Screening for problematic prescription opioid use

Internal and Environmental Predictors of Physician Practice Use of Screening and Medications for Opioid Use Disorders

Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-physician primary care and multispecialty practices. Drawing on an existing framework to characterize the internal and environmental context, we assess socio-technical, organizational-managerial, market-based, and state-regulation factors associated with the use of opioid screening and offering of MOUD in a practice. A total of 26.2% of practices offered MOUD, while 69.4% of practices screened for opioid use. Having advanced health information technology functionality was positively associated with both screening for opioid use and offering MOUD in a practice, while access to on-site behavioral clinicians was positively associated with offering MOUD in adjusted models. These results suggest that improving access to information and expertise may enable physician practices to respond more effectively to the nation's ongoing opioid epidemic.

Perioperative Pain Management for Elective Spine Surgery: Opioid Use and Multimodal Strategies

In recent years, physicians and institutions have come to recognize the increasing opioid epidemic in the United States, thus prompting a dramatic shift in opioid prescribing patterns. The lack of well-studied alternative treatment regimens has led to a substantial burden of opioid addiction in the United States. These forces have led to a huge economic burden on the country. The spine surgery population is particularly high risk for uncontrolled perioperative pain, because most patients experience chronic pain preoperatively and many patients continue to experience pain postoperatively. Overall, there is a large incentive to better understand comprehensive multimodal pain management regimens, particularly in the spine surgery patient population. The goal of this review is to explore trends in pain symptoms in spine surgery patients, overview the best practices in pain medications and management, and provide a concise multimodal and behavioral treatment algorithm for pain management, which has since been adopted by a high-volume tertiary academic medical center.

Patterns of prescription opioid utilization among adolescents and adults with comorbid chronic pain and mental health diagnosis

Our goal was to examine the association between mental health disorders (MHD) and subsequent risk of opioid use among commercially insured youth and adults (aged 14-64 years) with comorbid chronic noncancer pain (CNCP) conditions. We conducted a retrospective cohort study using IQVIA Health Plan Claims database from January 1, 2006, to December 31, 2015. Chronic noncancer pain was defined as any diagnosis of back, head, neck, arthritis, or chronic pain (index date). Mental health disorders were assessed in the 12 months before the index pain diagnosis. Based on days supply (none, acute, and chronic) and average daily dose (none, low, medium, and high), we constructed a 7-level categorical dependent measure of opioid use. We estimated the overall prevalence of MHD and opioid receipt. Among those with CNCP, multinomial logistic regression (AOR; 95 confidence interval) was used to estimate the association of MHD with opioid receipt. Among 879,815 individuals diagnosed with CNCP, 143,923 (16.4%) had comorbid MHD. Chronic/high-dose use of opioids was more common among those with CNCP and MHD compared to those with only CNCP. After adjusting for demographic and clinical factors, individuals with comorbid CNCP and MHD were significantly more likely to be prescribed opioids compared to those with only CNCP conditions. This effect varied by average daily dose and days supply: acute/low dose (1.08; 1.07-1.08); chronic/low dose (1.49; 1.49-1.50); acute/medium dose (1.07; 1.07-1.08); chronic/medium dose (1.61; 1.61-1.62); acute/high dose (1.03; 1.02-1.03); and chronic/high dose (1.53; 1.53-1.54). In individuals with CNCP, having a MHD was a strong predictor of prescription opioid use, particularly chronic use.

The dynamic interaction between pain and opioid misuse

In 2014, drug overdose surpassed automobile accidents as the number one cause of accidental death for the first time in the history of the United States. The overdose epidemic is largely driven by opioids, and genuine prescription opioid analgesics play the biggest role in this phenomenon. Despite advancements in abuse deterrent formulations, prescription drug monitoring programmes and clinical assessments for the detection of abuse potential, drug overdoses continue to escalate. The Center for Disease Control has recently issued new guidelines for opioid prescription, yet even these recommendations have their shortcomings. Furthermore, undertreated pain in patients with comorbid substance use disorder poses a major clinical challenge, particularly for patients on opioid replacement therapy. Despite the seemingly obvious interaction between the presence of pain and the abuse of pain-relieving opioids, there is surprisingly little mechanistic data to further our understanding of this vitally important topic. The need for novel pain interventions that minimize abuse liability is critical. Without a fundamental characterization of pain neurobiology and the interaction between chronic pain and the brain's reward system, we are unlikely to make progress in the alleviation of the opioid epidemic.

LINKED ARTICLES

This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.

Medical professionals' perspectives on prescribed and over-the-counter medicines containing codeine: a cross-sectional study

OBJECTIVES

To explore prescribing practitioners' perspectives on prescribed codeine use, their ability to identify dependence and their options for treatment in the UK.

DESIGN

Cross-sectional design using a questionnaire containing closed-ended and open-ended items.

SETTING

A nationally representative sample of prescribing professionals working in the UK.

PARTICIPANTS

300 prescribing professionals working in primary care and pain settings.

RESULTS

Participants stated that they regularly reviewed patients prescribed codeine, understood the risks of dependence and recognised the potential for codeine to be used recreationally. Over half the participants felt patients were unaware of the adverse health consequences of high doses of combination codeine medicines. One-quarter of participants experienced patient resentment when asking about medicines containing codeine. Just under 40% of participants agreed that it was difficult to identify problematic use of codeine without being informed by the patient and did not feel confident in identification of codeine dependence. Less than 45% of all participants agreed that codeine dependence could be managed effectively in general practice. Slow or gradual withdrawal was the most popular suggested treatment in managing dependence. Education and counselling was also emphasised in managing codeine-dependent patients in primary care.

CONCLUSIONS

Communication with patients should involve assessment of patient understanding of their medication, including the risk of dependence. There is a need to develop extra supports for professionals including patient screening tools for identifying codeine dependence. The support structure for managing codeine-dependent patients in primary care requires further examination.

Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk

Beginning in the late 1990s, a movement began within the pain management field focused upon the underutilization of opioids, thought to be a potentially safe and effective class of pain medication. Concern for addiction and misuse were present at the start of this shift within pain medicine, and an emphasis was placed on developing reliable and valid methods and measures of identifying those at risk for opioid misuse. Since that time, the evidence for the safety and effectiveness of chronic opioid therapy (COT) has not been established. Rather, the harmful, dose-dependent deleterious effects have become clearer, including addiction, increased risk of injuries, respiratory depression, opioid induced hyperalgesia, and death. Still, many individuals on low doses of opioids for long periods of time appear to have good pain control and retain social and occupational functioning. Therefore, we propose that the question, “Who is at risk of opioid misuse?” should evolve to, “Who may benefit from COT?” in light of the current evidence.

Prescription Opioid Use Among Seriously Mentally Ill Veterans Nationally in the Veterans Health Administration

Frequent prescription opioid use has been recognized as a growing problem but there have been no studies specifically among veterans with serious mental illness (SMI). National data from the Veterans Health Administration (VHA) during Fiscal Year 2012 show that VHA patients with SMI receive more opioid prescriptions than other veterans. Additionally, high numbers of opioid prescriptions is associated with greater use of anxiolytics/sedative-hypnotics, drug dependence and COPD-all of which pose an increased risk of respiratory depression and falls and warrant substantial caution and improved coordination between mental health and non-mental health prescribers to evaluate risk-benefit tradeoffs.

Primary care providers' experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings

BACKGROUND

Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper.

METHODS

Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology.

RESULTS

The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.

CONCLUSIONS

These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.

Risk stratification of opioid misuse among patients with cancer pain using the SOAPP-SF

BACKGROUND

Opioids are recognized as an integral part of the armamentarium in the management of cancer pain. There has been a growing awareness of the misuse of prescription opioids among cancer patients. More research is needed to detail risk factors and incidence for opioid misuse among cancer pain patients.

METHODS

We reviewed 522 patient charts that were seen in our Pain Center from January 1, 2009 to June 30, 2009 for risk stratification of opioid misuse with demographic and clinical factors utilizing the Screener and Opioid Assessment for Patients with Pain-short form (SOAPP-SF). Group differences based on High (≥4) and Low (<4) SOAPP-SF scores were evaluated at initial visit, follow-up within a month and 6-9 months.

RESULTS

One hundred forty-nine of the 522 (29%) patients had a SOAPP-SF score of ≥4. The mean age for patients with high SOAPP-SF score (≥4) was 50 ± 14 vs 56 ± 14 for patients with low SOAPP-SF score (<4) (P < 0.0001). The pain scores were higher for patients with high SOAPP-SF score compared with patients with low SOAPP-SF score at consult (P < 0.0001). Morphine equivalent daily dose (MEDD) was higher for patients with high SOAPP-SF score compared with patients with low SOAPP-SF score at consult (P = 0.0461). Fatigue, feeling of well-being, and poor appetite were higher among the high SOAPP-SF group at initial visit (P < 0.0001, <0.0001, <0.0149, respectively). The high SOAPP-SF score patients also had statistically significant (P < 0.05) higher anxiety and depression scores at all three time points. In the multivariate analysis, patients younger than 55 years have a higher odds of having a "high" SOAPP-SF score than patients 55 years and older {odds ratio (OR) (95% confidence interval [CI]) = 2.76 (1.58, 4.81), P = 0.0003} adjusting for employment status, disease status, treatment status, usual pain score, and morphine equivalency at consult. Patients with higher usual pain score at consult have higher odds of a "high" SOAPP-SF score (OR [95% CI] = 1.34 [1.19, 1.51], P < 0.0001) adjusting for age, employment status, disease status, treatment status, and morphine equivalency at consult.

CONCLUSION

Patients classified by the SOAPP-SF in the current study as high risk tended to be younger, endorse more pain, have higher MEDD requirement, and endorse more symptoms of depression and anxiety. These findings are consistent with the literature on risk factors of opioid abuse in chronic pain patients which suggests that certain patient characteristics such as younger age, anxiety, and depression symptomatology are associated with greater risk for opioid misuse. However, a limitation of the current study is that other measures of opioid abuse were not available for validation and comparison with the SOAPP-SF.

Problematic prescription opioid use in an HIV-infected cohort: the importance of universal toxicology testing

BACKGROUND

Providers treating chronic pain must attempt to relieve suffering, while minimizing problematic prescription opioid use, including addiction and diversion. Previously described risk factors for problematic use include history of substance use, younger age, male sex, psychiatric comorbidity, and lower education level.

METHODS

We examined these risk factors in HIV-infected individuals, using cross-sectional and longitudinal data from the Manhattan HIV Brain Bank. Problematic use was defined as illicit substance use (documented by urine toxicology or structured psychiatric interview), while receiving prescription opioids.

RESULTS

Among 173 participants prescribed opioids, 62% had problematic use, the majority of which was discovered by urine toxicology. Problematic use was associated with past substance use, current psychiatric disorder, and poorer adherence to antiretrovirals. However, when participants without problematic use at baseline were followed longitudinally, these factors were not predictive. Furthermore, the cumulative incidence of problematic use behaviors was no greater than in a similar group of participants who were not prescribed opioids.

CONCLUSIONS

Problematic prescription opioid use is common among HIV-infected individuals and is associated with history of substance use, current psychiatric disorder, and poor adherence to antiretrovirals. However, these factors do not predict future problematic use in those who are not currently using illicit substances, and the prescription of an opioid does not seem to predispose patients toward a future substance use disorder. Rather than attempting to assess risk for problematic prescription opioid use in HIV-infected individuals, we recommend baseline and follow-up urine toxicology.

Integrating pain management in clinical practice

There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. In this paper, we briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain.

Risk factor assessment for problematic use of opioids for chronic pain

Opioid analgesics provide effective treatment for noncancer pain, but many health providers have concerns about cognitive effects, tolerance, dependence, and addiction. Misuse of opioids is prominent in patients with chronic pain and early recognition of misuse risk could help providers offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. Many persons with chronic pain also have significant medical and psychiatric comorbidities that affect treatment decisions. Neuropsychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management. The assessment of different domains using semi-structured interviews, sensory and neuropsychological testing, and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral, and social issues in order to facilitate treatment planning. In this review we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic pain, and present an overview of assessment and treatment strategies that can be effective in improving outcomes associated with the use of prescription opioids for pain. Finally we briefly discuss the effect of opiate analgesics on cognition and review some intervention strategies for chronic pain patients.

