**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Management of Chronic Pain in Patients with Comorbid Substance Use Disorders**

**Presenter: Ben Morasco, PhD**

**November 6, 2012**

**Management of Chronic Pain in Patients with Comorbid Substance Use Disorders**

**November 6, 2012**

Dr. Kearns:     Welcome everybody. Good morning. Welcome to this month's webinar series, called "Spotlight on Pain Management. I want to begin by thanking our colleagues at The Center for Information Dissemination and Educational Resources, CIDER, which is an HSR&D funded resource center based in Boston. We are delighted that you are joining us this morning. If this is your first time, you may want to note that this is a monthly recurring program. We tend to have speakers who themselves are clinical investigators and who are delivering talks that are of interest to the clinician, research, educator, and even policy maker and administrator communities. Please spread the word about this program to your colleagues who you think would be interested. 

This morning we are privileged to have Dr. Ben Morasco, who is joining us from the Portland VA Medical Center where he is a staff psychologist at the Portland VA Medical Center and is an associate professor of psychiatry at the Oregon Health and Science University in Portland, Oregon. He has conducted empirical research studies, including examining chronic pain, treatment and outcomes, with a focus on treating chronic pain in patients with comorbid substance use disorders. In this seminar, Dr. Morasco will describe recent research conducted with chronic pain patients who have comorbid substance use disorders. He will provide empirically based recommendations for care management approaches, with a focus on management of these comorbidities in the primary care setting. With that, welcome Dr. Morasco. 

Dr. Morasco:     Thank you very much Dr. Kearns, Heidi, and everyone from CIDER.  Thank you for the invitation. I am excited to this presentation. I am pleased that there are many people participating. I also fully respect that this is an area that is an increasing source of focus, both in the clinical and research perspectives. Hopefully we can have some ideas and generate some discussion around these issues. I guess we will go ahead and get started. My name is Ben Morasco. I am from the Portland VA. Before we get started too much, I would like to acknowledge some collaborators on this project that we discussed. I received funding from the National Institute on Drug Abuse. I have no conflicts of interest to report in terms of any of the issues that we will be discussing today. 

Here are some general objectives. I am going to be talking about the prevalence of substance use disorders in different pain populations. I will be reviewing the data on prescription opioid misuse. I will be discussing treatment outcomes based on substance use disorder status. I will be discussing treatment practices for pain among patient with comorbid substance abuse. I will be providing recommendations for clinical practice. Of note, I have received a couple of questions in advance. There are people who have questions they were wondering if I would address while we talk. My clinical background is as a clinical psychologist. I do not prescribe medications. During this talk I am not going to be discussing specific medications. I will not be discussing prescribing practices for such things as opioid agonist therapy. I can provide some recommendations about where to go for some of those things. I will not be discussing that specifically. More of the talk is generally about managing chronic pain with general care practices, with a focus on primary care, but including some specialty services as well. 

Here is some background. Comorbid substance use disorders are common among patients with chronic pain. The systematic research is limited. There are prevalence rates of substance use disorders very widely across studies. There is very limited data available regarding treatment options for chronic pain in people with comorbid substance use disorders. With this as a backdrop, recently we conducted as systematic review that was designed to get a better understanding of the full breadth of knowledge that was out there about the prevalence associated demographic and clinical characteristics, as well as treatment outcomes, for people with chronic pain and comorbid substance use. During this talk I will be discussing some aspects of that systematic review. 

The first part relates to some prevalence. All of these studies are patients that have chronic pain. Among those with chronic pain presenting to different clinical settings, how many have a current substance use disorder? The first set of studies is from patients that are attending outpatient pain clinics. We see rates of 11% to 35%. Of patients presenting to inpatient pain clinics, maybe as much as 20% or 23% have a current substance use disorder. Among patients that are going to primary care settings, patient in primary care that also have chronic pain, from 4% up to about 19% may have a current substance use disorder. Some of these other studies are women with severe breast pain. This is a study, the Hoyt 1994 study, from patients who were admitted for severe AIDS related pain. The final study, Wilsley, was patients that were presenting to the emergency room for an opioid fill. Fifteen percent were found to have a current substance use disorder. 

As it relates to having a history of a substance use disorder, the range is about 15% to maybe as many as 50% of patients who are presenting to a specialty pain service have a history of a substance use disorder. Of patients in primary care with chronic pain, maybe up to 40% have a history of a substance use disorder. The final study was the Wilsey paper of patients presenting to the emergency room seeking an opioid fill or refill. As many as three-quarters had a history of a substance use disorder. I do not think the specific rates are not the main issue or the most important thing to think about. What it highlights for me is that substance use comorbidity is very common among patients with chronic pain. It is sort of the main take home point. We see the different rates, a low of 16% to a high of 50%, due largely in part to different methods used to assess substance use disorder status. The take home point is that they are common in both current and past. With that in mind, a basic recommendation would be that all patients should be assessed for current and past substance use disorders. Assessment for current use should be incorporated into all follow-up visits. I am going to discuss a couple of brief measures that might be able to be used to assess for current substance use disorder status. I am having that this is a little more geared toward our VA colleagues that are on the phone, as these measures are available in CPRS. They are all validated measures that are available widely. They can be accessed within CPRS. 

One is the Brief Addiction Monitor. This is a 17 item measure of addiction problem severity. It is designed to provide assessment for substance use disorder in specialty care settings. It is now routinely administered in VA substance abuse treatment programs. It is available in CPRS in the manner described below. It can also be administered as a paper and pencil test. If people like, they can exclude the questions on quality of life. That does provide some very important information. There are some other measures that are available. The AUDIT-C is perhaps one of the most widely used. The potential limitation is that it assesses alcohol only. There is also a recently developed measure called the ASSIST, which assesses both alcohol and substance use disorders. The number of items in the measure depends upon what is endorsed. It is relatively brief. It also includes questions about craving and misuse. 

