in the overall likelihood of being prescribed opioids in 2017 compared to 2014, the variation in hourly prescription likelihoods is similar in both years. The results show that while interventions to combat the opioid epidemic were successful in reducing the overall amount of opioids prescribed, they had minimal impact on the effect of decision fatigue. Clinical decision support tools, integrated into the electronic medical record, have been proven to reduce the clinical variation that indicates the presence of decision fatigue. In light of this, this project should be continued, and decision fatigue measured, after implementation of such tools.Item The Development and Preliminary Evaluation of MOTIVATE: Moving to Improve Chronic Back Pain and Depression in Older Adults(2021-03-10) Yang, Ailing Eileen; Makris, Una; Roche, Vivyenne; Saxon, LadonnaBACKGROUND: Chronic low back pain (cLBP) is the 2nd most common reason for physician visits; annual related costs exceed USD 100 billion and are expected to rise with the aging population. cLBP and depression often coexist, and current non-pharmacologic interventions have not focused on older adults with these challenging comorbidities. A feasible, effective non-pharmacologic intervention targeting cLBP and comorbid depressive symptoms in older adults is needed. MOTIVATE (Moving to Improve Chronic Back Pain and Depression in Older Adults) is a novel 8-session, 12-week, telephonic behavioral intervention targeting older adults with cLBP and comorbid depressive symptoms. A health coach utilizes motivational interviewing and value-concordant goal setting to capture individual motivations to increase physical activity. The ultimate goal is to improve back pain-related pain interference, disability, and depressive symptoms. OBJECTIVE: To develop a unique telephone-delivered behavioral intervention that is feasible, increases physical activity, and ultimately improves pain, function, and depressive symptoms among older Veterans. METHODS: In Phase 1, Dr. Makris' research team developed a telephone-delivered multicomponent behavioral intervention that targets older Veterans (>65 years old) with cLBP and comorbid depressive symptoms. Input from stakeholder groups [experts in pain, geriatrics, geriatric psychology, primary care, behavioral interventions, among others (n=8), patients (n=5), and key clinical leaders (n=6)] was used to inform and refine content for this unique population. In Phase 2, we conducted a single-arm rollout of MOTIVATE in older Veterans with cLBP and depressive symptoms to further refine future intervention content, procedures, and delivery based on stakeholder feedback. For qualitative interviews, the Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to develop the discussion guide and facilitate individual interviews with the following key stakeholder groups: Veteran participants (n=4) over the age of 65 with comorbid cLBP and depressive symptoms who received MOTIVATE, primary care providers (PCP) (n=4), clinic director (n=1), and health coach (n=1). RESULTS: Informed by interviews with 14 experts and 5 Veterans, we developed and iteratively refined the MOTIVATE manual and study procedures for Phase 1. In the single-arm MOTIVATE rollout (Phase 2), we enrolled 7 Veterans, with a mean age of 69 years who were predominately white (71%), male (86%), married (57%), and had some education beyond high school (71%). The eligibility mean pain intensity score was 7.3/10; baseline cLBP Pain, Enjoyment of Life, and General (PEG-3) Activity Scale was 7.14/10, back pain-specific Roland Morris Disability Questionnaire (RMDQ) Scale was 16.5/24; and depression PHQ-9 score was 16.7/27, with higher scores indicating greater impairment. Two case studies are provided for additional context and to more fully articulate important MOTIVATE intervention concepts. Upon completion of the intervention, semi-structured interviews with Veterans and other stakeholders provided valuable feedback on how to modify MOTIVATE moving forward. Briefly, Veterans who completed MOTIVATE engaged well with the health coach, were motivated to walk with a pedometer, and felt that being more active reduced pain and depressive symptoms. Of the four PCPs interviewed, all attributed the success of the intervention to the skills and engagement of the health coach; we also learned about the variability in how PCPs would like results relating to patient-identified values and goals to be communicated with them. The health coach noted that Veterans were able to identify value-concordant goals and easily link these to physical activities. All stakeholders stated that the individual health coach plays a critical role in activating and motivating older Veterans with complex medical and psychiatric conditions. CONCLUSION: MOTIVATE content and procedures were developed in Phase 1. The Phase 2 rollout showed that we were able to effectively recruit older Veterans with cLBP and depressive symptoms and deliver MOTIVATE via telephone. Feedback from key stakeholders regarding the iterative refinement of recruitment, study procedures, and content will aid the future evaluation and implementation of MOTIVATE in a pilot randomized controlled trial.Item Does 3DMR Provide Equivalent Information As 3DCT for the Pre-Operative Evaluation of Adult Hip Pain Conditions of Femoroacetabular Impingement and Hip Dysplasia?