Managing Chronic Nonmalignant Pain In Patients With Addiction


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  • More than 76 million people in U.S. are afflicted with chronic pain. (DHHS, 2006). 76 million people in U.S. with chronic pain vs. 25.8 million children and adults who have diabetes (it is estimated another 79 million people are pre-diabetic).from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011)Total prevalence of diabetesChronic pain is associated with higher rates of depression, anxiety, substance abuse, insomnia, sexual dysfunction, essential hypertension, memory and concentration deficits, emotional lability, poor performance, lost productivity and frustration. (Arnstein, 2010; Dewar et al., 2009; Gourlay, 2011).Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes.Diagnosed: 18.8 million peopleUndiagnosed: 7.0 million peoplePrediabetes: 79 million people*New Cases: 1.9 million new cases of diabetes are diagnosed in people aged 20 years and older in 2010.* In contrast to the 2007 National Diabetes Fact Sheet, which used fasting glucose data to estimate undiagnosed diabetes and prediabetes, the 2011 National Diabetes Fact Sheet uses both fasting glucose and A1C levels to derive estimates for undiagnosed diabetes and prediabetes. These tests were chosen because they are most frequently used in clinical practice.
  • Primary care providers are often reluctant to prescribe opioid analgesics, especially when patients have addition issues. ( Barry et al., 2010; Gallagher & Rosenthal, 2008). Providers often cite lack of education and training in pain management and addiction as a barrier to providing opioid pain medications for their patients with chronic nonmalignant pain. Reluctance to prescribe effective opioid analgesia can lead to the under-treatment of pain, which can be especially problematic for patients with addiction, as the physiological need for relief of pain may actually trigger relapse to active addiction (Gourlay et al. 2005). Undertreating pain can be problematic for patients with addiction (Gourlay, Heit, & Almahrezi, 2005). Behaviors used by patients in an attempt to cope with undertreated pain may be misinterpreted by providers as drug-seeking or addictive in nature. Such behaviors may include requests for early refills, frequent, unauthorized dose escalations or emergency room visits for complaints of chronic pain. These and other aberrant behaviors may be signs of addiction, or they may represent pseudoaddiction.The Federation of State Medical Boards of the United States (FSMB 2004) states in its revised policy that the medical board considers “…inappropriate treatment, including the under-treatment of pain, a departure from an acceptable standard of practice.”Pseudoaddiction: A failure to adequately treat pain. (ASAM, 2001 ASPMN, 2002; FSMB, 2004).Pseudoaddiction is a condition that represents a failure of the provider to adequately treat a patient’s pain which resolves when effective analgesia is achieved.Pseudoaddiction can be a significant barrier to effective opioid therapy if the provider lacks knowledge and training in differentiating it from active addiction.
  • The aims of this paper are to:a) discuss chronic pain and the use of opioid therapy for patients with addiction;b) identify common treatment barriers and risks associated with opioid therapy for patients with a history of or current addiction issues;c) summarize the literature that advocates utilization of expert recommendations and a universal precautions model for all patients in the treatment and management of chronic pain; andd) suggest use of an easy-to-use reference with screening tools designed to help practitioners meet new state of Washington requirements for examination, monitoring and documentation in the management of chronic, nonmalignant pain with opioid pain medications.
  • Henderson believed the individual has needs that are components of health and that the individual may require assistance to achieve health and independence. Her theory considers the patient has biological, psychological, sociological and spiritual components and that their mind and body are inseparable and interrelated (individual).Nursing care requires promotion of conditions which will allow the patient to perform the fourteen components of health to their highest independent degree possible (environment).Health may be challenged by age, cultural background, physical, emotions and intellectual capacities. It is the role of the nurse to encourage promotion of health and prevention and cure of disease for each individual according to their individual capacity (health).Nurses strive to make patients whole or complete, and assist patients in performing life activities. Henderson believed nurses should be scientific problem solvers and gain the knowledge necessary to provide individualized care to their patients (nursing).Henderson’s 14 concepts of health provide an effective template for evaluating patient function, while encouraging the nurse to incorporate a holistic, biopsychosocial model of care which is an approach supported by the current research. This conceptual framework forms the basis of the following literature review and subsequent recommendations for providing effective pain management for patients struggling with addiction issues.
