Pain and Addiction: Assessment Issues Russell K. Portenoy, MD Chairman, Dept of Pain Medicine and...

Pain and Addiction: Pain and Addiction: Assessment IssuesAssessment Issues

Russell K. Portenoy, MDChairman, Dept of Pain Medicine and Palliative Care

Beth Israel Medical CenterNew York, NY


• Prevalence of chronic pain• Populations with chronic pain and the

importance of assessment• Assessing the risk of substance abuse• Elements of the comprehensive assessment


• 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)


– 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%


– 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


Challenges in pain management– Heterogeneous disorders

Headache Low back painNeck pain ArthriditesPolyneuropathy CRPSCentral pain Myofascial painSomatoform Fibromyalgia disorders Interstitial cystitis


• Challenges in pain management– Heterogeneous pain-related outcomes

• Physical • Psychosocial• Role functioning• Family impact• Economic impact


• Challenges in pain management– Heterogeneous factors influencing pain

experience and related outcomes• Personality• Adaptation/coping• Family response• Past history • Comorbidities


• Challenges in pain management– Heterogeneous comorbidities

• Physical/medical• Psychiatric/psychosocial

Pain and DisabilityPain and Disability

Nociceptive

Pain impactPsychosocial factorsPhysical/medical comorbidities

Neuropathic Psychological Psychiatric/psycho-mechanisms processes social comorbidities

Family factors

Pain

Disability

Etiologies


• Challenges in pain management– Heterogeneous treatments

Pharmacotherapy Rehabilitative

Psychological Neurostimulatory

Surgical Anesthesiologic

CAM Lifestyle changes


• 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


• 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


• 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?


• Optimal opioid use requires assessment in all populations – Must include evaluation of risk

associated with misuse, abuse, addiction, diversion


• 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?


• 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



– 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



– Prior admission to drug rehabilitation– Prior failed treatment at a pain management

program– Heavy tobacco use– Heavy alcohol use



– Many automobile accidents– Family history of severe depressive or anxiety

disorder– Family history of drug abuse


• 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?


• 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


• 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


• 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


• 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.


• 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


• 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


• 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?


• 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


• 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


• Process of assessment– Collect the data

– Integrate the findings

– Develop the therapeutic strategy


• Integrate the findings– Pain diagnoses

• Etiology• Pathophysiology• Syndrome

– Impact of the pain– Relevant comorbidities


• Develop a therapeutic strategy for pain and its comorbidities– Primary treatment for underlying

etiology, if appropriate

– Symptomatic therapies


• Symptomatic therapyPharmacotherapy Rehabilitative

Psychological Neurostimulatory

Surgical Anesthesiologic

CAM Lifestyle changes

Pain and Addiction: Assessment Issues Russell K. Portenoy, MD Chairman, Dept of Pain Medicine and...

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