(2019-03-28) Yan, Kevin; Chhabra, Avneesh; Ashikyan, Oganes; Wells, JoelBACKGROUND: Femoroacetabular impingement (FAI) and hip dysplasia (HD) frequently affect young patients and are chronic pain conditions. They are frequently evaluated by isotropic CT (3DCT) for preoperative planning at the expense of radiation. OBJECTIVE: The aim was to determine if isotropic MRI (3DMR) imaging can provide similar quantitative and qualitative morphological information as 3DCT. METHODS: 25 consecutive patients with a final diagnosis of FAI or HD were retrospectively selected from December 2016-December 2017. Two readers (R1, R2) performed quantitative angular measurements on 3DCT and 3DMR, blinded to the diagnosis and each other's measurements. 3DMR and 3DCT of the hips were qualitatively and independently evaluated by a radiologist (R3), surgeon (R4), and fellow (R5). Interobserver and intermodality comparisons were performed. RESULTS: The ICC was good to excellent for all measurements between R1 and R2 (ICC:0.60-0.98) and the majority of intermodality measurements for R1 and R2. Average inter-reader and inter-modality PABAK showed good to excellent agreement for qualitative reads. On CT, all alpha angles (AA) were significantly lower in dysplasia patients than in cam patients (p<0.05). All lateral center-edge angle (LCEA) were significantly lower in dysplasia than in cam patients (p<0.05). On MR, AA at 12, 1, and 2 o'clock, and LCEA at center were significantly lower in dysplasia patients than in cam patients (p<0.05). CONCLUSION: 3DMR offers similar qualitative and quantitative analysis as 3DCT in adult hip pain conditions. 3DMR has good potential to replace 3DCT and serve as a one-stop modality for bone and soft tissue characterizations in the pre-operative evaluation of FAI and HD.Item The Effectiveness of Biopsychosocial Interventions at the Dallas Spinal Rehabilitation Center: Applying the NIDRR Logic Model(2013-09-10) Siles, Melisa Garcia; Chiu, Chung-Yi; Wolf, Tina; Casenave, Gerald W.BACKGROUND: The National Institute on Disability and Rehabilitation Research has developed a program evaluation framework, the NIDRR logic model describing and assessing the relationship between planning, implementing, and evaluating outcomes in rehabilitation service environments, such as the Dallas Spinal Rehabilitation Center. Standard primary care facilities have treated chronic pain with narcotic medications; however, controversies surrounding the lack of long-term efficacy, risk of addiction, and the physical and psychological side effects of these medications continue to be heavily debated. There is strong evidence to support a biopsychosocial treatment approach for chronic pain which reduces narcotic dependence and restores daily functioning. The purpose of this study is to assess the effectiveness of the comprehensive interdisciplinary pain rehabilitation (IPR) program at the DSRC based on the NIDRR logic model. SUBJECTS: A total of 226 patients (131 males [58%] and 95 females [42%]) with chronic pain were admitted to the IPR program at the DSRC between January 2010 and December 2012. Among the 226 patients, 150 patients required medication tapering at admission. The average age of patients was 47 years old (SD= 9.74). The DSRC assigned patients to one of two groups after assessing the severity of their chronic pain curbing their ADL limitations, their social functioning, and their individualized treatment goals; 60 patients were in the chronic pain program, and 166 patients were in the functional restoration program. Patients attended between 80 hours to 160 hours of treatment that included medication management, physical therapy, cognitive-behavioral therapy with psychoeducation and biofeedback, and vocational counseling. METHOD: The current study is a descriptive design. All patients completed self-report measures assessing their current level of pain, functioning, depression, anxiety, and fear-avoidance beliefs at pre- and post-treatment. A dependent paired-samples t-test was used to assess the significance of treatment effect. RESULTS: Overall, significant improvements were seen among patients in the areas of independent functioning, depression, anxiety, fear-avoidance beliefs, medication tapering, and return to work status. Physical demand level, assessing independent functioning, improved significantly, t(225)=27.79, p=.000, among all patients. Results indicated significant improvements in depression scores, t(225)=13.38, p= .000, and anxiety scores, t(225)= 12.94, p= .000. Average fear-avoidance beliefs pertaining to physical activity improved significantly, t(225)= 13.68, p= .000, as did those beliefs pertaining to work, t(223)= 15.33, p= .000. Additionally, 93% of patients successfully returned to work after completion of the program, and 96% of patients who required tapering at admission successfully tapered or discontinued their medication use. Improvements were also found within each treatment group. Physical demand level in the