  • Stanos (2007) notes that poor performance and frustration can be linked to the repeated interruptions undertreated pain can cause in daily life. Undertreated or untreated acute pain has the potential to cause chronic pain through N-methyl d-aspartate (NMDA) receptor activation, apoptosis, and other neurophysiologic changes (Millard, 2007).NMDA receptors can become sensitized to nerve signals from the sites of tissue or nerve injury leading to a cascade of change in cell function throughout the nervous system, including amplification and persistence of pain.Substance P, an inflammatory neuropeptide that coexists with the excitatory NMDA is activated along with NMDA when pain is ineffectively treated, and has been demonstrated to play a role in pain, nociception, mood disorders, anxiety and stress (Ren & Dubner, 1999). These brain function changes are similar to those found in other neurological conditions known to cause cognitive deficits such as autism, Alzheimer’s diseases, depression, schizophrenia and attention deficit hyperactivity disorder (Baliki, Geha, Apkarian, & Chialvo, 2008).Chronic pain can also lead to deficits in memory and concentration, difficulty making simple decisions, and to a low threshold for frustration, anger, depression, anxiety and trouble sleeping (Arnstein, 2010). Treating chronic pain in patients with addiction has the potential to improve individual functioning in many areas including memory, mental health, attention, addictive disease, job performance, and well-being and to reduce costs to society from decreased productivity, disability and overuse of emergency departments for undertreated pain.
  • Patients with chronic pain who have a history of addiction, or who are currently addicted, should not be summarily considered ineligible for treatment with opioid medications. Although active addiction may be an absolute contraindication for opioid pain medication, such patients can be referred to addiction specialists for treatment, if they are amenable to such a referral , and can be re-evaluated when their addiction is considered treated and in remission.For those who have a history of addiction, risk stratification by obtaining a careful history physical exam, and appropriate screening assessments can guide the provider in structuring an appropriate treatment plan with individualized monitoring, compliance testing, education, agreements and other accountability measures (Gourlay, 2005). Unfortunately, providers and patients alike face several significant issues when considering treatment with opioid medication. There are many inherent risks and barriers when prescribing opioids for the treatment of chronic nonmalignant pain.
  • Providers also face the possibility of litigation when patients overdose or die from a prescribed medication. In 2001, 13 lawsuits were filed in Virginia, Kentucky, Ohio, and West Virginia against Purdue Pharma and individual doctors for prescribing OxyContin.Many state laws protect providers from prosecution for opioid prescribing if they have adhered to accepted, published guidelines and state standards of practice. Alleviating pain is mandated by the Joint Commission as part of their accreditation process and demands healthcare providers adequately assess and treat pain. However, laws such as those recently enacted in the State of Washington also highlight the responsibility providers must accept for the possible consequences of providing opioid medications to patients in pain. As the problems of misuse, abuse and diversion increase, it is incumbent upon all providers to be aware, educated and mindful of the risks involved, and to become familiar with the regulations governing the use of opioid medications in their own states.The state of Washington has attempted to address some of these issues with new rules on opioid prescribing that has many physicians expressing fear and concern. Washington’s requirements for a higher level of documentation and examination in order to prescribe opioid medications are leading to some providers abandoning patients currently on opioid pain medications, and to their refusing to accept any new patients into their practices who might require opioid pain medications.Physicians have recently testified before lawmakers in this state regarding their reluctance to treat patients with pain out of fear of the new rules (Ostrom, 2012). Dr. J. Thompson, chief medical officer of the University of Washington’s Division of Pain Medicine, thinks the next 2-5 years will be very painful for patients, providers and the system, as the desire and legal mandate to treat pain is carefully balanced with the growing problems of abuse and diversion (Ostrom, 2012).Providers often feel ill-prepared to handle the risk for addiction with the prescribing of opioids for chronic pain, citing a lack of education and training in addiction and the use of opioids in general (Upshur, et al., 2006). Providers may fear that prescribing opioids for patients with chronic pain may acutally cause addiction in a person in whom no addiction has ever been manifest. Gourlay (2012) notes there is no evidence for or against being able to “create” an addict. He further notes that it is important to employ a rational, universal precautions approach for all patients with chronic pain which sets careful limits, appropriate boundaries and includes effective pharmacotherapy when needed.
