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 <40 and a smoker

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