Pain and Addiction: Assessment Issues

1
Pain and Addiction Assessment Issues

• Russell K. Portenoy, MD
• Chairman, Dept of Pain Medicine and Palliative
  Care
• Beth Israel Medical Center
• New York, NY

2
Pain and Addiction Assessment Issues

• Prevalence of chronic pain
• Populations with chronic pain and the importance
  of assessment
• Assessing the risk of substance abuse
• Elements of the comprehensive assessment

3
Pain and Addiction Assessment Issues

• Prevalence of chronic pain
• 2-40 in a review of 15 population-based surveys
  (Verhaak et al 1998)
• 22 in a WHO survey of 25,916 primary care
  patients (Gureje et al 1998)

4
Pain and Addiction Assessment Issues

• Telephone survey of community-dwelling adults in
  the U.S (Portenoy et al, in press)
• Nationally representative sample 454 Caucasians,
  447 African Americans and 434 Hispanics
• Prevalence of chronic pain 35 Caucasians, 39
  African Americans, and 28 Hispanics
• Overall prevalence of disabling pain 35.8

5
Pain and Addiction Assessment Issues

• Moderate to severe pain in the cancer population
• 1/3 of those with solid tumors during the period
  of active antineoplastic treatment
• 3/4 of those with advanced disease

6
Pain and Addiction Assessment Issues

• Challenges in pain management
• Heterogeneous disorders
• Headache Low back pain
• Neck pain Arthridites
• Polyneuropathy CRPS
• Central pain Myofascial pain
• Somatoform Fibromyalgia
• disorders Interstitial cystitis

7
Pain and Addiction Assessment Issues

• Challenges in pain management
• Heterogeneous pain-related outcomes
• Physical
• Psychosocial
• Role functioning
• Family impact
• Economic impact

8
Pain and Addiction Assessment Issues

• Challenges in pain management
• Heterogeneous factors influencing pain experience
  and related outcomes
• Personality
• Adaptation/coping
• Family response
• Past history
• Comorbidities

9
Pain and Addiction Assessment Issues

• Challenges in pain management
• Heterogeneous comorbidities
• Physical/medical
• Psychiatric/psychosocial

10
Pain and Disability

• Nociceptive
• Pain impact
• Psychosocial factors
• Physical/medical
• comorbidities
• Neuropathic Psychological Psychiatric/psycho
  -
• mechanisms processes social comorbidities
• Family factors

Disability
Pain
Etiologies
11
Pain and Addiction Assessment Issues

• Challenges in pain management
• Heterogeneous treatments
• Pharmacotherapy Rehabilitative
• Psychological Neurostimulatory
• Surgical Anesthesiologic
• CAM Lifestyle changes

12
Pain and Addiction Assessment Issues

• Implications of heterogeneity
• Few treatment standards
• Limited evidence - can guide therapy but does not
  capture complexity of practice
• Comprehensive assessment is the foundation for
  selection and implementation of treatments

13
Pain and Addiction Assessment Issues

• Example Long-term opioid therapy
• Evolving clinical use
• Consensus for use only in moderate-severe chronic
  pain due to cancer or AIDS, or life threatening
  illness
• Expanding role in chronic noncancer pain,
  including populations with known histories of
  addiction

14
Pain and Addiction Assessment Issues

• Now may consider opioids for all with severe
  pain, but weigh the following
• What is conventional practice?
• Are opioids likely to work well?
• Are there alternatives with evidence of equal or
  better outcomes?
• Is the risk of toxicity increased?
• What is the likelihood of responsible drug use
  over time?

15
Pain and Addiction Assessment Issues

• Optimal opioid use requires assessment in all
  populations
• Must include evaluation of risk associated with
  misuse, abuse, addiction, diversion

16
Pain and Addiction Assessment Issues

• Challenges in predicting drug-related problems
  during opioid therapy for pain
• What is being predicted?
• What is the outcome worth predicting?
• Are predictive variables the same across
  populations?