chronic pain program improved significantly, t(59)=12.19, p.000. Results indicated significant improvements in depression scores, t(59)= 5.79, p= .000, as well as anxiety scores, t(59)= 5.83, p=.000. Average fear-avoidance beliefs pertaining to physical activity improved significantly, t(59)= 7.16, p= .000, as did those beliefs pertaining to work, t(59)=8.77, p= .000. Forty-four (73%) patients in the chronic pain program successfully returned to work. Of the 45 patients that required medication tapering at admission, 101 (96%) tapered or discontinued their medications. DISCUSSION: The NIDRR logic model has provided an excellent framework to assess treatment effectiveness in rehabilitation centers. Findings suggest that a biopsychosocial approach for chronic pain (e.g., the IPR program) is effective and efficient in diminishing overall distress and corroborating more biopsychosocial long-term effects than a short term quick fix of narcotic medications.Item Effectiveness of Interdisciplinary Pain Management Programs in Elderly Populations(2016-07-25) Huber, Elizabeth Gray; Robinson, Richard C.; Gatchel, Robert J.; Noe, Carl; Deschner, Martin; Minhajuddin, AbuBACKGROUND: Chronic pain is a debilitating disease that affects millions of adults in the United States. In recent years, there has been a steady increase in the use of interdisciplinary interventions to treat chronic pain. While the effectiveness of such programs is well-documented in adult populations, little is known about the efficacy of such methods for elderly populations. OBJECTIVE: This study assessed the effectiveness of an interdisciplinary pain management program in addressing chronic pain and associated disability (e.g., loss of functioning, poor mood) in the elderly. Study aims also included a comparison of outcomes between elderly and non-elderly participants in an interdisciplinary pain management program, as well as an examination of which variables may serve as predictors for completion of such programs. METHOD: Participants included one hundred and thirteen chronic pain patients receiving treatment in an interdisciplinary program at the Eugene McDermott Center for Pain Management. Participants completed multiple measures pertaining to pain and associated conditions at baseline, mid-way through the program (2 weeks post-enrollment) and upon completion of the program (4 weeks post-enrollment). ANALYSIS: Repeated measures ANOVA analyses examined changes in participants’ scores over time on various self-report measures that assessed pain rating, functionality and mood. Separate analyses were conducted to evaluate results from elderly participants only, and then to compare results between elderly and non-elderly participants. A binomial logistic regression was performed to determine the effects of age and mood on the likelihood that participants in an interdisciplinary pain management program would complete treatment in the program. RESULTS: Although elderly participants’ mean scores across a variety of measures showed signs of improvement, these changes did not meet statistical significance. However, when examining elderly and non-elderly participants together, both groups demonstrated significant improvement across all outcomes with the exception of depression. There were group differences on a select number of outcomes, including those that assessed pain disability, anxiety and depression levels; on these measures, the mean scores for non-elderly participants were higher as compared to elderly participants. There were no interactions between the two groups for any of the variables assessed. The logistic regression model that examined the effects of age and mood on the likelihood that participants would complete treatment in the current study was not significant. DISCUSSION: The current study demonstrates that non-elderly participants experience benefit from participation in interdisciplinary pain management programs. Further research is warranted with a larger elderly population to assess how treatment may need to be tailored to the unique needs of the elderly.Item An Evaluation of the Predictive Validity of the Pain Medication Questionnaire With a Heterogeneous Group of Chronic Pain Patients(2006-08-11) Dowling, Leah Suzanne; Stowell, Anna W.The Pain Medication Questionnaire (PMQ) was initially developed by Adams and colleagues (2004) as a 26-item self-report assessment to screen for opioid medication misuse. The PMQ has demonstrated good reliability and validity, and was predictive of early termination from treatment and identified patients who demonstrated maximal benefit from interdisciplinary treatment (Holmes et al., 2006). This current study explored whether or not the initial PMQ score would accurately predict the development of aberrant opioid medication use behaviors relative to specific behavioral indices (i.e., request for early refills, use of a medication agreement) and a physician rating of medication misuse behaviors. Patients fell into two groups according to their initial score on the PMQ based on the median score of 25. Patients with higher PMQ (H-PMQ) scores reported greater levels of perceived disability and decreased physical