Purpose Chronic postoperative inguinal pain (CPIP), a complication of inguinal hernia repair, may negatively affect mental health. The rates of psychological disorders in patients with CPIP are unknown. We aimed to describe the prevalence of psychological disorders coinciding with CPIP. Methods A retrospective chart review was performed of all patients seen at the Cleveland Clinic Center for Abdominal Core Health's inter-disciplinary Chronic Groin Pain Clinic. This clinic is unique in that all patients are evaluated by a surgeon, a sonographer and radiologist, and a behavioral medicine psychologist. Patient psychological history and treatment, Depression Anxiety and Stress Scale (DASS) scores, pain catastrophizing, and trauma or abuse history were captured. Results From January 2018 to January 2022, 61 patients were evaluated and included in the study. Psychological treatment had been provided to 37 (61%) patients (present: 16 (27%), past: 21 (35%)). The most common psychological disorders represented were depression (N = 13, 22%), anxiety (N = 10, 17%), and post-traumatic stress disorder (N = 5, 8%). DASS scores indicated that 20 (33%) patients were reporting symptoms of depression and 16 (27%) patients were reporting symptoms of anxiety. Of the 40 patients assessed for pain catastrophizing, 28 (70%) reported rumination, 9 (23%) reported magnification, and 23 (58%) reported feelings of helplessness. A childhood history of emotional or physical abuse was reported by 11 (18%) patients. Conclusion An inter-disciplinary groin pain clinic has revealed that patients with CPIP frequently have pre-existing complex psychosocial issues. A multi-specialty approach to CPIP may improve preoperative assessments and identify patients who may benefit from further psychological evaluation and treatment.

Background: The effect of preoperative addictions on postoperative outcomes after total pancreatectomy with islet autotransplantation (TP-IAT) has not been studied. Methods: Retrospective review of prospectively collected data for patients that underwent TP-IAT from November of 2007 to December of 2016. All patients got pre-operative psychological assessments that included addiction assessments among other scales. Patients were assessed for addiction to alcohol, opiates, hallucinogens, and cannabis. For the purposes of the study, tobacco use alone was not considered in the definition for addiction. Results: 75 patients with chronic pancreatitis (CP) were evaluated for TP-IAT over the 8-year time period. Five had significant contraindications based on pre-operative psychological screening and 10 were able to have their pain controlled utilizing a multimodal approach, leaving 60 to undergo TP-IAT. Daily narcotic use was noted in 81.7% with the average ± SD morphine equivalents being 198.8 ± 467.4, and duration of pain 103.2 ± 93.6 months. 50% of patients had 1 or more addiction (opiates = 20%, alcohol = 31%, cannabis = 25%, stimulants = 5%, and hallucinogens = 3%). Excluding patients with alcoholic CP, 39% had 1 or more addiction. On univariate analyses, male gender predicted a 3 or more point decrease (29% male with less than 3 point decrease vs. 71% with 3 or more point decrease, p = 0.01) as well as a 50% or more decrease on postoperative pain scores (21% vs. 79%, p = 0.002) after TP-IAT. Absence of addiction did not predict pain improvements. When excluding alcoholic CP, similar results were noted with no relation of addiction to post operative pain improvements. Conclusion: A multidisciplinary team utilizing psychology is ideal to treat CP patients. While important to screen for addictions, their presence should not be used as a criteria to exclude TP-IAT.

Bei der Behandlung von chronischen Nicht-Tumor-Schmerzen mit Opioiden kann sich eine Abhängigkeitserkrankung entwickeln. Bei welchen Patienten dieses Risiko besonders hoch ausfällt, wurde bislang aber wenig untersucht. Dass eine frühere Abhängigkeitserkrankung ein relevanter Risikofaktor sein könnte, scheint theoretisch naheliegend, aber in den meisten Studien werden genau diese Patienten ausgeschlossen. Ein Zentrum aus Cleveland hat sich nun damit beschäftigt.