Molecular and cellular mechanisms of the age-dependency of opioid analgesia and tolerance

The age-dependency of opioid analgesia and tolerance has been noticed in both clinical observation and laboratory studies. Evidence shows that many molecular and cellular events that play essential roles in opioid analgesia and tolerance are actually age-dependent. For example, the expression and functions of endogenous opioid peptides, multiple types of opioid receptors, G protein subunits that couple to opioid receptors, and regulators of G protein signaling (RGS proteins) change with development and age. Other signaling systems that are critical to opioid tolerance development, such as N-methyl-D-aspartic acid (NMDA) receptors, also undergo age-related changes. It is plausible that the age-dependent expression and functions of molecules within and related to the opioid signaling pathways, as well as age-dependent cellular activity such as agonist-induced opioid receptor internalization and desensitization, eventually lead to significant age-dependent changes in opioid analgesia and tolerance development.

Opioid tolerance and dependence - do they matter?

The use of opioids has long been accepted as the standard of care in patients with cancer and acute pain. Opioids can further be used effectively in specific subgroups of patients with chronic nonmalignant pain states. While the development of tolerance and physical dependence are known effects of opioids in cancer and noncancer pain populations, these patients can not be regarded as addicted. However, long-term therapy with short-acting opioids predisposes to tolerance and addiction. Recent research has confirmed the important role of psychopathologic and psychosocial conditions as predictors of failed opioid effectiveness in a significant number of noncancer pain subgroups. The clinical picture of failed therapy may be complicated by noncompliance, concealed consumption of psychotropic substances, and diversion of prescribed opioids for various purposes as, e.g., selling for profit, or sharing excess opioids with others. This article discusses the effects of opioid therapy, including tolerance, physical dependence, drug-aberrant behavior, drug history, psychopathology, and somatization.

Assessment and treatment of abuse risk in opioid prescribing for chronic pain

Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no "gold standard" for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.

Long-term outcomes of lumbar fusion among workers' compensation subjects: a historical cohort study

STUDY DESIGN

Historical cohort study.

OBJECTIVE

To determine objective outcomes of return to work (RTW), permanent disability, postsurgical complications, opiate utilization, and reoperation status for chronic low back pain subjects with lumbar fusion. Similarly, RTW status, permanent disability, and opiate utilization were also measured for nonsurgical controls.

SUMMARY OF BACKGROUND DATA

A historical cohort study of workers' compensation (WC) subjects with lumbar arthrodesis and randomly selected controls to evaluate multiple objective outcomes has not been previously published.

METHODS

A total of 725 lumbar fusion cases were compared to 725 controls who were randomly selected from a pool of WC subjects with chronic low back pain diagnoses with dates of injury between January 1, 1999 and December 31, 2001. The study ended on January 31, 2006. Main outcomes were reported as RTW status 2 years after the date of injury (for controls) or 2 years after date of surgery (for cases). Disability, reoperations, complications, opioid usage, and deaths were also deter-mined.

RESULTS

Two years after fusion surgery, 26% (n = 188) of fusion cases had RTW, while 67% (n = 483) of nonsurgical controls had RTW (P ≤ 0.001) within 2 years from the date of injury. The reoperation rate was 27% (n = 194) for surgical patients. Of the lumbar fusion subjects, 36% (n = 264) had complications. Permanent disability rates were 11% (n = 82) for cases and 2% (n = 11) for nonoperative controls (P ≤ 0.001). Seventeen surgical patients and 11 controls died by the end of the study (P = 0.26). For lumbar fusion subjects, daily opioid use increased 41% after surgery, with 76% (n = 550) of cases continuing opioid use after surgery. Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively (P < 0.001). Final multi-variate, logistic regression analysis indicated the number of days off before surgery odds ratio [OR], 0.94 (95% confidence interval [CI], 0.92-0.97); legal representation OR, 3.43 (95% CI, 1.58-7.41); daily morphine usage OR, 0.83 (95% CI, 0.71-0.98); reoperation OR, 0.42 (95% CI, 0.26-0.69); and complications OR, 0.25 (95% CI, 0.07-0.90), are significant predictors of RTW for lumbar fusion patients.

CONCLUSION

This Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a WC setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.

Somatization is associated with non-adherence to opioid prescriptions

Non-adherence to opioid prescriptions can decrease the safety and efficacy of opioid therapy. Identifying factors associated with over- and under-use of opioids in patients presenting with pain may improve prescribing and pain management. Patients presenting with pain often also present with somatization, and somatization is associated with both excessive use of and non-adherence to medications. This study examines the relationship between somatization and non-adherence (over- and under-use) to opioid prescriptions in the Veteran sample. One hundred and ninety-one Veterans who received an opioid prescription at a Veterans Affairs Palo Alto Health Care System in the prior year participated by completing a 1.5 hour semistructured interview which included assessments of depressive symptoms, somatization, medication side effects, and opioid pain medication usage. The percentage of patients non-adherent to opioid prescriptions increased as a function of somatization: Compared to no somatization, all levels of somatization were associated with higher rates of underuse, while severe somatization was associated with increased rates of overuse. Consistent with previous studies of medication non-adherence, increased depression and medication side effects were associated with decreased adherence to opioid prescriptions. However, in exploratory analyses, somatization mediated the relationship between depressive symptoms and opioid-use patterns as well as medication side effects and opioid use patterns.

PERSPECTIVE

This article sought to explore the relationship between somatization and adherence to prescription opioid medications. Our findings suggest that pain management treatment plans may be optimized by addressing patient distress about physical symptoms when considering the use of prescription opioid medications.

[Anesthesia in drug addiction]

The growing social problem of drug abuse has increased the likelihood that anesthesiologists will find acute or chronic drug users among patients requiring anesthesia for elective or emergency surgery. We must therefore be aware of the effects drugs have on the organism and their possible pharmacokinetic and pharmacodynamic interactions with anesthetic agents in order to prevent complications during surgery and postoperative recovery. Such knowledge is required for the management of abstinence syndrome or overdose, which pose the greatest potential dangers for the hospitalized drug addict.

