# Presentation: 724360

## 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

- 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

- 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

- 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

- 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

- Pain and Addiction: Assessment Issues

- Challenges in pain management
- Heterogeneous disorders
- Headache            	Low back pain
- Neck pain	          	Arthridites
- Polyneuropathy	CRPS
- Central pain		Myofascial pain
- Somatoform		Fibromyalgia
-       disorders      	Interstitial cystitis

## Pain and Addiction: Assessment Issues

- 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

- 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

- Pain and Addiction: Assessment Issues

- Challenges in pain management
- Heterogeneous comorbidities
- Physical/medical
- Psychiatric/psychosocial

## Pain and Disability

**Pain and Disability**

- Nociceptive
- 						Pain impact
- 						Psychosocial factors
- 						Physical/medical
- 						   comorbidities
- Neuropathic     Psychological 		Psychiatric/psycho-
- mechanisms	processes		   social comorbidities
- 						Family factors
*	**	**	**	**	**	**	*
*	**	**	**	**	**	**	*

**Pain**

**Disability**

- Etiologies

## Pain and Addiction: Assessment Issues

- 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

- 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

- 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

- 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

- 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

- 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

- 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

- 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

- 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

- 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

- Pain and Addiction: Assessment Issues

- CAGE-AID screening tool (Brown & Rounds 1995)
- Tried to _**C**_ut down or _**C**_hange your pattern of drinking or drug use?
- Been _**A**_nnoyed or _**A**_ngry by others’ concern about your drinking or drug use?
- Felt _**G**_uilty about the consequences of your drinking or drug use?
- Had a drink or used a drug in the morning (_**E**_ye-opener) to decrease hangover or withdrawal symptoms?

## Pain and Addiction: Assessment Issues

- Pain and Addiction: Assessment Issues

- CAGE-AID screening tool
- Screens for ongoing abuse
- Ongoing abuse predicts future abuse
- Two or more positives has sensitivity of 60-95% and specificity of 40-95% for diagnosing alcohol or drug problems

## Pain and Addiction: Assessment Issues

- 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

- 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

- 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

- 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

- 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

- 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

- 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

- 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 

- Pain and Addiction: Assessment Issues

- Process of assessment
- Collect the data
- Integrate the findings
- Develop the therapeutic strategy

## Pain and Addiction: Assessment Issues

- Pain and Addiction: Assessment Issues

- Integrate the findings
- Pain diagnoses
- Etiology
- Pathophysiology
- Syndrome
- Impact of the pain
- Relevant comorbidities

## Pain and Addiction: Assessment Issues

- 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

- Pain and Addiction: Assessment Issues

- Symptomatic therapy
- Pharmacotherapy   	Rehabilitative
- Psychological		Neurostimulatory
- Surgical                  	Anesthesiologic
- CAM 	                	Lifestyle changes