Pain Program Dropouts: Risk Factors Identified – Medscape.com – Fran Lowry – March 13, 2019
Cleveland Clinic’s low back pain program, called Back on TREK, is a 10- to 12-week program that includes psychological and physical therapy sessions.
“Typically, the patient requirement is about 3 to 4 hours a week in two to three sessions in both group and individual sessions. We try to make it easy for patients,” said Mijatovic.
Despite the team’s best efforts, the dropout rate for the 12-week program was 58% of about 200 participants.
Many patients with EDS have been abused by the Cleveland Clinic, which tends to discount invisible chronic pain, so I’m not at all surprised that more than half drop out.
For the study, the researchers reviewed data on 217 patients (mean age, 48 years; 65% women) enrolled in the interdisciplinary pain program from August 2016 to December 2018. All patients were interviewed by the program’s pain psychologist.
My impression of these “pain programs” is that they work hard to convince patients that their pain can be managed with mental tricks and denial instead of opioids.
The demographic most often associated with early withdrawal was low income. Those with a median household income of $43,000 or more had greater program graduation rates compared to their counterparts with a median household income of $41,651 or less.
In addition, older individuals (median age, 51 years) were more likely to stay in the program than younger individuals (median age, 47 years).
Among those of Hispanic ethnicity, 10.8% (n = 16) graduated from the pain program, and 21.5% (n = 46) did not.
The above is not correct arithmetic under the assumption that there are only two options:
- Hispanics who graduated: 10.8% (n = 16)
- Hispanics who did not: 21.5% (n = 46)
I’m not aware of any other options.
Yet they claim 10.8% graduated and 21.5% didn’t. Where are the other 67.7%?
If 16 Hispanics are about 10% of the total, then the next number, 21.5% of the total, should be about double that, or 32, not 46.
But if a count of 46 is 21.5%, that makes the total about 230, whereas if a count of 16 is 10%, that would make the total about 160.
No matter how I slice it, these contradictory numbers in isolation don’t make sense.
I assume they are part of a larger dataset that might explain these numbers. But in that case, why isn’t the full data explained?
When data is hidden, I suspect it’s because it contradicts some point the researchers are trying to make.
In comparison, among whites, 95 (64.2%) of the participants graduated and 115 (53%) did not.
For whites, the total comes to 117.2%. Plus, how can a smaller percentage, 53% vs 63.2%, arise from a larger number, 115 vs 95?
I also don’t understand why the first statistic is described using percentages first followed by the actual count, and then the second one is described using the count first followed by the percentage.
This seems designed to deliberately confuse the reader, perhaps because it has confused the writer?
Interviews with the program pain psychologist yielded important psychosocial risk factors for dropout. These included
- fear avoidance beliefs,
- depressive reactions,
- excessive attention to physical symptoms,
- use of marijuana containing tetrahydrocannabinol (THC),
- use of opioids, and
- high health care utilization.
These factors clearly indicate people with more severe pain.
And the first thing these programs do is take you off opioids, so your now uncontrolled pain is given free rein.
Constant levels of severe pain will intrude on and repeatedly capture attention because that’s how pain is supposed to work (“excessive attention to physical symptoms“).
This does make people depressed (“depressive reactions“) and makes them go to the doctor over and over again until they get some relief (“high health care utilization“). Eventually, these patients are prescribed opioids when nothing else works – and it often doesn’t (“use of opioids“).
So, all this tortured arithmetic is pointless because the overriding factor determining which people stay in the program (after their opioids are taken away) is the severity of their pain.
By now, it’s clear that these programs only work for people with pain that is less severe and less constant, those who can tolerate their pain after they are given education (information) and training (skills) about how to handle their pain.
When pain is truly unbearable, no amount of information or training can relieve it.
Patients with anxiety and mood disorders had a very high dropout rate. Some 20% of those with anxiety dropped out before graduation and almost 40% of patients with other mood disorders dropped out.
Other factors associated with dropout risk included trouble sleeping due to pain, and substance abuse due to pain. The “high health care utilization patients” included those who believed that either surgery or medications were the best treatment, said Mijatovic.
