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Objective: Although chronic pain is prevalent among American Indian (AI) populations, the use of traditional healing practices has not been widely investigated. The aim of this qualitative study was to solicit information from adult AIs with chronic pain regarding use of traditional health practices (THPs) for chronic pain and pain reduction., Design: Prospective qualitative design., Setting: The Min No Aya Win Human Services Center, Fond du Lac Band Reservation in Cloquet, MN, and the Center for American Indian Resources, Duluth, MN., Patients: The cohort included 21 (10 women and 11 men) AI patients with chronic pain., Intervention: A semi-structured interview guide was developed, and audiotaped interviews were conducted with all patients., Outcome Measure: Audiotaped interviews were transcribed, and thematic analysis strategies were used to identify core concepts and categories for coding interview data. A qualitative software analysis program was used to facilitate data coding., Results: A range of THP were described including smudging (burning sage), sweat lodge (ceremonial sauna), sema (ceremonial tobacco), feasting (strengthening process), pipes (ceremonial herb and tobacco), storytelling (nonhierarchical environment for verbal communication), and contact with a traditional healer (elder spiritual leader). The majority of individuals from the Reservation described prior exposure to THP; however, the majority of urban individuals reported limited exposure. Although the majority of individuals endorsed inclusion of THP in ambulatory-based pain treatment programs, recommendations for inclusion of specific practices were not systematically identified., Conclusions: The findings of this qualitative study suggest AIs from this tribal community utilize THP, but which specific THPs should be included in an ambulatory-based pain treatment program will require further research., (Wiley Periodicals, Inc.)

Objectives: The primary aim of this study was to determine if the immediate outcomes of multidisciplinary pain rehabilitation were different for African Americans compared with Caucasians., Design: A retrospective repeated measures design was used, and all analyses were adjusted for marital and employment status, years of education, and pain duration., Setting: Multidisciplinary pain rehabilitation center., Subjects: Each African American (N = 40) consecutively admitted to a multidisciplinary pain rehabilitation program was matched with three Caucasians (N = 120) on age, sex, and treatment dates., Intervention: A 3-week outpatient multidisciplinary pain rehabilitation program., Outcome Measures: The Multidimensional Pain Inventory, Short Form-36 Health Status Questionnaire, Center for Epidemiologic Studies-Depression scale, and Pain Catastrophizing Scale were administered at admission and dismissal., Results:  At baseline, African Americans had greater pain severity (P < 0.001) and poorer physical function compared with Caucasians (P < 0.001). At program completion, African Americans had greater pain severity (P < 0.001) and poorer measures of life interference (P = 0.004), perceived control (P = 0.013), affective distress (P < 0.001), role physical (P = 0.001) and role emotional function (P = 0.001), physical (P < 0.001) and social function (P = 0.002), general health (P = 0.005), depression (P < 0.001), and pain catastrophizing (P < 0.001). A repeated measures analysis demonstrated a time by race interaction effect for pain interference (P = 0.038), affective distress (P = 0.019), role physical function (P = 0.007), social function (P = 0.029), and depression (P = 0.004), indicating African Americans experienced less improvement compared with Caucasians., Conclusions: The results of this study highlight an under-recognized health disparity which provides the basis for developing targeted interventions aimed at improving the clinical outcomes of African Americans with chronic pain., (Wiley Periodicals, Inc.)

Objective: The primary aim of this study was to determine the effects of spouse or significant other solicitous responses on morphine equivalent dose among adults with chronic pain., Design: Retrospective design., Setting: Multidisciplinary pain rehabilitation center., Patients: The cohort included 466 consecutively admitted patients who had a spouse or significant other and were using daily opioids. Intervention. Three-week outpatient pain rehabilitation program., Outcome Measures: Solicitous subscale of the Multidimensional Pain Inventory and morphine equivalent dose upon admission., Results: The mean solicitous subscale score and morphine equivalent dose were 49.8 (standard deviation [SD] = 8.7) and 118mg/day (SD =149), respectively. Univariate linear regression analysis showed that greater subscale scores were associated with greater doses of opioids (P = 0.007). In a multivariate model adjusted for age, sex, ethnicity, years of education, employment status, pain duration, depression, and pain severity, the association retained significance (P = 0.007)., Conclusions: These findings suggest solicitous responses from a spouse or significant other may have an important influence on opioid dose among adults with chronic pain., (Wiley Periodicals, Inc.)