There are some implications for having a comorbid substance use disorder. Patients with chronic pain and comorbid substance abuse are potentially more difficult to treat. We have concerns about other comorbidities, such as depression and anxiety. For patients who are prescribed opioids there may be increased risk for prescription opioid misuse. We are going to talk a little bit about the issue of prescription opioid misuse because it is so common. There tends to be strong empirical data about that. 

When we did the systematic review a couple of years ago, at that time there were seven studies that had specifically examined prescription opioid misuse based on having a substance use disorder status. Four of those seven studies found that patients with a history of a substance use disorder were more likely to exhibit current prescription opioid misuse. Of note, all of the studies that were rated higher in terms of methodolological rigor, by which I mean having an adequate sample size, using validated outcome measures, conducting appropriate statistical tests and controlling for important co-variance, the studies that were rated highest in methodological rigor all found that having a history of a substance use disorder was associated with current prescription opioid misuse. There is an individual, Dr. Steven Passik, who is a clinical expert in this area. He has discussed some potential signs for prescription opioid misuse. He describes it in terms of a range of concern. Some might be problematic, but in and of themselves they may not be most concerning to ones that are of greater concern. These are some ideas presented by Dr. Passik. He noted some behaviors that may be considered less indicative of "addiction." 

There might be some issues like hoarding medications, anxiety over symptoms, taking medications from others or requesting specific medications,  drinking alcohol while in pain, expressing concern when changing medications, smoking cigarettes for pain relief or using opioids to treat other symptoms. These are behaviors that may be considered on the range toward addiction. There are other behaviors that Dr. Passik considers as potentially more indicative of "addiction." If any of these are detected, these might be considered pathognomonic for having addiction or a substance use disorder. These are buying pain medications from a street dealer, stealing money to obtain medications, getting opioids from more than one source, performing sex for opioids or for money to obtain opioids, seeing two providers without them knowing, stealing the medications from others or prescription forgery. 

How often does prescription opioid misuse occur? That frankly depends on what we are referring to when we say prescription opioid misuse. If the issue is a diagnosable DSM-IV diagnosis of opioid abuse or dependence specifically due to new prescriptions of opioids, in that case a very small portion of patients develop opioid abuse or dependence. The full diagnostic is less than 4% of patients. There have been a couple of studies that have shown that. If the issue is indicators of potential misuse, the rates are much higher. I would just cite a study that we conducted a few years ago, showing high rates of patients reporting past year use of borrowing pain medications from others, taking more medication than prescribed, having multiple requests for an opioid dose increase, running out of pain medications early and requesting a refill, or even doctor shopping. 

There is a very interesting study that I just came across. It is "in press" at Pain Medicine, conducted by Ellen Meltzer and colleagues at the Boston University Medical Center. They conducted clinical research interviews with a large group of patients who were prescribed long term benzodiazepines or opioids. This is in inner city Boston. They gave research diagnoses of prescription drug use disorders to either opioids or benzodiazepines. They reviewed the medical records for all of the patients in the past year. They reviewed records to identify medical record documentation of prescription opioid misuse behaviors. Those were the things that I described on the prior slide, potential requests for early refills or reports of lost or stolen medications and having these occur multiple times. There was even doctor shopping or having urine drug screens that are positive for an illicit or a non-prescribed substance. They found that overall, 85% of patients from an inner city medical center had medical record documentation of a prescription misuse behavior. What perhaps is most striking is that they did not find any difference between those with and without a prescription drug use disorder, in terms of the rates of documented misuse. Taken together, the results from the recent study suggest that the prevalence of a diagnosable prescription substance use disorder is low, yet many patients may intermittently misuse pain medications. 

There is some data that is available about some predictors for current prescription opioid misuse. The most robust findings and most consistent findings relate to having a current or past substance use disorder as I described earlier. There have been a couple of other studies looking at some other demographics and clinical factors, such as being a little bit younger in age, having a personal or family history of legal problems. Anxiety and depression have also been associated with misuse. There have been a couple of studies that are interesting. More research in this area is certainly needed. Certain types of cognition, whether it is about the effectiveness of opioids or the perceptions of the threat of pain, these are associated with prescription opioid misuse. Those studies are interesting because they controlled for some of the other clinical factors, such as even substance use disorders. They found that these types of cognitions were associated with prescription opioid misuse above and beyond them. More research in that area is needed. 

The general idea, if you are assessing for the assessment of current misuse, the recommendation is that the assessment should include fluid and not static factors. As we are seeing people for treatment on an ongoing basis, we should be assessing things that change over time, things like craving and not just things that are a history of demographic variables that do not change. It is definitely worth noting that the type of pain disorder, the duration of pain, pain intensity, function and quality of life have not been associated with risk for prescription opioid misuse. There have been some recommendations that have been provided about ways to reduce the impact of medication prescription opioid misuse. This research is conducted by Dr. Robert Jamison at the Brigham and Women's Hospital in Boston. Dr. Jamison put out some ideas that for patients who show initial signs of prescription opioid misuse, some potential options may include more frequent opioid prescriptions, writing for prescriptions on a weekly fill at a time as opposed to monthly, providing 24 hour notice pill counts, recommending attempts at early detection of risk factors for misuse, recommending collaboration between substance abuse and with substance abuse and mental health professionals and also completing an opioid compliance checklist at follow-up visits. An opioid compliance checklist for their purposes was a 12 item yes or no questionnaire that primarily addresses the main components of an opioid therapy treatment agreement. The items focus on the responsible use of opioid medications, including taking the medication as prescribed, use of one pharmacy or one provider, not running out of medications early, maintaining follow-up appointments, not borrowing medications from others, avoiding the use of illegal substances and taking caution not to lose the medications. The final recommendation by Dr. Jamison was urine drug screens at each visit. 

