pain and addiction assessment issues
Download
Skip this Video
Download Presentation
Pain and Addiction: Assessment Issues

Loading in 2 Seconds...

play fullscreen
1 / 34

Pain and Addiction: Assessment Issues - PowerPoint PPT Presentation


  • 403 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Pain and Addiction: Assessment Issues' - Jimmy


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
pain and addiction assessment issues

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 issues2
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
pain and addiction assessment issues3
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)
pain and addiction assessment issues4
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%
pain and addiction assessment issues5
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
pain and addiction assessment issues6
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

pain and addiction assessment issues7
Pain and Addiction: Assessment Issues
  • Challenges in pain management
    • Heterogeneous pain-related outcomes
      • Physical
      • Psychosocial
      • Role functioning
      • Family impact
      • Economic impact
pain and addiction assessment issues8
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
pain and addiction assessment issues9
Pain and Addiction: Assessment Issues
  • Challenges in pain management
    • Heterogeneous comorbidities
      • Physical/medical
      • Psychiatric/psychosocial
pain and disability
Pain and Disability

Nociceptive

Pain impact

Psychosocial factors

Physical/medical

comorbidities

Neuropathic Psychological Psychiatric/psycho-

mechanisms processes social comorbidities

Family factors

Disability

Pain

Etiologies

pain and addiction assessment issues11
Pain and Addiction: Assessment Issues
  • Challenges in pain management
    • Heterogeneous treatments

Pharmacotherapy Rehabilitative

Psychological Neurostimulatory

Surgical Anesthesiologic

CAM Lifestyle changes

pain and addiction assessment issues12
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
pain and addiction assessment issues13
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
pain and addiction assessment issues14
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?
pain and addiction assessment issues15
Pain and Addiction: Assessment Issues
  • Optimal opioid use requires assessment in all populations
    • Must include evaluation of risk associated with misuse, abuse, addiction, diversion
pain and addiction assessment issues16
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?
pain and addiction assessment issues17
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
pain and addiction assessment issues18
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
pain and addiction assessment issues19
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
pain and addiction assessment issues20
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
pain and addiction assessment issues21
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?
pain and addiction assessment issues22
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
pain and addiction assessment issues23
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
pain and addiction assessment issues24
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
pain and addiction assessment issues25
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.
pain and addiction assessment issues26
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
pain and addiction assessment issues27
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
pain and addiction assessment issues28
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?
pain and addiction assessment issues29
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
pain and addiction assessment issues30
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
pain and addiction assessment issues31
Pain and Addiction: Assessment Issues
  • Process of assessment
    • Collect the data
    • Integrate the findings
    • Develop the therapeutic strategy
pain and addiction assessment issues32
Pain and Addiction: Assessment Issues
  • Integrate the findings
    • Pain diagnoses
      • Etiology
      • Pathophysiology
      • Syndrome
    • Impact of the pain
    • Relevant comorbidities
pain and addiction assessment issues33
Pain and Addiction: Assessment Issues
  • Develop a therapeutic strategy for pain and its comorbidities
    • Primary treatment for underlying etiology, if appropriate
    • Symptomatic therapies
pain and addiction assessment issues34
Pain and Addiction: Assessment Issues
  • Symptomatic therapy

Pharmacotherapy Rehabilitative

Psychological Neurostimulatory

Surgical Anesthesiologic

CAM Lifestyle changes

ad