***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Hydromorphone hydrochloride is a mu-opioid agonist with dose-dependent analgesic properties . Extended-release hydromorphone hydrochloride ( ER hydromorphone HCl ) capsules have been developed for administration every 24 hours . OBJECTIVES This prospect i ve evaluation focused on the first ( ie , conversion ) phase of 2 identically design ed , r and omized , controlled studies that compared the safety and efficacy of once-daily ER hydromorphone HCl capsules with immediate-release hydromorphone hydrochloride ( IR hydromorphone HCl ) tablets administered 4 times daily in the treatment of persistent moderate to severe cancer- and noncancer-related pain . METHODS Patients being treated with opioid analgesics for persistent moderate to severe pain were converted to ER hydromorphone HCl using an 8:1 conversion ratio . The dose was titrated to attain an average pain intensity ( API ) score < or = 4 on a 0- to 10-point numeric rating scale . Supplemental oral IR hydromorphone HCl tablets were used as rescue medication at a dose of one eighth to one sixth of the daily ER hydromorphone HCl dose . RESULTS A total of 343 patients ( 272 [ 79 % ] with cancer pain ; mean age , 57.8 years ) were enrolled and converted to ER hydromorphone HCl from their previous opioids . About half ( 51 % ) were women . At baseline , the mean ( SD ) API score  was 5.3 ( 2.1 ) . Mean ( SD ) API scores were 4.7 ( 2.0 ) after the first 48 hours and 3.4 ( 2.1 ) by the end of titration . After 4 to 21 days of titration , 239 ( 70 % ) patients reached stabilization defined as a > or = 48-hour period with an API score of < or = 4 , unchanged ER hydromorphone HCl dose , and < or = 2 rescue doses per day . The stabilized patients had mean ( SD ) API scores of 2.7 ( 1.1 ) at the end of titration . At stabilization , 102 ( 43 % ) of 239 patients remained at their initial conversion dose , 129 ( 54 % ) had a dose increase , and 8 ( 3 % ) had a dose decrease . Frequent ( > or = 10 % of patients ) adverse events that occurred within the first 48 hours after conversion and during the entire titration phase were nausea , somnolence , headache , constipation , vomiting , and dizziness . CONCLUSION In this prospect i ve evaluation of the conversion and titration phase of 2 r and omized , controlled studies , a conversion ratio of 8:1 mg of oral morphine to oral ER hydromorphone HCl was found to be clinical ly useful in patients with persistent moderate to severe cancer-related or noncancer-related pain Pain complaints are common among individuals with opioid dependence . However , few studies investigate pain during opioid detoxification or the impact this pain has on continued opioid use . This secondary analysis utilized data from two Clinical Trials Network r and omized controlled trials of buprenorphine-naloxone for short-term opioid detoxification to examine the extent to which pain was associated with continued opioid use during and immediately following a 13-day detoxification protocol . At follow-up , more severe pain was associated with a greater number of self-reported days of opioid use during the prior 30 days ( p < .05 ) but was not associated with urine toxicology results collected at follow-up . These results , although mixed , have potentially important clinical implication s for assessing and addressing pain during opioid detoxification . Pain that is experienced during and immediately following medically monitored detoxification may be associated with continued opioid use . These findings lend further support for continued research on pain among patients with opioid dependence UNLABELLED Opioid-experienced ( N = 250 ) patients with chronic , moderate to severe low back pain ( LBP ) were converted from their pre study opioid(s ) to an approximately equianalgesic dose of OPANA ER ( oxymorphone extended release ) . Patients continued slow titration , with 56 % stabilized within 1 month to a dose of OPANA ER that reduced average pain to < 40 mm on a visual analog scale with good tolerability . Stabilized patients ( n = 143 ) were r and omized to placebo or their stabilized dose of OPANA ER every 12 hours for a 12-week double-blind period . Pain intensity increased significantly more for patients r and omized to placebo than for patients who continued their stabilized dose of OPANA ER ; the increase from baseline ( at r and omization ) to final visit was 31.6 mm for placebo versus 8.7 mm with OPANA ER ( P < .0001 ) . During double-blind treatment , placebo patients were approximately 8-fold more likely than OPANA ER patients to discontinue because of lack of efficacy ( P < .001 ) . Discontinuations as a result of adverse events were similar between groups , 10 % with placebo and 11 % with OPANA ER . Opioid-related adverse