Addiction Severity Index in a chronic pain sample receiving opioid therapy

The treatment of chronic pain with opioids remains controversial. Physicians are concerned about addiction and drug diversion, and there is limited empirical information on the use of opioids in patients with chronic pain. This report presents data on the Addiction Severity Index (ASI) collected in a sample of patients (N = 908) receiving opioids from their primary care physicians. The ASI provides clinically important information about patients receiving opioid therapy. The ASI consists of seven subscales, including medical, alcohol, drug, employment/support, legal, family/social, and psychiatric domains. Clinically relevant findings include high ASI medical score (0.87), high psychiatric severity score (0.27), lifetime treatment of alcohol problems (reported by 22% of men), prior delirium tremens (5.6%), prior treatment for drug problems (10.1%), prior drug overdose (12.1%), and drunk-driving citations (28%); 40.3% of women had serious suicidal thoughts, and 23.8% had suicide attempts. The ASI provides important information that can help primary care physicians manage patients with chronic pain who are receiving opioid therapy.     

Opioid deprescribing: Qualitative perspectives from those with chronic non-cancer pain

AimDeprescribing is the systematic process of discontinuing medications when the harms outweigh the benefits. This study aimed to identify barriers and facilitators in people with chronic non-cancer pain when deprescribing opioid analgesics, and their views on resources that assist with deprescribing.MethodsA purposive sampling strategy was used to recruit 19 adults with chronic non-cancer pain from the community who were, or had been, on long-term opioid therapy. Recruitment continued until thematic saturation was achieved. Semi-structured telephone interviews were conducted. A five-step framework and thematic analysis method identified themes for each study aim.ResultsThemes identifying barriers to opioid deprescribing raised challenges of a lack of available alternatives, managing opioid dependency and withdrawal symptoms or inability to function without opioids when in extreme pain. Facilitating themes described the value of support networks, including a trusting doctor-patient relationship and finding individual coping strategies to address deprescribing barriers. We explored a variety of resources from electronic forms such as websites and apps to paper-based or face to face. Participants expressed that whatever the form, resources need to be educational but also simple and engaging.ConclusionsMost people suffering from chronic non-cancer pain expressed dissatisfaction with being on opioids but most were still unwilling to deprescribe due to insufficient alternatives, a lack of support from their doctors and lack of information about the deprescribing process. Deprescribing can be facilitated by improving supportive networks and strategies and providing simple and positive educational resources.     

Analgesic efficacy of opioids in chronic pain: recent meta-analyses

Opioids are regularly administered in acute and cancer pain. In chronic non-cancer pain (CNCP), however, their use is controversial. Previous meta-analyses and randomized controlled trials (RCTs) lack methodological homogeneity and comparable data. Here we analysed the maximum analgesic efficacies of opioids and non-opioids compared with placebo, and of physiotherapy and psychotherapy compared with active or waiting-list controls. We screened 3647 citations and included RCTs if treatment duration was at least 3 weeks, data were sufficient for meta-analysis, and criteria for high quality were met. Only 46 studies (10 742 patients) met the criteria. Weighted and standardized mean differences (WMD, SMD) between pain intensities were pooled to conduct separate meta-analyses for each treatment category. At the end of treatment the WMD for pain reduction (100-point scale) was 12.0 for ‘strong’ opioids, 10.6 for ‘weak’ opioids, 8.4 for non-opioids (each vs. placebo), 5.5 for psychotherapy and 4.5 for physiotherapy (each vs. active controls). Dropout rates were high in pharmacological studies. The 95% confidence intervals using the outcomes of control groups did not indicate statistical differences between efficacies of the five interventions. Because not enough eligible head-to-head trials were available, our analysis is limited to adjusted indirect comparisons. The heterogeneity of pre-post pain differences in control groups did not allow the definition of a common comparator. In conclusion, although there were statistically significant differences between maximum treatment efficacies, no intervention per se produced clinically important improvements in average pain intensity. Thus, opioids alone are inappropriate and multimodal treatment programmes may be required for CNCP.

LINKED ARTICLES

This article is part of a themed section on Opioids: New Pathways to Functional Selectivity. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2015.172.issue-2     

The Interface Between Substance Abuse and Chronic Pain Management in Primary Care: A Curriculum for Medical Residents

ABSTRACT

Objectives: To develop and assess a housestaff curriculum on opioid and other substance abuse among patients with chronic noncancer pain (CNCP). Methods: The two-hour, case-based curriculum delivered to small groups of medical housestaff sought to improve assessment and management of opioid-treated CNCP patients, including those with a substance use disorder. A two-page pre-post survey was administered to assess self-efficacy change on a scale from 1 (strongly disagree) to 5 (strongly agree). Results: Of 47/50 (94%) respondents, self-efficacy significantly improved across all items (mean pre vs. post ratings, P <.001). Housestaff were more prepared to manage patients on chronic opioid medication (2.8 vs. 3.8), including those with substance use disorders (2.3 vs. 3.4). They felt more prepared to identify opioid dependence (2.8 vs. 3.9) and overall rated the curriculum favorably (4.2). Conclusions: The brief curriculum was well received and appears effective. Further study is needed to determine practice impact.     

