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Pain and Addiction: Assessment Issues. Russell K. Portenoy, MD Chairman, Dept of Pain Medicine and Palliative Care Beth Israel Medical Center New York, NY. Pain and Addiction: Assessment Issues. Prevalence of chronic pain Populations with chronic pain and the importance of assessment

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Pain and Addiction: Assessment Issues

Russell K. Portenoy, MD

Chairman, Dept of Pain Medicine and Palliative Care

Beth Israel Medical Center

New York, NY


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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


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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)


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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%


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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


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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


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Pain and Addiction: Assessment Issues

  • Challenges in pain management

    • Heterogeneous pain-related outcomes

      • Physical

      • Psychosocial

      • Role functioning

      • Family impact

      • Economic impact


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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


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Pain and Addiction: Assessment Issues

  • Challenges in pain management

    • Heterogeneous comorbidities

      • Physical/medical

      • Psychiatric/psychosocial


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Pain and Disability

Nociceptive

Pain impact

Psychosocial factors

Physical/medical

comorbidities

Neuropathic Psychological Psychiatric/psycho-

mechanisms processes social comorbidities

Family factors

Disability

Pain

Etiologies


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Pain and Addiction: Assessment Issues

  • Challenges in pain management

    • Heterogeneous treatments

      Pharmacotherapy Rehabilitative

      Psychological Neurostimulatory

      Surgical Anesthesiologic

      CAM Lifestyle changes


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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


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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


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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?


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Pain and Addiction: Assessment Issues

  • Optimal opioid use requires assessment in all populations

    • Must include evaluation of risk associated with misuse, abuse, addiction, diversion


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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?


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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


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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


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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


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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


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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?


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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


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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


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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


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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.


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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


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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


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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?


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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


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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


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Pain and Addiction: Assessment Issues

  • Process of assessment

    • Collect the data

    • Integrate the findings

    • Develop the therapeutic strategy


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Pain and Addiction: Assessment Issues

  • Integrate the findings

    • Pain diagnoses

      • Etiology

      • Pathophysiology

      • Syndrome

    • Impact of the pain

    • Relevant comorbidities


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Pain and Addiction: Assessment Issues

  • Develop a therapeutic strategy for pain and its comorbidities

    • Primary treatment for underlying etiology, if appropriate

    • Symptomatic therapies


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Pain and Addiction: Assessment Issues

  • Symptomatic therapy

    Pharmacotherapy Rehabilitative

    Psychological Neurostimulatory

    Surgical Anesthesiologic

    CAM Lifestyle changes


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