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Guide to Aberrant Drug-Related Behavior When Prescribing Opioids
for Pain Management
Lynn R. Webster, MD
Vice President of Scientific Affairs
PRA International
Salt Lake City, UT
March 12, 2015
Accreditation
• The American Academy of Pain Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
• Credit Designation: The American Academy of Pain Medicine designates this live webinar for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Dr Webster: Disclosures
• 12-Month disclosures of financial relationships with commercial interests:
• This presentation does not contain off-label or investigational use of drugs or products
Honorarium: Consultant Honorarium: Advisory Board Travel Expenses
Acura Pharmaceuticals Depomed Acura Pharmaceuticals
AstraZeneca Egalet AstraZeneca
BioDelivery Sciences International Inspirion Pharmaceuticals BioDelivery Sciences International
CVS Caremark Insys Therapeutics Bristol-Myers Squib (BMS)
Grunenthal USA Kaleo Depomed
Mallinckrodt Pharmaceuticals Mallinckrodt Pharmaceuticals Grunenthal USA
Nevro Corporation Signature Therapeutics Inspirion Pharmaceuticals
Synchrony Healthcare Teva Pharmaceuticals Insys Therapeutics
Travena Jazz Pharmaceuticals
Kaleo
Mallinckrodt Pharmaceuticals
Nektar Therapeutics
Nevro Corporation
Orexo Pharmaceuticals
Teva Pharmaceuticals
Travena
Planning Committee, Disclosures
• Vitaly Gordin, MD Director of Pain Division Penn State Hershey Medical Center Hershey, PA
No relevant financial relationships
• Jennifer Westlund, MSW Director of Education American Academy of Pain Medicine
No relevant financial relationships
• Angela Casey VP, Medical Director PharmaCom Group
No relevant financial relationships
Target Audience
• The overarching goal of PCSS-O is to offer evidence-based
trainings on the safe & effective prescribing of opioid
medications in the treatment of pain &/or opioid addiction
• Our focus is to reach providers &/or providers-in-training
from diverse healthcare professions including physicians,
nurses, dentists, physician assistants, pharmacists, &
program administrators
Educational Objectives
• At the conclusion of this activity participants should be able to:
1. Understand how to assess for & interpret
aberrant drug-related behaviors
2. Devise a plan to incorporate common risk
assessment tools into clinical practice
3. Utilize information from risk assessment in order to
stratify patients’ risk
Definition of Terms
• Use of a medication (for a medical purpose) other than as directed or as indicated, whether willful or unintentional, & whether harm results or not
Misuse
• Any use of an illegal drug
• The intentional self administration of a medication for a non-medical purpose, such as altering one’s state of consciousness, eg, getting high
Abuse
• The intentional removal of a medication from legitimate distribution & dispensing channels Diversion
Addiction
• A primary, chronic, neurobiological disease, with genetic, psychosocial, & environmental factors influencing its development & manifestations
• Behavioral characteristics include one or more of the following: Impaired control over drug use, compulsive use, continued use despite harm, craving
Katz NP, et al. Clin J Pain 2007;23:648-60.
Comparison of DSM-IV & DSM-5 Criteria for Opioid Use Disorder
DSM-IV
Abuse DSM-IV
Dependence
DSM-5 Opioid Use
Disorder
Recurrent use in physically hazardous situations ≥1
criteria in
12-mo period*
-
≥3
criteria in
12-mo period
≥2 criteria
in 12-mo period
Social/interpersonal problems related to use - Neglected major roles at work, school, or home due to use -
Recurrent substance-related legal problems - -
Withdrawal -
Tolerance -
Used larger amounts or for longer than intended - Desired or unsuccessful attempts to quit/control use -
Much time spent obtaining, using, or recovering - Continued use despite physical/psychological problems -
Social/occupational/recreational activities given up/reduced due to use -
Craving or a strong desire or urge to use opioids - -
*And no diagnosis of dependence American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR®). Washington, DC: APA, 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: APA, 2013.
DSM-5 Opioid Use Disorder
• Severity of the disorder is based on the number of criteria endorsed:
Mild: 2 to 3 criteria
Moderate: 4-5 criteria
Severe: ≥6 criteria
• These 3 DSM-5 categories broadly correlate with:
Misuse (mild)
Abuse (moderate)
Addiction (severe)
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: APA, 2013.
Who Misuses/Abuses Opioids & Why?