Chronic pain renders many individuals incapacitated and increases the risk of opioid dependence throughout the lifetime course of treatment. The efficacy of an intensive non-opioid interdisciplinary chronic pain rehabilitation program (CPRP) was previously established in headache patients1 and was expanded to include a broader range of primary pain conditions in this study. Assessments of pain intensity (0-10), Depression Anxiety Stress Scale (DASS) and Perceived Stress Scale (PSS) scores (measuring mood), Pain Disability Index scores (PDI; measuring function), and coping styles, utilizing the brief COPE questionnaire were compared in 133 patients at admission versus discharge. Statistical and clinically significant improvements, in addition to the predictive potential of patient characteristics and baseline pain, mood, and function, were investigated using repeated measures, paired t-tests, binary logistic regression, and ANOVA. Depression (18.4±11.1 v. 6.8±7.3), anxiety (12.4±9.9 v. 5.9±6.7), disability scores (44.0±1.0 v. 21.3±14.9), and pain (6.8±2.1 v. 3.6±2.5) were significantly reduced over the course of CPRP (p<0.001). Marital status (Wilks’ Lambda= 0.89, F(4,228)=3.407, p=0.010) and primary pain condition (Wilks’ Lambda= 0.83, F(12,228)=1.925, p=0.033) impacted mood with the most significant improvement in depression of single individuals and anxiety of fibromyalgia patients. Clinically significant improvement of at least one level of depression was enhanced by acceptance type coping and was diminished by substance abuse coping, higher disability levels, and post-traumatic stress disorder symptoms at admission (X2(4)=32.6, p<0.001). Older age, single status, and planning style coping at admission predicted clinically lower disability by discharge (X2(4)=15.2, p=0.004). Improvement of pain and anxiety level were negatively impacted by each additional year of chronic pain an individual had already experienced (X2(1)=5.9, p=0.015 and X2(1)=11.0, p=0.001). Taken together, this study indicates the potential pain, mood, and function benefit of an interdisciplinary program and may enable improved risk stratification and personalization of chronic pain treatment. (1. Zheng, Headache, 2013.)

Patients with disabling chronic pain display higher rates of alexithymia (the inability to process and express emotions), and pain catastrophizing, than the general population. Additionally, previous research suggests that alexithymia is predictive of poor functioning and pain catastrophizing; however, there is a paucity of research examining the contribution of alexithymia to functioning and catastrophizing over and above the effects of anxiety and depression symptoms. Using 1,073 (698 female) chronic pain patients presenting to the Cleveland Clinic Chronic Pain Rehabilitation Program (CPRP) between January 2011 and September 2014, this investigation examined characteristics of alexithymic patients and attempted to elucidate the relations between alexithymia, functioning, and catastrophizing. When presenting to the CPRP, patients completed questionnaires measuring pain catastrophizing, anxiety/depression symptoms, functioning, and alexithymia. Based on their scores, patients were categorized as alexithymic or non-alexithymic. Alexithymic patients were significantly older in age, and reported significantly higher levels of depression, anxiety, pain intensity, and pain catastrophizing, specifically rumination and helplessness about pain. Hierarchical linear regressions were conducted to assess the ability of alexithymia to predict pain catastrophizing or functioning, when controlling for sex, age, pain intensity, depression, and anxiety. As expected, depression and anxiety were significant predictors in all regressions and accounted for the majority of the variance; however, alexithymia significantly predicted pain catastrophizing over and above depression and anxiety accounting for 1.3% of the variance, with the inability to identify feelings being the most salient factor. Alexithymia did not significantly predict functioning. These findings suggest that alexithymia, regardless of sex, pain intensity, and depression/anxiety symptoms, is predictive of pain catastrophizing, but not pain related functioning. Additionally, alexithymic chronic pain patients may engage in emotional avoidance rather than emotional processing, potentially responding to increased arousal by catastrophizing rather than using emotion regulation skills.