The global diversion of pharmaceutical drugs non-medical use and diversion of psychotropic prescription drugs in North America: a review of sourcing routes and control measures

AIMS

North America features some of the world's highest consumption levels for controlled psychoactive prescription drugs (PPDs; e.g. prescription opioids, benzodiazepines, stimulants), with non-medical use and related harms (e.g. morbidity, mortality) rising in key populations in recent years. While the determinants, characteristics and impacts of these 'use' problems are increasingly well documented, little is known about the 'supply' side of non-medical PPD use, much of which is facilitated by 'diversion' as a key sourcing route. This paper provides a select review of the phenomenon of PPD diversion in North America, also considering interventions and policy implications.

METHODS

A conceptual and empirical review of select-peer- and non-peer-reviewed research literature from 1991 to 2010 focusing upon PPD diversion in North America was conducted.

RESULT

The phenomenon of PPD diversion is heterogeneous. Especially among general populations, a large proportion of PPDs for non-medical use are obtained from friends or family members. Other PPD diversion routes involve 'double doctoring' or 'prescription shopping'; street drug markets; drug thefts, prescription forgeries or fraud; as well as PPD purchases from the internet.

CONCLUSIONS

The distinct nature and heterogeneity make PPD diversion a complex and difficult target for interventions. Prescription monitoring programs (PMPs) appear to reduce overall PPD use, yet their impact on reducing diversion or non-medical use is not clear. Law enforcement is unlikely to reach PPD diversion effectively. Effective reduction will probably require reductions in overall PPD consumption volumes, although such will need to be accomplished without compromising standards of good medical (e.g. pain) care.

Pilot study of a preliminary criterion standard for prescription opioid misuse

Multidisciplinary experts created a behaviorally defined preliminary criterion standard definition of probable prescription opioid misuse (PPOM) that could be rated from material found in administrative, pharmacy, and electronic health record databases. They then derived a scoring system to identify PPOM patients requiring referral to a specialist. Experts next rated cases of misuse and nonmisuse. Rater no. 1 correctly differentiated 37 of 40 cases (92.5%); kappa coefficient was .79 (CI: .57, 1.00). Rater no. 2 correctly identified 39 of 40 cases (97.5%); kappa was .94 (CI: .81, 1.00). Kappa for comparing raters was .73 (CI: .49, .98). This preliminary study demonstrates that multidisciplinary raters can use behaviorally based criteria to identify patients with known PPOM from health plan databases.

Alleged breaches of "standards of medical care" in a patient overdose death possibly related to chronic opioid analgesic therapy, application of the controlled substances model guidelines: case report

OBJECTIVES

The objectives of this medicolegal case report are the following: 1) to present details of a chronic pain patient (CPP) who was placed on chronic opioid analgesic therapy (COAT), and subsequently overdosed on multiple drugs, some of which were not prescribed by his COAT physician; 2) to present both the plaintiff's and defendant's (the COAT prescriber) expert witnesses' opinions as to the allegation that COAT prescribing was the cause of death; and 3) based on these opinions, to develop some recommendations on how pain physicians can utilize the use of Controlled Substances Model Guidelines in order to protect the patient and themselves from such an occurrence.

METHODS

This is a case report of a CPP treated by a pain physician.

RESULTS

Differences between the plaintiff's and defendant's expert's opinions are explained utilizing the Controlled Substances Model Guidelines.

CONCLUSIONS

Some CPPs may withhold information critical to their COAT treatment. Application of the Controlled Substances Model Guidelines and the newer Federation of State Medical Boards' policy on opioid prescribing can be helpful in improving patient care and may be helpful in protecting the physician medicolegally.

Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders

STUDY DESIGN

Prospective outcomes study involving patients with chronic disabling occupational spinal disorders (CDOSD) diagnosed with (n = 199) or without (n = 1124) postinjury opioid-dependence disorder (ODD), based on the Diagnostic and Statistical Manual of Mental Disorders-fourth edition cirteria.

OBJECTIVE

To determine whether prescription opioid dependence, assessed at the beginning of rehabilitation treatment, is associated with poorer treatment outcomes in patients with CDOSDs attending an interdisciplinary rehabilitation program.

SUMMARY OF BACKGROUND DATA

Controversy exists regarding the risk of iatrogenic ODD and treatment outcomes when long-term opioid therapy is used in the treatment of chronic nonmalignant pain conditions.

METHODS

A consecutive sample of patients with CDOSDs [n = 1323; mean (SD) length of disability = 18.8 (20.7) months] attending a tertiary referral center received intensive physical reactivation and pain/disability management interventions, based on a functional restoration model, including detoxification from opioids. One-year outcomes included return to work, work retention, healthcare utilization, new surgeries, recurrent injuries, and disability claim settlement.

RESULTS

Prevalence of ODD in this CDOSD population on entering the rehabilitation program was 15%. Even after adjusting for relevant demographic factors and comorbid psychiatric disorders, opioid-dependent patients were 1.7 times [95% confidence interval (CI): 1.0, 2.7] less likely to return to work, 2 times (95% CI: 1.3, 3.0) less likely to retain work at the 1-year interview, and 1.7 times (95% CI: 1.2, 2.5) more likely to engage in healthcare utilization from new providers, compared with nonopioid-dependent patients.

CONCLUSIONS

Iatrogenic prescription opioid dependence may be a risk factor for less successful long-term work and health outcomes, even after detoxification from opioids as part of an interdisciplinary functional rehabilitation program. Chronic prescription opioid dependence in this patient population is also associated with a significantly higher prevalence of comorbid psychiatric conditions, both axis I and II.

Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis

BACKGROUND

Opioids can provide relief for people with chronic pain. However, a minority may develop aberrant drug behaviors. A critical issue is identifying "at-risk" patients.

OBJECTIVE

To synthesize the evidence of published strategies for identifying at-risk patients to guide clinicians' decisions and practices for prescribing opioid treatment for chronic pain patients (CPP).

DATA SOURCES

MEDLINE database search from 1966 to March 20, 2007, searching the bibliographies from all retrieved articles, and articles available in the authors' files. Studies were limited to human studies in the English language related to screening for predictors of aberrant drug behaviors in CPP who were prescribed long-term opioids. We included studies reviewing, developing measures, or investigating outcomes related to screening for aberrant opioid behaviors in CPP.