Non-Medical Use o Recreational
abusers
o Patients with the disease of addiction
Medical Use
o Pain patients seeking more
pain relief
o Pain patients escaping emotional
pain
Spectrum of Behaviors
Nonmedical users Pain patients (nonpatients)
Passik SD, Kirsh KL. Exp Clin Psychopharmacol 2008;16:400-4.
SUD = substance-use disorder
Routes of Prescription Opioid Misuse/Abuse
• Most early misusers/ abusers ingest them orally
• As abuse progresses, users increasingly modify route of ingestion for a faster onset of action
• Even among individuals admitted to substance abuse treatment, 58.5% reported oral use
Oral 58.5%
Smoked 2.8%
Inhaled 20.7%
Injected 17.0%
Other 1.0%
Amongst those entering substance abuse treatment:
Katz N, et al. Am J Drug Alcohol Abuse. 2011;37:205-17. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2002-2012. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-71, HHS Publication No. (SMA) 14-4850. Rockville, MD: SAMHSA, 2014.
Major Opioid Risks
• Opioid use disorder
Misuse
Abuse
Addiction
• Diversion
• Overdose
Significant Risk Factors for Abuse & Overdose
• Pharmacologic substance
Potency
Tmax
Cmax
Availability
• Patient risk factors
Individual risk factors
Environmental risk factors
• Prescriber behavior
Improper patient selection, dosing, & titration
Improper patient counseling & management
Problem
Total chronic pain
population
ADRB (misuse)
40%
Abuse 20%
Addiction 2%-5%
Webster LR, Webster RM. Pain Med. 2005;6:432-42.
ADRB = aberrant drug-related behavior
Prevalence of Opioid Use Disorder Among Chronic Pain Patients
Study N Prevalence
Boscarino et al,
2011
705 • Lifetime opioid-use disorder as defined by DSM-5: 34.9%
(21.7% moderate; 13.2% severe)
• Lifetime opioid dependence as defined by DSM-IV: 35.5%
Noble et al, 2010 4,893* • Opioid use disorder†: 0.27%
Fleming et al,
2007
801 • Opioid use disorder: 3.8%
o Past 30 days opioid dependence as defined by DSM-IV: 3.1%
o Past 30 days opioid abuse as defined by DSM-IV: 0.6%
Von Korff et al,
2011 (reference
to Fleming et al,
2007 article)
801 • Purposeful over-sedation: 26%
• Increasing dose without prescription: 39%
• Obtaining extra opioids from other doctors: 8%
• Use for purposes other than pain: 18%
• Drinking alcohol to relieve pain: 20%
• Hoarding pain medications: 12%
Boscarino JA, et al. J Addict Dis 2011;30:185-94. Noble M, et al. Cochrane Database Syst Rev 2010;CD006605. Fleming MF, et al. J Pain 2007;8:573-582. Von Korff M, et al. Ann Intern Med 2011;155:325-8.
*Meta-analysis of 26 studies that enrolled a total of 4893 participants †As defined by each study
Aberrant Behaviors in Pain Patients With & Without Prescription Drug Use Disorder
0
10
20
30
40
50
60
70
80
90
≥ 1 ≥ 2 ≥ 3 ≥ 4 ≥ 5
Perc
en
t o
f p
ati
en
ts
Minimum number of aberrant behaviors
Cumulative number of aberrant behaviors
PDUD
No Disorder
Meltzer EC, et al. Pain Med 2012;13:1436-43.
N=264
Aberrant Behaviors Among Chronic Pain Patients
Total number of aberrant
behaviors reported
Percent of patients
(N=388)
0 55.4%
1 to 2 25.3%
3 to 4 8.5%
5 to 7 6.7%
≥8 4.1%
Passik SD, et al. J Opioid Manag. 2005;1:257-66.
44.6% of
respondents
engaged in
≥1 behavior
Aberrant Behaviors in Patients with Cancer & AIDS-Related Pain
0
10
20
30
40
50
60
70
0 1 to 2 3 to 4 ≥5
Perc
en
t o
f p
ati
en
ts
Number of aberrant behaviors
Cancer (n=100)
AIDS (n=73)
Passik SD, et al. Clin J Pain. 2006;22:173-81.