Research supports weaning patients from chronic opioid therapy (COT) in the context of an interdisciplinary chronic pain rehabilitation program (CPRP). The aim of the current study was to examine CPRP outcomes for patients with chronic non-cancer pain (CNCP) weaned off high-dose COT (HD; >100mg morphine equivalency dose-MED). Outcomes for these patients were compared with patients weaned from low-dose COT (LD, 0.01-99.9mg MED) and patients not on COT (ND). Data was available from 1248 patients admitted to a CPRP between 2007-2011. Cases were included in analyses if patients completed the program (81% n=1016), were on COT at admission (53%, n=659), and were fully opioid weaned upon discharge (n=557). This resulted in inclusion of 527 patients: 231 HD, 296 LD and 331 ND. Participants were predominately married (60%) females (65.7%) with a mean age of 42.2 (±13.8); however, patients in the HD group were more likely to be male (43%, p<.05). Outcome variables, including pain, functional impairment, depression and anxiety, were assessed at admission, discharge, 6 months and 12 months post-treatment. A one-way repeated measures MANOVA was used to assess outcomes at each time point. Results showed that while the HD group reported significantly higher levels of depression at admission (p=.01), at discharge all groups reported clinically and statistically significant improvements in pain severity (-50%, p<.01), pain related functional impairment (-59%, p<.01), normalization of depression (-69%, p<.01) and anxiety (-52%, p<.01). Significant treatment benefits were still observed at both 6 and 12 months. No differences in benefits were observed as a function of opioid dosing group. Results demonstrate that patients on high dose opioids can be successfully weaned from COT and obtain similar treatment benefits as their LD and ND counterparts, with significant improvements in depression, anxiety, pain severity, and pain-related functional impairment. Research supports weaning patients from chronic opioid therapy (COT) in the context of an interdisciplinary chronic pain rehabilitation program (CPRP). The aim of the current study was to examine CPRP outcomes for patients with chronic non-cancer pain (CNCP) weaned off high-dose COT (HD; >100mg morphine equivalency dose-MED). Outcomes for these patients were compared with patients weaned from low-dose COT (LD, 0.01-99.9mg MED) and patients not on COT (ND). Data was available from 1248 patients admitted to a CPRP between 2007-2011. Cases were included in analyses if patients completed the program (81% n=1016), were on COT at admission (53%, n=659), and were fully opioid weaned upon discharge (n=557). This resulted in inclusion of 527 patients: 231 HD, 296 LD and 331 ND. Participants were predominately married (60%) females (65.7%) with a mean age of 42.2 (±13.8); however, patients in the HD group were more likely to be male (43%, p<.05). Outcome variables, including pain, functional impairment, depression and anxiety, were assessed at admission, discharge, 6 months and 12 months post-treatment. A one-way repeated measures MANOVA was used to assess outcomes at each time point. Results showed that while the HD group reported significantly higher levels of depression at admission (p=.01), at discharge all groups reported clinically and statistically significant improvements in pain severity (-50%, p<.01), pain related functional impairment (-59%, p<.01), normalization of depression (-69%, p<.01) and anxiety (-52%, p<.01). Significant treatment benefits were still observed at both 6 and 12 months. No differences in benefits were observed as a function of opioid dosing group. Results demonstrate that patients on high dose opioids can be successfully weaned from COT and obtain similar treatment benefits as their LD and ND counterparts, with significant improvements in depression, anxiety, pain severity, and pain-related functional impairment.

Studies examining treatment outcomes among patients with chronic noncancer pain treated in interdisciplinary chronic pain rehabilitation programs (CPRP) are abundant, however outcome studies specific to patients with abdominal pain are virtually non-existent. This retrospective study examined the outcomes of patients with abdominal pain treated in the Cleveland Clinic's CPRP. Outcomes included pain severity, depression, anxiety and pain related functional impairment and were measured at both admission and discharge. Pain was rated using the NRS-11. Mood was measured with the Depression, Anxiety and Stress Scale. Pain related functional impairment was measured using the Pain Disability Index. Data were available for 119 patients with abdominal pain between January 2007 and December 2011. Cases were included in analyses if patients completed the program (89% n=106) and presented with abdominal pain as the primary disorder at admission (38%, n=45). Participants were predominantly female (71%), with a mean age of 36.9 (±13.4), presented with chronic abdominal pain that was either idiopathic (31%) or in the context of a diversity of diagnoses like Visceral Hyperalgesia (27%) or Crohn's disease. Of the total sample analyzed, 69% of the participants had at least one additional comorbid pain disorder, such as low back pain or fibromyalgia. Matched pair t-tests indicated that, at discharge, participants exhibited significant reductions in pain severity (p<.001), normalization of depression (p<.001), normalization of anxiety (p<.001), and improvements in pain related functional impairment (p<.001). Results show that a CPRP treatment can provide significant improvements in pain severity, depression, anxiety, and pain-related functional impairment for patients presenting with chronic abdominal pain.

The effectiveness of interdisciplinary rehabilitation programs in treating chronic non-malignant pain has been well documented, but there is a dearth of outcomes research on the success of such programs for older adults (≥65) who represent an increasingly large proportion of our population. The study aimed to understand whether older patients benefit from interdisciplinary approaches and whether they differ from younger patients in outcome. Using data obtained pre and post treatment between 2010 and 2014 in an interdisciplinary chronic pain rehabilitation program, the outcomes of older adults (N = 76) were examined in pain severity, mood, and pain-related catastrophizing. Older adults showed significant reduction in pain severity, depression, and anxiety from admission to discharge. Although pain catastrophizing did not reach the clinically significant cut-off at admission, a statistically significant decrease was observed at discharge in pain-related catastrophizing. The study also compared older adults with younger adults (age 30 to 50) to explore differences in self-reported pain severity, depression, anxiety, and pain-related catastrophizing pre and post treatment. There was no clinically significant difference in the two groups in pain severity, depression or anxiety at admission, however the younger patients reported significantly higher pain-related catastrophizing compared to the older group. At discharge, there was no significant difference in all the outcome variables between the two groups. This finding suggests that older adults may make less pain-related catastrophizing compared to younger patients when experiencing comparable amount of pain. The findings additionally support the clinical effectiveness of an interdisciplinary rehabilitation approach for treating chronic pain in older adults.

