Initial Assessment

From Clinicaltools.com

Contents 1 Course 1: Initial Assessment 1.1 Practice Gap/Need 1.2 Goal 1.3 Core Competencies & Clinical Skills 1.3.1 A. Medical History 1.3.2 B. Screening/Assessment Tools 1.3.3 C. Patient Interview 1.3.4 D. Physical Exam and Laboratory 1.3.5 E. Stratify by Risk and Triage 1.4 Case Studies/Standardized Patients

Course 1: Initial Assessment

Assessment for Substance Use Disorders (and Risk) at Initial Evaluations of Pain Patients

Practice Gap/Need

Co-morbid substance abuse affects 20 to 40% of patients on opioid therapy for chronic pain (Katz, et al., 2003; Manchikanti et al., 2001). Non-medical use of opioids is high: an estimated 4.7 million people over age 12 have used opiate pain medication in the past month, according to the 2008 National Survey on Drug Use and Health, which represents a slight increase over the past 5 years (SAMHSA, 2009).

The importance of preventing, identifying and treating substance abuse when managing chronic pain with opioids is well documented (Compton, 2008). However, a 2004 national survey of 979 physicians for a report on diversion by the National Center on Addiction and Substance Abuse at Columbia University (CASA) identified a number of deficiencies in both competency and practice in substance abuse practices that are important in pain management. For instance, nearly half of physicians do not ask about prescription drug abuse when taking an initial health history at a patient's first visit and physicians with more training in pain and addiction are more likely to ask for this information (CASA, July 2005, p. 53). The same survey found that nearly 25% of physicians do not discuss the possibility of addiction when prescribing a controlled substance (CASA, July 2005, p. 54). In CASA's national survey of 648 primary care physicians in 1999, only 30.2% felt "very prepared" to diagnose prescription drug abuse and rates were even lower for alcoholism (19.9%) and illegal drug use (16.9%) (CASA, April 2000, p. ii. The same survey found that very few physician (2.1%) feel that treatment is very effective for illegal drug abuse (CASA, April, 2000, p. iii).

In CASA's report on the problem of diversion, they recommended that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance abuse and addiction (CASA, July 2005, p. 100). In addition, the National Institute on Drug Abuse (NIH) has identified a need for increased education and training for physicians in the identification and treatment of comorbid pain and substance abuse (NIDA RFP 093, 2008). However, The majority of 979 physicians surveyed in 2004 by the National Center on Addiction and Substance Abuse at Columbia University (CASA) did not receive training, either in medical school or in CME, in identifying prescription drug abuse and addiction (CASA, JULY 2005, pp. 90-91).

A multidisciplinary panel, after a review of the evidence chronic opioid therapy in chronic non-cancer pain, recommended that physicians follow certain guidelines when prescribing opioids; many of the recommendations were designed to reduce the risk of addiction and other substance abuse (Chou, et al. 2009). According to these guidelines, ideally, physicians should screen every pain patient for substance abuse or risk of substance abuse (Chou, et al. 2009). Physicians should use first line pain therapies first, and only use opioids when they are indicated (Chou, 2009). Physicians should structure treatment so that the risk of developing addiction is minimized and modify treatment structure when risk is identified (Chou et al, 2009). Physicians should follow certain baseline precautions with every chronic pain patient requiring chronic opioic therapy (Gourlay et al, 2005). Furthermore, physicians should be aware of screening and assessment instruments for which there is the best evidence of effectiveness when the situation is complicated by the use of prescribed pain medications (Compton, 2008).

Goal

The learner will be able to assess pain patients for current or potential substance use disorders (and risk) at the initial patient evaluation.