• AIDS patients reported a mean of 6.14 aberrant behaviors/patient
Compared with a mean of 1.42 behaviors/patient among cancer patients
Patient Risk Factors for Aberrant Behaviors/Harm
Biological Psychiatric Social
• Age ≤45 years
• Gender
• Family history of prescription drug or alcohol abuse
• Cigarette smoking
• Physical Illnesses
• Pain severity
• Pain duration
• Sleep disorders
• Substance use disorder
• Preadolescent sexual abuse (in women)
• Major psychiatric disorder (eg, personality disorder, anxiety or depressive disorder, bipolar disorder)
• Depression
• Prior legal problems
• History of motor vehicle accidents
• Poor family support
• Involvement in a problematic subculture
• Unemployed
• Isolation
Katz NP, et al. Clin J Pain. 2007;23:103-18. Manchikanti L, et al. J Opioid Manag. 2007;3:89-100. Webster LR, Webster RM. Pain Med. 2005;6:432-42. Cheatle MD. Pain Med. 2011;12(s2):S43-8. Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.
Assessments of Aberrant Behaviors
• Urine drug testing
• Prescription-monitoring programs
• Predictive assessment tools
• Patterns of Use
• Family & friends
• Pharmacists
Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.
Assessment Tools
• Use prior to prescribing opioids
Screener and Opioid Assessment for Patients in Pain
(SOAPP)
Opioid Risk Tool (ORT)
Diagnosis, Intractability, Risk, Efficacy (DIRE)
• Use during prescribing of opioids
Current Opioid Misuse Measure (COMM)
Webster LR. Pain Med. 2013;14:959-61. Webster LR, Webster RM. Pain Med. 2005:6:432-42. Butler SF, et al. Pain. 2004;112:65-75. Belgrade MJ, et al. J Pain. 2006;7:671-81. Butler SF, et al. Pain. 2007;130:144-56.
Limitations of Familiar Screening Tools
• Designed to identify patients who already have problems managing substance intake, not to predict who may develop problems
• Not designed to screen specifically for opioid abuse
• Often take a long time to administer & require unique skills to interpret
Smith HS, Passik SD. Chapter 47. Screening for the risk of substance abuse in pain management. In: Pain and Chemical Dependency. 1st ed. New York, NY: Oxford University Press; 2008. Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.
Screener and Opioid Assessment for Patients with Pain (SOAPP): V.1.0-SF (5Q)
The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.
Please answer the questions below using the following scale:
0 = Never 1 = Seldom 2 = Sometimes 3 = Often 4 = Very Often
1. How often do you have mood swings? 0 1 2 3 4
2. How often do you smoke a cigarette within an hour after you wake up?
0 1 2 3 4
3. How often have you taken medication other than the way that it was prescribed?
0 1 2 3 4
4. How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past five years?
0 1 2 3 4
5. How often, in your lifetime, have you had legal problems or been arrested?
0 1 2 3 4
Please include any additional information you wish about the above answers. Thank you.
To score the SOAPP V.1.0-SF, add ratings of
all questions:
A score of ≥4 is considered positive
Sum of questions
SOAPP indication
4 +
<4 -
SOAPP is available in 3 formats: 5Q, 14Q, & 24Q
PainEDU. Screener and Opioid Assessment for Patients with Pain (SOAPP)® Version 1.0-SF. www.painedu.org/load_doc.asp?file=SOAPP_5.pdf
Opioid Risk Tool (ORT)
Mark each box that applies Female Male
1. Family history of substance abuse
Alcohol
Illegal drugs
Prescription drugs
1
2
4
3
3
4
2. Personal history of substance abuse
Alcohol
Illegal drugs
Prescription drugs
3
4
5
3
4
5
3. Age (mark box if 16-45 years) 1 1
4. History of preadolescent sexual abuse
3 0
5. Psychological disease
ADD, OCD, bipolar, schizophrenia
Depression
2
1
2
1 ADD = attention deficit disorder; OCD = obsessive-compulsive disorder
• Exhibits high degree of
sensitivity & specificity
• 94% of low-risk patients
did not display an
aberrant behavior
• 91% of high-risk patients
did display an aberrant
behavior
Total score
Risk % with
aberrant behavior
0-3 Low 6%
4-7 Moderate 28%
≥8 High 91%
Webster LR, Webster RM. Pain Med. 2005;6:432-42.
N=185
Level of Abuse in Stressful Environments
Low Moderate High
Patient stress level
Dru
g-a
bu
sin
g b
eh
avio
r
Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.