s The Journal of Pain S115 (556) Chronic pain rehabilitation and alcohol use disorder: promising outcomes in an interdisciplinary treatment program F Kenner, E Shella, B Tilahun, E Covington, M Mathews, and J Scheman; Cleveland Clinic Chronic Pain Rehabilitation Program, Cleveland, OH There is a significant literature on treating patients with co-morbid pain and addiction; however, most of these studies involve patients with addiction to medication used to treat their pain, including opioids and benzodiazepines. There is scant literature addressing chronic pain treatment outcomes of patients with alcohol use disorder. This study examined outcomes of 19 patients diagnosed with alcohol use disorder in the previous 30 days versus 19 ageand sex-matched controls following treatment in a comprehensive interdisciplinary 3-4 week chronic pain rehabilitation program at the Cleveland Clinic that includes a substance abuse education track for patients with any type of substance use disorder. Outcome variables included: pain, mood and function on admission and discharge following completion of the chronic pain rehabilitation program. Specific variables included pain intensity 0-10, scores on the DASS depression and anxiety scales; and the 7 items on the Pain Disability Index. Both groups had similar levels of pain, mood and impaired function, with the exception of higher admission anxiety scores for those with an alcohol use disorder (M = 17.5 vs. 8.2). There were no significant differences in outcomes between the two groups and no difference in discharge anxiety scores which normalized in both groups. Although this is a small number of patients, these findings suggest that patients with an active alcohol use disorder can benefit from treatment in a chronic pain rehabilitation program. Additional studies are underway to examine long term outcomes as well as sobriety rates. (557) Age and education matched comparison of female and male veterans participating in an inpatient chronic pain rehabilitation program S Rafie, K Phillips, and J Murphy; James A Haley Veterans’ Hospital, Tampa, FL Studies of Veterans Affairs (VA) patients show that pain is a significant problem among both male and female veterans. The number of female veterans is fast growing in the Veterans Health Administration (VHA), and is expected to continue rising. Current literature suggests there are differences between male and female veterans with regard to chronic pain treatment. To date, the efficacy of treatment for chronic non-cancer pain in female veterans is understudied. Furthermore, there is a paucity of studies that have compared females to an age and educationmatched comparison group ofmales. The purpose of the present study was to explore the differences between female and male veterans participating in an inpatient chronic pain rehabilitation program (CPRP). We conducted a retrospective survey of veterans (N=243) who completed the 3-week, interdisciplinary CPRP. Female (n=122) and male (n=121) veterans were matched within 2 years of age and 1 year of education. Participants were assessed at admission and discharge using self-report data. Females and males were compared on demographic (e.g., race), clinical (e.g., opioid analgesic use), and pain-outcome (e.g., pain level) variables using appropriate statistics (e.g., chi square or t-tests for baseline comparisons; repeated measures analyses of variance for change over time in pain-related outcomes between sexes). Datawill be presented on differences between sexes on demographic and clinical characteristics. Furthermore, results suggest that both male and female CPRP participants demonstrate improvements over time in pain-related outcomes, including pain level, pain-related negative affect, pain-related interference, and sleep (p-values<.01). Given the increase in the number of female veterans entering the VA system, these data are likely to address gaps in our current knowledge of female veterans’ experiences and needs in pain management, and have implications for better serving female veterans with chronic pain. (558) Child pain, function, and psychological outcomes in associationwith treatment duration in intensive interdisciplinary pediatric pain rehabilitation C Hoffart, R Anderson, A Chapman, B Dorton, D Feltrop, M Wilson, and D Wallace; Children’s Mercy Hospital, Kansas City, MO Weexamined the functional, psychological, and pain-related outcomes among children with chronic pain completing an intensive interdisciplinary pediatric pain rehabilitation program. We hypothesized that baseline psychological measures would predict a longer treatment course while baseline pain severity would not correlate with program duration. This outpatient program provides 5-6 hours of daily intensive physical therapy and occupational therapy in addition to yoga, self-regulation training, individual and group behavioral health intervention, group-based music and art therapy, and parent group intervention. All painmedications are discontinued, and no invasive therapeutic procedures are utilized. 22 patients (18 female) aged 11-18 with chronic musculoskeletal pain completed Functional Disability Inventory, 100mm Visual Analog Scale, PROMIS Anxiety, Depression, Pain Interference, and Mobility, PRCQ-catastrophizing, and the Pain AcceptanceQuestionnaire for Adolescents at baseline, the end of eachweek, and 19 have completed a one-month followup. Themean program duration was 3.6 (6 0.9) weeks, determined by achievement of functional goals. Using paired samples t-tests, current pain (VAS 0-100) significantly decreased from 61.7 to 31.0 (P=0.001) at post-treatment followup. FDI improved from 27.6 to 13.9 between baseline and program end (P<.0001), and continues to improve following treatment (P=0.002). Patient reported anxiety and depression decline significantly (P=0.004 and P=0.001, respectively), while pain acceptance increases significantly during treatment (P<.001). Patients report less catastrophizing following treatment (P=.001). Treatment program duration correlated with baseline pain interference (r=.470; P=.027), functional disability (FDI r=.664; P=.001), and presence of conversion symptoms (r=.548; P=.008). Patients with greater mobility (PROMIS; r =-.671; P =.001) and pain acceptance (CPAQ-A; r = -.537; P=.018) at baseline required shorter treatment intervention. Children with chronic musculoskeletal pain successfully restore function and improve pain without pharmacotherapy. Baseline functional disability and psychological factors correlate with treatment program duration. Prospective studies are warranted to determine long-term efficacy and effectiveness of this interdisciplinary program. (559) Rehabilitative therapy for the treatment of chronic abdominal pain in children W Bernal, J Tress, P Weiss, and D Sherry; The Children’s Hospital of Philadelphia, Philadelphia, PA Multidisciplinary rehabilitative therapy is effective in treating amplified musculoskeletal pain in pediatric patients, but its efficacy in the treatment of chronic abdominal pain is not known. Our center treats pediatric patients with amplified pain using physical & occupational therapy, psychotherapy, and art m 0-12 no to minimal , 13-29 moderate, 30-60 severe). 53 subjects fulfilled inclusion criteria, 43 (81%) of which had abdominal pain as part of chronic diffuse pain. 62%were female and 88%werewhite. At baseline evaluation, the mean verbal pain and FDI scores were 5.8 (95%CI: 5.0,6.7) and 26.7 (95% CI: 22.8,30.7), respectively. There were no significant differences in pain or FDI scores between patients with localized abdominal pain and those with diffuse pain. Of the initial 53 subjects, 40 (75%) were admitted to our rehabilitation program. Admitted subjects had higher mean pain (6.5 vs. 4.2, p < 0.05) and FDI (29.2 vs. 21, p < 0.05) scores. Most subjects (95%, N=38/40) completed the rehabilitation program. Mean length of stay was 25.2 days (95% CI: 21.2, 29.2). Completion of the program resulted in a mean change in the verbal pain and FDI scores of –3.9 (95% CI: -5.2,-2.7; p < 0.001) and– 19.5 (95% CI: -25.5,-13.6; p < 0.001), respectively, at 1 month after discharge. In pediatric patients disabled by amplified pain of the abdomen, multidisciplinary rehabilitative therapy restores function and decreases pain, and, importantly, this improvement was sustained after program discharge.