They conducted a very interesting randomized trial that was designed to reduce medication misuse. The empirical literature that I have seen would be considered the most robust that I have seen for an intervention designed specifically to reduce medication misuse. I will go through the results of this in some detail. They screened a large group of patients who all had chronic pain. They screened them at baseline for risks for prescription opioid misuse. They found a group of patients who were considered at higher risk. They were randomized to an experimental condition. I will go through a slide and describe the experimental condition. They also identified 19 patients who were at high risk for prescription opioid misuse. They were randomized to usual care. They did not receive additional treatment. This group was called the high risk control group. They also identified a similar number of patients who were screened to be at low risk for prescription opioid misuse. This group received usual care and they were followed as a second comparison group. The third group is referred to as the low risk control. All of the patients were followed for six months. 

The participants that had high risk and were randomly assigned to the experimental group received monthly completion of the opioid compliance checklist, which I have previously described. They completed monthly urine drug screens. They also received monthly individual therapy and monthly group therapy. They received some kind of therapy session once every two weeks. The individual therapy included review of the opioid compliance checklist, how participants were responding to the medication, advice for abstinence from illicit substances, support and education on pain management and discussion of non-compliance. The group therapy focused on opioid addiction risks, education about misuse and relapse, making lifestyle changes, avoiding drug use triggers and encouraged attendance to all appointments. This treatment is very focused on reducing prescription opioid misuse and coming from an addiction perspective, the recommendations sit well within addiction literature but would not be considered an intensive intervention. This would be low level intensity. 

In terms of their findings, they found pretty interesting findings. The outcome measure was this compendium that they called the drug misuse index, which was a composite measure that triangulated results from urine drug screens, staff readings of opioid abuse behaviors and self-report of prescription opioid misuse. They found that patients in the high risk control group, that is the patients that at baseline were considered high risk for misuse and did not receive additional treatment other than usual care, at six months out three-quarters of those individuals had indicators of prescription opioid misuse. In contrast, of the patients who were in the experimental condition, we saw a marked reduction in misuse behaviors. The difference between these two groups is statistically and clinically significant. Interestingly, the high risk experimental group had rates that were similar or did not differ from those in the low risk control group. 

I am going to switch gears. That was the last issue I am going to talk about specifically as it relates to prescription opioid misuse behaviors. We will talk more about issues of chronic pain treatment. This will certainly include focus on substance use disorders, but a little less on specific misuse. I want to provide some general reminders. I am sure you individuals are familiar with this, but these are general reminders as a backdrop. The best data available, as it relates to treatment for chronic pain, shows our best treatments relieve no more than 40% of pain. Opioid medications may result in as much 30% reduction in pain intensity for only about one-half of the patients that take them. Few patients are cured of chronic pain, whereas their pain is in complete remission. The best data available indicates that multi-disciplinary care is the optimal treatment for chronic pain. I just wanted some basic reminders. 

What do we know about treating pain in patients with a comorbid substance use disorder? Generally speaking, there is very little empirical data available. The reason for this is the primary exclusion criteria for most studies on chronic pain is having a history of a substance use disorder. This is very unfortunate, given that this is a patient population that has high rates of chronic pain. It is just unfortunate that we have very few empirical recommendations about how to best provide care. There have been no well conducted studies that have compared treatment outcomes for chronic pain based on substance use disorder status. There have been no published randomized trials examining medication or psychological intervention in pain patients with a comorbid substance use disorder. The studies that are out there are five studies that I identify here. Generally speaking, all of these studies that I describe are well conducted research. Their limitation is that they are largely cohort studies, doing prepost. Some have longer term follow-up and some do not. These are from a research methodology perspective, considered the best of what is available thus far. I will walk through these a little bit. 

The first study was conducted by Chelminski and colleagues at North Carolina. They evaluated patients that were referred to a primary care multi-disciplinary disease management program. This team included an internist, a pharmacist and a psychiatrist. Patients were referred if the provider was having difficulty managing their pain or if they suspected opioid misuse. They found that this multi-disciplinary team was effective in reducing pain and improving function. There is an interesting study conducted by Rhodin and colleagues. They enrolled patients who had pain and comorbid substance use disorders into a methadone maintenance program. In this program they continued to receive their regular ongoing care, but in addition they received regular group therapy and case management. They found that this program resulted in significant improvements in pain relief and quality of life. 

Many people on this call are going to be familiar with research that has been conducted out of the Philadelphia VA on the opioid renewal clinic. This is a great clinical program that has been developed. They found that participation in a pharmacy-led opioid renewal clinic was effective in reducing aberrant medication use while also maintaining pain management. There have been a couple of studies that have been conducted on cognitive behavioral therapy that incorporate relapse prevention. They found that this focused treatment helps to reduce pain, improve function and reduce relapse risk. Of note, the second study, author Dr. Mark Ilgen is out of the Ann Arbor VA. He is currently conducting a randomized trial comparing CBT to another psychosocial intervention specifically to treat pain in patients with comorbid substance use disorder. This will be the first study that I know that will have this outcome. I know that many individuals, myself included, are looking forward to the results from that study. Those studies in summary are the best that we have available about treatment studies specifically designed to treat pain in those with substance use disorder. 