Objective: The purpose of this study was to investigate the associations between morphine equivalent dose and heat pain (HP) perception in patients with chronic pain undergoing opioid tapering in the context of a multidisciplinary rehabilitation program., Design: Prospective design., Setting: Multidisciplinary pain rehabilitation center., Patients: The cohort included 109 patients using opioids (female 52%) who met inclusion criteria, and were consecutively admitted from March 2007 to June 2008., Intervention: Three-week outpatient multidisciplinary rehabilitation program that incorporates opioid tapering., Outcome Measures: Using a standardized quantitative sensory test (QST) method of levels, standardized values of HP perception were obtained one day following program admission and following completion of the opioid taper at program dismissal., Results: At admission, the mean morphine equivalent dose was 192 mg/day. Univariate linear regression analysis showed that greater baseline morphine equivalent dose was associated (P = 0.040) with lower, or more hyperalgesic, values of HP 5-0.5, which is a standardized measure of HP perception. The dose dependent association retained significance (P = 0.029) after adjusting for pain severity, pain duration and pain diagnosis. Tapering of greater morphine equivalent dosages was associated (P = 0.001) with lower values of HP 5-0.5. The association retained significance (P = 0.001) after adjusting for pain severity, pain duration, pain diagnosis, opioid withdrawal symptoms, and time between completion of the taper and performance of the dismissal QST., Conclusion: The use of a validated QST method of levels and standardized values of HP 5-0.5 may expand the methodological approaches available for investigating the clinical effects of opioids on HP perception., (Wiley Periodicals, Inc.)

Objective: The primary aim of this study was to investigate the associations between standardized values of thermal sensory perception and standardized scores of clinical pain among a heterogeneous cohort of adults with chronic pain that included individuals receiving chronic opioid therapy., Design: The study used a prospective design., Setting: The study was set in a multidisciplinary pain rehabilitation center at a tertiary medical center., Patients: The cohort included 163 patients (female 58%) who met inclusion criteria, and were admitted from March 2007 to June 2008., Intervention: Using a validated quantitative sensory test method of levels, standardized values of heat pain (HP) perception and cooling detection threshold were obtained 1day following admission., Outcome Measures: Standardized scores of clinical pain were obtained at admission using the pain severity subscale of the Multidimensional Pain Inventory., Results: At admission, 109 (67%) patients were using opioids, and the mean morphine equivalent dose was 192mg/day. The mean pain duration was 10.5years, and the two most frequent diagnoses were low back pain (29%) and headache (12%). A significant negative correlation was found between pain severity and HP threshold (r=-0.170, P=0.030), where lower values of HP threshold correlated with greater scores of pain severity. Post hoc linear regression analysis showed the association between HP threshold and pain severity retained statistical significance (P=0.039) after adjusting for opioid dose, pain duration and pain diagnosis., Conclusion: The use of standardized values of HP perception and clinical pain may be key methodological approaches for investigating the clinical correlates of HP perception among heterogeneous populations of adults with chronic pain., (Wiley Periodicals, Inc.)

Objective: This study examined depression, pain catastrophizing, psychosocial functioning, and physical and emotional health attributes for geriatric patients admitted to an interdisciplinary pain rehabilitation center compared with middle and younger age groups., Design: Quasi-experimental time series., Setting: Interdisciplinary pain rehabilitation center at a tertiary referral medical center., Patients: In total, 411 patients with chronic non-cancer pain completed the pain rehabilitation program from October 2004 to April 2006. Patients were divided into three groups based on age: older (ages 60+; n = 78); middle-age (ages 40-59; n = 230) and younger (ages 18-39; n = 141)., Intervention: A 3-week outpatient interdisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates opioid withdrawal., Outcome Measures: The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Pain Catastrophizing Scale (PCS), and Center for Epidemiological Studies-Depression Scale (CES-D) were administered at admission, discharge, and 6 months following treatment. The frequency of patients using opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines at each assessment point were compared., Results: Older patients reported reduced depression, catastrophizing, pain severity, and pain interference (P < 0.001) at discharge and 6 months follow-up. Older patients also reported increased perceived control, and physical and social functioning at discharge and follow-up (P < 0.001). Improvement in older patients was comparable in magnitude to that of middle-age patients on all variables, whereas younger patients exhibited greater improvement on four variables. Significant reductions in analgesic use were observed in all groups., Conclusion: Interdisciplinary pain rehabilitation incorporating opioid withdrawal can improve long-term psychological, social and physical functioning for geriatric chronic pain patients., (Wiley Periodicals, Inc.)

