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Assessing Ability To cope With chronic pain

Coping and anxiety are closely related, from a clinical viewpoint. The patient who has CNCP may have anxiety because of maladap­ tive coping skills, for example. The concept of acceptance has been studied in CNCP. This concept refers to the patient’s belief that there is more to life than pain, that being completely free of pain is unrealistic, and that activities should be pursued, even at the price of some increase in pain (Risdon, Eccleston, Crombez,

& McCracken, 2003). Patients who have high levels of acceptance report lower pain inten­ sity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily uptime, and better work status than do patients who have not accepted pain.
Patients who have chronic pain who score high on measures of self-efficacy or have an internal locus of control report lower levels of pain, higher pain thresholds, increased exer­ cise performance, and more positive coping efforts (Asghari, Julaeiha, & Godarsi, 2008; Barry, Guo, Kerns, Duong, & Reid, 2003). Exhibit 2-12 lists tools to assess coping skills. Information on obtaining these instruments

is provided in Appendix B.

exhibit 2-12 Tools To Assess coping


Tool

purpose

Format

Administration

Time

Chronic Pain Acceptance Questionnaire

Assesses willingness to experience pain and engage in activities

20 items

Self-administered

5 minutes

Fear-Avoidance

Beliefs Questionnaire

Assesses patients who have chronic low-back pain

16 items

Self-administered

10 minutes


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evaluating risk of Developing problematic opioid Use

When any patient with a behavioral health disorder is considered for opioid therapy for CNCP, the clinician must carefully weigh the risks and benefits of opioid use. Risk assess­ ment is made over time and may change over the course of treatment (Gourlay & Heit,

2009). A patient’s risk level is a matter of clinical judgment. Exhibit 2-13 presents one risk assessment schema. All patients who have SUD histories have some risk, which in many cases can be safely managed. However, in some patients, the risks of opioid use are so great and the likely benefit so small that they should not be treated with chronic opioid therapies.
Screening tools may be one element of a risk assessment. Two commonly used screening tools are the Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP–R) and the Opioid Risk Tool (ORT). Both can

be helpful for identifying patients at risk, but neither has been fully validated. Chapter 4 describes tools for assessing patients who have already begun opioid therapy.

Screener and Opioid Assessment for

Patients with Pain–Revised

SOAPP–R can predict which patients who have CNCP are at high risk for problems with chronic opioid therapy (Exhibit 2-14) (Butler, Fernandez, Benoit, Budman, & Jamison,

2008). It is a self-administered questionnaire answered on a 5-point scale ranging from 0 (never) to 4 (very often). The numeric ratings are added; a score of 18 or higher suggests

the patient is at high risk for problems with chronic opioid therapy.
Opioid Risk Tool

Opioid Risk Tool (ORT; Webster & Webster,

2005) identifies patients at risk for aberrant drug-related behaviors (ADRBs) if prescribed opioids for CNCP (Exhibit 2-15). Like SOAPP-R, ORT may help clinicians decide which patients may require close monitoring if opioids are prescribed for them. Most patients who have CNCP and histories of behavioral health disorders are likely to have elevated scores, indicating a high level of risk on opioid therapy.


exhibit 2-13 risk of patient’s Developing problematic opioid Use


risk

characteristics of patient

Low

No history of substance abuse
Minimal, if any, risk factors

Medium

History of non-opioid SUD
Family history of substance abuse
Personal or family history of mental illness
History of nonadherence to scheduled medication therapy
Poorly characterized pain problem
History of injection-related diseases
History of multiple unexplained medical events (e.g., trauma, burns)

High

Active SUD
History of prescription opioid abuse
Patient previously assigned to medium risk exhibiting aberrant behaviors

Analgesic Research, personal communication, October 30, 2009.
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2—Patient Assessment


exhibit 2-14 soApp–r Questions
1. How often do you have mood swings?
2. How often have you felt a need for higher doses of medication to treat your pain?
3. How often have you felt impatient with your doctors?
4. How often have you felt that things are just too overwhelming that you can’t handle them?

5. How often is there tension in the home?
6. How often have you counted pain pills to see how many are remaining?
7. How often have you been concerned that people will judge you for taking pain medication?

8. How often do you feel bored?
9. How often have you taken more pain medication than you were supposed to?
10. How often have you worried about being left alone?
11. How often have you felt a craving for medication?
12. How often have others expressed concern over your use of medication?
13. How often have any of your close friends had a problem with alcohol or drugs?
14. How often have others told you that you have a bad temper?
15. How often have you felt consumed by the need to get pain medication?
16. How often have you run out of pain medication early?
17. How often have others kept you from getting what you deserve?
18. How often, in your lifetime, have you had legal problems or been arrested?
19. How often have you attended an Alcoholics Anonymous or Narcotics Anonymous meeting?

