[Show abstract][Hide abstract] ABSTRACT: Long-term sick leave has considerably negative impact on the individual and society. Hence, the need to identify effective occupational rehabilitation programs is pressing. In Norway, group based occupational rehabilitation programs merging patients with different diagnoses have existed for many years, but no rigorous evaluation has been performed. The described randomized controlled trial aims primarily to compare two structured multicomponent inpatient rehabilitation programs, differing in length and content, with a comparative cognitive intervention. Secondarily the two inpatient programs will be compared with each other, and with a usual care reference group.Methods/design: The study is designed as a randomized controlled trial with parallel groups. The Social Security Office performs monthly extractions of sick listed individuals aged 18-60 years, on sick leave 2-12 months, with sick leave status 50% - 100% due to musculoskeletal, mental or unspecific disorders. Sick-listed persons are randomized twice: 1) to receive one of two invitations to participate in the study or not receive an invitation, where the latter "untouched" control group will be monitored for future sick leave in the National Social Security Register, and 2) after inclusion, to a Long or Short inpatient multicomponent rehabilitation program (depending on which invitation was sent) or an outpatient cognitive behavioral therapy group comparative program. The Long program consists of 3 1/2 weeks with full rehabilitation days. The Short program consists of 4 + 4 full days, separated by two weeks, in which a workplace visit will be performed if desirable. Three areas of rehabilitation are targeted: mental training, physical training and work-related problem solving. The primary outcome is number of sick leave days. Secondary outcomes include time until full sustainable return to work, health related quality of life, health related behavior, functional status, somatic and mental health, and perceptions of work. In addition, health economic evaluation will be performed, and the implementation of the interventions, expectations and experiences of users and service providers will be investigated with different qualitative methods.Trial registration: ClinicalTrials.gov: NCT01926574.
BMC Public Health 04/2014; 14(1):368. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In selected patients with chronic non-malignant pain, chronic opioid therapy is indicated. Published guidelines recommend long-acting over short-acting opioids in these patients. The aim of this systematic review was to investigate whether long-acting opioids in chronic non-malignant pain are superior to short-acting opioids in pain relief, physical function, sleep quality, quality of life or adverse events. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. PubMed, Embase and Cochrane Central Register of Controlled Trials were searched for relevant trials up to July 2012. Reference lists of included trials and relevant reviews were in addition searched by hand. Of the 1168 identified publications, 6 randomised trials evaluating efficacy and safety filled the criteria for inclusion. None of them found a significantly better pain relief, significantly less consumption of rescue analgesia, improved quality of sleep or improved physical function from long-acting opioids. None of the trials investigated quality of life. None of the trials investigated adverse events properly nor addiction, tolerance or hyperalgesia. Three trials in healthy volunteers with a recreational drug use, found no difference in abuse potential between long- and short-acting opioids. While long term, comparative data are lacking, there is fair evidence from short-term trials that long-acting opioids provide equal pain relief compared with short-acting opioids. Contrary to several guidelines, there is no evidence supporting long-acting opioids superiority to short-acting ones in improving functional outcomes, reducing side effects or addiction.
[Show abstract][Hide abstract] ABSTRACT: In previous studies on prescription patterns of opioids accurate data on pain are missing, and previous epidemiological studies of pain lack accurate data on opioid use. The present linkage study which investigates the relationship between pain and opioid use is based on accurate individual data from the complete national Norwegian prescription database and the Nord-Trøndelag health study 3 which includes about 46 000 persons. Baseline data were collected in 2006 to 2008 and the cohort was followed for three years. Of 14 477 persons who reported chronic non-malignant pain 85% did not use opioids at all, while 3% used opioids persistently and 12% occasionally. Even in the group reporting severe or very severe chronic pain the number not using opioids (2680) was far higher than the number who used opioids persistently (304). However, three quarters of persons using opioids persistently reported strong or very strong pain in spite of the medication. Risk factors for persons with chronic pain who were not persistent opioid users at baseline, to use opioids persistently three years later were occasional use of opioids, prescription of >100 defined daily doses/year of benzodiazepines, physical inactivity, reports of "strong" pain intensity, and prescription of drugs from eight or more ATC groups. The study demonstrated that most persons having chronic non-malignant pain are not using opioids, even if the pain is strong or very strong. However, the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment.