I am going to describe a general pain treatment study. I am going to go into quite a bit of detail on it. The reason why is because I am later going to describe a secondary analysis to look at pain treatment outcomes. In order to do it and make the most sense, I need to describe this study in detail. I was not involved with this. It was conducted by a colleague here at the Portland VA, Dr. Steven Dobscha. It was published a few years ago. They examined pain outcomes in a randomized perspective trial. They specifically examined to what extent a collaborative care intervention improved musculoskeletal pain and depression outcomes. The setting was one VA medical center, five primary care clinics within one VA. They recruited about 400 patients with chronic musculoskeletal pain. It was a randomized trial. Patients were randomized to either collaborative care or usual care. They included patients that had musculoskeletal pain and pain intensity and interference greater than and equal to four on the scale of zero to ten, with ten being high pain intensity greater than four, and having telephone access. Of note, as it is particularly germane to this talk today, they did not exclude patients with an active alcohol or substance use disorder. 

The intervention was referred to as Assistance with Pain Treatment. The primary components were discussing chronic pain and chronic illness. It included stepped care. It started at less intensive intervention and became more intensive as needed. It was working from a biopsychosocial framework. It had a lot of focus on developing individualized functional goals and trying to activate patients to make progress and work toward achieving functional outcomes. It had a multi-disciplinary approach. I am going to walk through this in more specific details. This appears to be a pretty busy slide. I will go through in detail what it is. 

In this over here we just see that this is for those assigned to the active treatment intervention. There is another arm for people that had usual care. That would be over to the side. I am not going to identify that in detail. It is just usual care. Of those that were assigned to the active intervention, they initially received a telephone call that was simply orientation to the intervention. They received some educational materials. It was designed to be in person, but veto was used if person was not available. They had an appointment with a psychologist care manager. They psychologist conducted an assessment for comorbid psychiatric conditions, education as it relates to chronic pain, evaluated barriers to care and treatment preferences. They also identified some treatment related goals. All of these recommendations were then also reviewed by an internist and a pain specialist who had also conducted a chart review of the patients' care. The recommendations from the psychologist and the internist were then packaged and sent to the primary care provider. Ultimately, in this research study, it was up to the primary care provider and the patient to implement what they thought was most important. The research team developed recommendations, but it was up to the PCP and the patient to implement what they thought was most important. 

Some of the recommendations may have included physical therapy, occupational therapy or recreational therapy. Patients may have been additionally referred to a specialty pain clinic. I will talk about some consultation and ongoing telephone contact. It may have included other consultations, such as mental health, physiatry or orthopedics. All of the participants were invited to participate in a four session behavioral skills workshop. Not all of the participants did. Everyone was invited. All of the participants also received phone calls, seven phone calls over a period of 12 months, by the psychologist care manager. These follow-up phone calls were to provide some additional education about chronic pain. The primary focus was on monitoring symptoms, evaluating where patients were at in terms of their pain treatment outcomes and their depression treatment outcomes. Recommendations were provided about additional things to provide, perhaps additional recommendations such as these recommendations referred again. It had a focus on the stepped care as it relates to some data from this study. 

Some issues worth highlighting, similar to many VA populations, are that the average age was about 62 years. Some things were really important. Only one-third of the participants had been working. Two-thirds were receiving Disability. Almost 40% met diagnostic criteria for chronic depression and 16% for current alcohol misuse. Seventeen percent had current PTSD, post-traumatic stress disorder. These are the main treatment outcomes. There was no difference between the two groups at baseline. Those that were randomized to the collaborative care intervention had significant improvements relative to those that were assigned to the treatment as usual. This treatment difference was clinically and significantly different. Those that were assigned to the intervention got better. Among patients with clinically significant depressive scores at baseline, those randomized to the collaborative care intervention had significant improvement in depression treatment outcomes relative to those that were assigned to usual care. The summary of findings from this study that were collaborative care resulted in improvements in measures of pain disability, pain intensity and depression severity, the patient rated global impression of change, patients and clinicians were satisfied and we had meaningful improvements for patients that had substantial baseline comorbidity. 

With that study as the backdrop, I want to describe the secondary analysis that was recently conducted. We wanted to look at, within the study conducted by Dr. Dobscha, if there were any factors that were evaluated at baseline, to identify if they could be used as predictors to see which participants would have treatment gains. In this case, treatment gains were defined as a 30% reduction between baselines in 12 months on a measure of pain related function. That definition of 30% improvement is a standardized definition of improvement within the chronic pain literature. For these analyses, they were stratified by intervention status, the collaborative care or treatment as usual, due to the very significant differences in pain care that the two groups received. Within this study, 20% of patients had a history of substance use disorder. In this case, we defined history of a substance use disorder based on administrative or electronic medical record data. The analyses that we saw earlier did ask questions about current misuse. We just wanted to look at having a history of a substance use disorder. This is what was documented in the medical record. This might be a little bit low. 

Of those that had a history of a substance use disorder, the most common were alcohol, marijuana, opiates whether prescribed or illicit, amphetamines or other. If we do baseline comparisons of those with substance use disorders versus pain only, we see differences. Those with a history of a substance use disorder were a little bit younger. They were a little bit less likely to be married. They were more likely to be prescribed an opioid. Patients with a history of a substance use disorder showed no differences in current pain intensity between the two groups. These scores are just the measures on a measure called The Chronic Pain Grade or Measure of Pain Intensity. Those with a history of a substance use disorder had more impairment on our measure of pain related function. They had more impairment. They were more likely to meet diagnostic criteria for a major depressive disorder. They were more likely to meet criteria for PTSD. They were more likely to have current alcohol misuse. 

