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Journal Club. Alcohol, Other Drugs, and Health: Current Evidence May-June 2007. Featured Article. Persistent pain is associated with substance use after detoxification: a prospective cohort analysis Larson MJ, et al. Addiction. 2007;(Online Early Articles):

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Journal Club

Alcohol, Other Drugs, and Health: Current Evidence

May-June 2007

www.aodhealth.org


Featured Article

Persistent pain is associated with

substance use after detoxification:

a prospective cohort analysis

Larson MJ, et al. Addiction. 2007;(Online Early Articles):

doi: 10.1111/j.1360-0443.2007.01759.x.

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Study Objective

To examine whether persistent pain is

associated with…

  • an increased odds of substance use after detoxification

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Study Design

  • This was a secondary analysis of 397 subjects who had participated in a randomized clinical trial.

  • All subjects had been admitted to an urban, residential drug and alcohol detoxification unit and interviewed periodically over 24 months.

  • Researchers assessed pain with the SF-36 Health Survey and substance use with the Addiction Severity Index.

  • Analyses were adjusted for potential confounders.

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Assessing Validity of an Article about Prognosis

  • Are the results valid?

  • What are the results?

  • How can I apply the results to patient care?

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Are the Results Valid?

  • Was the sample representative?

  • Were the subjects sufficiently homogeneous with respect to prognostic risk?

  • Was follow-up sufficiently complete?

  • Were objective and unbiased outcome criteria used?

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Was the sample representative?

  • The sample was a cohort of adults admitted to an urban, residential alcohol and drug detoxification unit.

    • It is unclear how many were referred; 470 of 642 consented to enroll in the randomized trial.

  • Because the primary study evaluated efforts to link patients to primary care after detoxification, patients who already had a primary care provider were excluded.

    • This somewhat limits the representativeness of the sample.

  • Other important exclusions included being pregnant, not being able to list 3 contacts, and not providing consent.

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Were the subjects sufficiently homogeneous with respect to prognostic risk?

  • All patients received standard detoxification services.

  • Randomization occurred after detoxification, indicating that the risk of relapse should have been similar in all subjects.

  • No information was provided on the distribution of pain disorders across the two study arms.

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Was follow-up sufficiently complete?

  • Subjects were assessed every 6 months over 24 months.

  • 69% completed the 24-month interview.

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Were objective and unbiased outcome criteria used?

  • Self-reported outcomes (in the past 30 days) were assessed with the Addiction Severity Index and included...

    • Heavy alcohol use (>3 drinks on at least 1 day or intoxication)

    • Cocaine use

    • Heroin/opioid use

    • Any substance use (i.e., heavy alcohol use or illicit use of cocaine or opioids)

  • There was no mention of blinding to the primary independent variable of pain as assessed by the SF-36.

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What are the Results?

  • How likely are the outcomes over time?

  • How precise are the estimates of likelihood?

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How likely are the outcomes over time?

Results (prospectively assessed):

  • 16% reported persistent pain (moderate-to-higher pain levels at all available interviews) in the 24 months after detoxification.

  • Subjects reporting persistent pain were more likely than those with mild or no pain to have (in the past 30 days at the 24-month follow-up)…

    • used any substance (odds ratio [OR], 4.21);

    • used heroin/opioids not prescribed for pain (OR, 5.36);

    • consumed >3 drinks on at least 1 day or been intoxicated (OR, 2.15);

    • used cocaine (OR, 2.05).

  • All results, except for cocaine use, were significant.

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How precise are the estimates of likelihood?

  • Confidence Intervals [CI] are wide:

    • For any substance use: OR, 4.21; 95% CI, 1.90-9.33

    • For heroin/opioid use: OR, 5.36; 95% CI, 2.09-13.75

    • For heavy alcohol use: OR, 2.15; 95% CI, 1.03-4.51

    • For cocaine use: OR, 2.05; 95% CI, 0.91-4.62

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How Can I Apply the Results to Patient Care?

  • Were the study patients and their management similar to those in my practice?

  • Was the follow-up sufficiently long?

  • Can I use the results in the management of patients in my practice?

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Were the study patients similar to those in my practice?

  • Subjects are fairly representative of patients receiving residential detoxification.

  • However, patients with existing primary care providers were excluded.

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Was the follow-up sufficiently long?

  • Follow-up occurred over 24 months.

  • This timeframe is clinically important.

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Can I use the results in the management of patients in my practice?

  • These results should be primarily used to heighten clinicians’ concern about the risk of relapse to any substance–particularly opioids or alcohol–in their patients discharged from detoxification.

  • Next steps should include exploring various strategies (nonopioid vs. opioid) for treating pain in patients with persistent complaints of pain after detoxification.

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