Response to methadone maintenance treatment of opiate dependent patients with and without significant pain
ABSTRACT Both clinicians and researchers have expressed doubt that opiate dependent patients with significant pain can be effectively treated in methadone maintenance treatment (MMT) programs; however, little research exists on this topic. Patients who report significant pain in the month preceding entry to MMT present with a distinct and more severe pattern of polysubstance use, medical and psychosocial problems than do those without pain. The present study investigated the 1-year treatment outcomes of MMT patients with opiate dependence and pain.
Analyses were based on a national sample of 200 patients presenting in MMT programs for treatment of opiate dependence. Substance use and related problems were measured at treatment entry and 12 months later. Patients reported pain severity over the month preceding treatment entry.
Compared to patients without significant pain, patients who reported significant pain at baseline (n = 103) showed similar substance-related functioning, but poorer psychosocial functioning at 1 year.
Patients with and without significant pain experience comparable reductions in substance use when provided with standard care in MMT programs. However, additional medical and/or mental health treatment is needed for their pain and other problems.
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ABSTRACT: Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients. We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings. Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites. Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study. Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0-100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2). Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3 %) and antidepressants (44.7 %), yet also used marijuana, alcohol, or cocaine (40.8 %) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04). Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain-depression nexus in novel ways.Journal of General Internal Medicine 02/2015; DOI:10.1007/s11606-015-3212-y · 3.42 Impact Factor
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ABSTRACT: Little is known about the experience of chronic pain and the occurrence of illicit drug use behaviors in the population enrolled in methadone maintenance treatment (MMT) programs. This is a secondary analysis of longitudinal data from two MMT samples enrolled in a randomized controlled trial of hepatitis care coordination. Patients completed pain, illicit drug use, and other questionnaires at baseline and 3, 9, and 12 months later. Associations were sought over time between the presence or absence of clinically significant pain (average daily pain ≥4 or mean pain interference ≥4 during the past week) and current illicit drug use (i.e., non-therapeutic opioid, cocaine or amphetamine use identified from self-report or urine drug screening). Of 404 patients providing complete data, within-patient variability in pain and illicit drug use was high across the four assessment periods. While 263 denied pain at baseline, 118 (44.9%) later experienced clinically significant pain during ≥1 follow-up assessments. Of 180 patients (44.6%) without evidence of illicit drug use at baseline, only 109 (27.0%) had similar negative drug use at all follow-up assessments. Across four assessment periods, there was no significant association between pain group status and current illicit drug use. This one-year longitudinal analysis did not identify a significant association between pain and illicit drug use in MMT populations. This finding conflicts with some earlier investigations and underscores the need for additional studies to clarify the complex association between pain and substance use disorders in patients in MMT program settings. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.Drug and Alcohol Dependence 02/2015; 149. DOI:10.1016/j.drugalcdep.2015.02.007 · 3.28 Impact Factor
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ABSTRACT: Chronic pain is a common cause of health care utilization and high levels of pain are pronounced in individuals engaged in methadone maintenance treatment. Although massage has been demonstrated to alleviate chronic pain symptoms, its use as an adjunctive therapy to modify pain during opioid-replacement treatment is absent from the literature. To consider the efficacy of Swedish massage in reducing pain in opioid-dependent patients with chronic pain receiving methadone treatment. Trial was conducted at a nonprofit methadone treatment center serving low-income patients. A randomized clinical trial with randomized to either 1) massage plus treatment-as-usual (TAU) (n = 27) or 2) TAU (n = 24). Durability of treatment effect was evaluated at Week 12. Eight weekly 50-minute Swedish massage sessions plus TAU or TAU alone. Pain, anxiety, depression, physical functioning, decreased substance use, and improvement in treatment engagement. Randomized participants were comparable at Baseline for demographic, pain, physical, and emotional variables. Massage group reported improved pain scores; worst pain had a clinically significant 2-point improvement while the other pain scores did not. Overall improvements were not observed in treatment engagement or levels of anxiety, depression, or physical functioning. A subgroup of the participants, who felt they could be pain-free, consistently reported improvements in pain from Baseline to Week 8, and this was most pronounced and clinically significant in the massage group. These preliminary findings do not support an overall clinically significant positive effect of Swedish massage on reduction in pain ratings or improvement in anxiety, depression, or treatment engagement in a substance-using, opioid-dependent population with chronic pain. Future nonpharmacologic pain research in marginalized substance-using populations may wish to consider some of the challenges and limitations faced in this project.International Journal of Therapeutic Massage & Bodywork Research Education & Practice 03/2015; 8(1):12-24.