Human Studies

Background and aims There is very little published evaluation of the treatment of military veterans with chronic pain, with or without post-traumatic stress disorder. Few clinical services offer integrated treatment for veterans with chronic pain and PTSD. Such veterans experience difficulty in accessing treatment for either condition: services may consider each condition as a contraindication to treatment of the other. Veterans are therefore often passed from one specialist service to another without adequate treatment. The veteran pain management programme (PMP) in the UK was established to meet the needs of veterans suffering from chronic pain with or without PTSD; this is the first evaluation. Methods The PMP was advertised online via veteran charities. Veterans self-referred with accompanying information from General Practitioners. Veterans were then invited for an inter-disciplinary assessment and if appropriate invited onto the next PMP. Exclusion criteria included; current severe PTSD, severe depression with active suicidal ideation, moderate to severe personality disorder, or who were unable to self-care in the accommodation available. Treatment was by a team of experienced pain management clinicians: clinical psychologist, physiotherapist, nurse, medical consultant and psychiatrist. The PMP was delivered over 10 days: five residential days then five single days over the subsequent 6 months. The PMP combines cognitive behavioural treatment, which has the strongest evidence base, with more recent developments from mindfulness-based CBT for pain and compassion-focused therapy. Standard pain management strategies were adapted to meet the specific needs of the population, recognising the tendency to use demanding activity to manage post-traumatic stress symptoms. Domains of outcome were pain, mood, function, confidence and changes in medication use. Results One hundred and sixty four military veterans started treatment in 19 programmes, and 158 completed. Results from those with high and low PTSD were compared; overall improvements in all domains were statistically significant: mood, self-efficacy and confidence, and those with PTSD showed a reduction (4.3/24 points on the IES-6). At the end of the programme the data showed that 17% reduced opioid medication and 25% stopped all opioid use. Conclusions Veterans made clinically and statistically significant improvements, including those with co-existing PTSD, who also reduced their symptom level. This serves to demonstrate the feasibility of treating veterans with both chronic pain and PTSD using a PMP model of care. Implications Military veterans experiencing both chronic pain and PTSD can be treated in a PMP adapted for their specific needs by an experienced clinical team.

Background and aims Patients usually receive a prescription for morphine or another opioid at discharge after surgery. Several studies have shown that many patients do not step down but develop persistent opioid use following surgery. The purpose of this study was to gain insight of patients' experiences with opioid tapering after surgery and to propose recommendations for clinicians to assist patients in opioid tapering. Methods Using a qualitative study design, 15 adult patients who took opioids before surgery and still had a daily consumption of opioids 6 months following spine surgery were interviewed. Results Analyses of the transcripts identified three major themes and eight subthemes. The major themes were as follows: (1) The patients' experienced that their whole life revolved around pain and opioids and felt stigmatized and suspected of being drug addicts by their social circle and health care professionals (2) Barriers for opioid tapering were increased pain, opioid dependency and fear of withdrawal symptoms (3) Motivational factors for opioid tapering were fear of dependency, the prospect of a better health, patient involvement in opioid tapering and a trusting relationship between patient and clinician. Conclusions The results of this study highlight that opioid tapering is challenging and may be influenced by many different factors. Some patients find opioid tapering particularly difficult and therefore need additional assistance in order to taper off successfully. Implications For opioid tapering to succeed, it is highly important to establish a trustful relationship with the patients, to take each patient's personal circumstances into account and to address fears of increased pain and withdrawal symptoms. Clinicians should also focus on patient involvement in opioid tapering and consider to offer a follow-up after discharge to patients at risk for prolonged opioid use.

Chronic pain is associated with poor physical and emotional functioning. Nonpharmacological interventions can help but improvements are small and not sustained. Prior clinical trials do not follow recommendations to comprehensively target objective and performance-based physical function in addition to self-reported physical function.

Mental, emotional, physical, and general fatigue, as well as vigor, have each been associated with pain interference-defined as pain-related disruption of social, recreational, and work-related activities-in patients with chronic orofacial pain (COFP). The objectives of the current study were to compare levels of these fatigue subtypes across younger, middle-aged, and older patients with COFP and test the associations between fatigue subtypes and pain interference in these age groups.