[Show abstract][Hide abstract] ABSTRACT: BackgroundA growing proportion of the population is using opioids for longer time periods, but little is known about the characteristics of patients who are persistent opioid users. We therefore studied the association between socio-economic factors and persistent vs. short-term opioid use 4 years later. Methods
The background population is the complete Norwegian population in 2001. The study population is derived from two groups aged 35 years or older in 2001 who met one of the following criteria in 2005: (1) persistent opioid users (n = 15,113) or (2) short-term opioid users (n = 214,061). The applied definition of persistent opioid use corresponds to an average daily dose indicating likely daily use of opioids during 365 consecutive days. The socio-economic factors work status, income, marital status, immigrant status and education were obtained from the Population and Housing Census of 2001, and data on opioid use in 2005 were obtained from the complete national Norwegian Prescription Database. For logistic regression analyses, the study population was stratified by gender and by age over/under 67 years. ResultsIn the 35- to 67-year-old age group, receiving a disability pension was more common in persistent opioid users compared with short-term opioid users (48% vs. 16% for women, 36% vs. 9% for men). Adjusted odds ratios for receiving a disability pension were 6.51 and 5.77 for women and men, respectively. Being divorced/separated was associated with being a persistent opioid user (odds ratio of 1.4 for both genders). There were also negative associations between persistent opioid use and attained education level, an unemployed working status and income status. Conclusion
Disability pension, not working, divorce, low income and low education in 2001 were associated with persistent opioid use in 2005.
[Show abstract][Hide abstract] ABSTRACT: In patients with chronic non-malignant pain (CNMP), co-morbid physical or mental health disorders are common and may have a negative impact on health-related quality of life and treatment outcomes. The purpose of this study was to examine the occurrence of chronic psychiatric and somatic diseases in persistent opioid users with CNMP compared with the general population in Norway.
In this cross-sectional study, prescription patterns of dispensed opioids were used to identify a study population of persistent opioid users with CNMP from the general population. Reimbursed prescriptions marked with diagnostic codes were used to identify the occurrence of 21 somatic and 3 psychiatric diseases for a 1-year period in the Norwegian Prescription Database. Occurrence of disease in persistent opioid users was compared to an age- and gender-specific population of all Norwegian residents aged 18-79 years in 2009. Standardized morbidity ratios (SMRs) for each disease were calculated.
Eighty-five percent of the persistent opioid user population had at least one co-morbid disease compared with 45% of the general population. Forty-two percent had three or more co-morbidities. SMRs in both men and women were generally increased except for dementia, glaucoma and renal disease, indicating a higher occurrence of disease in persistent opioid users.
A higher occurrence of both somatic and psychiatric co-morbidities in disease stages warranting pharmacological treatment was found in persistent opioid users with CNMP compared with the general population of Norway.
European journal of pain (London, England) 01/2014; · 3.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with chronic pain have impaired cognitive functions, including decision making, as shown with the Iowa gambling task (IGT). The main aim of this study was to elucidate whether patients' decision making is associated with a lack of the anticipatory skin conductance response (SCR). An increase in anticipatory SCR before making unfavorable choices is known to guide decisions in healthy controls during the IGT. Since several brain regions involved in decision making are reported to have altered morphology in patients with chronic pain, the second aim was to explore the associations between IGT performance and brain structure volumes. Eighteen patients with chronic pain of mixed etiology and 19 healthy controls matched in terms of age, sex, and education were investigated with a computerized IGT during the recording of SCR, heart rate, and blood pressure. The participants also underwent neuropsychological testing, and three-dimensional T1-weighted cerebral magnetic resonance images were obtained. Contrary to controls, patients did not generate anticipatory SCRs before making unfavorable choices, and they switched between decks of cards during the late phase of the IGT significantly more often, and this was still observed after adjusting for depression scores. None of the other autonomic measures differed during IGT performance in either group or between groups. In patients, IGT scores correlated positively with total cortical grey matter volume. In controls, there was no such association, but their IGT scores correlated with the anticipatory SCR. It may be speculated that the reduction in anticipatory SCRs makes the chronic pain patients rely more on cortical resources during decision making.