RESULTS

We identified 6 published articles addressing clinician-based predictors of substance misuse of opioids and 9 published studies evaluating the predictive ability of clinical interviews and self-report measures for aberrant opioid behaviors in CPP. Several attempts have been made to develop procedures to identify at-risk patients including urine toxicology screening, structured interviews, observation, and self-report questionnaires. In general, the psychometric properties of the published questionnaires and interview protocols are weak; moreover, the samples included in the studies are often small and unrepresentative. Thus, none of them can be recommended for use with any confidence.

CONCLUSION

Review of the published studies reveals that no one procedure or set of predictor variables is sufficient to identify CPP at-risk for opioid misuse or abuse. There is a scarcity of evidence regarding characteristics that predict aberrant behavior before beginning long-term opioids. Several predictors have been identified. Strong predictors include a personal history of illicit drug and alcohol abuse. Demographic factors have also been reported, but the results are not consistent. Prospective studies, especially ones with CPP who have not already been started on chronic opioid therapy, are needed.

Assessment and management of chronic pain in individuals seeking treatment for opioid dependence disorder

OBJECTIVE

To review the problem of chronic pain in patients with substance use disorders, focusing on the prevalence of chronic pain in patients with substance dependence disorders, especially prescription opioid dependence, associated comorbidities, and the impact on drug abuse treatment response.

METHOD

We identified relevant articles using PubMed from 1987 to 2008. Additional articles were obtained from the reference lists of key reviews of relevant topics. Studies were included if they investigated the relation between chronic pain and substance use disorders. Of particular interest were articles that proposed integrated treatment for both problems.

RESULTS

The high prevalence of chronic pain syndromes was only recently explored in patients seeking treatment for drug abuse. The presence of chronic pain increases the risk of poor response to substance abuse treatment and an increased likelihood of multiple comorbidities that further add to the negative impact experienced by patients with substance dependence disorders. Substance abuse treatment programs offering integrated medical and psychiatric care for these comorbidities improve outcomes, with stepped care approaches offering the best treatment by tailoring the level of care to the individual patient's needs.

CONCLUSIONS

Substance abuse treatment programs should expand their services to address the comorbidities likely to pose barriers to successful drug rehabilitation. Given the high prevalence and negative impact of chronic pain, new pain management services should be integrated within the drug treatment program and adapted as patients demonstrate the need for more intensive treatment. If applied to the problem of chronic pain, a model substance abuse treatment program of integrated stepped care would improve outcomes for patients with both devastating disorders.

Pain, substance use disorders and opioid analgesic prescription patterns in veterans with hepatitis C

To examine the prevalence of pain, substance use disorder (SUD) diagnoses, and opioid analgesic prescription patterns among veterans infected with the hepatitis C virus (HCV), a retrospective review of the medical records of 8,224 HCV-positive (HCV+) veterans was performed. Twenty-nine percent and 46% of HCV+ patients were prescribed opioids in the prior one and three years, respectively. Sixty-seven percent of HCV+ patients had documented pain diagnoses and 56% had SUD diagnoses. Patients with co-occurring pain and SUD were less likely to be prescribed opioids than patients with pain only (prior year: 36% vs. 43%, P<0.001; three years: 56% vs. 60%, P<0.01). There were no differences in numbers of early opioid prescription fills or numbers of opioid prescribers when comparing patients with co-occurring pain and SUD to patients with pain only. Veterans with co-occurring pain and opioid use disorder had fewer early opioid fills than veterans with pain only (prior year: 2.6 vs. 5.3 days, P<0.01; three years: 6.1 vs. 13.4 days, P<0.001). These data demonstrate that pain and SUD diagnoses were common among HCV+ patients, and that opioids were frequently prescribed. Co-occurring SUD was not associated with indicators of prescription opioid misuse.

Medication adherence in patients with chronic non-malignant pain: is there a problem?

Health care providers, treating patients with chronic non-malignant pain, often experience that medication is not as effective as expected. It is important to realize that the effectiveness of a pharmacological treatment can be influenced by the way the medication is taken. Medication adherence is a topic that gains more attention, especially in chronic conditions, because it affects treatment outcome. A systematic review of studies on medication adherence in patients with chronic non-malignant pain was performed to gain insight in the prevalence of the problem, the impact on treatment outcome, influencing variables and interventions. Searching several electronic databases (Medline, CINAHL, Psychinfo and Cochrane), 14 relevant articles were found. The results indicate that medication non-adherence is common in patients with chronic non-malignant pain. Both overuse and underuse of medication occurs. However, due to the scarce literature and important methodological limitations, it is not possible to make firm conclusions concerning the impact on outcome, influencing variables and optimal intervention strategies. This review highlights some important gaps in the adherence literature in a chronic non-malignant pain population and sets the stage for future research.

Interventions in chronic pain management. 4. Monitoring progress and compliance in chronic pain management

This self-directed learning module highlights the monitoring of progress and compliance in chronic pain management. It is part of the chapter on chronic pain in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. Specifically, the first module focuses on the use of pain rating scales to monitor progress, and the second and third learning objectives focus on evaluating abuse potential and interpreting drug screens. The fourth objective discusses issues pertaining to closure of a workers' compensation complaint, including when to declare that a patient meets the requirements for the designation maximal medical improvement.

OVERALL ARTICLE OBJECTIVE

To discuss monitoring of a patient's progress and compliance by describing how pain rating scales are used, what screening procedures are available to help identify patients at risk for drug abuse, and what the basis is for declaring a patient as having reached maximal medical improvement.

Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain

OBJECTIVE

The goal of this paper was to examine the relationship between history of substance use disorder (SUD) and self-reported prescription medication misuse in 127 primary care patients who receive opioid medications for treatment of chronic pain.

METHOD

Participants completed measures of pain location, pain intensity, disability due to pain, and misuse of prescription medications. Other measures included demographic characteristics, psychiatric symptomatology and quality of life.

