Treatment of Chronic Pain in Pa

with Comorbid Substance U

Disorder

Benjamin Morasco, Ph.D.

Mental Health and Clinical Neurosciences Divi

Portland VA Medical Medical Center

Department of Psychiatry, Oregon Health & Science 
Acknowledgements

• For collaboration on these projects:

– Rachel Atwater, M.S.W.

‐ Kathryn Corson, P

– Renee Cavanagh Cavanagh, M S. . ‐ Steven Dobscha Dobscha, M 

– Aysha Crain, M.S.W.

‐ Dennis Donovan, 

– Sue Gritzner, Ps

y.D.

‐ Peter Hauser, M.D.

– Elizabeth Grimaldi, B.A.

‐ Alan Marlatt, Ph.D

– Lynsey Lewis, M.A.  ‐ Dennis Turk, Ph.D

• Receive funding from the National Institute on Dru• No conflicts of interest to report.
Objectives

• Review the prevalence of SUD in different pain po

• Review data on prescription opioid misuse.

• Report treatment outcomes based on SUD status

• Identify current treatment practices for pain amo

patients wi ht comorbid SUD.

• Provide recommendations for clinical practice.
Pain and SUD

• Comorbid substance use disorders ( ) SUDs are com

patients with chronic pain, but systematic research 

• Prevalence rates of SUDs vary widely across studie

• Data are limited regarding treatment options for c

patients with comorbid SUD.

• Conducted a systematic review: To assess the prev

associated demographic and clinical characteristics

treatment outcomes for chronic pain patients with 

SUD.

Morasco et al., 2011; Pain, 
Proportion of Pain Patients with Current SUD

35%

40%

p

Outpatient pain clinic Inpatient pain cl

35%

30% 28%35%

19%

15%

2

20%25%

11%

8%

5%

10%15%

0%
Proportion of Pain Patients with Current SUD

60%

Proportion of Pain Patients with Current SUD

Primary care clinic Mastalgia AIDS 

50% 48%

60% Primary care clinic Mastalgia AIDS 

34%

30%40%

19%

20%30%

8% 10%

4%

10%

0%

Edlund,

2007

Fleming,

2007

Morasco,

2008

Morasco,

2011

Johnson,

2006

Hoyt, 1
Proportion of Pain Patients with a History of SU

70%80%

Pain clinic Primary 

44%

48% 50%

60%70%

22%

28%

33% 36%

28%

44%

28%

30%40%

50%

22%

16%

10%20%

0%
Assessment for SUD

• All patients should be assessed for current and pas

Assessment Assessment of current current use should be incorporated incorporated 

follow‐up visits.

• Brief Addiction Addiction Monitor Monitor (BAM), a validated validated 17‐item 

current alcohol and substance use, as well QOL.

– This measure is now routinely administered in VA substa

treatment programs.

– In CPRS, click on Tools Mental Health Assistant Instru

Administrator BAM

• Can also administer as a paper and pencil test:

https://vaww.portal.va.gov/sites/OMHS/SUD/Lists/BAM/AllItems.

• O ht er Measures:

– AUDIT‐C, 3 items, alcohol only– ASSIST, alcohol alcohol and illicit illicit substances substances, number of items de

what is endorsed; questions about craving, misuse, etc.
Implications Implications of Ha in v g a Comorbi

Comorbi

• Potentially more difficulty to treat.• Concern about other comorbidi it es (d i epression, an

• For patients prescribed opioids, there may be incre

for prescription opioid misuse.

Morasco et al., 2011; Pain, 
SUD Status and Prescription O

Misuse

• A total of 7 prior studies have examined prescriptio

misuse based on SUD status, status, and 4 found that pati

pati

history of SUD were more likely to exhibit prescrip

misuse.

– All of the prior studies that were rated higher in method

found that history of SUD was associated with current pr

opioid misuse.

Morasco et al., 2011; Pain, 
Signs of Prescription Prescription Opioid M

Behaviors Behaviors LESS indicative indicative of “addiction addiction”:‐anxiety/desperation over symptoms‐hoarding medications

‐taking medications from others

‐requesting specific medi i cat ons

‐used more opioids than recommended

‐drink more alcohol alcohol when in pain

‐express concern when changing medications

‐express concern that pain might lead to use of str

‐smoke cigarettes for pain relief

‐use of opioids to treat other symptoms

Passik et al., 2006; Clin J Pa
Signs of Prescription Prescription Opioid M

Behaviors MORE indicative of “addiction”:‐bought pain medications medications from a street dealer‐stole money to obtain drugs

‐tried to get opioid from more than one source

‐performed sex for opioids or for money to obtain 

‐saw two physicians at once without them knowin

‐stole drugs from others

‐prescription forgery

Passik et al., 2006; Clin J Pa
How Often Does Prescription O

Misuse Occur?

