1. Risk Management and Patient
Assessment in Pain
Management
Hongbiao (Hank) Liu MD PhD
Luna Medical Care
Primary Care and Nuclear Medicine

2. Objectives
 Discuss chronic pain and its interplay with
addictive disorders
 Rational assessment of chronic pain patient
in whom opiate tx is considered
 How to approach pain management in a
patient with a history of addiction
 How to monitor a patient on opiate tx
 What to do if problems arise

3. Chronic Pain
 Chronic Pain-Pain that persists beyond
normal tissue healing; assumed to be 3
months
 77 million adults over 20 experienced some
pain,43 million had chronic pain (National
Center for Health Care Statistics 2006)
 Healthcare expenditures for back pain alone
exceed 1 billion annually

4. Are Opiates Effective?
 Universal acceptance in Acute and
Malignant Pain
 Chronic Non Cancer Pain (CNCP)
Use has increased dramatically over last 20 years
Likely effective for decreasing pain for both nociceptive and
neuropathic pain
American Geriatrics Society Practice Guideline : Pharmacological
Management of Persistent Pain in Older Persons; 2009

5. Are Opiates Harmful?
 Between 2004 and 2005 11.8 million people
reported using opiates non-medically and
2.2 where new users
 Non-medical use of opiates increased 542%
between 1992 and 2003 with resultant
increases in mortality
 Prescription opiate abuse now equal to
Heroin abuse in patients seeking treatment

6. Are Opiates Harmful?
 Ameritox Study: Aberrancy rates noted to
be 70%
Couto, JE. Popul Health Manag. 2009; 12 (4): 185-190
Dunn, KM. Ann Intern Med. 2010 152: 85
Increased risk of overdose at higher doses of opiates
Only 51 events out of 9940 cases reviewed
Overdose rare in opiate naïve patients

7. Long Term Opiate Therapy
Reconsidered
Annals, Sept 6 2011
 Long term data supporting efficacy is
lacking
 Increasing public health consequences
 Safer prescribing called for
– Better patient selection
– Judicious opioid prescribing especially caution
with escalating doses

8. Scope of the Problem
 Currently approximately 1000 patients in
Buffalo on Methadone treatment (more
patients with Suboxone) for opiate
dependence. Generally only 10-20% of
addicted patients are in treatment.

9. Definitions
 Misuse: Use in a manner other than
intended without dysfunction
 Abuse: Behavioral abnormalities
associated with interpersonal impairment
leading to dysfunction
 Addiction: Greater degree of impairment
with loss of control, preoccupation
(cravings), social or occupational
disruptions and use despite harm.

10.  Physical Dependence: Withdrawal
 Tolerance: Need for increased dose for
same effect
 Pseudoaddiction: Aberrant behavior
associated with poorly treated pain

11. DSM IV Criteria
 Opiate Abuse ( 1 in 12 months)
Failure to fulfill major role obligations
Recurrent us in hazardous situations
Recurrent substance-related legal problems
Use despite persistent social problems
Opiate Dependence (3 in 12 months)
Tolerance Withdrawal
Taken Longer than intended Persistent desire to cut down/control use
Time spent obtaining/recovering Important activities reduced/given up
Ongoing use despite harm

12. How to Proceed?

13. Universal Precautions
 Diagnosis with appropriate referral
 Psychological assessment including risk for
addiction
 Informed consent
 Treatment agreement
 Pre and post-intervention assessment of
pain level and function

14.  Appropriate trial of opioid therapy
 Reassessment of pain and functional level
 Regular assessment of the 4 As (Analgesia
Aberrancy/ADL’s/Adverse effects)
 Periodic review
 Documentation
 Gourlay, Pain Mde. 2005:6(2) 107-112

15. Risk Assessment
 Biological
Age <45
Family History
Smoking History

16.  Psychological
Substance use disorder
Bipolar disorder
PTSD
Preadolescent sexual abuse
Depression
ADHD

17.  Social
Prior legal problems
History of MVA
Poor family support
Lack of involvement in recovery program

18. Physical Exam
 Careful attention to pupils
 Skin exam looking for track marks/scars
 Directed toward pain complaints

19. Screening Tools
 SOAPP (Screener and Opioid Assessment
for Patients with Pain) Specific screen for
patients with chronic pain being considered
for opioid tx
 COMM (Current Opioid Misuse Measure)
Identify risk in patients on opiate treatment

20. Screening Tools cont
 CAGE (Cut down/Annoyed/Guilt/Eye
opener)
 Urine Drug Testing

21. Trial of Opiate Therapy
 Informed consent
 Treatment agreement
 Urine Drug Testing
 Ongoing Assessment
 Taper dose if there is no benefit
Is there a maximum dose?

