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 Assessing the risk of substance abuse Elements of the comprehensive assessment

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 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 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 Issues Challenges in pain management – Heterogeneous disorders Headache Low back pain Neck pain Arthridites PolyneuropathyCRPS Central painMyofascial pain SomatoformFibromyalgia disorders Interstitial cystitis

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 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 Issues Challenges in pain management – Heterogeneous comorbidities Physical/medical Psychiatric/psychosocial

Pain and Disability Nociceptive Pain impact Psychosocial factors Physical/medical comorbidities Neuropathic Psychological Psychiatric/psycho- mechanismsprocesses social comorbidities Family factors Pain Disability Etiologies

Pain and Addiction: Assessment Issues Challenges in pain management – Heterogeneous treatments Pharmacotherapy Rehabilitative Psychological Neurostimulatory Surgical Anesthesiologic CAM Lifestyle changes

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 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 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 Issues Optimal opioid use requires assessment in all populations – Must include evaluation of risk associated with misuse, abuse, addiction, diversion

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 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 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 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 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 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 Issues CAGE-AID screening tool – Screens for ongoing abuse – Ongoing abuse predicts future abuse – Two or more positives has sensitivity of % and specificity of 40-95% for diagnosing alcohol or drug problems

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 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 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 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 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 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 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 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 Issues Process of assessment – Collect the data – Integrate the findings – Develop the therapeutic strategy

Pain and Addiction: Assessment Issues Integrate the findings – Pain diagnoses Etiology Pathophysiology Syndrome – Impact of the pain – Relevant comorbidities

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 Issues Symptomatic therapy Pharmacotherapy Rehabilitative PsychologicalNeurostimulatory Surgical Anesthesiologic CAM Lifestyle changes