For predictors of treatment outcome, essentially we wanted to look to see if any of these variables, any of these demographic or clinical factors such as age, gender, duration or pain, pain diagnoses, opiate prescription status, PTSD, major depression or history of substance use disorder, predicted who would benefit from treatment. When we look at just the patients that were randomly assigned to collaborative care, we see that the overall model was not significant. None of these factors predicted treatment outcome. Essentially, for the patients that were randomly assigned to collaborative care, people were as likely to have a benefit from treatment. There was no factor that predicted it. However, when we look at patients that were randomized to usual care, the overall model was significant. The only predictor of treatment outcome was having a history of a substance use disorder. As we can see from the odds ratio, those participants that had a history of a substance use disorder were 70% less likely to have a clinically significant improvement in pain related function. That is compared to those patients that did not have a history of a substance use disorder. 

The take home points from that study are this. Chronic pain patients with a history of a substance use disorder had poorer functioning at baseline and greater psychiatric comorbidity. They were more likely to be prescribed an opioid. For those that were randomized to usual care, they were 70% less likely to have a clinically significant improvement in pain related function. In contrast for patients who were randomized to collaborative care, substance use disorder status was not associated with long term functioning. The implications of this research are that chronic pain patients with a comorbid substance use disorder needed more intensive and supplementary treatments in order to have clinically significant improvements in pain related function. If we think about the five studies that I described initially about what we know about pain related outcomes for those with a substance use disorder, all of those interventions would be considered potentially more intensive than what may exist in usual care. 

What did participants in this study receive? They received usual care. They also received individualized assessments from a psychologist with bi-monthly telephone calls to offer support, identify treatment needs and encourage compliance. In collaboration with an internist, recommendations were given to the PCP for possible implementation. The suggestions may have included referral to mental health, specialty pain service, physical therapy or other services. There was potential imaging or medication change. All of the recommendations were consistent with treatment guidelines. It was a stepped care model in terms of varying degrees of intensity based on clinical needs. All participants were invited to participate in a four session pain workshop. 

With this in mind, we really started to wonder what usual care is. I am now going to describe a separate study that was conducted. We just wanted to get a better idea of what the usual care is that patients receive for chronic pain. In this case, we conducted a retrospective cohort study within Division 20. That is the Pacific Northwest. It includes Alaska, Washington, Oregon and Idaho. We included patients that had chronic non-cancer pain. They were prescribed chronic opioid therapy. They received opioids daily for 90 or more consecutive days. This was purely administrative record data. It was electronic medical records. We compared those that had a current diagnosis of a substance use disorder versus patients, and this is all VA patients, without a substance use disorder. They were receiving different indicators of guideline concordant care. We identified patients in 2008 and followed them for the subsequent 12 months. The goal was to examine the extent to which patients received different aspects of care in a manner that is consistent with opioid treatment guidelines. As we know, opioid treatment guidelines are considered aspirational in model. There is certainly not an expectation that all patients receive their care in that way. However, we would think that those with a substance use disorder are potentially at highest risk. If anyone should be receiving the most intensive care, it is those with a current substance use disorder. 

With current substance use disorders in patients, there were a total of about 5,800 patients in Division 20 who met our criteria. Of these, nearly 20% had a current substance use disorder that was documented in the medical record. These substance use disorders included alcohol, cannabis, cocaine, opioids whether prescription or illicit, amphetamines or polysubstance. Keep in mind that there are a lot of differences that are considered statistically significant, but this is a sample size of nearly 6,000 people, so I do not know if this difference is clinically significant, a difference in three years of age. It is consistent with other research. Those with current substance use disorders were a little bit less likely to be married. There was no difference in medical comorbidities. There were no differences in the average daily dose of opioids and morphine equivalents. Those with a current substance use disorder were more likely to have a diagnosis of depression, bipolar disorder, PTSD, schizophrenia and no differences in documented sleep disorders. Those with a substance use disorder had higher rates of current nicotine use. 

We examined different indicators of guideline concordant care. these were the ones that we examined primarily because they show up a lot in opioid treatment guidelines and they were also outcomes that we could identify through the electronic medical record without having to review charts by hand. This included more intensive treatment in primary care. For the purpose of our study, more intensive treatment was operationally defined as having four or more visits within a one year period. We just conducted a median split of frequency of primary care visits. We evaluated whether patients were receiving a long acting opioid, whether they received physical therapy, a urine drug screen, mental health visits and antidepressant medication. These were specifically just within the subsets of patients that had an Axis I psychiatric disorder or had a depressive disorder. I also note that these recommendations are from opioid treatment guidelines. All of them may or may not be grounded in empirical data. Some of these recommendations are clinical consensus, rather than recommendations based on science. These were some of the consensus. 

As it relates to outcomes, there were no differences in rates between the two groups of having more intensive treatment in primary care. There were no differences in rates of receiving a long acting opioid or a likelihood of having a visit to physical therapy. Those patients with a current substance use disorder were more likely to receive a urine drug screen. They were a little bit more likely to have a mental health visit. The summary of treatment in usual care shows mixed results. A large proportion of patients were meeting pretty intensely with their primary care provider within a one year period. Among those with a depressive disorder, many were also receiving antidepressants. There are some areas for improvement. Twenty-six percent were receiving a long acting opioid. Twenty-nine percent in the total population that we evaluated received physical therapy. Only 24% were administered a urine drug screen. 

Some of the potential and most urgent issues to address are, of those patients with a current substance use disorder and were prescribed opioids, only 35% received specialty substance abuse treatment. There are treatment guidelines that are provided by the VA and Department of Defense that indicate that opioid medications are not necessarily contraindicated for those with a current substance use disorder, but if they are provided patients should be enrolled in substance abuse specialty care. Forty-seven percent of patients with a current substance use disorder received a urine drug screen. This is only within the subset of patients that had a urine drug screen. Fourteen percent of those with a substance use disorder and 5% of those that did not have a current substance use disorder had a positive urine drug screen for an illicit substance. We did not evaluate what happened in the participants' care after a positive urine drug screen. That certainly would be an area for future investigation. 