22. Ongoing Assessment/Red Flags
 More Predictive of Addiction
Selling prescriptions
Forgery
Stealing or borrowing another pts drugs
Non-medical sources
Concurrent abuse of related illicit drugs
Multiple unsanctioned dose increases
Recurrent lost scripts

23. Red Flags
 Less Predictive
Aggressive complaining
Drug hoarding
Specific drug request
Acquisition from other medical sources
Dose increases once or twice (unsanctioned)
Unapproved use to treat another symptom
Other psychic effects not intended by the clinician
Passik Clin J Pain. 2006:22(2):173-181

24. Toxicology Screening
 Should be a part of routine monitoring of
most if not all patients on opiate therapy
 Literature support?
 Positive result can confirm compliance with
treatment
 Negative result may indicate diversion
 Use of other substances identified

25. Toxicology Screening
 Very important to understand testing
characteristics:
Some synthetic opiates may not be positive
(i.e. Methadone)
Correlate with history (when was opiate last
taken?)
False positives probably rare but possible
Sertraline (B), Quinolones (O),
Antipsychotics (A,M), NSAIDs and PPI (C)

26. Point of Care Testing
 Primary advantage is to identify problematic
use in a timely fashion
 Disadvantages include:
– Variable performance between available
products
– Less support than laboratory testing
– Limited testing menu
– Lack of confirmation

27. Interventions
 Maximally structured care for higher risk
patients
Frequent visits
Limited medication supply
Primarily long acting opiates
Judicious use of rescue meds
UDT
Pill counts
Recovery Program/Structured setting
Consultations

28. How are we doing?
 Three risk reduction strategies (Any urine tox,
regular office visit, restricted early refill)
 Five risk factors (Age <45, drug, alcohol or
tobacco use, MH dx)
 Mean duration of opiate use 1.9 years
 Urine tox-8%, Office visit-50%, Restricted refill-
76%, only 3% had all three
 Less than one quarter of patients with three or
more risk factors had a urine tox
 Journal of Internal Medicine, September 2011

29. Interventions
 Discharge
May be necessary based on patient inability or
unwillingness to comply with treatment plan
All patients suspected of diversion
Structured taper
Manipulative Behaviors: Consistency/Say No

30. Treatment for Opiate Dependence
 Medically supervised detox
 Inpatient rehabilitation
 Outpatient Treatment/Self Help
 Medication Assisted Treatment

31. Treatment for Opiate Dependence
 “Traditional” abstinence based treatment is
plagued by high rates of relapse
 Ongoing use of opiates for pain complaints
needs to be considered very carefully and
should not be done in the absence of a
stable recovery generally

32. Opiate Agonist Therapy
 Suboxone
Partial opiate agonist
Requires special XU DEA number
Indicated for treatment of opiate withdrawal and
maintenance therapy
Off label use for pain
Category C in pregnancy

33. Methadone
 Gold standard for treatment of opiate
dependence
 Full opiate agonist
 Can not be prescribed for treatment of
addiction outside of a registered treatment
program
 Can be prescribed for pain by any physician
 Category B

34. Other considerations
 Risk Management
One pharmacy
Proper prescription writing and storage
Understanding controlled substance law
Group practice agreements (i.e. no call ins/uniform practice
agreements)

35. Other considerations
 Documentation
4 A’s: Analgesia/Adverse effects/
ADL’s/Aberrancy
Document everything

36. Resources
 STAR (Substance Treatment and Recovery)
Amherst: 3730 Sheridan Drive, Amherst, 862-2059
St. Vincent's: 1595 Bailey Ave, Buffalo, 893-9350
Pathways Methadone Clinic
Benita 862-1565, 158 Holden St, Buffalo
Suboxone Physician Locator

37. Resources
 Clinical Guidelines for use of Chronic Opioid
Therapy in Chronic Non Cancer Pain
Journal of Pain. 2009; 10: 113-130
 American Academy of Pain Management
 www.aapainmanage.org
 American Academy of Pain Medicine
 American Academy of Addiction Medicine
 Urine Drug Testing in Clinical Practice
Monograph