Core Competencies & Clinical Skills

Each learner should be more proficient in the following core competencies and clinical skills after completing this course:

A. Medical History

Ask about substance abuse and risks for substance abuse in the medical history for pain patients

1. Ask patients about current and past substance use, including alcohol, prescription drugs, and licit and illicit substances as part of the medical history
2. Inquire about other factors that may increase risk for substance abuse, including family history and concurrent psychiatric problems
3. Recognize red flags suggesting substance abuse that can be detected in a medical history

B. Screening/Assessment Tools

Screen/assess for substance abuse and risks for substance abuse in pain patients

1. Screen for substance abuse risk using the Opioid Risk Tool or similar, screen for substance abuse using the CAGE-AID tool or similar
2. Assess extent of the problem when screen is positive using assessment tools such as ASSIST
3. Be prepared to use a variety of other screening/assessment tools appropriate to the situation: Screener and Opioid Assessment for Patients in Pain, Pain Assessment and Documentation Tool, Alcohol Use Disorders Identification Test

C. Patient Interview

Ask about substance abuse and risks for substance abuse when interviewing pain patients

1. Recognize red flags suggesting substance abuse that can be detected during a patient interview
2. Use sensitive interviewing techniques to obtain an accurate history of substance abuse and risks
3. Ask about current and past treatment for substance abuse if there is a history of it
4. Interview significant others and obtain other collateral information
5. Use structured interviews such as the Prescription Drug Use Questionnaire (PDUQ) when appropriate

D. Physical Exam and Laboratory

Look for evidence of substance abuse in all patients during physical exam and laboratory testing

1. Recognize red flags suggesting substance abuse that can be detected during a physical exam and by laboratory tests
2. Perform an initial Urine Drug Test on all patients who will receive potentially addictive medications for chronic pain

E. Stratify by Risk and Triage

Stratify patients by risk for developing opioid use problems and triage with respect to need for referral to specialists

1. Assign patients to one of three risk groups for developing opioid use problems
2. Triage patients to be managed with brief interventions and increased treatment structure without referral when appropriate
3. Consult with specialists when appropriate
4. Make referral to pain and/or addiction and/or counseling specialists for patient assessment, management, or comanagement when appropriate with increased treatment structure

Case Studies/Standardized Patients

Case 1: C-Section Sue - 30YOWF

• Chief Complaint: Needs physical evaluation for life insurance
• Narrative: Sue had not been to see a primary care provider for 3 years prior. Four months ago, her caesarian-section incision site got infected and had to be re-opened, cleaned, repaired (at 3 weeks postpartum). Her obstetrician prescribed Percocet after the initial c-section and then again after the repair surgery. Sue "doesn't know" if she currently has pain, but takes ibuprofen and 2 Percocet every morning to "stay ahead" of the pain (she says she has a busy life and cannot be slowed down by pain).
• Opioid Issue: Current, undiagnosed substance use disorder and chronic pain
• Relevant Past Medical, Psychosocial, Family History: C-section delivery 4 months ago; 4 children
• Competencies) Covered: A, B

Case 2: Fibromyalgia Janet - 37YOWF

• Chief Complaint: Increasingly severe pain from fibromyalgia
• Narrative: Janet was recently diagnosed with fibromyalgia and it is not responding as well as she would like to NSAIDs. She self-medicates with alcohol and has done so for the 2 years that she has had symptoms. She is experiencing co-morbid depression, and is concerned that her pain is increasing while her quality of life is decreasing, despite following recommendations of a physical therapist and participating in cognitive behavioral therapy. She feels she needs something to treat the chronic pain. She needs a new physician because her long-time family doctor recently retired.
• Opioid Issue: Pain not responding to combinations of acetaminophen, NSAIDs, antidepressants, or anti-seizure drugs that are often effective in fibromyalgia.
• Relevant Past Medical, Psychosocial, Family History: Onset of fibromyalgia 2 years ago following divorce; remains single, but has a good support system.
• Competencies Covered: C, D

Case 3: Hip Pain Paula - 33YOBF

• Chief Complaint: Needs additional medication to treat hip bursitis
• Narrative: Paula is a long-distance runner who has recently developed bursitis in her right hip and buttock. In the past 2 months her condition has been treated with a cortisone injection, ibuprofen, and Darvocet, and yet she is still having moderate pain and has limited range of motion in her leg and hip.
• Opioid Issue: Drug-seeking due to undertreated pain and/or substance abuse
• Relevant Past Medical, Psychosocial, Family History: Knee surgery (torn meninscus) 12 years ago; brother with history of substance abuse
• Competencies Covered: D, E