• It depends upon the definition of misuse.• Less than 4% of patients prescrib de opi id o s d l eve o

opioid abuse or dependence to the prescribed opi

al., 2008; Fleming Fleming et al., 2007).

• 78% of patients with chronic pain report 1 or more 

indicator of misuse (Morasco & Dobscha, 2008):

– Borrow pain medications from others – 8%

– Take more medication than prescribed – 53%

– Multiple Multiple requests requests for opioid dose increase increase – 56%– Ran out of pain medications and requested early refill – 

– Doctor shopping – 3%
Rates of Misuse

• A recent study examined the rate of prescription o

misuse behaviors behaviors documented documented in the medical medical reco

examined whether these were associated with clin

diagnoses diagnoses of a prescription prescription drug use disorder disorder (Meltze

(Meltze

press”, Pain Medicine).

– Reviewed medical records for patients prescribed long‐te

with opioids or benzodiazepines. They also conducted re

interviews to diagnose a drug use disorder.

– 85% of patients patients had medical medical record documentation documentation of pr

pr

opioid misuse.

– No difference between those with and those without a p

drug use di d sor er in rates of d td ocumented misuse.

• Taken together, results suggest the prevalence of a

diagnosable diagnosable prescription prescription SUD is low, yet many pati

pati

intermittently misuse pain medications. 
Predictors of Current Prescription 

Misuse

• Current or past substance use disorder (Barry et al., 2011; 

2007; Morasco & Dobscha, 2008; Reid et al., 2002)

• Younger age (Ives et al., 2006)• Personal or familial history of legal problems (Michna e• A i nx ety (Schieffer et al., 2005) or d i epression (Grattan et al., 2012)• Beliefs about the effectiveness of opioids (Schieffer et al• Perceptions of the threat of pain (Morasco et al., In press)• Type of pain disorder, duration of pain, intensity, fun

quality of life have not been associtd a e with ri ks for 

opioid misuse.
Recommendations to Reduce 

Impact of Medication Misu

For patients who show initial signs of prescription op(Jamison et al., 2007):

– More frequent opioid prescriptions (weekly)– 24 hour notice pill counts– Early detection of risk factors for misuse

– Collaborate with substance abuse and mental health profe

– Complete an opioid compliance checklist before opioid pre

item yes/no questionnaire)

– Give urine

drug screens

a

t eac

h

vi it s
A Randomized Randomized Trial Designe

Designe

Reduce Medication Misus

• All patients were assessed for likelihood of prescript

misuse at baseline. baseline. Participants Participants randomized randomized to 1 of 

– 19 patients at high‐risk were randomized to an experimen

(High‐Risk Experimental).

– 19 patients at high‐risk were randomized to usual care (Hi

– 20 patients at low‐risk for medication misuse received usu

were followed followed as a second comparison comparison group (Low‐Risk Co

Co

• All patients were followed for 6 months.

Jamison et al., 2010; Pain, 1
High‐Risk Experimental Gro

Compliance with Treatme

• Monthly completion of opioid compliance checklist• Monthly urine drug screens screens• Monthly individual therapy

– Review of compliance checklists, response to medication, 

abstinence from illicit substances, patient support, educat

management, and discussion of non‐compliance.

• Monthly group therapy

– Focused on opioid addiction risks, education about misuse 

making lifestyle changes, avoiding drug use triggers, and e

attendance at all appointments.

Jamison et al., 2010; Pain, 1
Results of a RCT Designed to Re

Medication Misuse

74%

70%80%

Proportion of Patients with Medication Misuse

50%60%70%

30% 26% 240%

50% 10%20%

0%

High‐Risk Control High‐Risk Experimental Low‐Ri

Jamison et al., 2010; Pa
Treatment of Chronic Chronic Pai

• The best data available indicate that most treatme

chronic pain relieve no more than 40‐50% of pain.

• O i id p o medi ti ca ons may result in as much as a 30% 

in pain intensity, for only one‐half of the patients t

them.

