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Journal Club

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

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  1. Journal Club Alcohol, Other Drugs, and Health: Current Evidence May-June 2007 www.aodhealth.org

  2. 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. www.aodhealth.org

  3. Study Objective To examine whether persistent pain is associated with… • an increased odds of substance use after detoxification www.aodhealth.org

  4. 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. www.aodhealth.org

  5. Assessing Validity of an Article about Prognosis • Are the results valid? • What are the results? • How can I apply the results to patient care? www.aodhealth.org

  6. 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? www.aodhealth.org

  7. 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. www.aodhealth.org

  8. 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. www.aodhealth.org

  9. Was follow-up sufficiently complete? • Subjects were assessed every 6 months over 24 months. • 69% completed the 24-month interview. www.aodhealth.org

  10. 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. www.aodhealth.org

  11. What are the Results? • How likely are the outcomes over time? • How precise are the estimates of likelihood? www.aodhealth.org

  12. 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. www.aodhealth.org

  13. 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 www.aodhealth.org

  14. 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? www.aodhealth.org

  15. 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. www.aodhealth.org

  16. Was the follow-up sufficiently long? • Follow-up occurred over 24 months. • This timeframe is clinically important. www.aodhealth.org

  17. 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. www.aodhealth.org

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