Assessing Abuse Potential in Pain Patients

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Assessing Abuse Potential in Pain Patients

Posted 03/26/2004

Lynn R. Webster, MD

Introduction

The prevalence of opiate abuse among patients with chronic pain is unknown

but is believed to be no greater than the prevalence of opiate abuse in the

general population.[1] Some studies disagree and estimate the danger of

addiction or abuse for pain patients to be higher than the norm.[2,3] Other

medical literature has put the prevalence of addictive disorders among

patients who sustain major trauma as high as 60%.[4] Despite the common use

of opioid analgesics in the treatment of chronic pain, considerable fear

exists among physicians that prescribing opioid drugs may contribute to

opiate abuse or addiction.

All physicians who prescribe opioid medications to chronic pain patients

must assess patients for potential abuse. This can be done in 3 ways. The

first way is to watch for aberrant behavior that may be associated with

abuse or addiction. The second way is to be familiar with the individual

risk factors for opiate abuse. The third way is by using assessment tools to

evaluate, diagnose, and possibly predict abuse or addiction in patients.

Aberrant Behaviors

A number of aberrant behaviors (Table 1) are associated with drug

abuse.[5,6] Although the display of any single behavior does not

automatically indicate a problem with abuse or addiction, in the absence of

a laboratory test to diagnose such disorders, the behavior displayed by the

patient is the best indicator of potential abuse available to the clinician.

This relationship to aberrant behaviors is reflected in the definitions of

abuse and addiction found in the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition.[7]

Individual Risk Factors

Many individual risk factors are linked to aberrant behaviors that might

indicate abuse or addiction. Clinicians need to monitor for these risk

factors to minimize the risk of contributing to abuse or addiction. The

following are what this author believes to be the most significant risk

factors for developing opiate abuse in chronic pain patients.

Family History of Substance Abuse (Alcohol, Illegal Drugs, or Prescription

Drugs)

A family history of substance abuse can create both genetic and

environmental risk factors for developing substance abuse or addiction.[8,9]

In a study of 3372 male twin pairs, Tsuang and colleagues[9] found that the

risk of developing any drug use disorder is influenced about equally by

genetic and environmental factors.

Personal History of Substance Abuse (Alcohol, Illegal Drugs, or Prescription

Drugs)

Clinical observation reveals that when patients have a history of abusing

prescriptions or illegal drugs, they are likely to continue the abuse and

aberrant behavior. The higher the number of aberrant behaviors exhibited by

the patient, the more likely they will display opiate abuse.

A retrospective study by Dunbar and Katz[10] showed that a recent history of

polysubstance abuse was associated with aberrant behavior. One study[11] of

personal polysubstance use has shown that most individuals hospitalized for

alcohol treatment also abused one or more other substances in the 3 months

before entering alcohol treatment.

According to Tsuang and associates,[12] an individual who developed a drug

use disorder was 7 times more likely to develop another drug use disorder.

Age

Onset of drug abuse can occur at very early ages. Middle-to-late adolescence

into mid-20s appears to be when most drug experimentation occurs.[13-15]

A survey of 3500 respondents found that 22% of 18- to 30-year-olds had a

substance abuse disorder.[14] Of those with multiple mental disorders, 80%

reported the onset of a substance abuse disorder before the age of 20 years.

Prevalence of nonalcohol substance abuse significantly declines later in

life.[16]

History of Preadolescent Sexual Abuse

It is generally accepted that women who experienced preadolescent sexual

abuse are at particular risk for mental and substance abuse

disorders.[17-19] In a study of 286 women,[20] roughly 9% of the sample

reported being victims of childhood sexual abuse, and of that group, 64% had

been treated for depression for at least 3 years.

In another study,[21] investigators reported that 55% to 99% of women

seeking substance abuse treatment who had a history of trauma had been

sexually or physically abused by the age of 18 years.

One 10-year study[17] found that depression, anxiety, panic disorders,

alcohol, and drug dependency all increased as a result of sexual abuse. Of

all the disorders measured, drug dependency occurred most frequently

following sexual abuse. There seems to be something uniquely traumatic to

this experience that is associated with substance abuse later in life.