Objective: The primary aim of this study was to determine the influence of sex and the interactions between sex and smoking status on the immediate treatment outcomes of patients undergoing multidisciplinary pain treatment., Design: A retrospective, repeated measures design. Setting. Multidisciplinary pain rehabilitation center at a tertiary referral medical center., Patients: The cohort (N = 1,241) included 928 women and 313 men of whom 313 were current smokers, 294 were former smokers and 634 were never smokers consecutively admitted from September 2003 through February 2007. Interventions. A 3-week outpatient multidisciplinary pain rehabilitation program., Outcome Measures: The Multidimensional Pain Inventory, Short Form-36 Health Status Questionnaire, Center for Epidemiologic Studies-Depression scale, Pain Anxiety Symptom Scale, and Pain Catastrophizing Scale were administered at admission and dismissal., Results: Women experienced significantly greater improvement in depressive symptoms compared with men (P = 0.023). Smokers experienced significantly greater improvements in depression (P = 0.039), pain catastrophizing (P = 0.010), and anxiety (P = 0.037) compared with former and never smokers. No significant interaction effects between treatment by sex by smoking status were observed. A significant sex by smoking status interaction was observed for daily morphine equivalent dose (mg/d) where male smokers consumed greater quantities of opioids compared with female smokers at program admission (P < 0.001)., Conclusions: The effects of smoking status on the immediate treatment outcomes of multidisciplinary pain treatment are not modified by sex. However, women experienced significantly greater improvement in depression than men and male smokers consumed significantly greater quantities of opioids compared with female smokers at admission.

Objective: Chronic nonmalignant pain (CNMP) is both a prevalent and a costly health problem in our society. Pain rehabilitation programs have been shown to provide cost-effective treatment. A treatment goal for some rehabilitation programs is reduction in the use of pain-related medication. Medication costs savings from pain rehabilitation programs have not been analyzed in previous studies., Design: This prospective cohort study of 186 patients with CNMP addresses the costs of medications at admission to a 3-week outpatient pain rehabilitation program, at discharge, and at 6-month follow-up. Medication use was determined through a detailed pharmacist interview with patients at admission and discharge. Patients were sent questionnaires 6 months after program completion, which obtained current medication information., Results: Statistically significant medication cost savings were seen for program completers at discharge and at 6-month follow-up (P < 0.05). The mean (standard deviation) daily prescription medication cost reduction from admission to discharge was $9.31 ($12.70) using the average wholesale price of medications. From the original study cohort, 121 patients completed the 6-month follow-up survey. The mean daily prescription medication cost savings from admission to 6-month follow-up was $6.68 ($14.40)., Conclusion: Patients benefited from significant medication cost savings at the completion of the 3-week outpatient pain rehabilitation program and maintained significant savings after 6 months. This study adds to the current literature on the economic value of comprehensive pain rehabilitation programs.

Objective: The primary aim of this study was to determine the effects of smoking on treatment outcomes following multidisciplinary pain rehabilitation. A secondary aim was to assess the tobacco use characteristics of smokers with chronic pain., Design: A prospective, nonrandomized, repeated measures design., Setting: Multidisciplinary pain rehabilitation center at a tertiary referral medical center., Patients: All patients (N = 193) consecutively admitted from August 2005 through February 2006., Interventions: A 3-week outpatient multidisciplinary pain rehabilitation program., Outcome Measures: The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Center for Epidemiologic Studies-Depression scale (CES-D), Pain Anxiety Symptom Scale (PASS-20) and Pain Catastrophizing Scale (PCS) were administered at admission and dismissal., Results: The study involved 49 (83% women) smokers and 144 (83% women) nonsmokers. The mean number of cigarettes smoked daily was 17.5 (SD 11.1) and the mean duration of smoking was 21.5 years (SD 12.1). After adjusting for demographic differences, repeated measures of analysis of covariance showed a main effect of smoking status for MPI affective distress (P = 0.008), CES-D (P = 0.001) and PCS (P = 0.011). An interaction of smoking status and time was found for the PASS-20 (P = 0.028), MPI affective distress (P = 0.033), MPI life control (P = 0.003) and SF-36 role-emotional (P = 0.004) subscale. While the majority of smokers were ready to consider smoking abstinence, 43% declined a brief smoking cessation intervention., Conclusions: In this series of patients undergoing multidisciplinary treatment for chronic pain, immediate treatment effects for a variety of outcome measures were similar or significantly better in smokers compared with nonsmokers.

