Pain Program Dropouts: Risk Factors Identified

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.

New Insights

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:

1. Hispanics who graduated: 10.8% (n = 16)
2. 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.

Important Takeaways

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?