and mental functioning. Total scores from the PMQ were moderately correlated with initial measures of physical and psychosocial functioning, and observed problematic medication use behaviors observed by physicians during evaluation. However, higher PMQ scores did not significantly predict the use of a medication agreement or requests for early refills. Five patients were identified from the H-PMQ group that demonstrated problematic opioid medication use that fell outside of the realm of early refill requests. These included utilizing leftover pain medications, taking narcotic medication prescribed to a family member, prescription forgery, and referral for detoxification. Although these patients varied on demographic variables, they each had a PMQ total score greater than 30. Indicating that although a PMQ total score ≥ 25 is indicative of problematic use, a score ≥ 30 suggests that a patient should be closely monitored when prescribed and opioid medication. Overall, this study demonstrated that a patient's self-report is significantly correlated with problematic behaviors observed by physicians. Therefore, when utilized in a busy clinic setting, the PMQ will aide in the identification of specific problematic behaviors and beliefs at the outset of treatment that may hinder successful treatment of a patient's pain condition.Item Improving Adherence to Opioid Prescribing CDC Guidelines for Chronic Pain(2021-05-01T05:00:00.000Z) Zamir, Aemen; Reed, W. Gary; Kandil, Enas; Phelps, EleanorBACKGROUND: The Centers for Disease Control and Prevention have released treatment guidelines for chronic pain care as concerns about opioid overuse and abuse increase. Additionally, The Texas Medical Board has outlined their policy for the use of medication for non-malignant chronic pain purposes in Rule 170.3 of the Texas Administrative Code. Some of the requirements include a signed pain management agreement, regular review of the Prescription Monitoring Program, a urine drug screen, and documentation of completion of requirements in patient's medical records. OBJECTIVE: Establish baseline adherence to TMB policy for opioid prescribing and implement electronic medical record tools to facilitate completion of requirements METHODS: A preliminary chart review of patients on the opioid registry, an intervention in early phase of implementation meant to easily identify patients receiving opioids for chronic pain, was conducted to determine baseline adherence to Rule 170.3 amongst physicians. Several CDC guidelines which corresponded with TMB requirements were chosen. Post-intervention data was collected from the chronic opioid registry regarding the percentage of patients who had annual review of Prescription Monitoring Database, a urine drug screen, a pain management agreement, and documentation of completion of requirements in patient's medical records. RESULTS: Of the 206 patients studied through chart review pre-intervention, only 6% had all three TMB mandated elements in their charts. After implementing the EMR tools meant to facilitate completion of TMB laws and CDC guidelines, the percentage of patients with a urine drug screen and review of PDMP increased while the percentage of patients with a pain management agreement in their chart decreased. CONCLUSION: Poor compliance in the UTSW system necessitates tools that will streamline the process for completing and documenting the requirements. The implementation of the EHR tools and the opioid registry best practice alerts, as they were rolled out by the Opioid Task Force, helped facilitate completion of requirements.Item Multidimensional Pain Inventory: Revised Profile Classification Based on Clinical Observations in a Pain Setting(2005-08-11) Ravani, Payal Jitendra; Stowell, Anna W.The purpose of this study was to build a new profile classification system for the Multidimensional Pain Inventory (MPI). According to some clinical researchers, the current profiles of the MPI do not fully portray how chronic pain patients evaluate and manage their pain because of the great variability in each subgroup. This study tried to revise the current profile classifications based on clinical observations, which may then lead to facilitate improved patient assessment, professional communication, and treatment planning. Participants, who completed pre- and post- treatment MPI measures, were randomly selected from the interdisciplinary program at the Eugene McDermott Center for Pain Management at UT Southwestern Medical Center at Dallas. Two hundred and eighty patients were then assigned to three different groups depending upon the re-coded scores from their pre-treatment MPI. Patients were grouped according to their MPI subscale scores. In order to determine if the hypotheses were supported or not, paired t-test were completed on six different psychosocial and functional outcome measures. Analyses were also conducted to check for differences among the nine different groups. As postulated, a number of significant relationships were identified. Paired t-test analyses demonstrated the significance of the relationship between certain MPI subscales. When Pain Severity (PS) and Interference (I) were below