Highlights From PAINWeek 2011
A number of posters at this year’s PAINWeek1 examined how physicians can improve assessment and risk management in patients on chronic opioid therapy (COT). Some looked at screening tools, whereas others assessed physician knowledge and comfort regarding prescribing opioids.
In the first poster, Pain Paradox, a continuing medical education (CME) company, examined how much their programs affect physician behavior.2 The company examined the responses of participants both before and after participating in their “learning gallery” at five recent medical meetings (PainWeek [2009 and 2010], American Pain Society [2009 and 2010], and the American Academy of Pain Medicine ).
The CME program consisted of a multimedia “education gallery” followed by faculty-led simulated case scenarios to improve clinician knowledge regarding best practices for risk assessment and management of patients on COT. A total of 428 attendees participated in the education gallery—the vast majority of whom were physicians (50%-52%), followed by nurses (14%-17%) and pharmacists (9%-10%). The activity focused on risk evaluation, including risk factors associated with addiction, urine drug testing (UDT), treatment agreements, legal requirements for prescribing controlled substances, and differential diagnoses related to aberrant behaviors.
The researchers reported that at baseline, a minority (29%) of clinicians correctly recognized that when federal and state regulations differ, the more stringent law applies. After the education gallery, a substantial minority (23%) still failed to recognize the appropriate regulations.
Interpreting UDT also remained problematic. At baseline, 56% of clinicians thought that unexpected UDT results were definitive evidence of diversion—as opposed to a broad differential that includes diversion. Even after education on the complexities of UDT, 32% of participants still interpreted a lack of opioid in UDT as definitive evidence of diversion.
When faced with clinical scenarios of aberrant opioid medication behavior, most participants (more than 90% of 638 clinicians) did not conclude diversion or addiction. They did, however, struggle to differentiate among pseudoaddiction (50%), medication tolerance (60%), and physical dependence (51%).
Also, when faced with initial presentation of aberrant behavior, participants did not appreciate the broad differential diagnosis driving the behavior—instead, they jumped to a definitive diagnosis before sufficient information was available.
Through the activities, however, clinician comfort in prescribing opioids significantly improved—from 67% at baseline (comfortable/very comfortable) to 87% after the activity (n=470; P<0.01). What’s more, the benefits endured: At 3 months, 86% of clinicians reported comfort with prescribing opioids.
The authors concluded that in order to help clinicians attain optimal performance when it comes to assessment and risk management in COT, there should be multiple iterations of educational and quality improvement activities.
Screening for Psychiatric Comorbidities
Undiagnosed or untreated psychiatric comorbidities may contribute to medication misuse, abuse, or diversion among patients with chronic pain. Personality traits are key factors that may contribute to aberrant behaviors and are of importance to prescribers of opioid regimens. Therefore, increasing numbers of practitioners are prescreening patients for psychosocial issues before starting them on a pain program. But which screening tools are most effective at predicting which behaviors?
In order to determine correlations between high-risk behaviors and personality type, investigators from Hattiesburg, Mississippi, examined a large outpatient sample of patients with chronic pain being screened for appropriateness of long-term opioid therapy.3 Ninety-six patients were administered the Millon Behavioral Medicine Diagnostic (MBMD), which measures psychosocial assets and liabilities that affect treatment response, and the Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R), which is a measure designed to predict aberrant medication-related behavior.
The researchers found that when the psychiatric indicators of the MBMD were added, 42.7% of the variance in SOAPP-R scores (P<0.001) could be explained. Number of pain sites and emotional lability significantly predicted SOAPP-R score over other psychiatric indicators.
Identifying patients who are at risk for opioid misuse has significant importance, noted the investigators. “These findings suggest personality assessment serves as an effective adjunct to risk stratification. Personality factors such as emotional lability and traits of borderline personality may increase opioid misuse potential,” they added. Clinical interview, history taking, and psychological assessment are valid ways pain specialists can assess personality. Prescribing strategies such as prescreening, close monitoring, limit setting, and inclusion of psychological support can mitigate risk, they concluded.
Adherence to Hospital Policy On Screening
Opioid analgesics are effective for severe chronic pain, yet providers remain reluctant to prescribe them because of concerns about tolerance, dependence, and addiction. Guidelines for the management of chronic noncancer pain (CNCP) clearly emphasize certain assessment tools to help identify and prevent misuse, abuse, and diversion. But how well are these tools being implemented? According to a study by one institution, the majority of primary care physicians (PCPs) were using opioid treatment agreements and urine toxicology screening (UTS), but were less likely to implement baseline risk stratification and periodic risk assessment—including psychological assessment and SOAPP-R.4
The study, which was designed to identify the prevalence of risk assessment and management for patients following the implementation of an institution-wide opioid therapy policy at the Phyllis Jen Center for Primary Care at Brigham and Women’s Hospital in Boston, Massachusetts, contacted PCPs for a current list of patients with CNCP on COT. Patients who met the following criteria were included in the analysis: age at least 18 years, CNCP (defined as pain for at least 6 months unrelated to cancer or other malignancy), and taking COT between May 2008 (date of implementation of institution-wide opioid therapy policy) and May 2011.
To determine the prevalence of opioid risk assessment and adherence to policy guidelines, the following parameters were identified: use of pain assessment tools (verbal numeric rating scale, Brief Pain Inventory, McGill Pain Questionnaire), documentation of physical exam specific to pain, use of opioid treatment agreements, use of initial and subsequent UTS, use of SOAPP-R, use of Current Opioid Misuse Measure (COMM), and use of Addiction Behaviors Checklist (ABC). As a secondary analysis, correlations between patient demographics and risk assessment parameters were evaluated using Statistical Packages for Social Sciences (SPSS).