  • Starrels et al., (2010) points out that opioid misuse is a growing problem and must be addressed through more research and improved opioid prescribing strategies. In 2008, nearly 5 million Americans reported using prescription pain relievers in the past month for nonmedical reasons; that is, these individuals used prescription analgesics that were not prescribed for the or they used these medications simply for the feeling the drugs caused.CDC reports that between 1999 and 2004, unintentional poisoning deaths related to opioid prescription drugs rose 142% while heroin related overdose was down 9%, with approximately 27,000 unintentional drug overdose deaths in the U.S. in 2007 alone. ER visits for drug-related issues have risen sharply since 2004. (DAWN Report, 2009). Between 2004 and 2008 the Drug Abuse Warning Network (DAWN) data reveals a 111% increase in ER visits for the nonmedical use (misuse) of several commonly prescribed opioid medications, and the misuse of opioids as the number one cause of poisoning. Maxwell (2011) points out that while popular belief is that people who abuse opioids obtain their pills illegally from the internet or from drug dealers on the street, the majority of prescription opioid medication that is misused comes form friends and family who receive their drugs from a single prescriber.Addiction is a rare risk among patients treated with opioid pain medications, but unfortunately is one reason many providers choose not to treat pain with opioids (ASAM, 2001). Research has consistently revealed a very low risk of a patient developing addiction while receiving chronic opioid analgesic medications from an estimated 0.19% rate among those with no previous history of addiction, to 2.37% among those with personal or family history of addiction (Fishbain, 2008). This can be compared to prevalence estimates of substance dependence or abuse in the general population which is around 9% (SANHSA, 2008). Evidence supports the position that using opioids for the management of chronic pain does not lead to high rates of addiction, however, providers must be vigilant in assessing, diagnosing and managing patients on opioid medications so those who do abuse, divert or become addicted can be identified early and provided with appropriate intervention and referrals. Effective monitoring strategies can help ensure both patient safety and treatment success for patients with chronic pain, while minimizing the risk for abuse misuse, diversion, and addiction.Aberrant drug-related behaviors providers must be aware of with any patient receiving opioids for pain management include frequent late-night visits to the ER, lost or stolen prescriptions, use of multiple names, stealing or forging prescriptions, diverting or selling prescriptions, and patients focusing on a particular medication despite the offer of an alternative and despite experiencing uncomfortable side effects from the requested medication.Providers must be prepared to monitor their patients carefully for aberrant drug-related behaviors and addiction, not only to reduce the risk to their patients, but to protect themselves from liability. The challenge for providers is to overcome common barriers to opioid medication management, while mitigating the potential for abuse and addiction, enabling them to provide effective chronic pain management treatment for all their patients. Published guidelines and expert recommendations can assist providers in overcoming these barriers and in handling the risks involved with opioid prescribing. This is critical if we are to adequately address the needs of the large numbers of patients who suffer from chronic pain and who may also have a history of or current addiction issues.
