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Pain and Addiction: Assessment Issues

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Populations with chronic pain and the importance of assessment ... Somatoform Fibromyalgia. disorders Interstitial cystitis. Pain and Addiction: Assessment Issues ... – PowerPoint PPT presentation

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Title: Pain and Addiction: Assessment Issues


1
Pain and Addiction Assessment Issues
  • Russell K. Portenoy, MD
  • Chairman, Dept of Pain Medicine and Palliative
    Care
  • Beth Israel Medical Center
  • New York, NY

2
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

3
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)

4
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

5
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

6
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

7
Pain and Addiction Assessment Issues
  • Challenges in pain management
  • Heterogeneous pain-related outcomes
  • Physical
  • Psychosocial
  • Role functioning
  • Family impact
  • Economic impact

8
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

9
Pain and Addiction Assessment Issues
  • Challenges in pain management
  • Heterogeneous comorbidities
  • Physical/medical
  • Psychiatric/psychosocial

10
Pain and Disability
  • Nociceptive
  • Pain impact
  • Psychosocial factors
  • Physical/medical
  • comorbidities
  • Neuropathic Psychological Psychiatric/psycho
    -
  • mechanisms processes social comorbidities
  • Family factors

Disability
Pain
Etiologies
11
Pain and Addiction Assessment Issues
  • Challenges in pain management
  • Heterogeneous treatments
  • Pharmacotherapy Rehabilitative
  • Psychological Neurostimulatory
  • Surgical Anesthesiologic
  • CAM Lifestyle changes

12
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

13
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

14
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?

15
Pain and Addiction Assessment Issues
  • Optimal opioid use requires assessment in all
    populations
  • Must include evaluation of risk associated with
    misuse, abuse, addiction, diversion

16
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?

17
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

18
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

19
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

20
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

21
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?

22
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

23
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

24
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

25
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.

26
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

27
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

28
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?

29
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

30
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

31
Pain and Addiction Assessment Issues
  • Process of assessment
  • Collect the data
  • Integrate the findings
  • Develop the therapeutic strategy

32
Pain and Addiction Assessment Issues
  • Integrate the findings
  • Pain diagnoses
  • Etiology
  • Pathophysiology
  • Syndrome
  • Impact of the pain
  • Relevant comorbidities

33
Pain and Addiction Assessment Issues
  • Develop a therapeutic strategy for pain and its
    comorbidities
  • Primary treatment for underlying etiology, if
    appropriate
  • Symptomatic therapies

34
Pain and Addiction Assessment Issues
  • Symptomatic therapy
  • Pharmacotherapy Rehabilitative
  • Psychological Neurostimulatory
  • Surgical Anesthesiologic
  • CAM Lifestyle changes
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