[Show abstract][Hide abstract] ABSTRACT: This study aimed to (1) See whether increased or decreased variation relate to subjective reports of common somatic and psychological symptoms for a population on long-term sick leave; and (2) See if this pattern in variation is correlated with autonomic activation and psychological appraisal.
Our participants (n = 87) were referred to a 3.5-week return-to-work rehabilitation program, and had been on paid sick leave >8 weeks due to musculoskeletal pain, fatigue and/or common mental disorders. An extensive survey was completed, addressing socio-demographics, somatic and psychological complaints. In addition, a physician and a psychologist examined the participants, determining baseline heart rate, medication use and SCID-I diagnoses. During the 3.5-week program, the participants completed the Trier Social Stress Test for Groups. Participants wore heart rate monitors and filled out Visual Analogue Scales during the TSST-G.
Our participants presented a low cortisol variation, with mixed model analyses showing a maximal increase in free saliva cortisol of 26% (95% CI, 0.21-0.32). Simultaneously, the increase in heart rate and Visual Analogue Scales was substantial, indicating autonomic and psychological activation consistent with intense stress from the Trier Social Stress Test for Groups.
The current findings are the first description of a blunted cortisol response in a heterogeneous group of patients on long-term sick leave. The results suggest lack of cortisol reactivity as a possible biological link involved in the pathway between stress, sustained activation and long-term sick leave.
PLoS ONE 01/2014; 9(5):e96048. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Guidelines for opioid treatment of chronic non-malignant pain recommend long-acting over short-acting opioid formulations. The evidence for this recommendation is weak. This study is a randomized, double blind, double dummy, 8-week comparison of long-acting dihydrocodeine tablets (DHC-Continus®) with short-acting dihydrocodeine tablets in 60 chronic non-malignant pain patients referred to a multidisciplinary pain clinic. All patients used codeine-paracetamol tablets before the trial and paracetamol was added in both groups during the trial. The primary outcome was stability in pain intensity, measured as the difference between the highest and least pain intensity reported on an 11-point numerical rating scale in a 7-day diary. The secondary outcomes were differences in quality of life, quality of sleep, depression and episodes of breakthrough pain between the two formulations. Spontaneously reported adverse events were recorded. Thirty-eight patients completed, 22 withdrew before the end of the trial. The reasons were adverse events, lack of efficacy, or both and were similar between the groups. There were no significant differences in stability of pain intensity between groups. There were no significant differences between groups in quality of sleep, depression, health-related quality of life or adverse events. Breakthrough pain was experienced in both groups during the trial. Long-acting dihydrocodeine was not superior for any of the outcomes in this trial. This study does not support current guidelines recommending long-acting opioids.
[Show abstract][Hide abstract] ABSTRACT: Clinical studies of short duration have demonstrated that strong opioids improve pain control in selected patients with chronic nonmalignant pain. However, high discontinuation rates and dose escalation during long-term treatment have been indicated. The aim of the present study was to determine discontinuation rates, dose escalation, and patterns of co-medication with benzodiazepines. The Norwegian Prescription Database provides complete national data at an individual level on dispensed drugs. A complete national cohort of new users of strong opioids was followed up for 5years after initiation of therapy with strong opioids. Of the 17,248 persons who were new users of strong opioids in 2005, 7229 were dispensed a second prescription within 70days and were assumed to be intended long-term users. A total of 1233 persons in the study cohort were still on opioid therapy 5years later. This equals 24% of the study cohort who were still alive. Of the participants, 21% decreased their annual opioid dose by 25% or more, whereas 21% kept a stable dose (±24%) and 34% more than doubled their opioid dose from the first to the fifth year. High annual doses of opioids were associated with high annual doses of benzodiazepines at the end of follow-up. It is an issue of major concern that large dose escalation is common during long-term treatment, and that that high doses of opioids are associated with high doses of benzodiazepines. These findings make it necessary to question whether the appropriate patient population receives long-term opioid treatment.
[Show abstract][Hide abstract] ABSTRACT: Patients with chronic nonmalignant pain syndromes frequently report cognitive dysfunction, in particular with respect to concentration and attention. Such complaints have, in general, been attributed to depressive symptoms. In this study we showed that cognitive complaints in chronic pain patients are significantly associated with objective test performance in the area of inhibitory control after partialling out degree of depressive symptoms. Furthermore, about 20% of the patients performed below cut-off for clinically significant impairment on tests of basic neurocognitive functioning. A larger proportion of patients with generalized and neuropathic pain performed below this cut-off, whereas patients with localized pain exhibited impaired function to a lesser degree. Chronic pain patients receiving opioids did not perform worse than patients off opioid treatment. Systematic assessment of basic neurocognitive functions in centres treating chronic pain patients is warranted.
