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Besides the Pain…Clinical Assessment of Chronic Pain

Co-Morbidities

Andrew J Smith, MDCM

Medical Lead

Interprofessional Pain and Addiction Recovery Clinic (IPARC)

Centre for Addiction and Mental Health (CAMH)

Faculty/Presenter Disclosure

Faculty: Andrew J Smith, MDCM

Relationships with commercial interests:

None to report

This program has received financial support from the Ministry of Health and Long Term Care, Government of Ontario.

Besides the Pain: Learning Objectives

By the end of the session, participants will be able to:

1. Determine how to screen for depression and other mental health conditions

2. Screen for substance misuse, abuse, and addiction

3. Recognize common medical conditions that impact chronic pain, such as sleep apnea, renal failure, chronic liver disease etc..

Chronic Pain and Its Comorbidities:

• Pain

• Mood

• Sleep

• Substances

• And then some….• Chronic renal disease

• Liver disease• Iatrogenic

Chronic Pain and Its Comorbidities:Pain Comorbidities

• Associated with the worst quality of life when compared with other chronic diseases such as chronic cardiovascular or respiratory diseases (Jovey et al. 2010)

• Mood and anxiety disorders are 2 – 7 x more prevalent in populations of chronic pain and migraine patients in primary, specialty and tertiary care samples (Tunks et al 2008)

• Co-morbidities multiply functional compromise and QOL restrictions with pain (NB: OUTCOMES)

• Suicide risk 2x higher in CP population vs the non-pain population (Tang, 2006)

• Substance use disorder among patients with chronic pain: 2-14%

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Untreated Pain: A Global Health Problem

• Inadequately treated acute pain (following surgery or trauma) 25% burden of chronic pain

• Reduced mobility

• Impaired immunity

• Reduced concentration

• Anorexia

• Sleep disturbances

• Social isolation

• Dependence on caregivers

• Impaired relationships with friends and family

• 4x risk of depression and anxiety

• AT RISK: poor, elderly, mentally ill, children, women, racial/ethnic minorities

Prescription opioid use is risky: Medical Use

When used as directed (i.e. “medical use”), risks include:

• Injury (e.g. motor vehicle collisions, falls)

• Fracture risk

• In persons 60 yo + >50mg Meq/day 2x (Saunders et al, 2010)

• Falls/fractures in OA: 3.3 (vs COX-2); 4.1 (vs NSAID) (Rolita, 2013)

• National register study: case-control falls

• Morphine 1.47; Fentanyl 2.23; Methadone 1.39; Oxy 1.36

• NB: Buprenorphine/naloxone 0.8

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Prescription opioid use is risky: Medical Use

• MI small increased risk (Li et at, 2013)

• Road trauma: 1.42 OR for high doses (Gomes et al, 2013)

• Sleep apnea, COPD

• Reduced renal function (narrower therapeutic window)

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Opioid Dose & Opioid-Related Deathsin Ontario

Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011 Apr 11;171(7):686-91

Controlled for previous drug use (SSRI, other psychotropics, BZDs, CNS depressants, methadone), number of meds used in the past 6 months, duration of OpiRx, number of physicians prescribing opioids, number of pharmacies dispensing opioids, presence of any long-acting opioid dispensed in the exposure window

Overdose Risk: Opioids

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Dasgupta N et al, Pain Med 2016

• Linear dose risk through 200mg ? Tolerance

• OD mortality strongly influenced by concurrent benzo use, especially at higher benzo doses

Prospective Obs cohort with 1 yrfollow-up

Overdose Risk: Opioids + Benzos

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Dasgupta N et al, Pain Med 2016

• Benzos rx in

• Cohort: 80%

• US: 5%

• ???!!!???!!!**!%

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Risk of Developing an Opioid Use Disorder and Opioid Dose / Duration

HealthCore Rx data (US) in the US

All individuals 18 and over with a new episode of chronic non-cancer pain (CNCP) and no prior opioid use or opioid use disorder (n=568,640)

Followed x 18 months

Opioid days supply (none, acute, chronic)

Average daily dose (none, low dose, medium dose, and high dose)

New diagnosis of opioid use disorder.