There are some recommendations based on all of this. We are getting close to wrapping up. Risk monitoring for prescription opioid misuse should be done with all patients who are prescribed opioids. This should occur prior to starting opioids and throughout treatment. As it specifically relates to urine drug tests, there was a really interesting study conducted several years ago now by Dr. Nathaniel Katz. There are two studies for backdrop. There was one that sort of found that providers that routinely utilize urine drug screens with all patients will encounter unexpected or aberrant results in up to 40% of tests. That is just given to all patients. There was a second study conducted by and described by Dr. Katz. He found that of those patients who were prescribed chronic opioid therapy and appeared complaint with treatment, approximately 20% of these pain patients who appeared compliant with treatment, 20% tested positive for an illicit or non-prescribed substance. With this as a backdrop, we do believe that urine drug screens should be a regular part of treatment. 

There are standardized measures of misuse that can be used. Other things can be used to detect prescription opioid misuse, such as urine drug testing, pill counts, opioid compliance checklists and collateral interviews. Monitoring of pain, function, adverse events and misuse should occur at every visit. The detection of aberrant medication use is an opportunity to discuss treatment options. I think that is an important piece. Simply because some tests positive for an illicit substance on a urine drug test does not automatically mean that all opioids should be removed. I think it is an opportunity to evaluate pain and function. We can evaluate what aspects of the care are occurring and if there are additional intensive or supplementary treatments that need to be included. Patients with pain and comorbid substance use disorders should be enrolled in specialty addiction treatment. This is a necessity for those with substance use who are prescribed opioids. Data indicates that in order for patients with comorbid substance use disorder to have clinically significant improvements in pain related function, the treatment must be more intensive and include additional components relative to usual care. 

Certainly we cannot provide all of our patients with chronic pain and substance use disorders referrals to a specialty pain service or multi-disciplinary care. There may be ways to incorporate aspects of multi-disciplinary care into an outpatient generalist practice, such as referrals and perhaps more intensive case management. There is system support that would be needed. There might be ways to include that and include referral to addiction services and mental health. Data indicates that cognitive behavioral interventions that incorporate relapse prevention have strong preliminary data to help reduce pain, improve function and reduce relapse risk. 

There are some additional readings. I discussed briefly the clinical practice guidelines offered by the VA and the Department of Defense. Here is the URL about how to find those. There are also clinical practice guidelines that have been published in The Journal of Pain. These were commissioned by The American Pain Society and The American Academy of Pain Medicine. SAMSHA has developed a TIP sheet. I forgot what TIP stands for. It is Treatment Intervention Protocol or something like that. I do not remember. They are free resources. Here is the URL about how to find and download. You can download the PDF and right at the moment, print it. You can also request that they send it to you. This is a free resource. It provides some really good recommendations about managing pain in patients with substance use disorders. 

That was all of my information. I very much appreciate your attention and you taking the time for those that stuck with me. I believe we can have the opportunity to open up for questions if any happen. 

Heidi:     We definitely have received some questions in. First I want to thank you Ben, very much for presenting. For the audience, if you do have a question, please use the Q&A screen to submit that into us. We do not have a huge amount of time left for questions. We are going to end at the top of the hour. We will get through as many as we can here. The first question I have here is where can we find all of the full references for the citations in the slides? 

Dr. Morasco:     I have not put them on there. Heidi, do you mail this talk out to people later? Is it just available on the website? 

Heidi:     It is available on the website. I do also send an archive notice out to everyone. If you do have that information we can make an additional handout or include that information in that notice that I will probably send out tomorrow or the next day. 

Dr. Morasco:     Yes. I can update this and include an additional slide that includes all of these references. I can pull that together. I will send it to you later today. When you send it out to participants the archive can include the full references. 

Heidi:     Perfect. That sounds great. Okay. The next question is how valid is assessment of SUD in patients seeking opioid prescriptions? Current methods of detecting abuse must be vulnerable to gross patient under reporting, correct? If so, how do we obtain better screening instruments? 

Dr. Morasco:      I think that is an excellent question. I do not think there is a single answer. I do not think that we can look to a single measure. It is nice having the urine drugs screens. In some ways they are held as some as being a gold standard. I think they are a strong component to include. It is this sort of outcome measure. So much is based on self-reporting. We do not want to be in a position where providers and patients are pitted against each other. One of the best methods is strong rapport between patients and the providers. The evaluation should be ongoing. It should also be normalized. I think it is important to note that 75% to 80% of patients do not necessarily take opioids in all the ways that are recommended. We want patients to take them every day, five times a day or whatever it is. The majority of patients do not always take medications at the same time every day. I think that is an important piece to know. We continue to recommend it. We can also have honest conversations with people about what their practices are. 

There are validated self-reporting measures that are available. I did not get into those specifics. Some of the ones that have the best data are something called the COMM, the Current Opioid Misuse Measure. I like that. The COMM was developed by Steven Butler. There is also the pain medication questionnaire by Robert Gatchel The reason I like those is that they include evaluation of fluid factors of misuse. They discuss things about craving for opioids. They normalize people that crave medications or take a little bit more than prescribed. That kind of opens up the conversation about it. I also like them because they are not dependent upon static demographic factors such as having a history of a substance use disorder. Certainly that is important, but these things change over time. There are the recommendations that I discussed as well, that were put out by Dr. Jamison, and whether or not people want to include the things about 24 hour pill counts and urine drugs tests at every visit, as well as collateral interviews. Certainly those things are options. Thank you. 

Heidi:     Great. Thank you. The next question I have here is when diagnosing opioid misuse versus abuse or dependence, what diagnostic code do you use in your documentation? The person typically uses a substance related diagnosis? 

Dr. Morasco:     The question was when you diagnose misuse versus an explicit substance abuse disorder? That is the question? 