[Show abstract][Hide abstract] ABSTRACT: Population-based studies have reported conflicting findings on the relationship between physical activity and pain, and most studies reporting a relationship are cross sectional. Temporal relationships are therefore difficult to infer and associations may be subject to confounding from a variety of other factors. The aim of the current study was to investigate the association between exercise and pain longitudinally and to use within subjects analyses to remove between subjects confounding.
In the population-based HUNT 3 study, participants reported both pain and level of exercise. A random sub-sample of 6419 participants was in addition invited to report their last week pain and exercise every three months over a 12 month period (five measurements in total). We used multilevel mixed effects linear regression analyses to prospectively estimate the association between regular levels of exercise (measured in HUNT 3) and subsequent longitudinal reporting of pain. We also estimated within-subjects associations (i.e. the variation in pain as a function of variation in exercise, over time, within individuals) to avoid confounding from between subject factors.
Among those invited to participate (N = 6419), 4219 subjects returned at least two questionnaires. Compared with subjects who reported no or light exercise, those who reported moderate levels of exercise or more at baseline, reported less pain in repeated measures over a 12 month period in analyses adjusted for age, sex,education and smoking. Adjusting for baseline level of pain distinctly attenuated the findings. Within subjects, an increase in exercise was accompanied by a concurrent reduction in intensity of pain. However, we found no indication that exercise level at one occasion was related to pain reporting three months later.
This longitudinal population-based study indicates that exercise is associated with lower level of pain and that this association is close in time.
PLoS ONE 01/2013; 8(6):e65279. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The reported prevalence of chronic pain ranges from 11% to 64%, and although consistently high, the calculated economic burden estimates also vary widely between studies. There is no standard way of classifying chronic pain. We have repeated measurements of pain in a longitudinal population study to improve validity of the case ascertainment. In this paper, associations between chronic pain and demographic characteristics, self reported health and functioning, work incapacity and health care use were investigated in a sample from the general Norwegian population.
A random sample of 6419 participants from a population study (the HUNT 3 Study) was invited to report pain every three months during a 12 month period. Chronic pain was defined as moderate pain or more (on the SF-8 verbal rating scale) in at least three out of five consecutive measurements. Self reported health and functioning was measured by seven of the eight subscales on the SF-8 health survey (bodily pain was excluded). Health care utilisation during the past 12 months was measured by self report, and included seeing a general practitioner, seeing a medical specialist and seeing other therapists. The survey data was combined with information on income, education, disability pension awards and unemployment by Statistics Norway, which provided data from the National Education database (NUDB) and the Norwegian Labour and Welfare Administration (NAV).
The total prevalence of chronic pain was 36% (95% CI 34–38) among women and 25% (95% CI 22–26) among men. The prevalence increased with age, was higher among people with high BMI, and in people with low income and low educational level. Smoking was also associated with a higher prevalence of chronic pain. Subjects in the chronic pain group had a self-reported health and functioning in the range of 1–2.5 standard deviations below that of those without chronic pain. Among the chronic pain group 52% (95% CI 49–55), of participants reported having seen a medical specialist during the 12 month study period and 49% (95% CI 46–52) had seen other health professionals. The corresponding proportions for the group without chronic pain were 32% (95% CI 29–34) and 22% (95% CI 20–25), respectively. Work incapacity was strongly associated with chronic pain: compared with those not having chronic pain, the probability of being a receiver of disability pension was four times higher for those with chronic pain and the probability of being unemployed was twice has high for those with chronic pain. The population attributable fraction (PAF) suggested that 49% (95% CI 42–54) of the disability pension awards and 20% (13–27) of the unemployment were attributable to chronic pain.
Conclusion and implications
Chronic pain is a major challenge for authorities and health care providers both on a national, regional and local level and it is an open question how the problem can best be dealt with. However, a better integration of the various treatments and an adequate availability of multidisciplinary treatment seem to be important.
