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referring for Further Assessment
If the clinical interview, collateral interview, medical records, and screening suggest an unacknowledged SUD in a patient seeking treatment for CNCP, the clinician should refer the patient to an SUD specialist, if pos sible. Ideally, clinicians should develop a strong referral network of substance abuse treatment clinicians who can collaborate in the care of these high-risk patients, but specialists may not always be available or accessible. Referral for an SUD does not obviate the need for pain treatment because addiction treatment facili ties rarely have the resources or expertise to treat pain.
Patients may react negatively to a referral to an
SUD specialist. To avoid surprising the patient and putting the specialist in an awkward situ ation, the clinician should clearly explain the purpose of the referral. When referring the patient, clinicians should:
• Present the referral to the SUD specialist as they would a referral to any specialist, using a matter-of-fact and unapologetic tone.
• Explain to the patient the importance of assessing factors that may be contributing to chronic pain, including substance use, and the problems SUDs or substance use may present for optimal treatment of chronic pain.
• Avoid getting distracted by the patient’s explanation of his or her substance use.
• Assure the patient that the referral does not mean transfer of care. The patient needs to know that care will be coordi nated among all professionals involved,
if indicated, and that discussions of short- and long-term treatment will involve everyone, including the patient.
exhibit 2-9 elements of screening, Brief Intervention, and referral to
• Help the patient make the appointment or make the appointment for the patient.
The clinician–patient relationship is especially critical for patients who have comorbid pain and an SUD. They may anticipate that clini cians will criticize their substance use and discount their pain, and they may misinterpret a concern about an SUD as a lack of concern for their pain. They may blame themselves
for having developed an SUD and expect the clinician to do the same. Therefore, the clinician must maintain an attitude of respect and concern. The clinician should assure the patient that both pain and the SUD are unin vited chronic illnesses and that both need to
be treated concurrently.
Federal regulations hold clinicians to a high standard of confidentiality regarding patient drug and alcohol treatment information (Exhibit
2-10). Appendix C provides elements of a written consent and a sample consent form from 42 Code of Federal Regulations (CFR).
Both CNCP and SUDs are associated with high rates of psychiatric comorbidities, such as anxiety, depression, PTSD, and somatoform disorders (Chelminski et al., 2005; Dersh, Polatin, & Gatchel, 2002; Lebovits, 2000; Manchikanti et al., 2007; Saffier, Colombo, Brown, Mundt, & Fleming, 2007). Psychiatric comorbidity can be preexisting, or it can
exhibit 2-10 Federal protection of patient health Information
develop or worsen with chronic pain or SUDs.
Therefore, the presence of comorbid psychiat ric conditions should be assessed regularly in every patient with CNCP (see CSAT [2005b], for information on treating SUDs in people with co-occurring disorders).
Adults with chronic pain often exhibit fear about the loss of control over routine aspects of daily life; apprehension that clinicians will view their pain reports as exaggerated, imaginary, or contrived; and catastrophic thinking (hopelessness based on a convic tion that things are worse than they really are). However, the distress that frequently accompanies CNCP may or may not signal
a psychiatric disorder, so the clinician should try to make the distinction. Nevertheless, the decision to treat is based on the patient’s level of suffering and not on whether the symp toms reach the threshold for a DSM-IV-TR diagnosis. It is often difficult to differentiate
a substance-induced condition from a pri mary psychiatric disorder, and evaluation of symptoms over time may be necessary. Where indicated, refer patients to a mental health provider. Exhibit 2-11 identifies instruments to assess distress, anxiety, fear, and depression.
Information on obtaining these instruments is in Appendix B.
Anxiety is common among people with CNCP and a current SUD, and it may persist in some people recovering from SUDs. It is frequently associated with depression but can be present without it. Patients who have CNCP, espe cially those with a history of trauma, have increased rates of both anxiety symptoms and anxiety disorders (Dersh et al., 2002).
The presence of an anxiety disorder has a negative effect on treatment of CNCP. Anxiety contributes to patient suffering and can make patients less able to participate in their pain management. Treating anxiety lowers pain
scores, reduces the need for analgesics, and
improves quality of life.
Patients who have CNCP and comorbid depression tend to:
• Have high pain scores.
• Feel less in control of their lives.
• Use passive–avoidant coping strategies.
• Adhere less to treatment plans than
patients who are not depressed.
• Have greater interference from pain, including more pain behaviors observed by others.
• Respond less well to pain treatment,
unless depression is addressed.
Clinical depression has been shown to worsen other medical illnesses, interfere with their ongoing management, and amplify their det rimental effects on health-related quality of life (Cassano & Fava, 2002; Gaynes, Burns, Tweed, & Erickson, 2002). For these reasons, depression should be treated. It may be diffi cult to determine whether a patient’s negative
affect represents clinical depression or the psy chological distress of chronic pain, an SUD, or other medical conditions. Sleep apnea, hypo thyroidism, and hypogonadism can present
as depression. Hypogonadism is particularly relevant because it can result from prolonged exposure to opioids.
Post-Traumatic Stress Disorder
CNCP and PTSD frequently co-occur; Asmundson and colleagues (2002) report that PTSD symptoms are especially common in patients who have CNCP who have high pain scores, high pain affect, and high pain interfer ence. Otis and colleagues (2003) recommend that patients presenting with either condition be assessed for both.
exhibit 2-11 Tools To Assess emotional Distress, Anxiety, pain-related Fear, and Depression
Symptoms for CNCP and PTSD often over lap (Asmundson et al., 2002). These include anxiety, hyperarousal, avoidance behavior, emotional lability, and elevated somatic focus. Both conditions are also characterized by hypervigilance, attentional bias, stress response, and pain amplification.
Symptoms may be mutually reinforcing. For example, if CNCP resulted from a trauma, the pain may trigger flashbacks.
Somatization refers to inordinate preoccupation with and communication about physical symp toms. Although a diagnosis of somatization disorder is rare in patients who have chronic pain, multiple pain complaints are almost always present in somatization disorder. Many patients who have multiple unexplained symp toms have subsyndromal forms of somatization disorder.
This may be categorized as undifferentiated somatoform disorder. When psychological fac tors are thought to contribute to a pain syn drome, patients may be diagnosed with pain disorder with psychological factors or pain disor der with both psychological factors and a general medical condition. Patients who have chronic pain and medically unexplained symptoms are at risk for iatrogenic consequences of unneeded diagnostic tests, medications, and surgery.
Studies show an association between CNCP and suicidal ideation and suicide attempts that is not explained by the presence of co occurring SUDs (Braden & Sullivan, 2008) or co-occurring mental disorders (Braden
& Sullivan, 2008; Ratcliffe, Enns, Belik, & Sareen, 2008; Scott et al., 2010; Tang & Crane, 2006). In their review of 12 articles on suicide (including suicidal ideation and suicide attempts) and CNCP, Tang & Crane (2006) found that the risk for suicide “appeared to be at least doubled” in patients who experienced CNPC (p. 575). (See CSAT [2009a], for information on addressing suicidal thoughts and behaviors in substance abuse treatment).