Although there is a well-documented relationship between pain and smoking, there is limited research on the outcomes of patients with chronic pain who smoke and have been treated in a chronic pain rehabilitation program. The current study examined the immediate treatment outcomes in patients who completed an interdisciplinary chronic pain rehabilitation program as compared to non-smokers who completed the same program. The study population was a convenience sample of 849 patients who were admitted to the Cleveland Clinic Chronic Pain Rehabilitation Program from 2010-2012. Patients were more likely to be non-smokers (72%). Smokers were more likely to be male and single. Smokers were less likely to complete the program; the overalls program completion rate was 82% for all patients and 77% for smokers. Pain duration and age were similar for both groups. Outcomes variables included: depression and anxiety as measured by the DASS; pain intensity as measured using an 11 point scale; and disability due to pain as measured by the Pain Disability Index. On admission, smokers had clinically significantly higher scores on the measure of depression and anxiety as compared to non-smokers. Smokers reported severe depression and anxiety on the DASS whereas non-smokers were in the moderate range for both. Pain levels and disability due to pan were similar for both groups. At discharge both groups showed similar normalization of mood and function, and both showed clinically significant decreases in their pain. These data support the findings of Hooten et al. (Pain Medicine, 2009) the only other study of this pupation in the literature and provide additional evidence that comprehensive chronic pain rehabilitation programs can be effective for both smokers and nonsmokers, specifically regarding pain intensity, anxiety, depression, and pain disability outcomes.