There were 497 (0.1%) new diagnoses of opioid use disorder in the following 18 months.

Edlund et al. Clin J Pain. 2014 Jul;30(7):557-64.

Risk of Developing an Opioid Use Disorder and Opioid Dose / Duration

Low-dose, acute (16% of the cases) OR 3.03

Low-dose, chronic OR 14.92

Med dose, acute (15%) OR 2.80

Med dose, chronic OR 28.69

High dose, acute OR 3.10

High dose, chronic (0.1%) OR 122.45

Acute use = 1 to 90 daysChronic use > 90 days

Low dose = 1-36 MEQ Medium dose = 36 to 120 MEQHigh dose = 120 MEQ

Chronic Pain and Substance Use Disorders

• Prevalence of Opioid addiction in CNCP patients receiving opioids?• Opioid addiction 3.3% in CNCP patients

• Aberrant drug related behaviors 11.5%

• Urine drug screen (UDS) with illicit drugs present 14.5%

• UDS with non-prescribed opioids present 20.4%

• Based on review of 67 studies (Fishbain 2008) – many limitations• No breakdown of the clinics studied or dates of study (opioid dependence increasing)

• Dx of addiction depends on clinician’s judgement

• ADRBs and positive UDSs are only proxy measures of addiction

Fishbain DA et al. Pain Medicine 2008 May;9(4):444-59.

Opioid Risk Tool

Administration•On initial visit•Prior to prescribing

Scoring• 0 – 3 low risk• 4 – 7 moderate risk• 8+ HIGH RISK

Webster et al. Pain Med 2005; 6: 432

Risk Assessment: Screening Tools

• ORT demonstrated high sensitivity and specificity for detecting individuals presenting to a pain clinic at risk for developing aberrant behaviors around use of opioids (Webster, 2005)

• BUT, none of the screening tools can be recommended with confidence, because samples were small and unrepresentative (Turk, 2008)

• A personal history of drugs or alcohol use disorder remains the strongest predictor of opioid aberrant use OR use disorder

Turk DC, et al. Clinical Journal of Pain 2008 Jul;24(6):497-508.Webster LR, Webster RM. Pain Med. 2005;6:432-442.

ADDOP: The Five Pillars of Pain Management

• Assess: Symptoms and Risk

• Define the problem: where and what is it?

• Diagnose the kind of pain and treat it

• Other issues: mood, anxiety, sleep, addiction, sex

• Personal management, self management

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Risk Assessment• “Universal Precautions” history (Gourlay et al, 2005)

• Current and previous pain treatment• Aberrant drug-related behaviours• Personal history of problematic drug/alcohol use• Family history of problematic drug/alcohol use• Affective disorders• Childhood abuse• Significant Personality Disorder• PTSD• Problematic chronic medical condition in last 12 months• Involvement of multiple body regions• Low Function ( 2SD < below norm eg SF-12)• Poor coping (low pain self-efficacy)• Lack of social support• Urinary drug screen and identification

• Identify the individuals with the greatest risk of aberrant behaviour NOT to stigmatize, but to improve care

Clinician Knowledge and Therapeutic Alliance Reduces Risk & Improves Outcomes

One of the biggest barriers to appropriate treatment of chronic non-cancer pain and addiction is insufficient pain management education for physicians

-CPSO Opioid Report: Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis (2010)

Terminology

Distinguish

Abuse/Misuse

Aberrant Drug-Related Behaviours

Addiction

Substance dependence

Substance Use Disorder

Physical dependence

Tolerance

Aberrant Drug Related Behaviours

• Any medication-related behaviours that depart from the agreed-upon therapeutic plan of care

• Medication/Drug Abuse: the use of an illicit drug or the intentional self-administration of a prescription (or over-the counter) medication for any nonmedical purpose, such as altering one’s state of consciousness

• Medication Misuse: the use of a medication (with therapeutic intent) other than as directed or indicated, whether willful or unintentional, and whether it results in harm or not

White WL, Kelly JF: Alcohol/drug/substance “abuse”: The history and (hopeful) demise of a pernicious label. Alcoholism Treatment Quarterly. 2011; 29 (3):317-321

Aberrant Drug Related Behaviours

• Selling medications / RX Forgery

• “Street” sourcing

• Crushing / Snorting / Injecting

• Multiple dose-escalations or other non-compliance with therapy despite discussions

• Multiple episodes of prescription loss or theft

• Double doctoring

• Functional deterioration seemingly related to drug use

• Repeated resistance to change in therapy despite clear evidence of therapeutic failure or adverse effect

Addiction (5Cs)

“A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.