Psychological Diseases

Substance abuse has been associated with numerous psychological

disorders.[14,22-26] Data indicate patients diagnosed as having

attention-deficit/hyperactivity disorder, depression, anxiety,

obsessive-compulsive disorder, schizophrenia, or bipolar disorder are at

significant risk for abusing substances.[14,24,25]

One study[24] showed that among individuals with a lifetime mental disorder

diagnosis, 22.3% displayed alcohol abuse or addiction and 14.7% exhibited

drug abuse or addiction. Among those with no history of mental disorder, the

rate of alcohol abuse was 11% and drug abuse was 3.7%. Thus, having a

lifetime mental disorder is associated with more than twice the risk of

experiencing an alcohol disorder and more than 4 times the risk of

experiencing another drug abuse disorder.

Assessment Tools

Of the currently available diagnostic tools for opiate abuse, several take a

long time to administer and require unique skills to interpret. Screening

tools have 2 common problems when used to assess for potential opiate abuse

in chronic pain patients. First, they are designed to identify patients who

already have problems with substances not to predict who may develop

problems, and second, they are not designed to screen specifically for

opiate abuse.

Some, such as the CAGE (from " cut, annoyed, guilty, eye " ) and the Two-Item

Conjoint Screening (TICS) tools have been adapted for use in opiate abuse

screening but were originally designed as alcohol abuse screening tools.

Others, such as the Structured Clinical Interview for DSM-IV (SCID) and

Prescription Drug Use Questionnaire (PDUQ), have some predictive validity

but are lengthy to administer and score.

One exception is the Webster Assessment Tool (manuscript in preparation). It

screens new patients for the common risk factors discussed in this column

and has been found to have high predictive validity.

The choice of which assessment tool to use will depend on the clinician's

expertise or access to specialists in the field, the time available, and

other aspects of the clinical situation. For new patients, predictive tools

can help clinicians assess potential risk before treatment begins. For a

current patient, when aberrant behavior is suspected, a diagnostic tool

would be helpful.

Table 2 highlights the characteristics of the most common substance abuse

assessment tools.

In conclusion, the purpose of assessing patients for the risk of abusing

opiates is not to deny treatment to moderate-risk to high-risk patients. All

patients deserve treatment for pain. However, higher-risk patients require

more careful monitoring and clinical vigilance if opiates are to be safely

prescribed. This should be done to mitigate the harm opiate abuse can bring

to society and to our patients. Clinicians can assess for potential opiate

abuse by watching for aberrant behaviors, identifying individual risk

factors and using specific validated assessment tools designed to detect

opiate abuse. The method a clinician uses to assess for potential abuse must

be tailored to the patient, taking into account the resources and expertise

of the clinician.

Tool Alcohol/Drugs Predictive Administered Length

Addiction Severity Index (ASI)[27] Yes/yes No Self or interview

200 items, 1 hour

Structured Clinical Interview for DSM-IV (SCID)[28] (psychoactive substance

use module only) Yes/yes Yes Interview 30-60 minutes

CAGE[29] from " cut, annoyed, guilty, eye " ) Yes/no No Interview 4

items, <1 minute

TICS (Two-Item Conjoint Screening Tool)[30] Yes/no No Interview

2 items, <1 minute

Screener and Opioid Assessment for Patients With Pain (SOAPP)[31] Yes/yes

Testing Ongoing Self or interview 24 items, 10 minutes

Prescription Drug Use Questionnaire (PDUQ)[32] No/yes Yes Interview

42 items, 20 minutes

RAFFT[33] (from " relax, alone, friends, family, trouble " ) Yes/yes No

Self 5 items, approximately 1 minute

Drug Abuse Screening Test (DAST)[34] No/yes No Self 20 items, 5

minutes

Severity of Opiate Dependence Questionnaire (SODQ)[35] No/yes No

Self 21 items, approximately 5 minutes

Webster Assessment Tool (WAT)[5] Yes/yes Yes Self 5 items, 1

minute

Lynn R. Webster, MD, Medical Director, CEO, Lifetree Pain Clinic, Salt Lake

City, Utah

Disclosure: Lynn R. Webster, MD, has disclosed that he has received grants

for clinical research and served as an advisor or consultant for Cephalon.

Dr. Webster has also served as a principal investigator for Elan, PTI,

NeurogesX, Purdue, and GlaxoKline, as well as a consultant for

Mallinckrodt. He has reported that he does not discuss any investigational

or unlabeled uses of commercial products in this activity.

Medscape Neurology & Neurosurgery 6(1), 2004. © 2004 Medscape