average (as determined by recoded T scores), patients had a good prognosis. When Life Control (LC) equaled Affective Distress (AD), participants were seen to have a good prognosis as well. Associations between the other MPI subscales were also assessed, but data did not support those hypotheses. The majority of the outcomes did not meet expectation, because of several limitations with the study design.Item Opioid Treatment for Chronic Pain and Interdisciplinary Care(2015-08-31) Warrington, Lacy Kay; Robinson, Richard C.; Noe, Carl; Gatchel, Robert J.BACKGROUND: The amount of individuals suffering from chronic pain (3 months or more) is growing. Along with this growth, the amount of money spent on medical treatment of chronic pain with or without relief is growing. A major issue that stems from this is the misuse and abuse of prescription opioid medication. This brings a massive loss of productivity and quality of life. SUBJECTS: Patients included in the current study suffer from chronic pain, are at least 18 years of age, and are capable of providing informed consent, and reading and speaking English. EMCPM provides an interdisciplinary program including; cognitive-behavioral therapy, group cognitive-behavioral therapy focusing on psychoeducation, and physical therapy. Patients receive 8 sessions of individual CBT, group CBT, and physical therapy throughout the program. Patients receive these sessions twice a week throughout the 4 week program. METHOD: This study used outcomes that measure ratings of pain; pain, pain interference, depression, anxiety, sleep disturbance, sleep related impairment, satisfaction with participation in discretionary social activities, satisfaction with social roles and activities, and global health. Opioid status was determined as “no,” “decreased,” or “same” for each patient after oral morphine equivalents were calculated at baseline and monitored throughout the 4-week program. One-way within-subjects ANOVAs were conducted for each opioid status as the factor and the outcome measure T scores as the dependent variable. If significant, polynomial contrasts were used to determine linear effects. One-way within-subjects ANCOVAs were then conducted for each opioid status as the factor, outcome measure T scores as the dependent variable and pre-program outcome measure T scores as the covariate to control for pre-morbid dysfunction. If significant, polynomial contrasts were used to determine linear effects. Finally, three Pearson correlations were run between percent change of outcome measure T scores and pre-, post-, and percent change in morphine equivalents. RESULTS: Overall, individuals with chronic pain who participated in a four-week interdisciplinary pain program maximized their results by maintaining no or low opioid dosage, or by decreasing moderate-high opioid doses throughout the program, as expected. Individuals who entered the interdisciplinary pain program with no opioid use showed significantly more improvement (p<.01) than those with initial opioid use over the course of the program on several outcome measures; pain (composite pain rating and pain interference), depression, anxiety, social satisfaction (satisfaction with participation in discretionary social activities and satisfaction with social roles and activities), and global health. Significant (p<.01) linear effects were also found on all previously mentioned outcome measures. Anxiety levels showed significantly more improvement (p<.01) over the course of the pain program only when a control for pre-morbid anxiety was added. A significant (p<.01) linear effect was also found. Individuals who entered the interdisciplinary pain program using opioid medication and decreased the dosage of opioid medication over the course of the program reported significantly more improvement (p<.01) in pain (both composite pain rating and pain interference) and social satisfaction (satisfaction with participation in discretionary social activities only when controlled for pre-morbid social satisfaction with participation in discretionary social activities) when compared with participants who maintained initial opioid dosage. Significant (p<.01) linear effects were found on all three outcome measures. Individuals who maintained a low opioid dosage over the course of the interdisciplinary pain program reported significantly more improvement (p<.01) on; pain (composite pain rating and pain interference), anxiety, sleep (sleep-related impairment only), social satisfaction (satisfaction with participation in discretionary social activities and satisfaction with social roles and activities), and global health. Significant (p<.01) linear effects were found on all of the above measures except pain related impairment. Weak Pearson correlations (r=22) between pre-morphine equivalent and percent change in sleep-related impairment was found. This was again found between post-morphine equivalent and percent change in sleep-related impairment (r=29), as well as a weak negative correlation with pain interference (r=-.28). More research is indicated to determine the relationship between these correlations. Pearson correlations between percent change in