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Inpatient vs outpatient treatment
[Williams et al. 1996, 1999]
From the start of the unit for several years, patients who agreed to be
randomised to inpatient or outpatient treatment were entered into a trial
comparing those treatments with one another and with no treatment while
waiting for admission (for 3 months only). While both groups benefitted
on all measures taken at one month, over 6 and 12 months those who had
inpatient treatment did better on some measures, particularly those to
do with physical function and with returning to doctors for further treatment.
We subsequently compared those patients who agreed to be randomised with
those who were treated at the same time as inpatient or outpatients but
chose which treatment they had, and the results were much the same. This
was an important demonstration that treatment in general was as good as
in the rather special trial.
Drug reduction
[Ralphs et al.]
Another study examined whether patients who were cut down from their opioid
dose on a cocktail (when they knew they were reducing, but not exactly
which day) did better or worse than those who cut down their tablets by
agreed amounts on specified days. In fact, those who took a cocktail were
more likely to be off all opioids by the time they left four week inpatient
treatment, but more likely to be back on them by follow-up, even though
at a lower dose. So in the longer term, patients managed better if they
were in control of their drug reduction, using a plan drawn up with medical
and nursing staff, and this is what almost all patients now do.
Dropout [Coughlan
et al.]
A few patients drop out of treatment for a variety of reasons, and since
places on the programme are precious, it would help to be able to reduce
this. When we investigated it, we found that three things predicted that
a patient would drop out: a combination of low confidence in being able
to manage despite pain and low current mobility; and being the odd one
out, such as the only one with abdominal pain among a group with back
pain, or the only one under 30 in a group of over-50s. That doesn't mean
that all such patients dropped out, only that they were more likely to
do so. As a result, we tried not to have "odd ones out" in the
groups we admitted, and to offer more support to those with low confidence.
Dropout rate subsequently fell to under 5% of patients admitted.
Return to work [Richardson
et al., Adams & Williams]
One of the questions we are often asked, particularly by doctors, is whether
patients return to work. Of course, that can only apply to those who are
in work or are prevented from being in work because of pain, and there
are many homemakers and retired people among our patients to whom it doesn't
apply. We found that patients who are working when they are admitted do
go back to work and find it easier, while some who were not working start
training, or voluntary or paid work, often on a part-time basis at least
initially. A recent study of patients with upper limb pain ("repetitive
strain injury") showed that those who returned to work were not necessarily
fitter or in less pain than those who didn't, but they were more optimistic
about support available from work colleagues, managers, and Department
of Employment resources, and had often had better experience of such support
before they came to INPUT than those who were rather pessimistic about
the help and understanding they would receive at work. This latter study
was funded by the South Thames NHS Executive R&D Directorate.
References
Williams
ACdeC, Richardson PH, Nicholas MK, Pither CE, Harding VR, Ridout KL, Ralphs
JA, Richardson IH, Justins DM, Chamberlain JH (1996). Inpatient vs. outpatient
pain management: results of a randomised controlled trial. Pain 66 13-22.
Williams ACdeC, Nicholas MK, Richardson PH, Pither CE, Fernandes J (1999)
Generalizing from a controlled trial: the effects of patient preference
versus randomization on the outcome of inpatient versus outpatient chronic
pain management. Pain 83, 57-65.
Ralphs JA, Williams ACdeC, Richardson PH, Pither
CE, Nicholas MK (1994). Opiate reduction in chronic pain patients: a comparison
of patient-controlled reduction and staff controlled cocktail methods.
Pain 56 279-288.
Coughlan GM, Ridout KL, Williams ACdeC, Richardson
PH (1995). Attrition from a pain management programme. British Journal
of Clinical Psychology 34 471-479.
Richardson IH, Richardson PH, Williams ACdeC,
Featherstone J, Harding VR (1994). The effects of a cognitive-behavioural
pain management programme on the quality of work and employment status
of severely impaired chronic pain patients. Disability and Rehabilitation
16, 26-34.
Adams JH, Williams ACdeC (2003). What affects return to work for graduates
of a pain management programme with chronic upper limb pain? Journal of
Occupational Rehabilitation 13: 91-106.
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