Objective: Vitamin D inadequacy is associated with medication refractory musculoskeletal pain and neuromuscular dysfunction. This vitamin deficiency could subsist as an unrecognized comorbid condition among patients with chronic pain. The primary objective of this study was to determine the prevalence and clinical correlates of vitamin D inadequacy in patients seeking treatment for chronic pain., Design: Retrospective case series., Setting: Multidisciplinary pain rehabilitation center at a tertiary referral medical center., Patients: The study involved 267 chronic pain patients admitted from February to December 2006., Intervention: Serum 25-hydroxyvitamin D (25[OH]D) was drawn at admission., Outcome Measures: Patients with serum 25[OH]D levels < or=20 ng/mL were considered to have inadequate levels and those with levels >20 ng/mL were considered to have adequate levels. Upon admission, opioid intake was documented and patients completed the Short Form-36 Health Status Questionnaire., Results: The prevalence of vitamin D inadequacy was 26% (95% confidence interval, 20.6-31.1%). Among patients using opioids, the mean morphine equivalent dose for the inadequate vitamin D group was 133.5 mg/day compared with 70.0 mg/day for the adequate group (P = 0.001). The mean duration of opioid use for the inadequate and adequate groups were 71.1 months and 43.8 months, respectively (P = 0.023). Opioid users with inadequate levels reported worse physical functioning (P = 0.041) and health perception (P = 0.003) than opioid users with adequate levels., Conclusion: The prevalence and clinical correlates identified in this pilot study provide the basis for the assertion that vitamin D inadequacy may represent an under-recognized source of nociception and impaired neuromuscular functioning among patients with chronic pain.

Objective: This study was conducted to test the hypothesis that gender differences in physical and emotional functioning are present among patients with fibromyalgia undergoing multidisciplinary pain rehabilitation., Design: Retrospective case-matched series. Setting. Multidisciplinary pain rehabilitation center at a tertiary referral medical center., Patients: Thirty-three consecutive men with fibromyalgia admitted from January 2002 through June 2005 were matched to 33 women with fibromyalgia for age, treatment dates, and program completion status. Interventions. A 3-week outpatient multidisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates analgesic medication withdrawal., Outcome Measures: Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Coping Strategies Questionnaire-Catastrophizing subscale (CSQ-C), and the Center for Epidemiologic Studies-Depression scale (CES-D) were administered before and after treatment. The numbers of patients using opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines before and after treatment were compared., Results: Pretreatment MPI and SF-36 scores revealed men had lower health perception (P = 0.017) and more physical limitations (P = 0.004) while women had greater life interference due to pain (P = 0.005). Mean differences in all pre- and post-treatment outcome measures demonstrated a statistically significant treatment response. However, men had lower post-treatment scores on the SF-36 health perception (P = 0.023), role limitations-physical (P = 0.021), and social functioning (P = 0.033) subscales. Significant within-gender reductions in opioid analgesic, NSAID, and benzodiazepine use were observed but no significant between-gender differences were identified., Conclusions: These results support the hypothesis that pretreatment gender differences are present among fibromyalgia patients undergoing multidisciplinary pain rehabilitation and post-treatment gender differences persist despite improvements in physical and emotional functioning.

Objective: This study of patients with a diagnosis of fibromyalgia (FM) was conducted to test the hypothesis that immediate posttreatment measures of psychosocial functioning, health attributes, negative pain-related emotions, and depressive symptoms improve significantly during multidisciplinary pain rehabilitation while concurrently withdrawing analgesic medications., Design: Prospective case series., Setting: Multidisciplinary pain rehabilitation center at a tertiary referral medical center., Patients: In total, 159 consecutive patients with a diagnosis of FM admitted to the pain rehabilitation program from January 2002 to December 2003., Interventions: A 3-week outpatient multidisciplinary pain rehabilitation program based on a cognitive-behavioral model that incorporates analgesic medication withdrawal., Outcome Measures: Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Coping Strategies Questionnaire-Catastrophizing subscale (CSQ-C), and the Center for Epidemiologic Studies-Depression scale (CES-D) were administered at admission and dismissal and the mean differences in scores were compared using paired t-tests. The number of patients using opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, and muscle relaxants at admission and dismissal were compared using chi-squared analyses., Results: The difference in admission and dismissal scores from the MPI, SF-36, CSQ-C, and CES-D demonstrated a favorable response to treatment (P < 0.001). Compared with admission, the number of patients using opioids (P < 0.001), NSAIDs (P < 0.001), benzodiazepines (P < 0.001), and muscle relaxants (P < 0.01) at program dismissal was significantly reduced., Conclusion: The results of this study support the hypothesis that immediate posttreatment measures of physical and emotional functioning are favorable for patients with FM following multidisciplinary pain rehabilitation that incorporates withdrawal of analgesic medications.