Scandinavian Journal of Pain 01/2013; 4(4):182–187.
[Show abstract][Hide abstract] ABSTRACT: Recent guidelines for opioid treatment of chronic non-malignant pain discourage co-medication with benzodiazepines and benzodiazepine-related hypnotics, whereas co-medication with non-opioid analgesics and co-analgesics may offer a beneficial opioid sparing effect, and is recommended. The aim of this study was to describe 1-year periodic prevalence of co-medication with benzodiazepines, benzodiazepine-related hypnotics, non-opioid analgesics, co-analgesics and antidepressants in persistent opioid users with chronic non-malignant pain.
The study is based on data from the Norwegian Prescription Database, covering all drugs dispensed to outpatients in 2008. Concomitant medication levels were compared between users in two definitions of persistent opioid use, all Norwegian adults dispensed opioids in 2008 and the Norwegian background population.
Of the Norwegian adult population studied, 1.2% met the criteria of persistent opioid use based on prescription pattern and prescription level. Sixty per cent of persistent opioid users were dispensed a benzodiazepine or benzodiazepine-related hypnotic in amounts indicating regular use, with 15% dispensed a high amount of both classes. Sixty-two percent of persistent opioid users were dispensed one or more non-opioid analgesics, 47% an antidepressant and 33% were dispensed an antiepileptic drug.
Approximately 60% of persistent opioid users also receive benzodiazepines or benzodiazepine-related hypnotics in amounts indicating regular use. This is in conflict with recent guidelines for the treatment of chronic non-malignant pain and may indicate that these users are at an increased risk of developing problematic opioid use.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: During opioid treatment of cancer pain, constipation is one of the most prevalent and bothersome side effects. Guidelines suggest that treatment with laxatives should be initiated when opioid therapy is started. AIM: This study aims: (1) to determine to what extent patients, starting on opioids due to cancer pain, receive laxatives; (2) to examine the temporal relationship between initiation of opioid therapy and initiation of treatment with laxatives; and (3) to study to which extent the treatment follows current guidelines. METHODS: Data from the Norwegian prescription database (NorPD) were used to investigate dispensed prescriptions of laxatives to outpatients in Norway, who are receiving opioids for cancer pain. Data from NorPD cover all dispensed prescriptions of drugs to outpatients, making it possible to follow patients over time. The study cohort was followed from 2005 to the end of 2008. RESULTS: Of 2,982 patients who started opioid therapy directly with WHO step III opioids, 1,325 patients (44.4 %) did not receive laxatives during the study period. Only 738 patients (24.7 %) received laxatives at the same time as opioid therapy was initiated. Another 657 patients (22.0 %) received laxatives after their initiation of opioids at some time during the study period. CONCLUSION: Of those who started directly on a strong opioid, only one fourth received laxatives concomitantly with the first opioid, and nearly half did not receive laxatives at all. These findings indicate that the current guidelines are not followed.
Supportive Care in Cancer 06/2012; · 2.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Methods for classifying chronic pain in population studies are highly variable, and prevalence estimates ranges from 11% to 64%. Limited knowledge about the persistence of pain and the validity of recall questions defining chronic pain make findings difficult to interpret and compare. The primary aim of the current study was to characterize the persistence of pain in the general population and to validate recall measures against longitudinal reporting of pain. A random sample of 6419 participants from a population study (the HUNT 3 study in Norway) was invited to report pain on the SF-8 verbal pain rating scale every 3 months over a 12-month period and to report pain lasting more than 6 months at 12-month follow-up. Complete data were obtained from 3364 participants. Pain reporting was highly stable (intraclass correlation 0.66, 95% confidence interval 0.65 to 0.67), and the prevalence of chronic pain varied considerably according to level of severity and persistence: 31% reported mild pain or more, whereas 2% reported severe pain on 4 of 4 consecutive measurements. When defined as moderate pain or more on at least 3 of 4 consecutive measurements, the prevalence was 26%. Compared with the longitudinal classification, a cross-sectional measure of moderate pain or more during the last week on the SF-8 scale presented a sensitivity of 82% and a specificity of 84%, and a sensitivity of 80% and a specificity of 90% when combined with a 6-month recall question. Thus pain reporting in the general population is stable and cross-sectional measures may give valid prevalence estimates of chronic pain.