Kaivalya Deshpande, MD, said the study did a good job in identifying potential barriers to completing such programs.
“These include fear avoidance beliefs, depressive reactions, excessive attention to physical symptoms, use of THC and opioids, and high health care utilization. But these factors will be ubiquitous throughout all participants who may enroll in such programs,” said Desphande, who was not involved with the Cleveland Clinic research.
“The underlying goal of interdisciplinary programs is to target individuals with those risk factors and help them to reframe their reaction to pain while decreasing drug dependence,” he added.
Why is being dependent (not addicted) on a drug considered a problem only with opioids, when we are practically forced to become dependent on others, like blood pressure medication or blood thinners, which we are expected to take for the rest of our lives?
Wow, this is one of the most egregious examples of insanely biased &/or nonsensical “research” I’ve seen in a while, & that is saying a lot. I too tried to make sense of the “statistics” they spew…they don’t even seem to grasp that most basic facts, such as, if they talk about a group, their group percentages need to add up to 100%. If the total is less than that it’s necessary to explain what happened to the others (as you pointed out they did not do with the mystery 67.7% –or whatever number or percentage they left out). If the total is greater than 100%, that also screams for explanation, since it makes zero sense.
And honestly, anything coming out of the Cleveland Clinic has as much chance of being sound science as the crap that comes out of the Oregon chronic pain task farce, or a publication on the safety of vaccines from rabid anti vaxxers, or info on the shape of the Earth from the Flat Earth Society.
I actually attended a multi-week intensive PM program back in the sunny days of 2003…it had an MD, a therapist specializing in chronic pain, PT, OT, etc etc. The MD thought pain should be relived using whatever tools worked: he was willing to try different opioids, dosages, combos with other meds & with “alternative” treatments, etc. It was extraordinarily well-designed to actually attempt to maximize patients’ benefits, functionality, QOL, & minimize pain levels. It was quite beneficial & effective. The parent company closed it abruptly a couple weeks before the end of my program; the best thing I got out of it was the shrink; he moved to private practice. I’d have kept seeing the MD if he wasn’t 3 hours away.
This bunch, however…”The underlying goal of interdisciplinary programs is to target individuals with those risk factors and help them to reframe their reaction to pain while decreasing drug dependence…” Why don’t they just come right out & call it a “Stop the so-called patient from whining & using drugs & force them to deal with (our version of) reality.”
What’s even more criminal is the Cleveland Clinic is absolutely creating a new pool of CPPs as they refuse to adequately treat acute pain, thus vastly increasing the likelihood of the acute pain becoming permanent. They’re creating their own clientele for their “pain management” program. I wish i could believe that all the docs & nurses & administrators of the Cleveland Clinic would get denied any pain meds after surgeries or injuries, but you know that ain’t gonna happen…I’m sure THEIR pain is real & should be treated, unlike any poor schlub of a patient that gets stuck there.
I ran across a paper yesterday with some dubious numbers & conclusions, tho I can’t access the full text. Wondered if you’d seen it…one who claims that pain gets better after stopping opioids* (that was the basic conclusion, tho once again this was announced after admitting earlier that the # wasn’t statistically significant…I was surprised Chou’s name wasn’t on it, as that’s one of his specialties; talking in Results about a correlation (X got sorta-maybe-kinda worse with opioid use) that is NOT statistically significant, then confidently asserting in the Discussion that ‘opioid use causes X.’ Which manages to violate TWO rules of good science: correlation does not imply causation, & you cannot declare that Y causes X when even the correlation is not statistically significant. He commits even worse in his papers, amazingly enough. And he’s one of their Big Guns…they should be embarrassed.
Chou, HERC, Cleveland Clinic – they’re all being sadistic and causing the chronification of their patients’ pain. It’s hard to fathom how they can believe what they’re saying – and of course, their own pain would be so very, very different.
Thanks for that link. I notice it says “Pain intensity after discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation”. Opioids should not have been prescribed for “mild to moderate pain”, yet those of us with serious pain and being thrown I into the same big pile of chronic pain patients.
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