How a biopsychosocial approach to assessing pain better aligns with the realities of treating pain pathways—and how that can limit opioid depedence.
The burden of the opioid epidemic is not going to be resolved from physicians simply not prescribing the addictive therapies anymore. A more in-depth plan—one that takes addiction risks into consideration well before a physician even prescribes treatment—is needed to affect addiction rates.
In a symposium held at the American College of Physicians (ACP) 2019 Internal Medicine Annual Meeting in Philadelphia, PA, Steven P. Stanos, DO, led a discussion on how established understanding of opioids’ effects and treating different forms of pain should influence a physician’s process of avoiding drug addiction-risk scenarios.
The Johnson & Johnson-sponsored session, “Addressing the Opioid Epidemic: A Call to Action to Save Our Communities,” highlighted the various pathways of pain that were once being treated broadly with opioids. As Stanos, of Swedish Health System Pain Medicine and Services in Seattle, WA, noted, there are intricacies among 3 known chronic pain pathways: nociceptive pain, neuropathic pain, and nociplastic pain.
The most recently assessed pathway, nociplastic, is one that was referred to as “hypersensitization” just years ago. A recent definition of the new term emphasized the futility of the pain assessment model physicians were then using for their patients.
“With nociplastic pain, nocireceptors are activated, but there is no tissue damage along nerve tissues,” Stanos explained. “So, the nocireceptors are activated, and we’re not sure why.”
This finding affects the pain assessment model comprehensively. The previously accepted model was based on biomedical approaches, Stanos said, as physicians believed that treating tissue damage was treating the entire scope of pain in a patient. As nociplastic chronic pain is driven by a lack of tissue damage, the model has limited to no value.
Physicians should now follow a biopsychosocial model, Stanos explained, which would add more factors to prescribing pain therapy. The model calls for a physical assessment which seeks to answer the patient’s underlying cause of pain, and what tools can be used to assess that pain. It also calls for an assessment of anxiety and depression using tools like the Generalized Anxiety Disorder 7-item scale (GAD-7) and Patient Health Questionnaire-9 (PHQ-9).
The psychosocial aspect of assessment would also call for the use of pain catastrophizing tools, aberrant medication behavior predictor tools, and an emphasis on patient pain, enjoyment of life, and general activity.
Opioid addiction risks can be stratified into 3 considerations, Stanos said: the presence of acute to chronic pain, aberrant behaviors and addiction, and current patient medications and conditions. He also highlighted the value of the Opioid Risk Assessment Tool, a five-question scoring metric specified for either gender’s risk of addiction on their initial physician visit or prior to beginning opioid therapy.
“You can use this to help stratify your patients and their risk for aberrant behavior,” Stanos said. “The more aberrant behaviors they have could be a clue that there’s a substance abuse problem.”
Among the assessed metrics for risk are patient age, prior substance abuse, family history of substance abuse, and prevalence of psychological conditions. Female risk scores are also weighed by whether or not they have had a history of preadolescent sexual abuse, Stanos explained. An outpatient study of 295 participants found that substance use is 4 times greater among victims of emotional and sexual abuse than those in the control group.
Stanos advised physicians prescribe multimodal analgesia non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or gabapentin for pain management. If opioids are to be prescribed, it should only be immediate-release drugs, and they should be prescribed for as brief a period as possible. Stanos also referred physicians to the current Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain.
Through the biopsychosocial assessment model, physicians should also be considering behavioral medicine, physical intervention, and improved patient monitoring and education when treating for pain management.
In instances of treating patients already on a high dosage of opioids for pain management, physicians should focus on a slow tapering strategy that allows patients to acclimate to lower dosages. Because of the psychological burden that opioid dependence puts on patients, Stanos pressed that nonjudgmental mannerisms are critical to addressing tapering and discussions surrounding the risks of high opioid dependence.
“The key is getting them on an appropriate use of opioids, as well as using non-opioids,” he said.