It is characterized by behaviors that include one or more of the following: Control impaired over drug use

Compulsive use

Continued use despite harm

Cravings”

American Society of Addiction Medicine. Public Policy Statement: Definition of Addiction. 2011. http://www.asam.org/DefinitionofAddiction-LongVersion.html

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DSM-V Diagnostic Criteria for Substance Use Disorder (2013 - )

Tolerance*

Withdrawal*

More use than intended

Craving for the substance

Unsuccessful efforts to cut down

Spends excessive time in acquisition

Activities given up because of use

Uses despite negative effects

Failure to fulfill major role obligations

Recurrent use in hazardous situations

Continued use despite consistent social or interpersonal problems

*not counted if prescribed by a physician

Clinical Interview – Building Alliance

• Pain management Step 1: Listen. (Mary Lynch, Clinical Pain Management, 2011.

• There is the need of ill people to tell their stories in order to construct new maps and new perceptions of their relationship to the world.

-Frank A (1995). The Wounded Storyteller.

• How can I help you? (Promotes ownership and opens SMART talk)

• Pain history

• Medical History (brief…more detailed as needed)

• Medications – get the facts… Pharmacy printout very helpful

Clinical Interview – Exploring Comorbidities

• Day-In-The-Life• When do you usually get up?

• Do you feel rested?

• What’s your sleep like?

• Sleep hygiene?

• Fragmented? Trouble falling asleep?

• Snoring? Restless sleeper (NB partner)? Mouth-breather? AM headaches? Prominent dreams/nightmares?

• How do you feel when you get

up? Pain intensity in AM? Worst of the day? (Take meds overnight or not?)

• When do you take meds? How do you feel after you take them?

• How long do the meds “work”? How long before next dose do they wear off? NB: TOLERANCE, WITHDRAWAL

Clinical Interview – Exploring Comorbidities

• Day-In-The-Life (continued)

• Do you ever have to take more meds than prescribed?

• How do you actually take the medication?

• NB PAIN AND SUFFERING…NORMALIZE, NORMALIZE, NORMALIZE

• Functional inquiry, nutritional status, social, occupational, recreational

• Sex! Libido, erectile dysfunction, etc… NB hypogonadism

• What else do you do during the day to feel better?

• Do you experience any side effects from medication

• Medication Control: loss, theft, aberrancy…

Clinical Interview – Exploring Comorbidities

• Substance use inquiry: NORMALIZE, NORMALIZE, NORMALIZE… Can open with CAGE-AID Start with current use…tobacco, EtOH, THC (does it help with pain? Function?)… • EtOH: first drink?, first drunk? Low/High

responder? Consequences? DUI…

• (Any other legal troubles along the way?)

• Previous treatment? AA? 12-step?

1. Do you drink alcohol?

2. Have you ever experimented with drugs?

Cut down

Annoyed

Guilty

Eye-opener

Clinical Interview – Exploring Comorbidities

• Family history… these things often run in families…NORMALIZE, EDUCATE RE: DISEASE MODEL OF ADDICTION, FREQUENT CO-MORBIDITIES, NEURAL BASIS, ETC…

• Mental Health Inquiry• Current symptoms: PHQ-4 (4-questions on a 5-point Likert scale)…GAD and MDD…

if positive can move on to more detailed tools…eg PHQ-9

• Previous diagnoses? Treatments? Current?

• Admissions? Suicidality? (NB ASSESSMENT)

• Trauma, abuse

• School History (learning disabilities, etc)

• Employment, etc…

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ECHO Ontario: VISION

That all primary care providers in Ontario have the knowledge and support to manage chronic pain safely and effectively.

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