Differential Diagnosis: Aberrant Drug-Taking Attitudes & Behavior
• Addiction
• Pain-relief seeking
• Pain-relief seeking & substance-use disorder
• Other psychiatric diagnosis
Organic mental syndrome
Personality disorder
Chemical coping
Depression/anxiety/situational stressors
• Criminal intent (diversion)
Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007. Passik SD, Kirsh KL. Curr Pain Headache Rep. 2004;8:289-94.
Aberrant Medication Taking Behaviors Pain-Relief Seeking: Differential Diagnosis
• Disease progression
• Poorly opioid responsive pain
• Withdrawal mediated pain
• Opioid-induced hyperalgesia
• Opioid analgesic tolerance
Drug Seeking: Addiction
• A clinical syndrome presenting as…
Loss of Control
Compulsive use
Continued use despite harm
Craving
• Addiction is NOT the same as physical dependence
Biological adaptation with signs & symptoms of withdrawal
(eg, pain) if opioid is abruptly stopped
Savage SR, et al. J Pain Symptom Manage. 2003;26:655-67.
Aberrant medication-
taking behaviors
(pattern & severity)
Behaviors Concerning for Addiction The Spectrum: Yellow to Red Flags
Portenoy RK. J Pain Symptom Manage. 1996;11:203-14. Passik SD, et al. Oncology (Williston Park ) 1998;12:517-21, 524.
○ Requests for increased opioid dose
○ Requests for specific opioid by name, “brand name only”
○ Unsanctioned dose escalation or other noncompliance with therapy on 1 or 2 occasions
○ Nonadherence with other recommended therapies (eg, physical therapy)
○ Resistance to change therapy despite adverse effects (eg, over-sedation)
○ Deterioration in function at home & work
○ Multiple dose escalations or other noncompliance with therapy despite warnings
○ Nonadherence with monitoring (eg, pill counts, urine drug testing)
○ Multiple “lost” or “stolen” opioid prescriptions
○ Illegal activities (eg, forging prescriptions, selling prescription opioids)
Discussing Possible Addiction
• Give specific & timely feedback why patient’s behaviors raise your concern for possible addiction, eg, loss of control, compulsive use, continued use despite harm
• Remember patients may suffer from both chronic pain & addiction
• May need to “agree to disagree” with the patient
• Benefits no longer outweighing risks
“I cannot responsibly continue prescribing opioids as I feel it
would cause you more harm than good”
• Always offer referral to addiction treatment
• Stay 100% in “Benefit/Risk” mindset
When to Refer to an Addiction Medicine Specialist
• When a patient:
Is using illicit drugs
Is experiencing problems with other prescription drugs
− eg, benzodiazepines
Has an addiction or abuse to alcohol
Agrees they have an opioid addiction & wants help
Has a dual or a trio diagnosis of pain, addiction, &
psychiatric disease
Diversion
• Drug diversion is defined as a supply of prescription medication intended for one person being given, bartered or sold to another
• Patients who have had medications stolen, lost, or otherwise taken unintentionally also qualify as participants in drug diversion
Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62. Bell J. Addiction. 2010:105:1531-7. Inciardi JA, et al. Pain Med. 2009:10:537-48.
Frequency & Type of Diversion Among a Pain Clinic Population
# of
incidents
Type of diversion
Sharing Selling Stolen Lost
n=340 n=336 n=338 n=342
0 304 (89.4%) 330 (98.2%) 238 (70.4%) 272 (80.0%)
1 16 (4.7%) 4 (1.2%) 54 (16.0%) 42 (12.3%)
2 4 (1.1%) 1 (0.3%) 26 (7.7%) 21 (6.1%)
3 5 (1.5%) 0 10 (3.0%) 5 (1.5%)
4 0 0 2 (0.6%) 1 (0.3%)
≥5 11 (3.2%) 1 (0.3%) 8 (2.4%) 1 (0.3%)
≥1 36 (10.6%) 6 (1.8%) 100 (29.6%) 70 (20.5%)
Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.