Patients weaned from opioid within an interdisciplinary chronic pain rehabilitation program (CPRP) show improvements in improve pain and function. Patients with chronic non-cancer pain (CNCP) and comorbid opioid addiction also face potential relapse. Suboxone has been demonstrated to decrease the odds of opioid relapse; however, little research has examined it’s use in a CPRP. This retrospective study compared 12 month treatment outcomes of patients with opioid addiction discharged on Suboxone for with patients with opioid addiction who were opioid weaned. 30 patients were discharged on Suboxone between 2007-2012. Cases were matched in age and gender, resulting in a total n of 60. Participants were predominately married (56.7%, n=34) males (n=39, 65.0%) with a mean age of 42.55 (±12.49). Both groups were equally likely to have a lifetime history of a substance use disorder (63.3%, n=38, χ2=.86, 1, ns) and there was no difference between the two in mean morphine equivalence dosage at admission (M=280.28±300.42). Pain and function ratings were collected at admission, discharge and 12 months post-treatment and opioid resumption at 12 months. Repeated measures MANOVA indicated participants reported improvements in pain (p<.01) and function (p<.01) from admission to discharge and sustained improvement at 12 months (p<.01). There were no between-group differences. At 12 months, opioid resumption data was available for 28 opioid weaned and 24 Suboxone patients. 38.5% of patients had resumed opioid use, with weaned patients more likely to resume (χ2=4.74, 1, p<.05). 50% of weaned patients resumed opioid use: 6 resumed chronic opioid therapy and 8 found opioid cravings unmanageable (4 initiated Suboxone and 4 relapsed). 5 Suboxone patients (20.83%) had used opioids; all had relapsed. Findings show that patients with pain and comorbid addiction benefit from CPRP treatment in terms of pain and function and treatment with Suboxone decreases the odds of resumption of other opioids.

Treatment outcomes of patients with and without active marijuana use within an interdisciplinary chronic pain rehabilitation program. Sweis, Giries W., Psy.D.; Kenner, Frank M., Ph.D.; Shella, Elizabeth, MA; Kuzma, Eleonora Z., Psy.D; Scheman, Judith, Ph.D.; Huffman, Kelly L., Ph.D. There has been a recent increase in the call for wider access to marijuana (MJ) use for medical conditions, including chronic pain conditions. However, outcome studies examining patient with chronic non cancer pain and MJ use in an interdisciplinary chronic pain rehabilitation program (CPRP) are virtually non-existent. This retrospective study compared treatment outcomes of patients actively using MJ, non MJ users and patients who have a chemically dependence (CD) but not using MJ. Outcomes included rate of program completion, mean treatment days completed, pain, mood and functional impairment. Pain was rated on a 0-10 visual analog scale. Mood was measured with the Depression, Anxiety and Stress Scale. Functional impairment was measured with the Pain Disability Index. Data were gathered from 135 patients who were treated in a CPRP between January 2010 and December 2011. Patients were matched on discharge date, gender and age. Analyses were intent to treat, with change scores = 0 for non-completers or cases with missing data on outcome variables. Number of treatment days completed and admission scores were covaried. Results showed that: 1) marijuana users dropped out at a higher rate than non-users and CD non-users [χ2 (2, N = 135) = 16.312, p < .001]; 2) marijuana users averaged fewer days in treatment than non-users and CD non-users [F (2, 132) = 8.662, p < .001]; and 3) all groups showed significant improvements in self-reported pain, mood and functioning at time of discharge [Wilks' Lambda = .943, p = .729]. Treatment outcomes of patients with and without active marijuana use within an interdisciplinary chronic pain rehabilitation program. Sweis, Giries W., Psy.D.; Kenner, Frank M., Ph.D.; Shella, Elizabeth, MA; Kuzma, Eleonora Z., Psy.D; Scheman, Judith, Ph.D.; Huffman, Kelly L., Ph.D. There has been a recent increase in the call for wider access to marijuana (MJ) use for medical conditions, including chronic pain conditions. However, outcome studies examining patient with chronic non cancer pain and MJ use in an interdisciplinary chronic pain rehabilitation program (CPRP) are virtually non-existent. This retrospective study compared treatment outcomes of patients actively using MJ, non MJ users and patients who have a chemically dependence (CD) but not using MJ. Outcomes included rate of program completion, mean treatment days completed, pain, mood and functional impairment. Pain was rated on a 0-10 visual analog scale. Mood was measured with the Depression, Anxiety and Stress Scale. Functional impairment was measured with the Pain Disability Index. Data were gathered from 135 patients who were treated in a CPRP between January 2010 and December 2011. Patients were matched on discharge date, gender and age. Analyses were intent to treat, with change scores = 0 for non-completers or cases with missing data on outcome variables. Number of treatment days completed and admission scores were covaried. Results showed that: 1) marijuana users dropped out at a higher rate than non-users and CD non-users [χ2 (2, N = 135) = 16.312, p < .001]; 2) marijuana users averaged fewer days in treatment than non-users and CD non-users [F (2, 132) = 8.662, p < .001]; and 3) all groups showed significant improvements in self-reported pain, mood and functioning at time of discharge [Wilks' Lambda = .943, p = .729].