  • Use of expert national guidelines:National guidelines have been published by a number of organizations all of which aim to assist providers of all professions with these dual aims. While there is an unfortunate paucity of research to empirically validate recommendations, expert panels have carefully reviewed the available evidence and formulated consensus guidelines aimed at optimizing benefits and reducing risk (Chou et al., 2009). (AHRQ, 2009; ASAM, 2001; ASPMN, 2002; Chou et al., 2009; FSMB, 2004). 2) Adopt a Universal Precautions Model
  • Universal precautions help to reduce bias and stigma, standardize treatment and management for all patients, and improve outcomes in analgesia, function and compliance (Gourlay et al., 2005).See handout for 10 items on this list…Discuss the screening tools listed…
  • The state of Washington has recently enacted new rules governing the prescribing of opioid pain medication for chronic, nonmalignant pain in an effort to curtail the growing problems of abuse, misuse, addiction and diversion. Many primary care providers have voiced concerns that the new rules are so strict they create a hostile environment for those who prescribe opioid pain medications and greatly increase the fear of regulatory punishment and other legal sanctions (Ostrom, 2012, February 10). It is common to hear providers state they will no longer accept pain management patients, community healthcare organizations have declared they will not take any new pain management patients, and current chronic pain patients are being referred to specialists is as many cases as possible. There seems to be a mass exodus of providers away from providing chronic opioid pain management for their patients.The president of the Washington State Medical Association (WSMA), recently testified to state lawmakers that, “I think that (the new law) has spooked a lot of physicians to where they are no longer willing to write prescriptions for these conditions,” (Ostrom, 2012, February 10, p. 1). Denny Maher, director of legal affairs for the WSMA states, “A lot of what we are hearing is physicians are afraid to take care of patients or they have concerns about taking care of patients because of the documentation requirements and the examination requirements,” (Ostrom, 2012, February 10, p. 1). At the same hearing, two patients told the committee member they had been abruptly cut off of their pain management treatment because of the new law and have been struggling ever since to find new providers. Dr. Jeff Thompson, chief medical officer of the states’ Medicaid program, said of doctors, “They’re scared, and they need some help, and they need some tools…” (Ostrom, 2012, February 10, p. 2).Appendix B contains both a summary of and actual text from WAC 246 to assist providers in becoming familiar with the requirements of the new state of Washington law.Expert clinical guideline sources are provided on p. 18 of this paper. Adherence to national guidelines can improve practice outcomes and protects patients and providers from potential harm.
  • Providers can overcome common barriers to opioid pain management by:managing all patients with a universal precautions approach,b) obtaining the education and training necessary to treat chronic pain and prescribe opioid medications appropriately,c) becoming familiar with national guidelines and recommendations,d) becoming well-versed in state laws, ande) utilizing specialists as needed.The risks associated with opioid prescribing can be mitigated by appropriate initial screening, rational prescribing, regular supervision and on-going monitoring for all patients, urine drug testing, treatment agreements and referrals to other mental health, addiction or healthcare specialists as needed.Universal precautions allow providers to offer equal access to care for all patients with chronic nonmalignant pain, regardless of addiction history or status, and to provide that care safely and effectively.
  • Managing Chronic Nonmalignant Pain In Patients With Addiction

    1. 1. Karen S. RawlinsWashington State University
    2. 2. Introduction More than 76 million people in the U.S. are afflicted with chronic pain (DHHS, 2006).
    3. 3. Introduction  Providers have an ethical obligation to provide adequate analgesia for all their patients. (ASPMN, 2002; ASAM, 2001) Opioid medications are effective for moderate to severe chronic nonmalignant pain. (Chou, 2009; Smith & Bruckenthal, 2010)
    4. 4. Statement of Purpose  Chronic pain and the use of opioid medications for patients with addiction. Risks and barriers with opioid prescribing. Universal Precautions model for all patients. Screening tools and WAC 246
    5. 5. Conceptual Framework  Virginia Henderson’s Need Theory Four major concepts include the individual, environment, health, and nursing. 14 components
    6. 6. Chronic Pain“…persistent pain, which can beeither continuous or recurrent andof sufficient duration and intensityto adversely affect a patient’s well-being, level of function, and qualityof life.” (D’Arcy & McCarberg,2007). It is generally consideredpain which lasts longer than 6months.