• Most common type of drug diversion was loss due to theft 29.6% of respondents
Frequency of Stolen Medications Per Age Group
Age group
(years)
How many times medications stolen (%) % of responses
≥1 0 1 2 3 4 5
18-24
(n=2)
2
(100.0%)
0
(0.0%)
0
(0.0%)
0
(0.0%)
0
(0.0%)
0
(0.0%)
0%
25-34
(n=29)
19
(65.5%)
5
(17.2%)
1
(3.4%)
2
(6.9%)
0
(0.0%)
2
(6.9%)
34.5%
35-44
(n=62)
38
(61.3%)
14
(22.6%)
6
(9.7%)
1
(1.6%)
0
(0.0%)
3
(4.8%)
38.7%
45-54
(n=119)
76
(63.9%)
18
(15.1%)
16
(13.4%)
5
(4.2%)
2
(1.68%)
2
(1.68%)
36.1%
>55
(n=101)
81
(80.2%)
14
(13.9%)
3
(3.0%)
2
(2.0%)
0
(0.0%)
1
(1.0%)
19.8%
Total
(n=313) 216 51 26 10 2 8 31.0%
Frequency missing = 14
Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.
Frequency of Stolen Medications Per Marital Status
Marital status How many times medications stolen (%) % of
responses ≥1 0 1 2 3 4 5
Never married
(n=28)
19
(67.9%)
3
(10.7%)
3
(10.7%)
0
(0.0%)
0
(0.0%)
3
(10.7%) 32.1%
Divorced
(n=63)
39
(61.9%)
12
(19.0%)
3
(4.8%)
4
(6.3%)
0
(0.0%)
5
(7.9%) 38.1%
Widowed
(n=11)
7
(63.6%)
2
(18.2%)
2
(18.2%)
0
(0.0%)
0
(0.0%)
0
(0.0%) 36.4%
Married
(n=206)
148
(71.8%)
33
(16.0%)
17
(8.3%)
6
(2.9%)
2
(1.0%)
0
(0.0%) 28.2%
Total
(n=308) 213 50 25 10 2 8 30.8%
Frequency missing = 19
Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.
Suicide
161.6 151.6
182.8
197.1 199.5 198.4
212.7
228.4
16.9 17.8 24.5
29.9 26.8 29.6 32.9 31.7
0
25
50
75
100
125
150
175
200
225
250
2004 2005 2006 2007 2008 2009 2010 2011
Nu
mb
er
of
ED
vis
its f
or
dru
g-
rela
ted
su
icid
e a
ttem
pts
(t
ho
usan
ds)
All drugs Opioid analgesics
87% increase in opioid suicide attempts
41% increase in drug suicide attempts
Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: SAMHSA, 2013.
ED = emergency department
Why Suicide? Non-Pain Patients
Escape from severe suffering Only option
Permanent solution Hopelessness
Kraft TL, et al. Arch Suicide Res. 2010;14:375-82.
Suicide Ideation in Chronic Pain Patients
• Hitchcock
50% chronic pain
patients had suicidal
thoughts due to pain
• Fishbain
Pain severity
Severe comorbidity
(depression)
19%
13%
5% 5%
0%
5%
10%
15%
20%
Passive suicide ideation
Actual thoughts
Current plan
Previous attempt
Planned suicide
N=153
Hitchcock LS, et al. J Pain Symptom Manage. 1994;9:213-8. Fishbain DA. Semin Clin Neuropsychiatry. 1999;4:221-7. Smith MT, et al. Pain. 2004;111:201-8.
Risk for Suicide Among Pain Patients
Family history of suicide
History of childhood
abuse
Previous suicide attempts
History of mental disorder, particularly depression
Hopelessness
History of substance abuse
Impulsive & aggressive
behaviors
Losses such as work, family, self-esteem
Isolation
Physical illness
+1: Access to potentially lethal doses of prescription medications (ie, opioids)
Fishbain DA. Semin Clin Neuropsychiatry. 1999;4:221-7. Tang NK, Crane C. Psychol Med. 2006;36:575-86.
Risk Stratification
Lower Risk Moderate Risk Higher Risk
Primary care patients Primary care patients with
specialist support Pain specialist patients
ORT Score 0-3 ORT Score 4-7 ORT Score ≥8
No past or current
history of substance use
disorders
No family history of past
or current substance
use disorders
No major or untreated
psychopathology
Consistent UDT results
Consistent PDMP
results
Mild to moderate pain
May be a past history of
substance use disorders
May be a family history of
problematic drug use
May have past or
concurrent
psychopathology
Not actively addicted
Usually consistent UDT
results
Consistent PDMP results
Mild to severe pain
Active substance
use disorders
Major, untreated
psychopathology
Poor social support
Actively addicted
Inconsistent UDT
results
PDMP multiple
prescribers
Moderate to severe
pain
Gourlay DL, et al. Pain Med. 2005;6:107-12. Webster LR Webster RM. Pain Med. 2005;6:432-42.
