The Neurological Center for Pain’s Chronic Pain Rehabilitation Program (CPRP) at the Cleveland Clinic has created a Chemical Education Track designed specifically for patients with chronic non-cancer pain who also have a therapeutic opioid addiction. Initial results are promising. Patients who complete the program report low opioid resumption rates 12 months after they complete the program. They also report sustained improvements in pain severity, mood and pain-related functional impairment.
The Chemical Education Track began in 2009 and was designed to help the growing number of patients with both chronic pain and addiction, explains Sara Davin, Psy.D, MPH, of the Cleveland Clinic’s Neurological Center for Pain (NCP). While it is not a chemical dependency treatment program, patients are educated about addiction and how it has affected their lives and their pain, said Dr. Davin, who spoke about the program with the NCP’s Director, Edward Covington, MD, at the recent American Academy of Pain Medicine meeting.
The CPRP’s intensive day-treatment program lasts three to four weeks, from 7:30 a.m. to 5 p.m. All patients treated in the program, including those in the chemical education track, are offered a variety of services, including medication management, physical and occupational therapy, psychodynamic group therapy, individual psychotherapy, biofeedback training and group and individual cognitive behavioral therapy, including relaxation training. The program also emphasizes weekly participation in family education and family therapy.
“Often people with chronic non-cancer pain have gone through a lot of treatments— and for our patients, pain takes hold of their lives to the point that it is disabling,” Dr. Davin says. “They often are not working, they may have depression and anxiety related to their pain, or maybe it was there before, and got worse as time went on. We don’t offer a cure, but we offer coping strategies and tools to help folks get their lives back.”
All patients in the program, whether or not they have a therapeutic opioid addiction, are tapered off opioids and other habituating medications. “Other, adjunctive medications are used that carry less risk of addiction and have been shown to be more effective in treating chronic non-malignant pain,” she notes.
Each patient coming into the pain treatment program undergoes an extensive evaluation that includes questions about substance use. “If someone is struggling with an active recreational addiction, we ask them to get chemical dependency treatment before they come into the program,” Dr. Davin explains.
Throughout the program, patients are monitored and assessed for possible misuse of opioids and other prescribed medications, through urine toxicology, information from family and through continued meetings with the program staff.
The chemical education track includes daily classes that cover topics such as the myths of addiction, the signs and symptoms of addiction in people with chronic pain who are using prescription medication, and the pros and cons of using opioid medications to treat chronic pain. “We encourage self-help program involvement when appropriate, and we talk about relapse prevention,” Dr. Davin states. “If a patient leaves our program and develops an acute pain incident that requires treatment with opioids, we talk about how they can do that safely without developing a full-blown relapse.”
Drs. Huffman and Sweis of the Neurological Center for Pain have been tracking the outcomes of patients with co-occurring chronic pain and therapeutic opioid addiction who have been treated for pain in the CPRP. Preliminary results indicate these patients do just as well as those without an addiction. Patients with substance use disorders, who were dropping out of the program at higher rates than other patients, are now staying in the program at the same rate, notes Kelly L. Huffman, PhD., M.S. “We found both groups, whether they are in the chemical education track or not, improved on measures of pain, mood and function,” explains Giries W. Sweis, Psy.D., MHS.
Drs. Sweis and Huffman followed 120 patients for a year after they left the program. Only 22.5 percent reported resuming opioid use after one year. Patients who were addicted to opioids were no more likely to resume use than patients without an addiction. They note this is very significant, as abstinence-based chemical dependency programs treating those with non-medical opioid addictions have found relapse rates as high as 91 percent. Only patients who were depressed, whether or not they had a history of substance abuse, were more likely to have resumed opioid use a year after the program. They also noted while co-occuring therapeutic opioid addiction did not increase the odds of resumption, levels of depression at the time of program completion did.
“Overall, our data suggests that our multi-disciplinary CPRP benefits those seeking relief from these intractable conditions. It is especially encouraging to see such a strong and long-lasting improvement in these patients, and based on these findings patients’ mood is more on my radar,” says Dr. Sweis.