• Few patients are “cured” of their chronic pain.

• Multidisciplinary Multidisciplinary care is the most optimal optimal treatme

treatme

chronic pain, which may include primary care, phy

therapy, occupational therapy, mental health, nurs

work, pharmacy, and potentially specialty medical 

(physiatry, orthopedics, anesthesiology, etc.).
What do we Know about Treating Treating 

Patients with SUD?

• Little empirical data available.

– Primary exclusion criteria for most clinical studies on chronic p

having a history of SUD.

• No well‐conducted conducted studies studies have compared compared treatm

treatm

outcomes for chronic pain based on SUD status.

• There have been no published published randomized randomized trials e

e

medication or psychological intervention in pain pa

comorbid SUD.

Morasco et al., 2011; Pain, 
What is the Efficacy of Treatme

Patients with Pain and SUD

1. A primary care multidisciplinary disease managem

was effective in reducing pain and improving funct

et al., 2005).

2. Enrollment in a methadone maintenance program, 

included regular g p rou therapy and case managem

in significant improvements in pain relief and quali(Rhodin et al., 2006).

3. Participation in a pharmacy‐led opioid renewal clin

effective in reducing aberrant medication use and 

pain management management (Wiedemer (Wiedemer et al., 2007).

4. Cognitive‐behavioral therapy, incorporating relapse

prevention, helps reduce pain, improve function, arelapse risk (Currie et al., 2003; Ilgen et al., 2011).
Pain Outcomes Outcomes in a Prospec

Prospec

Randomized Trial

• Research Question: To what extent does a col

care i t ti i h i l k 

intervention improve chronic musculoske

and depression outcomes?

• Setting: 5 primary care clinics of one VA Medic

: 5 primary care clinics of one VA Medic

• Participants:

– 401 primary care patients with musculoskeletal pain 401 primary care patients with musculoskeletal pain– 42 primary care clinicians

Dobscha et al., 2009; JAMA, 
Methods

• Cluster randomized controlled trial.

• Compared collaborative care to usual care for the t

of pain and d i epression.

• Inclusion criteria: diagnosis of chronic musculoske

pain intensity intensity and interference interference > 4, and telephone telephone 

• Exclusion criteria: psychotic‐spectrum disorder, de

cognitive impairment.

– Did not exclude patients with active alcohol or substance 

disorders.

Dobscha et al., 2009; JAMA, 
Intervention: Assistance w

Pain Treatment (APT)

• Main Conceptual Components:

– Chronic illness model; stepped care Chronic illness model; stepped care– Biopsychosocial framework– Focus on developing individualized functional goal– Multidisciplinary approach– Behavioral/activating approach

• Full-time Psychologist Care Manage

r

• Up to 1 day/week Physician Pain Specialist 

Dobscha et al., 2009; JAMA, 

Selected Baseline Patie

Characteristics

Mean age, years Male Self

‐reported race/ethnicity—Caucasian/white 

Married Worked during past 12 months Currently receiving disability payment 

Current depression 

Positive alcohol misuse screen Posttraumatic stress disorder disorder 
Selected Baseline Patie

Characteristics

Mean age, years Male Self

‐reported race/ethnicity—Caucasian/white 

Married Worked during past 12 months Currently receiving disability payment 

Current depression 

Positive alcohol misuse screen Posttraumatic stress disorder 

stress disorder 
Roland-Morris Score Change Over Time

1614

14.5

15

15.5

rris Score TAU

12.5

13

13.5

14

Roland-MoInte

12

0 3 6 12

Time Point

PHQ Score Among Those With PHQ GE 10 at Baseline

16131415

core TA

9

101112

PHQ ScTA

Inte

89

0 3 6 12

Time Point 
Summary of Findings Summary of Findings

• Collaborative Care resulted in improvements 

measures of:

– Pain disability

– Pain intensity

– Depression severity Depression severity– Patient-rated global impression of change

• Clinicians and patients satisfied with interven

Clinicians and patients satisfied with interven

• Meaningful improvements for this population 

substantial baseline disabilit

y y /comorbidit

y

Dobscha et al., 2009; JAMA, 
Predictors of Treatment Treatment Outc

Outc

• Conducted a secondary analysis to determine if an

assessed at baseline were associated with treatme

outcome.

• Clinically significant improvement was defined as a 

red i uct on between b li ase ne and 12 months on the 

Morris Disability Questionnaire.