morphine equivalent and percent change in outcome measure T scores did not yield any significant (r>.29) correlations.Item Pre-Surgical Behavioral Medicine Evaluation (PBME) for Implantable Devices for Pain Management : a One-Year Prospective Study(2006-08-11) Heckler, David Robert; Stowell, Anna W.Chronic pain affects millions of individuals around the world financially, physically, psychologically, and socially. When nonoperative care does not provide adequate pain relief, surgically invasive procedures are often considered. However, poor surgical outcome affect the patient, the physician, the employer, and the insurance company. In order to reduce negative surgical outcomes, pre-surgical psychological evaluations are used in order to better predict prognosis. The current study looked at the utility of the Presurgical Behavioral Medicine Evaluation (PBME) and revised algorithm that was described in Shocket's (2005) investigation that determines a patient's prognosis for invasive pain procedures. Patients were placed in a Green, Yellow I, Yellow II, or Red prognosis group, with Green having the best prognosis for surgery and Red having the worst prognosis. A total of 95 patients completed the PBME evaluation, with most patients being evaluated for a spinal cord stimulator or intrathecal pump. Variables, including gender, disability payment status, and involvement in pending litigation, were found to be significantly different among the groups. Analysis of data at the initial evaluation indicated that patients within the Red group endorsed significantly more physical/functional limitations, depressive symptomatology, and reported more psychological distress than the Green group. Patients were followed-up 6- and 12-months post-evaluation with both physical/functional and psychosocial measures. Analysis of the 12-month follow-up data indicated that there were significant differences among the four groups in terms of the VAS, BDI, MCS, OSW scores, and the catastrophizing scale on the CSQ. In addition, the Tukey HSD and Mann Whitney tests revealed specific significant differences among the groups. A repeated measures analysis of the initial evaluation, 6-month, and 12-month follow-up data revealed the Green and Red group was significantly different in terms of the VAS, OSW, BDI, and MCS. In addition, nonparametric analysis indicated that there were significant differences among the groups on total risk factor scores as determined by the PBME algorithm.Item Predictors of Attrition in an Interdisciplinary Pain Management Program(2019-07-08) Chong, Jeanette Lee; Robinson, Richard C.; Jarrett, Robin B.; Hynan, Linda S.; Noe, Carl; Zafereo, JasonBACKGROUND: Chronic pain is a debilitating condition that affects millions of adults in the United States. In recent years, particularly with the growing concerns about opioid use, there has been a steady increase in the use of interdisciplinary pain programs (IPP) to treat chronic pain. The effectiveness of such programs has been well-documented; however, attrition has also been identified as a neglected topic in outcome studies. OBJECTIVE: This study aimed to investigate the extent to which demographic/clinical characteristics predict attrition in an IPP. Study aims also included examining longitudinal changes in score for the completion group for a variety of clinical measures, and an exploratory analysis comparing changes between non/completion groups. METHOD: Participants included one hundred and seventy-eight patients receiving treatment for chronic pain conditions in an IPP at the Eugene McDermott Center for Pain Management at UT Southwestern Medical Center. Participants completed measures related to pain and psychosocial functioning at baseline, mid-intervention (2 weeks post-enrollment), and post-intervention (4 weeks post-enrollment). ANALYSIS: This study used logistic regression analyses to identify variables most predictive of attrition in five domains: 1) selected demographic variables, 2) number of medical diagnoses [psychiatric and non-psychiatric], 3) opioid use/risk of misuse, 4) pain-related cognition and behavior, and 5) physical, social, and mental well-being. Mixed models analyses were also conducted to examine longitudinal changes in score on a variety of clinical measures for the completion group. RESULTS: Participants who were of younger age, unemployed, and not on opioids pre-intervention had higher odds of dropping out. The completion group demonstrated improvement pre- to post-intervention on each of the measures assessed in the 1) pain-related cognition and behavior domain and 2) physical, social, and mental well-being domain, except for one measure. DISCUSSION: Mean age of non-completers was 48.72 years (SD = 13.44); these patients may have had difficulty with program compliance due to more outside stressors (e.g., younger children, demanding jobs). Participants may have been unemployed due to a number of potential contributing factors (e.g., lack of transportation, lower motivation, physical mobility), which would create barriers to program completion. Previous findings suggest opioid dependency contributes to higher odds of dropout; however, results