The Clinical journal of pain
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Comparative Study
Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study.
The assessment of addiction-related outcomes is crucial to the management of chronic pain with opioid drugs in all patients. Pain management for patients who have concomitant drug abuse or addiction issues is a particularly complex task involving a need for a common nomenclature as well as empirically derived data to support management strategies during treatment regimens. Complicating the issue is the notion of pseudoaddiction, which is an abuse of medications driven by unrelieved pain that appears on the surface to be very similar to the behavior patterns of addicts. ⋯ What is ultimately needed is a broad-based spectrum of research that highlights the epidemiology of drug-taking behaviors for different medical illnesses ranging from cancer to back pain. This article focuses on some of these issues as well as recounting attempts by our research group to address these issues systematically in hopes of shedding light on the nature of abuse issues in the medically ill. Although advances have been made, there is a definite need for large-scale studies that address the issues of identification and treatment of aberrant behavior in medically ill patients in the effort to provide the best possible outcomes for patients with chronic pain.
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Randomized Controlled Trial Comparative Study Clinical Trial
The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo.
Several cognitive-behavioral factors contribute to the persistence of pain disability in patients with chronic back pain. Fear-avoidance beliefs and fear of movement/(re)injury in particular have been shown to be strong predictors of physical performance and pain disability. Patients reporting substantial pain-related fear might benefit from exposure in vivo to a set of individually tailored, fear-eliciting, and hierarchically ordered physical movements rather than more general graded activity. ⋯ Time series analysis of the daily measures showed that improvements in pain-related fear and pain catastrophizing occurred only during the exposure in vivo and not during the graded activity, irrespective of the treatment order. Analysis of the pretreatment to post-treatment differences also revealed that decreases in pain-related fear also concurred with decreases in pain disability and pain vigilance and an increase in physical activity levels. All improvements remained at the 1-year follow-up.
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Recognition is growing that self-report of drug use, prescribed or otherwise, among patients with chronic pain treated with opioids is often unreliable. This fact is well known to the addiction management community. Patients may inaccurately report use of prescribed medications, fail to report use of nonprescribed medications or medications prescribed by other physicians, or fail to report use of illicit drugs. ⋯ The authors review the use of urine toxicology testing in monitoring patients with chronic pain, including laboratory aspects. They also present evidence from recent studies that suggests that monitoring the behavior alone of patients on chronic opioid treatment will fail to detect potential problems revealed by urine toxicology testing. The authors conclude that, although further research is urgently needed, at this time it is appropriate to conduct routine urine toxicology testing in patients with chronic pain treated with opioids.
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The identification of the disease of addiction is important to safe and effective clinical management of pain in persons with addictive disorders. The disease of addiction affects approximately 10% of the general population, and its prevalence may be higher in subpopulations of patients with pain. The presence of active addiction may facilitate the experience of pain. ⋯ The roles of medical interview, physical examination, laboratory studies, and standard addiction screening tools in assessing for addiction are outlined. Differential considerations in distinguishing therapeutic use of opioids for analgesia from addictive or other nontherapeutic use of opioids are discussed. In summary, the article provides salient background and a detailed approach to assessment for addictive disorders in the context of pain treatment.
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Randomized Controlled Trial Comparative Study Clinical Trial
Comparison of multiple against single pain intensity measurements in complex regional pain syndrome type I: analysis of 54 patients.
To describe the comparison of multiple and single pain ratings in patients with complex regional pain syndrome type I (CRPS I). ⋯ In patients with CRPS I a single pain rating is an accurate predictor of the average pain measured by a multiple pain-rating test. Moreover, both assessments are accurate enough to determine changes in pain over time with an effective treatment.