• Analyses Analyses were stratified stratified by intervention intervention status (co

(co

care or treatment‐as‐usual) due to significant diffe

pain care received.

Morasco et al., 2011; The Journal of Pa
History of SUD

• Of the 362 participants with 12 month follow‐up d

(n=72) had a history of SUD.

– Alcohol ‐ 86%– Cannabis ‐ 14%– Opiate (prescribed and/or illicit) ‐ 8%– Amphetamine ‐ 3%– Other ‐ 18%
Comparisons Comparisons Based on History History 

– Baseline

Pain & SUD Pain Only (n=72) (n=290)

Mean age, years* 58 (10) 63 (12) 

Male gender 92% 92% Married* 47% 63% C i aucas an 90% 89% VA service‐connected 53% 52% Duration Duration of pain diagnosis diagnosis 14 years 15 years Current opioid prescription* 40% 26% 
Baseline Comparisons

Pain & SUD i O l 

(n=72)

Pain Only

(n=290)

Pain intensity intensity 68 (12) 67 (14) Pain‐related function* 16 (16) 14 (4) Major depressive depressive disorder disorder* 26% 14% PTSD* 25% 14% Positive Positive alcohol alcohol misuse screen* screen* 11% 4% 
Predictors of Treatment Treatment Outc

Outc

For patients randomized to Collaborative Care, the ovewas not significant and no factor predicted outcome.

Odds R ti a o 95% C fid on enc

Step 1

Age 0.99 0.95 – 1.Male Gender 0.91 0.23 – 3.

Pain Duration 1.01 0.98 – 1.

Number of Pain Diagnoses 1.04 0.61 – 1.

Opioid Prescription 0.60 0.28 – 1.

Step 2

PTSD 0.73 0.22 – 2.

Major Depression 3.72 0.77 – 18

j p

History of SUD 1.06 0.37 – 3.
Predictors of Treatment Treatment Outc

Outc

For patients randomized to Usual Care, the overall msignificant significant, and the only predictor predictor of outcome outcome was his

his

SUD.

Odds R ti a o 95% C fid on enc

Step 1

Age 0.99 0.95 – 1Male Gender 0.64 0.12 – 3

Pain Duration 0.96 0.92 – 1

Number of Diagnoses 0.55 0.28 – 1

Opioid Prescription 0.72 0.28 – 1

Step 2

PTSD 4.46 0.73 – 27

Major Depression 1.26 0.28 – 5

j p

History of SUD 0.30 0.11 – 0
Summary of Data

• Chronic pain patients with a history of SUD:

– Had poorer functioning and greater psychiatric comorbid

– Were more likely to be prescribed an opioid

– For those randomized to usual care, were 70% less likely 

clinically significant improvement in pain functioning

• For patients patients randomized randomized to collaborative collaborative care, SUD 

not associated with long‐term functioning.

• Implications Implications: Chronic Chronic pain patients patients with comorbid comorbid 

more intensive and supplementary treatment in o

clinically significant improvements in pain‐related 

Morasco et al., 2011; The Journal of Pain
What Did Participants Participants in This 

Receive?

• Usual care.

• Individualized assessments from a py g s chologist wit

bimonthly telephone calls to offer support, identif

needs, and encourage compliance.

• In collaboration with an internist, recommendation

given to the PCP for possible implementation:

– S i uggestions may have i ldd nc u ed ref l erra to mental h lh ea t 

pain service, PT, or other service; imaging; medication ch

Recommended guideline‐concordant treatment.

• Stepped‐care model.• Eligible to participate in a 4‐session pain workshop 

by psychologist and physical therapist).
What is Usual Care?

• Conducted a retrospective cohort study with 5,814 

who received care in the Pacific Northwest.

– All patients had chronic non‐cancer pain and were presc

opioid therapy.

• Compared patients with a current diagnosis of SUD 

those without without current current SUD on receiving receiving different different i

i

guideline concordant care.

– Patients Patients were identified identified in 2008 and followed followed for the sub

sub

months.

• Goal was to examine the extent to which patients 

different aspects of care in a manner that is consis

opioid treatment guidelines.

Morasco et al., 2011; J Gen In
Current Current SUDs in Patients Patients with Ch

Ch

Pain

• Of the 5,814 patients with chronic pain and prescr

chronic opioid therapy in 2008, 19.5% had a curren

diagnosis documented in the medical record.

