Numerous studies have demonstrated the efficacy of an interdisciplinary approach in the treatment of patients with intractable chronic pain and functional impairment. This approach addresses multiple pathologies in this population, and thus incorporates medical, psychological, physical and occupational rehabilitation.1-6 Opioids and benzodiazepines are widely used in patients with chronic pain and may cause significant undesired effects. It has been suggested that they may not only impair overall functioning but also lead to impaired concentration. These impairments can be further exacerbated by the individual\'s emotional state.7-13 Individuals with chronic pain often experience depression that isolates and further debilitates them.1, 14 Given the extensive affective modulation produced by opioids and benzodiazepines, it is important to determine their contributions to the patient’s function and dysfunction, and to distinguish this from the effects of mood disorder. It was hypothesized that CPRP treatment would lead to improved cognition, and that this benefit would be primarily in those in whom benzodiazepines and opioids were eliminated. Numerous studies have demonstrated the efficacy of an interdisciplinary approach in the treatment of patients with intractable chronic pain and functional impairment. This approach addresses multiple pathologies in this population, and thus incorporates medical, psychological, physical and occupational rehabilitation.1-6 Opioids and benzodiazepines are widely used in patients with chronic pain and may cause significant undesired effects. It has been suggested that they may not only impair overall functioning but also lead to impaired concentration. These impairments can be further exacerbated by the individual\'s emotional state.7-13 Individuals with chronic pain often experience depression that isolates and further debilitates them.1, 14 Given the extensive affective modulation produced by opioids and benzodiazepines, it is important to determine their contributions to the patient’s function and dysfunction, and to distinguish this from the effects of mood disorder. It was hypothesized that CPRP treatment would lead to improved cognition, and that this benefit would be primarily in those in whom benzodiazepines and opioids were eliminated.

1. Effects of the withdrawal of opioids and benzodiazepines on cognitive functioning in the context of an interdisciplinary chronic
pain rehabilitation program
Daniel Fishman MA Judith Scheman PhD Edward Covington MD
Neurological Center for Pain, Cleveland Clinic Foundation
Hierarchical Linear Regression continued ment. However, no significant difference was observed be-
Measures: Study information was collected upon admission to and Mixed 2-way ANOVA
Introduction discharge from CPRP. tween groups dummy coded for admission opioid and ben-
Multiple Regression Analysis for ΔDSST by AMS, ΔPDI, ΔPI and ΔBDI
15-17 Treatment Effects on DS & DSST
zodiazepine status. Recall that the patient’s admission medi-
Numerous studies have demonstrated the efficacy of an in- Mood: Assessed with the Beck Depression Inventory – II (BDI-II). (within subjects Mixed 2-way ANOVA) Independent Variable B Std. Error Beta t p

cation status was dummy coded to represent neither opioids
terdisciplinary approach in the treatment of patients with in- 10.27 10.02 AMS -0.34 0.218 -0.122 -1.565 0.120
Cognitive Functioning: Assessed with Digit Span (DS) and Digit Sym- 9.77 
or benzodiazepine, opioids alone, benzodiazepines alone, or
tractable chronic pain and functional impairment. This ap- bol Substitution Test (DSST). 10, 18
8.75

ΔPDI -0.015 0.017 -0.082 -0.884 0.378
proach addresses multiple pathologies in this population, 
both classes of medication. Thus the lack of difference be-
0.12 0.109 0.098 1.103 0.272
and thus incorporates medical, psychological, physical and Pain Intensity (PI): Assessed via self-report on a 10 point Likert scale,
ΔPI
tween these groups in cognitive improvement strongly sug-
1-6 -0.077* 0.025 -0.257* -3.014 0.003
occupational rehabilitation. Opioids and benzodiazepines with 0 representing no pain and 10 representing the worst pain im- ΔBDI gests that these medications were not a significant cause of
are widely used in patients with chronic pain and may cause aginable.
pre-treatment cognitive impairment.
significant undesired effects. It has been suggested that they Digit Span Scaled Score
Admission
Digit Symbol Substitution Scaled Score
Discharge *Error bars represent standard error of the mean (SEM)
R2 = 0.078; F(1,159) = 9.014 p=0.003
may not only impair overall functioning but also lead to im- Pain Related Functioning: Assessed with the Pain Disability Index
(PDI) which measures functional impairment secondary to pain
paired concentration. These impairments can be further ex-  Digit symbol substitution scaled score improvement was remarkably more pronounced Correlation Matrix and Descriptive Statistics for AMS, ΔPDI, ΔPI, ΔBDI and ΔDSST Hierarchical Linear Regression Modeling (HLRM): The HLRM
7-13 within 7 domains of daily living. Total scores range from 0 (no func- -58
than was digit symbol (F = 496.22, p = 4.31x10 vs F = 6.48, p = 0.012).
acerbated by the individual's emotional state. Individuals tional impairment) to 70 (total impairment). 19, 20 ΔDSST AMS ΔPDI ΔPI ΔBDI
analyses demonstrate that mood change (ΔBDI) does predict
with chronic pain often experience depression that isolates  The use/discontinuation of opioids and benzodiazepines was not significantly associated
ΔDSST
AMS
1.000
-0.065 1.000 cognitive improvement (ΔDSST)
1, 14
and further debilitates them. Given the extensive affec- with cognitive improvement. ΔPDI -0.127 -0.005 1.000
tive modulation produced by opioids and benzodiazepines, it Analyses ΔPI
ΔBDI
-0.006
-0.235
-0.027
-0.233
0.513
0.373
1.000
0.251 1.000
is important to determine their contributions to the patient’s Admission medication status (AMS) was dummy coded to reflect
 Within-subjects contrast analysis demonstrated little crossover between treatment and
Mean 1.17 2.09 -27.70 -2.70 -13.78
We, therefore, conclude that cognitive inefficiencies
AMS (DS*AMS: F = 0.77, p = 0.51; DSST*AMS: F = 0.44, p = 0.72).
function and dysfunction, and to distinguish this from the Standard Deviation 3.00 1.08 16.19 2.44 9.95
seen in chronic pain patients may be less a conse-
presence of opioids, benzodiazepines, neither, or both.
effects of mood disorder. It was hypothesized that CPRP
Hierarchical Linear Regression Note: N = 166. ΔDSST is the dependent variable. The correlation between ΔBDI and ΔDSST is
quence of sedating drugs than of comorbid mood
treatment would lead to improved cognition, and that this significant at p =0.001. No other correlations were found to be statistically significant
Paired samples t-tests were used to compare admission and dis-
benefit would be primarily in those in whom benzodiaze- Correlation Matrix and Descriptive Statistics for AMS, ΔPDI, ΔPI, ΔBDI and ΔDS  disorder.
charge scores of pain (PI), mood (BDI), and functioning (PDI).
pines and opioids were eliminated. ΔDS AMS ΔPDI ΔPI ΔBDI
 The overall model generated with AMS, ΔBDI, ΔPDI, & ΔPI as IVs predicting ΔDSST was
ΔDS 1.000
found to account for 7.8% of the variance in ΔDSST (R2 = 0.078; F(1,159) = 9.014
Mixed 2-way ANOVA analysis was employed to
AMS -0.117 1.000
p=0.003). References
Objective 1. compare pre- and post-treatment scores for DS and DSST
ΔPDI
ΔPI
0.067
-0.039
-0.004
-0.026
1.000
0.509 1.000
 Mood (ΔBDI) was found to have a statistically significant, indirect relationship with
ΔBDI -0.076 -0.235 0.388 0.270 1.000
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
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*Error bars represent standard error of the mean (SEM)
shown to be more sensitive to change resulting from treat-