17
Pain and Addiction Assessment Issues

• Factors identified by clinicians as potential
  predictors of substance abuse (Jovey 2002)
• Past history of drug abuse
• History of personality disorder associated with
  poor symptom control
• History of amplifying symptoms
• History of physical/sexual abuse

18
Pain and Addiction Assessment Issues

• Factors identified by clinicians as potential
  predictors of substance abuse (Jovey 2002)
• History of using drugs to cope with stress
• History of severe depressive or anxiety disorder
• Regular contact with high risk people or high
  risk environments
• Current chaotic living environment
• History of criminal activity

19
Pain and Addiction Assessment Issues

• Factors identified by clinicians as potential
  predictors of substance abuse (Jovey 2002)
• Prior admission to drug rehabilitation
• Prior failed treatment at a pain management
  program
• Heavy tobacco use
• Heavy alcohol use

20
Pain and Addiction Assessment Issues

• Factors identified by clinicians as potential
  predictors of substance abuse (Jovey 2002)
• Many automobile accidents
• Family history of severe depressive or anxiety
  disorder
• Family history of drug abuse

21
Pain and Addiction Assessment Issues

• CAGE-AID screening tool (Brown Rounds 1995)
• Tried to Cut down or Change your pattern of
  drinking or drug use?
• Been Annoyed or Angry by others concern about
  your drinking or drug use?
• Felt Guilty about the consequences of your
  drinking or drug use?
• Had a drink or used a drug in the morning
  (Eye-opener) to decrease hangover or withdrawal
  symptoms?

22
Pain and Addiction Assessment Issues

• CAGE-AID screening tool
• Screens for ongoing abuse
• Ongoing abuse predicts future abuse
• Two or more positives has sensitivity of 60-95
  and specificity of 40-95 for diagnosing alcohol
  or drug problems

23
Pain and Addiction Assessment Issues

• Screening Instrument For Substance Abuse
  Potential (SISAP) (Coambs et al 1996)
• High sensitivity/low specificity for problems
  during therapy
• Factors associated with increased risk
• Heavy drinking
• Marijuana use last year
• Age

24
Pain and Addiction Assessment Issues

• Factors identified in veterans in a pain program
  as predictive of opioid abuse (Chabal et al 1997)
• focus on opioids during clinic visits
• pattern of early refills or dose escalation
• multiple telephone calls or visits pertaining to
  opioid therapy
• other prescription problems
• obtaining opioids from other sources

25
Pain and Addiction Assessment Issues

• Factors identified in a pain clinic population as
  predictive of substance use disorder (Compton et
  al 1998)
• tendency to increase the dose
• preference for a specific route of administration
• considering oneself addicted.

26
Pain and Addiction Assessment Issues

• Screening Tool for Addiction Risk (STAR) (Li et
  al 2001)
• Factors distinguishing pain patients with history
  of substance abuse from others
• prior treatment in a drug rehabilitation facility
• nicotine use
• feeling of excessive nicotine use

27
Pain and Addiction Assessment Issues

• Predicting drug-related problems during opioid
  therapy current status
• Several questionnaires available and several
  others in development
• Varied predictor variables
• Variably predict aberrant drug-related behavior
  or substance use disorders

28
Pain and Addiction Assessment Issues

• Existing studies do not adequately clarify
• What should be predicted?
• What are the best predictor variables?
• Can screening be done in a clinically feasible
  manner?
• Are the predictors generalizable across pain
  populations?

29
Pain and Addiction Assessment Issues

• What to do?
• Must assess risk even in the lack of conclusive
  information
• Substance use history is essential nature of
  prior and current history of drug abuse likely to
  be important
• Other important factors (?) major psychiatric
  pathology, age, family history

30
Pain and Addiction Assessment Issues

• What to do?
• Based on this clinical assessment, categorize
  patient in terms of risk of problematic
  drug-related behavior
• Categories of high, medium, and low can
  guide the structure of therapy
• Integrate this evaluation routinely into the pain
  assessment

31
Pain and Addiction Assessment Issues

• Process of assessment
• Collect the data
• Integrate the findings
• Develop the therapeutic strategy

32
Pain and Addiction Assessment Issues

• Integrate the findings
• Pain diagnoses
• Etiology
• Pathophysiology
• Syndrome
• Impact of the pain
• Relevant comorbidities

33
Pain and Addiction Assessment Issues

• Develop a therapeutic strategy for pain and its
  comorbidities
• Primary treatment for underlying etiology, if
  appropriate
• Symptomatic therapies

34
Pain and Addiction Assessment Issues

• Symptomatic therapy
• Pharmacotherapy Rehabilitative
• Psychological Neurostimulatory
• Surgical Anesthesiologic
• CAM Lifestyle changes