Screening for Addiction and Monitoring for Aberrant Behavior in Patients with Chronic Pain

Click to access Speaker4-presentation.pdf

By UNM Health Sciences Center (undated)

“Prescribing opioids will lead to abuse/addiction in a small percentage of chronic pain patients, but a larger percentage will demonstrate aberrant drug related behaviors and illicit drug use. These percentages appear to be much less if CPPs are preselected for the absence of a current or past history of alcohol/illicit drug use or abuse/addiction.” (Fishbain et al.)

Prevalence of Addiction in Chronic Pain Patients

24 studies with 2,057 patients with rate of 3.27% for abuse/addiction.
• Rate of abuse/addiction in patients with no history or current use of substances was 0.19%
• Fishbain DA. Pain Med. 2008;9:444-58.

Aberrant Behavior Prevalence

• 17 studies of 2,466 chronic pain patients found rate of 11.5% for aberrant behavior.
• For patients without SUD, rate was 0.59%.
• 5 studies (15,542 patients) by urine toxicology: 20.4% had no Rx opioid or an opioid not prescribed.
• 5 studies (1,965 patients): 14.5% had illicit drugs.

Risk Factors for aberrant behavior

• Lifetime history of substance use disorder (alcohol, tobacco, illicit substances)
• Psychiatric co-morbidity
• History of pre-adolescent sexual abuse
• Family history of substance abuse
• History of legal problems
• Younger age (16 – 45)
• Increased functional impairment

Tobacco, really?  So, if you’re a smoker, no pain meds for you.  And which chronic pain patients don’t also have psychiatric issues?  And if you’ve been sexually abused, no pain meds for you either.  Who’s family doesn’t have substance abuse problems?  And watch out, if you’ve got “legal” problems, no pain meds for you either.  Same goes for those between the ages of 16 and 45, a rather large group.  As for functional impairment, doesn’t the constant and unmanaged pain cause that too?

Risk Factors Predictive of Dependence

I can answer this one:  If you’re an American.

Spectrum of Aberrant Behaviors: mild, moderate, and severe

Risk Assessment Tools

Do patients with other medical problems have specific risk assessment tools?  And how many patients would that consist of, considering the majority of them are going to be seeking pain relief?  Perhaps pain patients should feel flattered that the medical industry is going to all this trouble to… protect us (them).

• SOAPP®-R

• DAST© Drug Addiction Screening Tool

• DIRE©

• ORT©

• COMM (Chronic Opioid Misuse Measure)TM

How to use risk assessment tools

Should not be used to deprive patients of pain management or opioid therapy but to identify those who are at risk for addiction…

Sure, that’s what will happen — the tools won’t be abused, no way.  And how would anyone be able to tell if the tools were used in a discriminatory manner?  I mean, once your “identified” as at risk for addiction, you now have a label you’ll carry for the rest of your life.  Pretty soon, if you’ve been given that label, your health insurance premiums will increase, just like they have for smokers.

Sure, doctors won’t use these “tools” as their reasons for denying pain medications.  Not that they have to — doctors can just stop prescribing these life-saving drugs.

Balancing Benefits/Risks

Patients with addiction less likely to use illicit drugs if painful conditions controlled…

Ha, that’s funny… the medical industry believing they can control pain.  And if the drug addict being treated for pain develops an even stronger addiction?  Why, that’s the patient’s fault, not the fault of a doctor who wouldn’t prescribe the needed amount of medications.  (But, see, I’ve documented the use of all these tools!  I have proof that this person is at high risk for addiction!)

Management of Risk

UNIVERSAL PRECAUTIONS: every patient is potentially at risk..

Okay, you just said that doctors shouldn’t prejudge patients, but you go ahead and do it anyway.

When to Taper Opioids

DO NOT abandon the patient even if you refer…

Gosh, I wish there was a law that said this, because doctors do it all the time, with no consequences whatsoever.  Recently, if a doctor has patients who die of drug overdoses, they’re considered criminals.  Then why isn’t abandoning a patient considered a crime also? Don’t doctors think that some of these abandoned patients go on to commit suicide?

Summary

The management of chronic pain with opioids is challenging and rewarding…

Challenging and rewarding?  Yeah, because who doesn’t want the DEA overseeing every decision you make as a doctor?

Considering the low incidence of addiction in the chronic pain patient population, this seems like a lot of effort to catch the small percentage of us that may become addicted to our legally prescribed medications.