RESULTS

Seventy-eight percent of participants reported at least one indicator of medication misuse in the prior year. After adjusting for age and clinical factors (pain severity, depression severity, current alcohol or substance use disorder), participants with SUD history were significantly more likely than participants without SUD history to report borrowing pain medications from others (OR=6.62, 95% CI=1.4-30.7) and requesting an early refill of pain medication (OR=3.86, 95% CI=1.5-9.6).

CONCLUSIONS

Misuse of prescription medications is a concern among primary care patients with chronic pain. Participants with a lifetime history of SUD are more likely to endorse some aberrant medication-related behaviors. Patients with SUD histories should be carefully evaluated for medication misuse potential and may require more intense assessment and follow-up.

Development and validation of the Current Opioid Misuse Measure

Clinicians recognize the importance of monitoring aberrant medication-related behaviors of chronic pain patients while being prescribed opioid therapy. The purpose of this study was to develop and validate the Current Opioid Misuse Measure (COMM) for those pain patients already on long-term opioid therapy. An initial pool of 177 items was developed with input from 26 pain management and addiction specialists. Concept mapping identified six primary concepts underlying medication misuse, which were used to develop an initial item pool. Twenty-two pain and addiction specialists rated the items on importance and relevance, resulting in selection of a 40-item alpha COMM. Final item selection was based on empirical evaluation of items with patients taking opioids for chronic, noncancer pain (N=227). One-week test-retest reliability was examined with 55 participants. All participants were administered the alpha version of the COMM, the Prescription Drug Use Questionnaire (PDUQ) interview, and submitted a urine sample for toxicology screening. Physician ratings of patient aberrant behaviors were also obtained. Of the 40 items, 17 items appeared to adequately measure aberrant behavior, demonstrating excellent internal consistency and test-retest reliability. Cutoff scores were examined using ROC curve analysis and reasonable sensitivity and specificity were established. To evaluate the COMM's ability to capture change in patient status, it was tested on a subset of patients (N=86) that were followed and reassessed three months later. The COMM was found to have promise as a brief, self-report measure of current aberrant drug-related behavior. Further cross-validation and replication of these preliminary results is pending.

Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders?

STUDY DESIGN

An epidemiologic prevalence study.

OBJECTIVES

To clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSDs).

SUMMARY OF BACKGROUND DATA

Few empirical data are available regarding the "chicken-or-egg" question of which occurs first: the injury or incident culminating in the painful CDOSD or the psychiatric disturbance.

METHODS

Subjects attended a tertiary interdisciplinary rehabilitation program. Psychiatric disorders were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID-DSM-IV). Psychiatric disorders were characterized as preexisting if they manifested themselves before the work-related injury claim (whether or not they resolved, continued, or reoccurred after injury). They were determined postinjury diagnoses only if they manifested for the first time after the injury claim.

RESULTS

A total of 38.7% of the present cohort had at least one preexisting major psychiatric disorder, while 98.9% developed one or more psychiatric disorders for the first time after injury onset (57.9% when pain disorder was excluded). The percentage of patients with preexisting psychiatric disorders was lower than general population base rates (48%). The first onset of certain psychiatric disorders was found to be elevated in patients only after the work-related injury; these included Pain Disorder (95.7%), Major Depressive Disorder (49.7%), and Opioid Dependence (15%). Moreover, 5 times as many patients with MDD, and 10 times as many with opioid dependence, developed these disorders for the first time after the injury.

CONCLUSIONS

In general, psychiatric disturbance is not a risk factor for developing a CDOSD. Psychiatric disorders are much more likely to develop after the onset of the work injury, indicating that such injuries and accompanying stressors are likely to be precipitants, rather than consequences, of psychopathology.

Long-term opioid contract use for chronic pain management in primary care practice. A five year experience

BACKGROUND

The use of opioid medications to manage chronic pain is complex and challenging, especially in primary care settings. Medication contracts are increasingly being used to monitor patient adherence, but little is known about the long-term outcomes of such contracts.

OBJECTIVE

To describe the long-term outcomes of a medication contract agreement for patients receiving opioid medications in a primary care setting.

DESIGN

Retrospective cohort study.

SUBJECTS

All patients placed on a contract for opioid medication between 1998 and 2003 in an academic General Internal Medicine teaching clinic.

MEASUREMENTS

Demographics, diagnoses, opiates prescribed, urine drug screens, and reasons for contract cancellation were recorded. The association of physician contract cancellation with patient factors and medication types were examined using the Chi-square test and multivariate logistic regression.

RESULTS

A total of 330 patients constituting 4% of the clinic population were placed on contracts during the study period. Seventy percent were on indigent care programs. The majority had low back pain (38%) or fibromyalgia (23%). Contracts were discontinued in 37%. Only 17% were cancelled for substance abuse and noncompliance. Twenty percent discontinued contract voluntarily. Urine toxicology screens were obtained in 42% of patients of whom 38% were positive for illicit substances.

CONCLUSIONS

Over 60% of patients adhered to the contract agreement for opioids with a median follow-up of 22.5 months. Our experience provides insight into establishing a systematic approach to opioid administration and monitoring in primary care practices. A more structured drug testing strategy is needed to identify nonadherent patients.

An opioid screening instrument: long-term evaluation of the utility of the Pain Medication Questionnaire

The Pain Medication Questionnaire (PMQ) was designed to assess the risk for opioid medication misuse in chronic pain patients. A preliminary study showed a positive relationship between higher PMQ scores and concurrent measures of substance abuse, psychopathology, and physical/life-functioning. Using a larger sample size, the present study sought to replicate these findings, and to expand upon them by examining the relationship between PMQ scores and various treatment outcomes. The PMQ was administered to 271 newly evaluated chronic pain patients who were subsequently re-evaluated immediately post-treatment, as well as six months following discharge. Subgroups were then formed according to the lowest (L-PMQ), middle (M-PMQ), and highest (H-PMQ) one-third of PMQ total scores. It was found that the H-PMQ group was 2.6 times more likely to have a known substance-abuse problem, 3.2 times more likely to request early refills of prescription medication, and 2.3 times more likely to drop out of treatment, as compared to the L-PMQ group. They also had diminished biopsychosocial functioning. In addition, at six months following discharge, patients who completed the program experienced a significant decrease in PMQ scores over time relative to those patients who were unsuccessfully discharged from the program or who dropped out. This study represents the second stage in the development of a psychometrically sound screening tool for measuring risk for opioid medication misuse among chronic pain patients, and findings suggest the long-term utility of the PMQ in identifying patients who are more likely to complete and benefit from a pain management program.