    7. 7. Opioid Therapy forChronic Pain inPatients withAddictionIn the U.S. opioid medications aresome of the most frequentlyprescribed drugs. The use of opioidmedications in chronicnonmalignant pain is supported bynational consensus guidelinesacross many professions. A historyof addiction should notautomatically mean no treatmentwith opioid medications.
    8. 8. Barriers to OpioidTherapyFrequently cited barriers includefear of regulatory punishment andinadequate education and trainingin pain management and chemicaldependency.
    9. 9. Risks Associated with Opioid PrescribingThe risks associated with opioid prescribing include abuse, misuse and diversion of opioid medications, aberrant drug-related behaviors and addiction.
    10. 10. Recommendations for Treatment Management Managing chronic pain requires diligence from providers to ensure adequate levels of analgesia and function are achieved with their pain management patients, while also mitigating the risks of abuse, misuse, addiction and diversion (Starrels, 2010).
    11. 11. Universal Precautions Model  Diagnosis  Reassessment of pain w/appropriate and function at regular differential intervals Screening for addiction  Assess the “Five A’s” and mental health disorders  Periodically review Informed Consent pain diagnosis and Treatment Agreement comorbid conditions Assessment of pain and  Documentation function
    12. 12. Reference for PCP’sproviding painmanagement in theState of WashingtonThe state of Washington hasenacted new rules governing theprescribing of opioid painmedication for chronic,nonmalignant pain in an effort tocurtail the growing problems ofabuse, misuse, addiction anddiversion.
    13. 13. Summary Patients and providers alike benefit from a universal approachwhich emphasizes patient accountability, provider competence,and provides a well-structured and predictable framework for patients receiving pain management treatment with opioids.
    14. 14. References  Adams, D. (2001, September). AAFP pens directive against limiting pain prescriptions. American Medical News. Retrieved 02/2012 from http://www.ama- Agency for Healthcare Research and Quality. Institute for clinical Systems Improvement (ICSI). (2009). Assessment and management of chronic pain. Guideline Summary NGC-7602. Retrieved 12/2011 from the Agency for Healthcare Research and Quality website: hronic+pain American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine (2001). Definitions related to the use of opioids for the treatment of pain: Consensus statement. Retrieved 12/2011 from American Society of Addiction Medicine website: statements/2011/12/15/definitions-related-to-the-use-of-opioids-for-the-treatment-of-pain- consensus-statement American Pain Foundation. (2008). A reporter’s guide: Covering pain and its management. Retrieved 01/2012 from the American Pain Foundation’s website: American Society of Pain Management Nurses (2002). ASPMN Position Statement: Pain management in patients with addictive disease. Retrieved 12/2011from American Society for Pain Management Nursing website:
    15. 15. References  Arnstein, P. (2010). Is my patient drug-seeking or in need of pain relief? Nursing, 40(5), 60-61. doi: 10.1097/01.NURSE.0000371136.70791.13 Arnstein, P. & St. Marie, B. (2010). Managing chronic pain with opioids: A call for change. A white paper by the nurse practitioner healthcare foundation. Retrieved 12/2011from Nurse Practitioner Healthcare website: ids.pdf Baliki, M. N., Geha, P. Y., Apkarian, A. V., & Chialvo, D. R. (2008). Beyond feeling: Chronic pain hurts the brain, disrupting the default-mode network dynamics. The Journal of Neuroscience, 28(6), 1398-1403. Barry, D. T., Irwin, K. S., Jones, E. S., Becker, W. C., Tetrault, J. M., Sullivan, L. E., Hansen, H., O’Connor, P. G., Schottenfeld, R. S., & Fiellin, D. A. (2010). Opioids, chronic pain, and addiction in primary care. The Journal of Pain, 11(12), 1442-1450. Butler, R., & Sheridan, J. (2010). Innocent parties or devious drug users: The views of primary healthcare practitioners with respect to those who misuse prescription drugs. Harm Reduction Journal, 7, 21-32. doi: 10.1186/1477-7517-7-21
    16. 16. References  Centers for Disease Control and Prevention (CDC). (2007). Unintentional poisoning deaths – United States, 1999-2004. MMWR Morbidity and Mortality Report, 56:93-96. [PMID: 17287712]. Centers for Disease Control and Prevention (CDC). (2012). CDC grand rounds: Prescription drug overdoses – a U.S. epidemic. MMWR Morbidity and Mortality Report, 61(01):10-13. Centers for Disease Control and Prevention, National Center for Health Statistics. (2011). Antidepressant use in persons aged 12 and over: United States, 2005-2008. (Data Brief No. 76). Hyattsville, MD: Pratt, L. A., Brody, D. J. & Qiuping, G. Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P., Donovan, M. I., Fishbain, D. A., Foley, K. M., Fudin, J., Gilson, A. M., Kelter, A., Mausko, A., O’Connor, P. G., Passik, S. D., Pasternak, G. W., Portenoy, R. K., Rich, B. A., Roberts, R. G., Todd, K. H., & Miaskowski, C. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113-130. D’Arcy, Y., & McCarberg, B. (2007). Management: Patients with a substance use disorder. The Nurse Practitioner, 32(9), 37-44.
