Continuing looking at what has become a pervasive problem in the medical community.
Michael E. Schatman, PhD, CPE
In last month’s Pain Perspectives, we examined some of the empirically-established risk factors for opioid-related aberrancy, and the importance of obtaining a thorough and accurate history in order to prevent abuse among patients with chronic pain.
While taking a good history is an imperative, doing so is not enough to ensure your patients’, as well as your practices’, safety. In this month’s column, I will discuss some of the simple psychometric tools that can be efficiently utilized to assess some of the risk factors — thereby providing primary care clinicians with evidence-based objective data that will help you more accurately determine which patients are least likely to benefit from ongoing opioid analgesia, and which are most likely to suffer its consequences and reprocussions.
As discussed, depression and anxiety are two strong predictors of opioid aberrancy1,2. Unfortunately, these are two disorders that take many forms, and are accordingly difficult to detect at times simply through the physician-patient encounter 3. Ultra-short, for example, one question measures of emotional distress are available, although they have been determined to identify only a minority of patients suffering from mood or anxiety disorders 4. Although the use of ultra-short measures is tempting, it is important to recognize that relatively brief measures for identifying depression and anxiety are readily available.
While numerous measures of depression have been published, I highly recommend the Center for Epidemiologic Studies Depression Scale (CES-D) 5. Not only has the CES-D been validated in numerous studies of patients with chronic pain, but it has also been utilized in the investigation of depression as a predictor of opioid aberrancy 6. The CES-D is a 20-item measure that requires approximately 5-10 minutes to administer and score, and is available in the public domain here.
To measure anxiety, I recommend the General Anxiety Disorder Scale (GAD-7) 7, which has been found to measure post-traumatic stress disorder, social anxiety, and panic disorder as well as generalized anxiety. Again, this is an appropriate tool, as it has been well-validated and has been utilized in the study of anxiety’s association with opioid aberrancy8. As a seven-item measure, the GAD-7 requires only minutes to administer and score. Like the CES-D, the GAD-7 is free — available through the public domain here.
The final type of screener that can help primary care physicians identify patients at various levels of risk for opioid aberrancy are those psychometric tools designed specifically for that purpose. While a number of such tools are available, those with the highest levels of validity are the Screener and Opioid Assessment for Patients with Pain — Revised (SOAPP-R) 9 and the Pain Medication Questionnaire (PMQ) 10. While both tools boast excellent selectivity and sensitivity, can be administered and scored in 5-10 minutes, and are free to use within the public domain, the developers of the SOAPP-R have gone to great lengths to make their tool “user friendly”, with tutorials available at no cost. The SOAPP-R is used in pain clinics around the world, so why not in primary care? With tools such as those described in this month’s column, your confidence as primary care pain managers will hopefully continue to grow.
1) Manchikanti L, Giordano J, Boswell MV, et al. Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients. J Opioid Manag. 2007;3:89-100.
2) Sullivan MD, Edlund MJ, Zhang L, et al. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med. 2006;166:2087-2093.
3) Smolders M, Laurant M, Verhaak P, et al. Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis. Gen Hosp Psychiatry 2009;31:460—469.
4) Mitchell AJ, Coyne JC. Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies. Br J Gen Pract. 2007;57:144-151.
5) Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas.1977;1:385-401.
6) Kipping K, Maier C, Bussemas HH, Schwarzer A. Medication compliance in patients with chronic pain. Pain Physician 2014;17:81-94.
7) Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-1097.
8) Banta-Green CJ, Merrill JO, Doyle SR, et al. Opioid use behaviors, mental health and pain--development of a typology of chronic pain patients. Drug Alcohol Depend. 2009;104:34-42.
9) PainEDU. Opioid risk management. 2003-2014. Available at: https://www.painedu.org/soapp-development.asp.
10) Adams LL, Gatchel RJ, Robinson RC, et al. Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Manage. 2004;27:440-459.
About the Author
Michael E. Schatman, PhD, CPE, is a clinical psychologist who has spent the past 27 years working in pain management. He is currently the Executive Director of the Foundation for Ethics in Pain Care in Bellevue, WA, where he also maintains a part-time practice in pain psychology. Schatman is the author of more than 80 peer-reviewed and invited journal articles and book chapters on pain management, and he lectures regularly on both local and national bases. He is the editor of Ethical Issues in Chronic Pain Management and Chronic Pain Management: Guidelines for Multidisciplinary Program Development, both of which were released in 2007. Currently, he is Editor-in-Chief of the Journal of Pain Research, Ethics Section Head Editor of Pain Medicine and Psychological Injury & Law, and Deputy Editor-in-Chief of the International Journal of Cannabinoid Medicine. Schatman serves on the Board of Directors of the American Society of Pain Educators, which named him 2011 Clinical Pain Educator of the Year.