ORT = Opioid Risk Tool; PDMP = Prescription Drug Monitoring Program; UDT = urine drug testing
Conclusion
• Aberrant drug-related behaviors must be assessed
• Risk assessment can be easily implemented into most clinical practices
• Risk assessment leads to risk stratification
• Risk stratification can help match appropriate monitoring to mitigate abuse, potential diversion, suicide, & overdoses
References • American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR®). Washington, DC: APA, 2000.
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: APA, 2013.
• Belgrade MJ, et al. J Pain. 2006;7:671-81.
• Bell J. Addiction. 2010:105:1531-7.
• Boscarino JA, et al. J Addict Dis 2011;30:185-94.
• Butler SF, et al. Pain. 2004;112:65-75.
• Butler SF, et al. Pain. 2007;130:144-56.
• Cheatle MD. Pain Med. 2011;12(s2):S43-8.
• Fishbain DA. Semin Clin Neuropsychiatry. 1999;4:221-7.
• Fleming MF, et al. J Pain 2007;8:573-582.
• Gourlay DL, et al. Pain Med. 2005;6:107-12.
• Hitchcock LS, et al. J Pain Symptom Manage. 1994;9:213-8.
• Inciardi JA, et al. Pain Med. 2009:10:537-48.
• Katz NP, et al. Clin J Pain. 2007;23:103-18.
• Katz NP, et al. Clin J Pain 2007;23:648-60.
• Katz N, et al. Am J Drug Alcohol Abuse. 2011;37:205-17.
• Kraft TL, et al. Arch Suicide Res. 2010;14:375-82.
• Manchikanti L, et al. J Opioid Manag. 2007;3:89-100.
• Meltzer EC, et al. Pain Med 2012;13:1436-43.
• Noble M, et al. Cochrane Database Syst Rev 2010;CD006605.
• PainEDU. Screener and Opioid Assessment for Patients with Pain (SOAPP)® Version 1.0-SF. www.painedu.org/load_doc.asp?file=SOAPP_5.pdf
• Passik SD, et al. Clin J Pain. 2006;22:173-81.
• Passik SD, et al. Oncology (Williston Park ) 1998;12:517-21, 524.
• Passik SD, Kirsh KL. Curr Pain Headache Rep. 2004;8:289-94.
• Passik SD, et al. J Opioid Manag. 2005;1:257-66.
• Passik SD, Kirsh KL. Exp Clin Psychopharmacol 2008;16:400-4.
• Portenoy RK. J Pain Symptom Manage. 1996;11:203-14.
• Savage SR, et al. J Pain Symptom Manage. 2003;26:655-67.
• Smith MT, et al. Pain. 2004;111:201-8.
• Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2002-2012. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-71, HHS Publication No. (SMA) 14-4850. Rockville, MD: SAMHSA, 2014.
• Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: SAMHSA, 2013.
• Tang NK, Crane C. Psychol Med. 2006;36:575-86.
• Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.
• Von Korff M, et al. Ann Intern Med 2011;155:325-8.
• Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.
• Webster LR, Webster RM. Pain Med. 2005:6:432-42.
• Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.
• Webster LR. Pain Med. 2013;14:959-61.
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• PCSS-O Colleague Support Program is designed to offer general
information to health professionals seeking guidance in their clinical
practice in prescribing opioid medications.
• PCSS-O Mentors comprise a national network of trained providers with
expertise in addiction medicine/psychiatry and pain management.
• Our mentoring approach allows every mentor/mentee relationship to be
unique and catered to the specific needs of both parties.
• The mentoring program is available at no cost to providers.
• Listserv: A resource that provides an “Expert of the Month” who will
answer questions about educational content that has been presented
through PCSS-O project. To join email: pcss-o@aaap.org.
For more information on requesting or becoming a mentor visit:
pcss-o.org/ask-colleague
PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in
partnership with: Addiction Technology Transfer Center (ATTC), American Academy of
Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of
Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA),
American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine
(AOAAM), American Psychiatric Association (APA), American Society for Pain Management
Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast
Consortium for Substance Abuse Training (SECSAT).
For more information visit: www.pcss-o.org
For questions email: pcss-o@aaap.org
Twitter: @PCSSProjects
Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The views expressed in written
conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names,
commercial practices, or organizations imply endorsement by the U.S. Government.
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