events included constipation ( 6 % ) , somnolence ( 3 % ) , and nausea ( 3 % ) . Fifty-seven percent of opioid-experienced patients with chronic , moderate to severe LBP achieved a stable dose of OPANA ER that was efficacious and generally well-tolerated for up to 12 weeks . PERSPECTIVE In a 12-week , double-blind , r and omized , placebo-controlled trial in opioid-experienced patients with chronic , moderate to severe LBP , OPANA ER provided efficacious , long-term analgesia and was generally well-tolerated . OPANA ER may provide clinicians with a new treatment option for patients experiencing suboptimal analgesic responses or poor tolerability with other opioids Chronic migraine ( CM ) patients frequently overuse symptomatic medications ( SM ) . These medications may create a cycle of rebound , worsening of headache and withdrawal symptoms that perpetuate the headache itself . In addition , the overuse of such substances is believed to counteract the efficacy of preventive treatments . We conducted a prospect i ve r and omized open-label trial comparing approaches to out-patient management in 150 CM patients ( 125 women , 25 men ; ages 18 - 80 years , mean 40.3 ± 13.8 ) with overuse of SM . In each group , 50 patients received education and orientation and were then abruptly withdrawn from all SM . Immediately following withdrawal , the first group took prednisone ( 60 mg/day 2 days , 40 mg/day 2 days and 20 mg/day 2 days ) for 6 days , the second group did not have any regular medications to take and the third group took naratriptan ( 2.5 mg twice a day ) during this initial period . All patients had similar profiles of headache characteristics and consumption ( quality and quantity ) of SM before initiation of the treatment , but most were not severe headache sufferers , heavy SM overusers or were overusing opioids . After 5 weeks the headache frequency and intensity , the prevalence and frequency of withdrawal symptoms and consumption of rescue medications during the first 6 days were compared between groups . In addition , adherence to treatment ( who returned or not and for which reasons , between groups ) and headache frequency , week by week , among the groups of patients were also compared . Forty-four ( 88 % ) patients from the prednisone group , 41 ( 82 % ) from the ‘ nothing ’ group and 35 ( 70 % ) from the naratriptan group adhered to the treatment and returned . The were no differences between groups with regard to treatment adherence ( P = 0.072 ) , headache frequency as well as intensity ( P = 0.311 ) and decreasing of days with headache after 5 weeks and weekly ( P = 0.275 ) . However , the incidence of withdrawal symptoms and consumption of rescue drugs was higher among the patients who did not take regular medications during the first 6 days ( P = 0.0001 and P = 0.006 ) . We concluded that CM patients with moderate overuse of SM other than opioids may be detoxified on an out-patient basis regardless of the strategy adopted with regard to the use of regular drugs during the initial days of withdrawal , but prednisone and naratriptan may be useful for reducing withdrawal symptoms and rescue medication consumption . Further controlled studies are necessary to confirm these observations & NA ; Chronic pain patients who show aberrant drug‐related behavior often are discontinued from treatment when they are noncompliant with their use of opioids for pain . The purpose of this study was to conduct a r and omized trial in patients who were prescribed opioids for noncancer back pain and who showed risk potential for or demonstration of opioid misuse to see if close monitoring and cognitive behavioral substance misuse counseling could increase overall compliance with opioids . Forty‐two patients meeting criteria for high‐risk for opioid misuse were r and omized to either st and ard control ( High‐Risk Control ; N = 21 ) or experimental compliance treatment consisting of monthly urine screens , compliance checklists , and individual and group motivational counseling ( High‐Risk Experimental ; N = 21 ) . Twenty patients who met criteria indicating low potential for misuse were recruited to a low‐risk control group ( Low‐Risk Control ) . Patients were followed for 6 months and completed pre‐ and post‐ study question naires and monthly electronic diaries . Outcomes consisted of the percent with a positive Drug Misuse Index ( DMI ) , which was a composite score of self‐reported drug misuse ( Prescription Drug Use Question naire ) , physician‐reported abuse behavior ( Addiction Behavior Checklist ) , and abnormal urine toxicology results . Significant differences were found between groups with 73.7 % of the High‐Risk Control patients demonstrating positive scores on the DMI compared with 26.3 % from the High‐Risk Experimental group