The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain

This study introduces the Addiction Behaviors Checklist (ABC), which is a brief (20-item) instrument designed to track behaviors characteristic of addiction related to prescription opioid medications in chronic pain populations. Items are focused on observable behaviors noted both during and between clinic visits. One hundred thirty-six consecutive veterans in a multidisciplinary Veterans Affairs Chronic Pain Clinic who were receiving long-term opioid medication treatment were included in this study. This study represents one of the first to follow a sample of chronic pain patients on opioid therapy over time, using a structured assessment tool to evaluate and track behaviors suggestive of addiction. Interrater reliability and concurrent validity data are presented, as well as a cut-off score for use in determining inappropriate medication use. The psychometric findings support the ABC as a viable assessment tool that can increase a provider's confidence in determinations of appropriate vs. inappropriate opioid use.

Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP)

The Screener and Opioid Assessment for Patients with Pain (SOAPP) is a brief, self-administered screening instrument used to assess suitability of long-term opioid therapy for chronic pain patients. This study presents preliminary data to examine the reliability and validity of the SOAPP as a measure of risk of opioid abuse for patients on opioid medication. Patients taking opioids for noncancer pain (n=396) from two pain centers completed the SOAPP prior to being placed on opioids for pain. Demographic data, SOAPP scores, and results of urine toxicology screens from the patients' medical records were examined. Patients were divided into two groups of high and low risk of opioid abuse potential based on cutoff scores of 8 and higher on the SOAPP. Results showed that patients in the high-risk group were younger, more likely to be asked to give a urine screen, and had more abnormal urine screens compared with those in the low-risk group (P<0.05). A combined factor analysis of the SOAPP revealed five factors labeled 1) history of substance abuse, 2) legal problems, 3) craving medication, 4) heavy smoking, and 5) mood swings. Preliminary support was found for the internal reliability and predictive validity of the SOAPP. Current limitations of the SOAPP and future directions for change are discussed.

Using opioids with persisting noncancer pain: a biopsychosocial perspective

OBJECTIVE

Despite the growing use of opioids for persisting noncancer pain, evidence for their effectiveness is limited, especially in relation to functional outcomes. Guidelines have been developed for prescribers, but their utility is untested. This review examines the use of opioids in this population from a biopsychosocial perspective and makes a number of recommendations.

DATA SOURCES

Published comparison studies and reviews of oral opioids in chronic noncancer pain, as well as 5 published guidelines for the prescription of opioids and systematic reviews of cognitive-behavioral pain management programs.

METHODS

Outcomes of the opioid comparison studies were reviewed and compared to those achieved by pain management programs.

CONCLUSIONS

The available evidence indicates that by themselves, oral opioids generally achieve only modest reductions in pain levels in patients with chronic noncancer pain. Functional outcomes are inconsistent across studies. There are questions about the timing of their use and patient selection. There are risks in trials of opioids only after other conservative interventions have been tried unsuccessfully. Also, in some patients, ongoing use of opioids risks repeated over-doing of pain-generating activities and reinforcing escape/avoidance responses that promote disability. These risks may be lessened by assessment of current use of pain self-management strategies among potential candidates for opioids. This offers advantages in promoting collaborative management of persisting pain as well as better pain and functional outcomes. In this view, opioids may be considered as one possible element of a management plan rather than the primary treatment.

Analgesic Addiction and Pseudoaddiction in Painful Chronic Illness

OBJECTIVES

Research is needed to enable more effective assessment and treatment of analgesic addiction among patients with painful chronic illnesses and to improve our understanding of the staff-patient interactions that give rise to pseudoaddiction. This study tested predictions that certain drug-use behaviors and pain-coping strategies were associated with analgesic addiction, and that certain were associated with risk of pseudoaddiction.

METHODS

Analgesic addiction and risk of pseudoaddiction among patients with sickle cell disease were measured by symptom counts, using an interview method for classifying symptoms as pain-related (pseudoaddiction) or non-pain-related (analgesic addiction). Concern-raising drug-use behaviors and treatment requirements for pain were also assessed, and participants completed the pain-coping strategies questionnaire. Qualitative case descriptions of patients meeting criteria for analgesic addiction and pseudoaddiction were examined to identify common and distinctive features of the two groups.

RESULTS

Consistent with predictions, multiple regression analyses showed that disputes about analgesics were independently associated with risk of pseudoaddiction. Physiological dependence and illicit drug use were both associated with analgesic addiction, independently of other factors. The qualitative data showed that analgesic addiction was not an obvious, clear-cut phenomenon: addiction and pseudoaddiction were superficially similar, and even symptoms of genuine addiction originated in patients' experiences of pain and illness.

CONCLUSIONS

These tentative findings were broadly consistent with what is known about analgesic addiction and pseudoaddiction in other painful conditions. They also suggested that current recommendations about addiction in pain patients could understate the potential importance of physiological dependence. The findings could inform staff training programs to improve pain management and reduce the incidence of pseudoaddiction. The classification of pain-related and non-pain-related symptoms could be used in further research on the development of analgesic addiction and the factors that influence staff attributions about addiction in patients with pain.

State policy affecting pain management: recent improvements and the positive impact of regulatory health policies

Criteria-driven policy analysis resources from the University of Wisconsin Pain and Policy Studies Group (PPSG) evaluated drug control and professional practice policies that can influence use of controlled substances for pain management, and documented changes over a 3-year period. Additional research was needed to determine the extent of change, the types of messages contained in the policies, and what has contributed to changing policy content. Four research aims guided this study: (1) evaluate change between 2000 and 2003 of state policy that can affect pain relief, (2) describe content differences for statutes, regulations, guidelines, and policy statements, (3) evaluate differences between policies specific to pain management and policies governing general healthcare practice, and (4) compare content of policies specific to pain management created by healthcare regulatory boards to those created by state legislatures. Results showed that more current policies, especially policies regulating health professionals, tend to encourage pain management and avoid language that restricts professional decision-making and patient treatment. In addition, pain policies from healthcare regulatory boards were generally less restrictive than statutes or policies that govern general healthcare practice. These findings suggest that the positive policy change results primarily from state medical, pharmacy, and nursing boards adopting policies promoting pain management and the use of opioids, while containing few if any restrictions. Despite this improvement, further progress can be made when states continue to abrogate additional restrictions or clinically obsolete provisions from policies. PPSG policy evaluations provide guidance to lawmakers, healthcare regulators, and clinicians who are striving to achieve balanced policy, an attainable but redoubtable goal, to benefit patient care.