Heidi:     Yes. 

Dr. Morasco:     To be honest, I have not thought about it. It is an excellent question. I am slightly embarrassed that I have not thought about it. For typical abuse or dependence, there would be an ICD-9 code for that. I can make thoughts about other substance abuse sorts of things. I have not thought that through. This is really unfortunate. I would like to have a discussion with others and see what other people are doing. It is an unfortunate that we cannot hear from some of the others that are on the call that have addressed this. 

Heidi:     That is one drawback with this. 

Dr. Morasco:     One thing I would say, and I am sorry to interrupt, is yes. I think it can be documented. I am sorry. I should have said this. Our documentation should include that. As someone who reads a lot of primary care notes and other treatment notes, there are difficulties in trying to do charting. These are some things that should be noted in the medical record. If we can find out a diagnosis code is one thing. One sentence of text is also very helpful. 

Heidi:     Okay, great. Thank you. The next question we have here is commonality among the efficacious interventions appears to be that they include numerous collaborative and comprehensive biopsychosocial services. Add in the research based assessment batteries and it appears like it might be quite demanding for patients. What was the attrition rate among the experimental groups, higher or lower than those seen among standard care patients? 

Dr. Morasco:     That is a really interesting question. The studies that were done were largely cohort studies. They included prepost evaluations. Some aspects of them, and I am thinking of the studies from the opioid renewal clinic, for patients that chose not to participate in that, my understanding is that they no longer received opioids. That was a choice that they received in their care. Some of the other studies, like the multi-disciplinary care and the methadone maintenance program, are certainly more rigorous. I am trying. I do not have the attrition numbers specifically that they had. I know that those were ultimately made into the care practices for those patients, particularly the Chelminski North Carolina study. That was their care. If patients wanted to continue receiving care it was done in the multi-disciplinary fashion. 

The issue of burden is a very real one. In a busy primary care practice, trying to incorporate these things with a single provider may not be a realistic thing to do, particularly as the person brought, in terms of all of the documentation of the questionnaires. Being able to include system support in some way and trying to find ways to include the questionnaires, and for someone to provide results and then also to support providers in referring patients. I think an essential piece is helping the patients follow up. I think it is one thing to provide the recommendations to patients. I think one of the reasons why the collaborative care study conducted by Dr. Dobscha here at the Portland VA was so effective was that it had that case management piece. Patients were called every two months by the care manager to evaluate treatment outcomes. Frankly, that is an additional level of treatment intensity that might be beyond what occurs in typical practice. I think that is the piece. So many times, we provide recommendations to patients and we check in. We see them at the next follow-up visit however much later. People may or may not have gone. Whether it is depression or pain, it has stagnated or in many cases worsened. I think that opportunity to then provide those regular follow-ups is an opportunity to work with the patient and adjust treatment goals. It is a level or more intensity treatment. Thank you. That is a great question. 

Heidi:     Great. Thank you. The next question I have here is do you have data on why subjects did not participate in the behavioral skills? 

Dr. Morasco:     No. That was referred to the study conducted by Dr. Dobscha with the collaborative care intervention. I personally was not involved with it. In talking with Dr. Dobscha, they did not ask questions specifically about why patients did or did not choose to engage in that. For some patients that did, not all of them participated in all four sessions. No, they did not collect data specifically about why people did not complete all of those. I think that is also consistent. I think our VA also has a specialty pain service that includes cognitive behavioral therapy group classes. Sometimes there is a waiting list. Sometimes there is not as much compliance or follow through with that group as we would hope. 

Heidi:     Okay, great. Thank you. We are at the top of the hour. We do still have a lot of pending questions. Ben, I do not know if you are able to stay longer or if you would prefer to handle some of these offline? 

Dr. Morasco:     How many people are still on the line? 

Heidi:     We have got just over 200 people still on the call. Because most people's schedules have an hour for this, we are going to have a huge drop off right now. 

Dr. Morasco:     I am happy to take a couple more calls. I also have something. I can do a couple more. 

Heidi:     Okay. Let's try to get you a couple more. 

Dr. Morasco:     Certainly if questions are sent, I can respond to them. 

Heidi:     That sounds good. Let's try to get through some. The numbers are just plummeting right now. People have to go. I totally understand. We will see what we can get through here. The next question is was pain from malignancy and/or patients judged within six months of end of life in any of these studies? 

Dr. Morasco:      That is an excellent question. I should have highlighted that. No, the studies only looked at, particularly when I examined what pain is in usual care, were only patients with chronic non-cancer pain. It may have included neuropathy or fibromyalgia. There were a lot of musculoskeletal pains. We specifically excluded those that had cancer. We excluded those that were palliative care. That is also true with Dr. Dobscha's study. They included only those that had current musculoskeletal pain. 

Heidi:     Okay, great. Thank you. The next question is kind of long. I am going to try to get through this here. The question is nice work with summarizing treating those with chronic pain and SUD. With questionable benefit of opioids in chronic pain, particularly axial low back pain i.e. 30% reduction is only documented in studies up to 16 weeks. With the associated risks of overdose, should we treat this higher risk population with SUD with intense mental health therapy, structured exercise and not with opioids i.e. should opiates be contraindicated for this high risk group? Could we better use our limited resources on SATP and CBT rather than asking primary care to do more appropriate screening for opiate misuse? 

Dr. Morasco:     That is an excellent question. I love it. To repeat, given that patients with substance use disorders have risks for misuse and there is data coming out about potential overdose, is this a patient population that we should potentially restrict opioids to and instead include other ancillary treatments, such as cognitive behavioral therapy, physical therapy and specialty addiction treatment? That is my understanding of the question. 