– Al h l co o  ‐ 73%– Cannabis ‐ 16%– Cocaine ‐ 11%– Opiate (prescription and/or illicit) ‐ 15%– Amphetamine ‐ 8%– Polysubstance ‐ 7%
Bivariate Comparisons

Pain & SUD(n=1136)

Pain Only(n=4678)

Age 53 (9) 56 (12) 

Male gender 93% 90% 

Married 33% 50% Charlson comorbidity score 1.2 (1.5) 1.1 (1.5) Average daily opioid dose morphine

equivalent

57 mg/day(SD=86)

57 mg/day

(SD=122)

3 or more documented documented pain 31% 27% 

diagnoses

31% 27% 
C i ompar son of P hi t i Psychiatric Diag

Pain & SUD(n=1136)

Pain Only(n=4678)

Depression 53% 37% Bipolar disorder 12% 4% PTSD 40% 25% Schizophrenia 6% 2% Any sleep disorder 11% 10% 

Nicotine disorder 56% 27% 
Indicators of Guideline Guideline Concordan

Concordan

Pain & SUD

(n=1136)

Pain Only

(n=4678)

Odd

(95% 

More intensive treatment inprimary careReceive Receive a long‐acting opioidPhysical therapyUrine drug screenMental health visitA tid t Antidepressant M di ti Medication
Likelihood of Receiving Guide

Concordant Care

Pain & SUD

(n=1136)

Pain Only

(n=4678)

Odd

(95% 

More intensive treatment inprimary care

63% 61% 1.1 

Receive Receive a long‐acting opioid 27% 26% 0.9 Physical therapy 31% 29% 1.1 Urine drug screen 47% 18% 3 5. Mental health visit 30% 17% 1.5 A tid t Antidepressant M di ti Medication 88% 86% 1 3. 
Summary of Tx in Usual Care

Among patients with chronic pain who were prescrib

opioid therapy:

The Good:

• 62% met with PCP four or more times in 1 year• 86% with a depressive disorder received an antidepress

Room for Improvement:

• 26% received received a long‐acting opioid• 29% received physical therapy• 24% were administered a UDS

Most Urgent Issues to Address:

• 35% of patients with a current SUD received substance a• 47% of patients patients with a current current SUD received received a UDS• Of patients that had a UDS, 14% of those with a SUD an

without had a positive UDS for an illicit substance
Recommendations for Treating Treating 

Patients with Comorbid SU

• Ris

k monitoring

for prescription opioi

d misuse

s

h 

o

done with all patients prescribed opioids.

– This occurs prior to starting starting opioids opioids and throughout throughout trea

trea

– There are standardized measures of misuse that can be 

– Urine drug testing, pill counts, opioid compliance check

collateral interviews interviews are also options options.

• Monitoring of pain, function, adverse events, and 

should occur at every visit.

• Detection of aberrant medication use is an opport

discuss treatment options.
Treatment Recommendatio

• Patients with pain and comorbid SUD should be en

specialty addiction treatment.

– Is a necessity necessity for patients patients with SUD who are prescribed prescribed o

o

• Data indicate that, in order for patients with como

have clinically significant improvements in pain‐rel

function, treatment must be more intensive and in

additional components, relative to usual care.

– Highest Highest recommendation recommendation is for multidisciplinary multidisciplinary treatme

treatme

• Cognitive‐behavioral interventions, that incorporat

p , revention, have strong p y reliminary data for help 

in 

pain, improve function, and reduce relapse risk.
Additional Readings

• VA/Department of Defense Clinical Practice Guidelin

treating chronic pain with opioid therapy:

– http://www.healthquality.va.gov/Chronic_Opioid_Therapy

• Cli i l Clinical practice guid li e nes for the use of ch i ron c op

in chronic noncancer pain, commissioned by the Am

Society Society and the American American Academy Academy of Pain Medicin

Medicin

– http://download.journals.elsevierhealth.com/pdfs/journa

5900/PIIS1526590008008316.pdf

• SAMSHA Manual on Managing Chronic Pain in Adult

Recovery From Substance Use Disorders (TIP 54)

– h // h / d / http://store.samhsa.gov/product/TIP‐54‐Managing‐Chron

Adults‐With‐or‐in‐Recovery‐From‐Substance‐Use‐Disorde
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Thank you!

Questions? Comments?