20. How often have you been in an argument that was so out of control that someone got hurt?

21. How often have you been sexually abused?
22. How often have others suggested that you have a drug or alcohol problem?
23. How often have you had to borrow pain medications from your family or friends?
24. How often have you been treated for an alcohol or drug problem?
Reprinted from Butler et al., 2008. Validation of the revised screener and opioid assessment for patients with pain.

Journal of Pain, 9, 360–372. Used with permission from Elsevier.


29
exhibit 2-15 orT


Item mark each Box Item score Item score

That Applies if Female if male

1. Family history of substance abuse

Alcohol  1 3

Illegal drugs  2 3

Prescription drugs  4 4

2. Personal history of substance abuse

Alcohol  3 3

Illegal drugs  4 4

Prescription drugs  5 5

3. Age (mark box if 16–45) 1 1

4. History of preadolescent sexual abuse 3 0

5. Psychological disease
Attention deficit disorder, obsessive-  2 2 compulsive disorder, bipolar, schizophrenia

6. Depression 1 1


Total

Total score risk category
Low risk: 0–3

Moderate risk: 4–7

High risk: ≥ 8

Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Medicine, 6(6), 432–442. Reproduced with permission of Blackwell Publishing, Ltd.


ongoing Assessment

Clinicians must assess all patients who have

CNCP at regular intervals because a variety

of factors can emerge that can alter treatment needs. For example, a patient may develop tolerance to a particular opioid, the underlying disease condition may change another physi­ cal or mental health problem, which might develop or worsen, or there may be changes

in the patient’s cognitive functioning.
Comparative data can be obtained by using the same assessment tools over time. For patients who have SUD histories or other behavioral health disorders, regular assessments

should include checking for evidence of medi­ cation misuse. Chapter 4 provides a discussion on assessing and documenting the behavior of patients on opioid therapy.
The clinician should regularly:
• Assess adherence to all the recommended treatment modalities.

• Assess patient reactions to the treatment regimen.

• Determine the extent of adherence to the prescribed regimen (otherwise, the reported response may inaccurately reflect on the therapies prescribed).


30

2—Patient Assessment



• Obtain the perspectives of significant

others on the patient’s relief from pain, the effects of analgesia on function, and adherence to and safety with prescribed medications. (Permission to obtain col­ lateral information is a prerequisite for prolonged opioid treatment.)
Nicholson and Passik (2007) recommend that the elements in Exhibit 2-16 be documented

and kept current in a patient’s record. The

frequency with which these areas need to

be assessed in individual patients is a matter of clinical judgment.

Treatment setting

A clinician may conclude that optimal treat- ment includes more specialized care, such as that provided at a pain clinic. Where distance,


exhibit 2-16 elements To Document During patient visits


Area

elements of Documentation

History and Physical Evaluation

History of present illness Pain score/intensity Medication history SUD/addiction history Screening tool assessments Medical history

Physical examination
Mental status/cognition
Results of diagnostic studies

Diagnostic/Clinical Indication for

Prescribing Opioids

Most probable pathological explanation of chronic pain

Treatment Plan

Pharmacological treatments
Nonpharmacological treatments (e.g., physical therapy, exercise, behavioral therapy, lifestyle changes)

Treatment goals and anticipated time course
Adherence measures (e.g., urine drug testing, pill counts)

Informed Consent and Agreements for Treatment

Informed consent (e.g., discussion of risks and benefits of treatment options)

Agreement specifying patient’s responsibilities and clinic policies

Periodic Review

Pain score/intensity
Physical, occupational, and overall function; family and social relationships; and mood and sleep patterns

Side effects (including severity) ADRBs

Medication
Mental status/cognitive changes

Consultations and referrals

As appropriate to provide comprehensive care

Adapted from Nicholson & Passik, 2007.

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costs, or other factors prohibit such a refer­ ral, the clinician must be resourceful, perhaps combining various local resources and sup­ port groups or suggesting specific electronic resources. Chapter 5 provides more details.
The vast majority of chronic pain syndromes

(e.g., lumbago, osteoarthritis) in patients who do not have major psychopathology or

histories of SUDs (excluding tobacco) are managed by primary care physicians. When the pain syndrome is atypical, or when there

is comorbid psychiatric illness or SUD history, specialty consultation may be indicated. In the presence of current or past SUD, addiction­ ology consultation may be necessary before instituting chronic therapy with scheduled medications.

Key points

• Patients should receive a comprehensive initial assessment.

• It is important to discover the cause of a patient’s chronic pain; however, clinicians should not assume a patient is disingenuous if the cause is not discovered.

• The patient’s personal and family substance use histories and current substance use pat­

terns should be assessed.

• It is crucial to obtain collateral information on the patient’s pain level and functioning, as well as SUD status.

• Comorbid psychological disorders should be assessed and treated.

• Assessment of the patient with co-occurring chronic pain and SUD or other behavioral health disorders should be ongoing.

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