My talk and my background are that I am a clinical psychologist. I am not going to jump too much into the debate about whether or not opioids should or should not be prescribed. There are recommendations that are starting to come out that some people are starting to say that long term opioid therapy is contraindicated for all patients. That is one view. Some people find that as being extreme. There is debate about that. There is some data potentially showing what we are really treating when we prescribe long term opioid therapy. In talking with my clinical colleagues, there are many clinical colleagues who say some patients do very well on long term opioids and do not show any indicators of misuse. Their pain is well managed. Specifically as it relates to those with a substance use disorder, definitely yes, I think all of these things should be included. I think there is strong empirical data showing that particularly those with a substance use disorder need to be included in substance abuse specialty care. I think they need behavioral interventions. I think all of those things should be included. Whether or not it should also include prescription opioids, I think that is an empirical question, at least for me, given that I do not prescribe. 

For me it is an empirical question and one that we do not yet have an answer to. That is an unsatisfying response. I know there are some studies that are being conducted now that show that the relation we all know as it relates opioids, the best data available is following patients for three months or six months. We do not know about the outcomes of the efficacy of prescriptions of opioids long term. I know that there is some research being done on this at... in Seattle through The Group Health, and potentially others. I think that is an empirical question and one that we need research to identify whether they should or should not be prescribed long term. 

Heidi:     Thank you. The next question received here is of the 20% of patients who had positive UDAF for illicit drugs, how many were from cannabis? What are the pros and cons of separating the use of cannabis from the data? 

Dr. Morasco:     Yes. I do not know specifically about which set of 20% that question referred to. I could go back through and look through the slides. This is the disadvantage of not having the person in person. What proportion of them? The majority of positive urine drug screens were from cannabis. We were not able to disentangle whether or not the cannabis was medicinal marijuana or taken illicitly. That is a tricky and thorny issue within the VA. There are notices put out about medicinal marijuana. The question ultimately is should these urine drug screens be considered illicit or are they known? Ultimately I do not know. I think that it also looks at what the actual clinical outcomes are associated with patients taking medicinal marijuana. I think that is also an empirical question. It is one where we do not have satisfactory empirical data to know. Specifically as it relates to the question, yes, most but not all of the positive urine drug screens were for cannabis. There were also significant numbers for cocaine and amphetamines. 

Heidi:      Great. Thank you. Are you still okay staying a little bit longer? 

Dr. Morasco:     I was looking at my watch. I was thinking I had one more. 

Heidi:     One more? Okay. 

Bob:     I think that is a good idea. 

Heidi:      Okay. That sounds good. the last question that we have here is in reference to Slide 37, Summary of Data, is there any evidence to suggest that chronic pain patients with comorbid SUD would indeed experience a clinically significant improvement in pain related function with more intensive and supplementary treatment? Do we merely want to believe this is true? 

Dr. Morasco:     I got slightly distracted when I was going through my slides. You said at Slide 35?

Heidi:     Slide 37. 

Dr. Morasco:     Thirty-seven? Excuse me. 

Heidi:     Summary of Data. Is there any evidence to suggest that chronic pain patients with comorbid SUD would indeed experience a clinically significant improvement in pain related function with more intensive and supplementary treatment? 

Dr. Morasco:     That is a great question. I do believe they would. I do believe that if patients with a comorbid substance use disorder receive more intensive treatment, they would have clinically significant improvements in pain related function. The reason why I believe that is based on the data. I am slowing down for those who are looking at the slides. For those who were randomized to collaborative care and received the more intensive treatment, we see that having a history of a substance use disorder, that those individuals were as likely to improve from treatment as those that did not have a history of a substance use disorder. I also think about the studies that I cited earlier about the cohort studies, whether it be the CBT studies by Dr. Ilgen and Dr. Curry, the multi-disciplinary care , the prepost cohort studies that showed that individuals that were assigned to those multi-disciplinary care or were treated in a methadone maintenance type program did have improvements in pain related function and quality of life. 

Heidi:     Great. Thank you. Ben or Bob, do either of you have any closing comments you want to make? 

Dr. Morasco:     I am just going to say thank you again. These are wonderful questions. I really appreciate these resources. This was a great opportunity to talk. I guess the only unfortunate part is that we could not talk directly with people. This is great feedback. I am glad there is so much enthusiasm. 

Heidi:     Fantastic. 

Bob:     This is Bob. Can you hear me? 

Heidi:     Yes we can. 

Bob:     That is great. Thank you to Heidi and our colleagues at CIDER for their support for this. Thank you to Ben. What a tremendous presentation. What I hope most people who are still on the call appreciate is the importance and the priority that we place in The National Pain Management Program Office about trying to promote education of our community of researchers, educators and clinicians, as an integrated community, and particularly the importance of trying to promote evidence based practice and policy in the VA. Some may be anxious for VA Central Office to push forward with more specific policy guidance around tough issues like this one. I really want to show respect for Dr. Morasco's presentation and some of his answers to the questions, which were to plead that in some cases, they maybe withhold judgement in the absence of actual data that can support decisions about practice and policy issues. I would personally want to encourage people that are still on the call to tune in for these presentations, and a growing number of similar presentations that are being sponsored by CIDER in particular and by other groups in the VA, that address some of the tough clinical and clinical research challenges that were confronted in VA-related pain and pain management. I just want to thank Ben, Heidi and all of the participants on today's call. Thank you very much for your interest and your work with veterans. 

Heidi:     Great. Thank you. I want to echo Bob. Thank you so much for presenting today. We do very much appreciate it. For our audience, the next session in this series is scheduled for December 4th. Linda Goleski and John Salinger will be presenting. We will be sending out additional information and registration information once we get a little bit closer to that session. Thank you everyone for joining us today. This formally concludes today's cyber seminar. Thank you. 

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