Age-dependent opioid escalation in chronic pain patients

Rapid opioid dose escalation, possibly caused by tolerance, has been observed in some patients on daily opioid therapy, although clinically identifiable characteristics of these patients are unknown. In this retrospective chart review of 206 patients, we examined whether the age of the patient was related to opioid escalation. Initial starting doses of long-acting opioids were similar in younger patients (< or =50 yr; 49 +/- 3 mg/d oral morphine-equivalent dose) versus older patients (> or =60 yr; 42 +/- 3 mg/d). Younger patients reached a maximum dose of 452 +/- 63 mg/d over 15.0 +/- 1.3 mo, whereas older patients achieved a maximum dose of 211 +/- 23 mg/d over 14.4 +/- 1.5 mo (P < 0.0001). At the last clinic visit, younger-patient dosing averaged 365 +/- 61 mg/d, with older patients averaging 168 +/- 18 mg/d (P < 0.0001). Only older patients demonstrated a reduction in visual analog scale scores from start of opioid therapy until discharge from the clinic (6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01). These clinical data suggest that age is an important variable in opioid dose escalation. Although factors other than opioid tolerance can result in dose escalation, it is possible that older patients may have a reduced rate of tolerance development.

The drug-seeking patient in the emergency room

Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that has not been appropriately managed. Opioids produce euphoria in some patients, providing the motivation for abuse, which can be detrimental even with occasional use. Even in the absence of overt euphoria, opioids are highly self-reinforcing and can be problematic in a large number of patients, requiring that acute care physicians exercise caution in whom they are administered. Habitual patient files, narcotic contracts, pain management letters, and patient tracking and management programs can be used for the benefit of both drug seeking-patients and chronic pain patients. For many patients, drug-seekers and chronic pain patients alike, withholding opioids may be an important part of their long-term management. For others, long-acting opioids such as long-acting morphine or methadone are a reasonable option.

Management of Chronic Pain in the Acute Care Setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.

Validation of a screener and opioid assessment measure for patients with chronic pain

There has been a need for a brief assessment tool for providers who treat chronic pain patients to determine potential risk of abuse when prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a self-administered screening tool (Screener and Opioid Assessment for Patients with Pain, SOAPP) for chronic pain patients considered for long-term opioid therapy. A consensus of 26 pain and addiction experts was obtained on important characteristics of chronic pain patients that predict future medication misuse using concept mapping. A 24-item SOAPP (version 1.0) was developed based on this consensus and was administered to 175 patients who were taking opioids for chronic pain. After 6 months, 95 of these patients were re-evaluated. Validation of the SOAPP was conducted by identifying those patients exhibiting aberrant drug-related behavior as determined by any of the following: a positive score on the Prescription Drug Use Questionnaire (PDUQ) interview, positive urine toxicology screen, and/or ratings by staff as to whether patients had a serious drug problem. Of the original 24 items, 14 SOAPP items appeared to predict subsequent aberrant behaviors. Coefficient alpha for these 14 items was acceptable for a short scale (0.74). Receiver operating characteristics curve analysis yielded an area under the curve of 0.881 (P<0.001), suggesting adequate sensitivity and specificity for a screening device. These reliability and predictive validity results suggest that the SOAPP is a promising step toward screening risk potential for substance misuse among persons with chronic pain.

Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history

Physicians can encounter problems in prescribing opioids for some patients with chronic pain such as multiple unsanctioned dose escalations, episodes of lost or stolen prescriptions, and positive urine drug screenings for illicit substances. This study explored the usefulness of questions on abuse history in predicting problems with prescribing opioids for patients at a hospital-based pain management program. One hundred forty-five (145) patients who were taking long- and short-acting opioids for their pain were classified as high or low risk on the basis of their responses to interview questions about 1) substance abuse history in their family, 2) past problems with drug or alcohol abuse, and 3) history of legal problems. The treating physicians completed a questionnaire about problems that they had encountered with their patients. Problem behaviors were verified through chart review. No differences in demographic characteristics were found between those classified as high and low risk. Patients who admitted to a family history of substance abuse, a history of legal problems, and drug or alcohol abuse were prone to more aberrant drug-related behaviors, including a higher incidence of lost or stolen prescriptions and the presence of illicit substances in their urine (P < 0.05). Patients classified as high risk also had a significantly higher frequency of reported mental health problems and motor vehicle accidents. More of these patients smoked cigarettes, tended to need a cigarette within the first hour of the day, took higher doses of opioids, and reported fewer adverse effects from the medications than did those without such a history (P < 0.05). This study demonstrates that questions about abuse history and legal problems can be useful in predicting aberrant drug-related behavior with opioid use in persons with chronic noncancer pain.

Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients

This study constituted the first step in the psychometric development of a self-report screening instrument for risk of opioid medication misuse among chronic pain patients. A 26-item instrument, the Pain Medication Questionnaire (PMQ), was constructed based on suspected behavioral correlates of opioid medication misuse, which heretofore have received limited empirical investigation. The PMQ was administered to 184 patients at an interdisciplinary pain treatment center. Reliability coefficients for the PMQ were found to be of moderate but acceptable strength. Construct and concurrent validity were examined through correlation of PMQ scores to measures of substance abuse, physical and psychological functioning, and physicians' risk assessments. To explore high and low cutoff points for misuse risk, subgroups were formed according to the upper and lower thirds of PMQ scores and compared on validity measures. Higher PMQ scores were associated with history of substance abuse, higher levels of psychosocial distress, and poorer functioning. Future psychometric analyses will consider predictive validity and examine shortened versions of the instrument.