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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
27 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
 Analgesic Research, personal communication, October 30, 2009.28  2—Patient Assessmentexhibit 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
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
 Adapted from Nicholson & Passik, 2007.31 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. 32 |