and 25.0 % from the Low‐Risk Controls ( p < 0.05 ) . The results of this study demonstrate support for the benefits of a brief behavioral intervention in the management of opioid compliance among chronic back pain patient at high‐risk for prescription opioid misuse UNLABELLED This paper examines whether a telephone-based , automated maintenance enhancement program can help to reduce opioid and nonsteroidal anti-inflamatory drugs ( NSAID ) analgesic use in patients with chronic pain . Following 11 weeks of group cognitive-behavioral therapy ( CBT ) , 51 subjects with chronic musculoskeletal pain were r and omized to 1 of 2 study groups . Twenty-six subjects participated in 4 months of a Therapeutic Interactive Voice Response ( TIVR ) program in addition to st and ard follow-up care , while a control group of 25 subjects received st and ard follow-up care only . TIVR is an automated , telephone-based tool developed for the maintenance and enhancement of CBT skills . Opioid analgesic use decreased in the experimental group in both follow-ups : 4 and 8 months postCBT . In addition , at 8-month follow-up , 21 % of the TIVR subjects had discontinued the use of opioid analgesics , 23 % had discontinued NSAIDS , and 10 % had discontinued antidepressant medications . In contrast , the control group showed increases in opioid and NSAIDS use . Analysis of covariance ( ANCOVA ) revealed significant between-group differences in opioid analgesic use at 8-month follow up ( P = .004 ) . We have previously demonstrated the efficacy of TIVR to decrease pain and improve coping ; this analysis demonstrates that the use of TIVR may also result in concurrent reductions in opioid analgesic and NSAID medications use . PERSPECTIVE This article demonstrates that the Therapeutic Interactive Voice Response maintenance enhancement program can help to reduce opioid analgesic use in patients with chronic pain . This automated maintenance enhancement program could potentially assist patients not only to decrease pain and improve coping , but also to diminish the likelihood of opioid dependence & NA ; We developed Therapeutic Interactive Voice Response ( TIVR ) as an automated , telephone‐based tool for maintenance enhancement following group cognitive – behavioral therapy ( CBT ) for chronic pain . TIVR has four components : a daily self‐monitoring question naire , a didactic review of coping skills , pre‐recorded behavioral rehearsals of coping skills , and monthly personalized feedback messages from the CBT therapist based on a review of the patient ’s daily reports . The first three components are pre‐recorded and all four can be accessed remotely by patients via touch‐tone telephone on dem and . Following 11 weeks of group CBT , 51 subjects with chronic musculoskeletal pain were r and omized to one of two study groups . Twenty‐six subjects participated in 4 months of TIVR , while a control group of 25 subjects received st and ard care only . The TIVR group showed maximum improvement over baseline at the 8‐month follow‐up for seven of the eight outcome measures ; improvement was found to be significant for all outcomes ( p ⩽ .001 ) . Between‐group analysis of covariance ( ANCOVA ) revealed significantly greater improvement for the experimental group at both 4‐ and 8‐month follow‐ups for most of the outcomes . Results demonstrate that TIVR can be used to decrease pain , improve coping and decrease likelihood of relapse into pain behavior . Preliminary analysis of medication usage suggests that the superior outcome of the TIVR group was unlikely to be a consequence of differential medication use For many of us working in the field of pain medicine , 2003 represented a turning point . For a decade a more liberal approach to opioid prescribing , supported in part by a steady stream of short-term , r and omised controlled trials and facil 
    Output:
    
The studies included acupuncture , mindfulness , and cognitive behavioral therapy interventions aim ed at reducing opioid consumption , misuse of opioids , or maintenance of chronic pain management treatments .
We also found mixed findings for pain intensity and physical functioning .
The interventions did not show between-group differences for psychological functioning across all studies .
There is no evidence for the efficacy or safety of methods for reducing prescribed opioid use in chronic pain .
There is a small number of r and omised controlled trials investigating opioid reduction , which means our conclusions are limited regarding the benefit of psychological , pharmacological , or other types of interventions for people with chronic pain trying to reduce their opioid consumption .
The findings to date are mixed : there were reductions in opioid consumption after intervention , and often in control groups too