Total pancreatectomy (TP) with auto-islet transplant (AIT) is an extreme treatment for chronic pancreatitis, and we reviewed our experience to assess the impact on quality of life (QOL).

Numerous studies have demonstrated the efficacy of an interdisciplinary approach in the treatment of patients with intractable chronic pain and functional impairment. This approach addresses the multiple etiologies present in this treatment resistant population, and thus incorporates medical, psychological, physical and occupational rehabilitation. Two classes of medication widely used in patients with chronic pain are opioids and benzodiazepines. Unfortunately, these may cause significant undesired effects. It has been suggested that, although prescribed to provide analgesia, they may not only impair overall functioning but also lead to opioid induced hyperalgesia and impaired concentration. These impairments in cognition and function can be further exacerbated by the individual's emotional state. Individuals with chronic pain often experience extremely debilitating depression that isolates and further debilitates them. Given the extensive affective modulation produced by opioids and benzodiazepines, it is important to determine their contributions to the patient's function and dysfunction, and to distinguish this from the effects of mood disorder . The present study utilized the database of the Cleveland Clinic Chronic Pain Rehabilitation Program (CC-CPRP) to examine the relationships of: 1) opioids/benzodiazepines and 2) mood, to cognitive function as assessed by Digit Span and Digit Symbol Coding, two commonly employed indices of cognitive function. After controlling for such potentially confounding variables as Function and Pain Intensity, several significant and interesting relationships were found. While medication withdrawal had minimal effect on neurocognitive function, mood had a pronounced effect on both Pain Intensity and neurocognitive function. We conclude that cognitive inefficiencies seen in chronic pain patients may be less a consequence of sedating drugs than of comorbid mood disorder.

There has been a steep increase in the prevalence of comorbid chronic pain and addiction. The Cleveland Clinic Chronic Pain Rehabilitation Program (CPRP) is a 3-4 week long out patient, comprehensive, interdisciplinary approach to the treatment of chronic pain and includes identification of patients with comorbid addiction. When diagnosed with an addiction, patients receive education and start 12 step meetings. At the time of discharge, recommendations are made for additional treatment. All patients are weaned from habituating substances, regardless of addiction status. This retrospective study examined if: 1) chemically dependent (CD) patients are more likely than non-CD patients to resume opioids and sedative hypnotics after CPRP treatment that included weaning from all habituating substances 2) whether patients who resume opiates and/or sedatives report greater levels of pain, depression, anxiety and higher levels of functional impairment. Data were gathered from January 2007 – October 2011. At 12 months, data were available for 219 patients; 23.4% (n=60) had a diagnosis of addiction. Pain was rated on a 0-10 visual analog scale. Mood was measured with the Depression, Anxiety and Stress Scale. Functional impairment was measured with the Pain Disability Index. Overall, 21% of 219 patients reported resuming opiate and/or habituating sedatives at 12 months. CD patients were not more likely to resume opiates or habituating sedatives than non-CD patients (23.3% vs. 20.1%, p=.60 by chi-square analysis). A one way MANCOVA, controlling for chemical dependency, demonstrated that patients resuming opiates and/or habituating sedatives reported higher levels of pain, depression, anxiety and functional impairment both at discharge (p<.03) and at 12 months (p<.01). Results suggest resumption is related to self reported levels of pain, mood and functional impairment and that weaning in the context of interdisciplinary CPRP treatment results in a relatively low resumption rate. There has been a steep increase in the prevalence of comorbid chronic pain and addiction. The Cleveland Clinic Chronic Pain Rehabilitation Program (CPRP) is a 3-4 week long out patient, comprehensive, interdisciplinary approach to the treatment of chronic pain and includes identification of patients with comorbid addiction. When diagnosed with an addiction, patients receive education and start 12 step meetings. At the time of discharge, recommendations are made for additional treatment. All patients are weaned from habituating substances, regardless of addiction status. This retrospective study examined if: 1) chemically dependent (CD) patients are more likely than non-CD patients to resume opioids and sedative hypnotics after CPRP treatment that included weaning from all habituating substances 2) whether patients who resume opiates and/or sedatives report greater levels of pain, depression, anxiety and higher levels of functional impairment. Data were gathered from January 2007 – October 2011. At 12 months, data were available for 219 patients; 23.4% (n=60) had a diagnosis of addiction. Pain was rated on a 0-10 visual analog scale. Mood was measured with the Depression, Anxiety and Stress Scale. Functional impairment was measured with the Pain Disability Index. Overall, 21% of 219 patients reported resuming opiate and/or habituating sedatives at 12 months. CD patients were not more likely to resume opiates or habituating sedatives than non-CD patients (23.3% vs. 20.1%, p=.60 by chi-square analysis). A one way MANCOVA, controlling for chemical dependency, demonstrated that patients resuming opiates and/or habituating sedatives reported higher levels of pain, depression, anxiety and functional impairment both at discharge (p<.03) and at 12 months (p<.01). Results suggest resumption is related to self reported levels of pain, mood and functional impairment and that weaning in the context of interdisciplinary CPRP treatment results in a relatively low resumption rate.