Psychometric validation of the electronic chronic pain questions (eCPQ) in a primary care setting

Objective: Collecting data that helps evaluate different types of pain may improve physicians’ decision-making with regard to treatment selection and on-going monitoring of patients. To date, no chronic pain assessments have been widely implemented in primary care. The aim of this study was to psychometrically validate the electronic Chronic Pain Questions (eCPQ) in a primary care setting.

Research design and methods: All men and women ≥18 years arriving at two similar primary care clinics in southeastern Michigan were invited to participate. Clinic staff verbally administered the eCPQ to patients and recorded their answers into the electronic medical record (EMR) prior to physician consultation with results available for physician review. Concurrent validity was assessed using Spearman correlations between eCPQ and patient-completed ancillary measures. Known-group validity was assessed by stratifying patients on self-reported chronic pain as well as by pain diagnosis (i.e. ICD-9 codes). To compare patients with chronic pain versus no chronic pain t-tests and chi-square tests were performed. Reproducibility was assessed between interviewer- and self-administration over time.

Results: A total of 534 patients were invited to participate and 455 patients consented to take part in the study (85.2% response rate); 395 patients had analyzable eCPQ data; 70.1% were Caucasian; 68.1% female; mean age was 43.4; 52.7% (n?=?208) self-reported chronic pain. Correlations between eCPQ and ancillary measures supported concurrent validity. Excellent discrimination between groups was evidenced based on self-reported chronic pain and ICD-9 diagnosis. Patients with self-reported chronic pain reported significantly (p?Key limitations: Discriminant validity was determined by comparing participants based on ICD codes. Utilizing ICD codes to identify individuals with chronic pain may not be a reliable approach as it is dependent upon providers accurately and consistently entering chronic pain diagnoses in the EMR.

Conclusions: The eCPQ has sound psychometric measurement properties, including concurrent validity, discriminant validity, and reproducibility. The eCPQ appears to be useful to identify patients with chronic pain and to assess and monitor symptoms over time.     

Patterns of prescription opioid abuse and comorbidity in an aging treatment population

Very little is known about the impact of age and gender on drug abuse treatment needs. To examine this, we recruited 2,573 opioid-dependent patients, aged from 18 to 75 years, entering treatment across the country from 2008 to 2010 to complete a self-administered survey examining drug use histories and the extent of comorbid psychiatric and physical disorders. Moderate to very severe pain and psychiatric disorders, including polysubstance abuse, were present in a significant fraction of 18- to 24-year-olds, but their severity grew exponentially as a function of age: 75% of those older than 45 years had debilitating pain and psychiatric problems. Women had more pain than men and much worse psychiatric issues in all age groups. Our results indicate that a “one-size-fits-all” approach to prevention, intervention, and treatment of opioid abuse that ignores the shifting needs of opioid-abusing men and women as they age is destined to fail.     

Altered synaptic connections and inhibitory network of the primary somatosensory cortex in chronic pain

Chronic pain is induced by tissue or nerve damage and is accompanied by pain hypersensitivity (i.e., allodynia and hyperalgesia). Previous studies using in vivo two-photon microscopy have shown functional and structural changes in the primary somatosensory (S1) cortex at the cellular and synaptic levels in inflammatory and neuropathic chronic pain. Furthermore, alterations in local cortical circuits were revealed during the development of chronic pain. In this review, we summarize recent findings regarding functional and structural plastic changes of the S1 cortex and alteration of the S1 inhibitory network in chronic pain. Finally, we discuss potential neuromodulators driving modified cortical circuits and suggest further studies to understand the cortical mechanisms that induce pain hypersensitivity.     

The use of opioid medications in patients with chronic non-malignant pain who have drug dependence

The use of opioid medications in the management of painful medical conditions is currently being 'rediscovered'. However, although drug-dependent patients are likely to be over-represented in the chronic pain population and are also arguably less likely to respond to non-pharmacological interventions for chronic pain, opioid medications are considered to be relatively contraindicated for such a patient group. This paper explores, first, the background to this situation before proposing a set of interim guidelines for the use of opioid medications in the management of chronic pain in drug-dependent patients in order to protect access to this treatment strategy for this difficult patient group, while data from controlled studies are obtained for more definitive policy formation.     

A history of sexual, emotional, or physical abuse predicts adjustment during opioid maintenance treatment

This study examined how having a history of sexual, physical, or emotional abuse is related to overall functioning as assessed by the Addiction Severity Index during short-term opioid maintenance treatment with either buprenorphine/naloxone or methadone. Furthermore, the relation between abuse history and overall functioning by sex was explored. Participants (N = 268) were opioid-dependent adults entering an outpatient randomized clinical trial with buprenorphine/naloxone and methadone. Latent growth modeling indicated that females with an abuse history entered treatment with more problems in the psychiatric and family domains as compared with females without an abuse history. Over the course of treatment, a history of abuse predicted problems in the psychiatric and alcohol domains. Furthermore, a history of abuse predicted slower recovery times and less recovery overall for females in some domains. Males with an abuse history entered treatment with more severe psychiatric and family problems as compared with males with no history of abuse. Victims of abuse may present to substance abuse treatment with weaknesses in the areas of family relations, psychiatric status, and alcohol use. The nature of these problems and their trajectory over time differed by sex.