from the current study suggest pre-intervention opioid use--not dependency--does not contribute to higher odds of attrition.Item [Southwestern News](1999-03-03) Harrell, Ann; McNeill, Bridgette RoseItem [Southwestern News](1999-01-25) Donihoo, RachelItem [Southwestern News](2001-11-27) Harrell, AnnItem Treatment Considerations for Comorbid Insomnia and Chronic Pain: A Biopsychosocial Approach to Clinical Care(2016-08-25) Van Ness, Olivia Elizabeth; Robinson, Richard C.; Gatchel, Robert J.; Noe, CarlBACKGROUND: Interdisciplinary pain management programs have proven to be quite effective in alleviating presenting patient symptoms. Sleep is a complex process not well understood and the effects it maintains on subsequent daytime function appear to influence pain and related symptoms. SUBJECTS: 134 qualifying participants were drawn from an interdisciplinary pain management program. The majority of subjects were females of Caucasian race with sample ages ranging from 20 to 86 years. Participants were compensated a small amount for their time. METHOD: Patients were administered computerized testing on measures of pain, mood, and function prior to and upon successful completion of the program. Participants were placed into groups based on their performance on sleep measures to be examined for differences. RESULTS: Time spent in the interdisciplinary program was shown to be effective across all measures administered, including sleep measures. The sleep improvement group showed significantly more change on measures of physical function and social satisfaction. DISCUSSION: This study further strengthens the argument for the use of interdisciplinary pain management by providing an example of global improvement among the sample. Particular attention should be paid to physical function and social satisfaction when observing differences in sleep disturbance and sleep-related impairment.Item Understanding Institutional Physician Chronic Opioid Prescription Practices for the Improved Implementation of Newly Developed EMR Tools(2021-03-12) Gagrani, Sonal; Reed, W. Gary; Phelps, Eleanor; Kandil, EnasBACKGROUND: Chronic non-cancer pain (CNCP) affects a significant portion of the United States population each year and is often treated with chronic opioids. There has been a rise in prescription opioids over the past 20 years, accompanied by a rise in overdose deaths as well. In order to improve patient safety related to opioid prescribing, several state and national policies including the 2016 "CDC Guidelines for Prescribing Opioids for Chronic Pain" have been developed recently to guide CNCP management. These recommendations include the use of pain management agreements, urine drug screening, prescription monitoring programs (PMP) and risk and pain assessments among others. LOCAL PROBLEM: In Texas, several recent policies have made CNCP practices mandatory, requiring support in order to enforce them. At the University of Texas Southwestern Medical Center (UTSW), there is no current reliable measure of CNCP policy adherence. Preliminary chart review by students at our institution showed low adherence overall, which may be secondary to poor documentation. METHODS: A set of surveys were developed to subjectively measure physician barriers to policy adherence, attitudes toward the policy components and current opioid prescribing practices. This survey was administered via electronic communication before and after the intervention to any physician at our academic medical center prescribing chronic opioids to at least one patient. Implementation science outcomes of appropriateness, adoption and acceptability were targeted by these surveys in order to inform implementation strategies for the intervention. INTERVENTIONS: A multi-faceted intervention including an electronic medical record (EMR) navigator tool, chronic opioids registry and physician education was developed by the institutional opioid task force to improve accessibility, documentation and understanding of opioid prescribing guideline recommendations. RESULTS: Physicians who had used the EMR navigator tool reported overall greater use of several guideline-concordant treatment components compared to those who had not used it (p < .05). Physicians who received opioid prescribing training were more aware and familiar with the policy (p < .0001). Those who were more familiar with the policy were more likely to use pain management agreements, urine drug screens and pain assessments. No specific barriers to policy adherence stood out as a remediable concern. Only a small percentage of respondents reported co-prescribing naloxone for high-risk CNCP individuals. CONCLUSION: An EMR navigator tool to improve accessibility of treatment components is effective in improving policy adherence at an academic medical center. Physician education is also effective in improving awareness and familiarity with the policy. Future steps include the study of patient-centered outcomes surrounding the intervention. There is also room for the support of other CNCP guidelines including co-prescription of naloxone for high-risk individuals and decreasing chronic opioid prescription strengths at our institution.