    17. 17. References  Dewar, A., Osborne, M., Mullett, J., Langdeau, S., & Plummer, M. (2009). Psychiatric patients: How can we decide if you are in pain? Issues in Mental Health Nursing, 30, 295-303. doi: 10.1080/01612840902754297 Drug Abuse Warning Network. (2009). The DAWN report. National estimates of drug-related emergency department visits. Substance Abuse and Mental Health Services Administration. Rockville, MD. Accessed 02/2012 from Elander, J., Marczewska, M. Amos, R., Thomas, A., & Tangayi, S. (2006). Factors affecting hospital staff judgments about sickle cell disease pain. Journal of Behavioral Medicine, 29(2), 203-214. doi: 10.1007/s10865-005-9042-3 Federation of State Medical Boards of the United States (FSMB), Inc. (2004). Model policy for the use of controlled substances for the treatment of pain. Policy Statement. Retrieved 12/2011 from the Federation of State Medical Boards of the United States website: Finney, L. (2010). Nursing care for the patient with co-existing pain and substance misuse: Meeting the patient’s needs. MEDSURG Nursing, 19(1), 25-30, 53. Fishman, S. M. (2007). Responsible opioid prescribing. Washington, DC: Waterford Life Sciences.
    18. 18. References  Furlan, A. D., Sandoval, J. A., Mailis-Gagnon, A., & Tunks, E. (2006). Opioids for chronic noncancer pain: A meta-analysis of effectiveness and side effects. Canadian Medical Association Journal, 174(11), 1589-1594. Gallagher, R. M., & Rosenthal, L. J. (2008). Chronic pain and opiates: Balancing pain control and risks in long-term opioid treatment. Archives of Physical Medicine and Rehabilitation, 89(Suppl. 1), S77-S82. Gourlay, D. L., Heit, H. A., & Almahrezi, A. (2005). Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. American Academy of Pain Medicine, 6(2), 107- 112. Henderson, V. (1991). The nature of nursing reflections after 25 years. New York: National League for Nursing. Kelly, J. P., Cook, S. F., Kaufman, D. W., Anderson, T., Rosenberg, L., & Mitchell, A. A. (2008). Prevalence and characteristics of opioid use in the US adult population. International Association for the Study of Pain, 138, 507-513. doi: 10.1016/j.pain.2008.01.027 Maxwell, J. C. (2011). The prescription drug epidemic in the United States: A perfect storm. Drug and Alcohol Review, 30, 264-270. doi: 10.1111/j.1465-3362.2011.00291.x Meltzer, E. C., Rybin, D., Saltz, R., Samet, J. H., Schwartz, S. L., Butler, S. F., & Liebschutz, J. M. (2011). Identifying prescription opioid use disorder in primary care: Diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain, 152(2), 397-402. doi: 10.1016/j.pain.2010.11.006
    19. 19. References  Merrill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A., & Bradley, K. A. (2002). Mutual mistrust in the medical care of drug users: The keys to the “narc” cabinet. Journal of General Internal Medicine, 17, 327-333. Millard, W. B. (2007). Grounding frequent flyers, not abandoning them: Drug seekers in the ed. Annals of Emergency Medicine, 49(4), 481-486. Modesto-Lowe, V., Johnson, K., & Petry, N. M. (2007). Pain management in patients with substance abuse: Treatment challenges for pain and addiction specialists. The American Journal on Addiction, 16, 424-425. Mojtabai, R. & Olfson, M. (2011). Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Affairs, 30(8), 1434-1442. doi: 10.1377/hlthaff.2010.1024 Ostrom, C. M. (2012, February 10). Doctors want to amend new rules on prescribing pain medications. Seattle Times. Retrieved 02/2012 from Passik, S. D. (2009). Issues in long-term opioid therapy: Unmet needs, risks, and solutions. Mayo Clinic Proceedings, 84(7), 593-601. Portenoy, R. K., (1996). Opioid therapy for chronic nonmalignant pain: A review of the critical issues. Journal of Pain and Symptom Management, 11(4), 203-217. Reid, M. C., Engles-Horton, L. L., Weber, M. B., Kerns, R. D., Rogers, E. L., & O’Connor, P. G. (2002). Use of opioid medications for chronic noncancer pain syndromes in primary care. Journal of General Internal Medicine, 17, 173-179.
    20. 20. References  Ren, K. & Dubner, R. (1999). Central nervous system plasticity and persistent pain…including commentary by Dionne R., Hu, J. W., and Widmer, C. G. with author response. Journal of Orofacial Pain, 13(3), 155-171. Saffier, K., Colombo, C., Brown, D., Mundt, M. P., & Fleming, M. F. (2007). Addiction severity index in a chronic pain sample receiving opioid therapy. Journal of Substance Abuse Treatment, 33, 303-311. doi: 10.1016/j.sat.2006.12.011 Savage, S. R. (2009). Management of opioid medications in patients with chronic pain and risk of substance misuse. Current Psychiatry Reports, 11, 377-384. Smith, H. & Bruckenthal, P. (2010). Implications of opioid analgesia for medically complicated patients. Drugs & Aging, 27(5), 417-433. Starrels, J. L., Becker, W. C., Alford, D. P., Kapoor, A., Williams, A. R., & Turner. (2010). Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of Internal Medicine, 152, 712-720. Stanos, S. P. (2007). Biopsychosocial assessment for chronic opioid use. Pain Management Nursing, 8(3), S14-S22. doi: 10.1016/j.pmn.2007.04.003 Substance Abuse and Mental Health Services Administration. (2010). The DAWN report: Trends in emergency department visits involving nonmedical use of narcotic pain relievers. Retrieved 01/2012 from Substance Abuse and Mental Health Services Administration. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD
    21. 21. References  Upshur, C. C., Luckmann, R. S., & Savageau, J. A. (2006). Primary care provider concerns about management of chronic pain in community clinic populations. Journal of General Internal Medicine, 21, 652-655. doi: 10.1111/j.1525-1497.2006.00412.x U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. (2006). Health, United States, 2006: With chartbook on trends in the health of Americans (DHHS Publication No. 2006-1232). Retrieved 01/2012 from Webster, L. R., & Fine, P. G. (2010). Approaches to improve pain relief while minimizing opioid abuse liability. The Journal of Pain, 11(7), 602-611. doi: 10.1016/j.jpain.2010.02.008 Wilsey, B. L., Fishman, S. M., Ogden, C., Tsodikov, A., & Bertakis, K. D. (2008). Chronic pain management in the emergency department: A survey of attitudes and beliefs. American Academy of Pain Medicine, 9(8), 1073-1080. doi: 10.1111/j.1526-4637.2007.00400.x