The prevalence of comorbid chronic pain and addiction is increasing. This retrospective study examined if patients with comorbid pain and addiction treated in a Chronic Pain Rehabilitation Program (CPRP) obtain the same benefit from treatment as patients without a chemical dependency diagnosis (CD). The Cleveland Clinic comprehensive CPRP includes weaning all patients, regardless of addiction diagnosis, from all addictive substances, and substance abuse education for patients with a diagnosis of chemical dependency (CD). Outcomes included pain, mood and functional impairment. Pain was rated on a 0-10 visual analog scale. Mood was measured with the Depression, Anxiety and Stress Scale. Functional impairment was measured with the Pain Disability Index. Completed discharge data were available for 797 patients, 313 with a CD diagnosis (39.3%), who completed the program between Jan 2007 and Oct 2011. Repeated measures MANOVA demonstrated that all pts showed significant improvements in pain, mood and function at discharge (p= .001), regardless of CD status. 12 month follow up data were available for 222 patients (follow up rate of 25.3%) of those, 65 had a CD dx (29.3%). Two repeated measures ANOVAS and one repeated measures MANOVA were used to analyze the data. At 12 months, all patients, regardless of chemical dependency status, demonstrated and maintained significant improvements in pain, mood and function compared to their status at admission (p=.001). There were no significant differences in levels of pain, anxiety and functional impairment between CD and non CD patients at 12 months. Data revealed a significant interaction for depression (p=.01) and post hoc analysis revealed CD patients reported higher levels of depression (12.2 vs 8.39, p=.01) at 12 months. Results of this study show that patients with comorbid pain and substance use disorders can successfully be treated within an interdisciplinary CPRP.

Persistent pain following stroke is most commonly associated with central post-stroke pain, post-stroke headache, or pain that persists in the affected sites in the periphery. Little has been written regarding treatment of patients with any post-stroke pain in a comprehensive pain rehabilitation program. This multiple case study examined the outcomes of 10 patients with post-stroke pain who participated in the Cleveland Clinic Chronic Pain Rehabilitation Program from 1999-2011. Sixty percent were female, and their mean age was 52 years; the range of duration of pain was 3-37 years. Fifty percent had only post-stoke pain, while others had multiple pain diagnoses with the most common co-morbidities being cervical pain and neuropathies. Eight of the 10 patients completed the program and outcomes analysis was on completers only. The Chronic Pain Rehabilitation Program is a comprehensive, interdisciplinary pain rehabilitation program that consists of 3-4 weeks of physiotherapy, occupational therapy, relaxation training, psychophysiological pain and stress management, as well as group and individual psychotherapy, and medication management including weaning from all addictive substances. Outcome variables examined in the present study included pain (as measured on a Visual Analogue Scale 0-10), impairment in function, as measured by the Pain Disability Index (7 item scale with each item being its own domain of function, on a 0-10 scale, with total scores ranging from 0-70), and depression as measured by the Beck Depression Inventory or the Depression, Anxiety, Stress Scales. Following treatment, patient's pain was significantly reduced (p < .05), as was disability due to pain (p < .05) and depression (p < .05). Although the sample size is very small, this case study appears to demonstrate the efficacy of pain rehabilitation with this population.