2. Perform Assessments

Gather Data and Perform Assessments

To do our jobs, we need data. To understand our patients complaints, and to know which treatments are indicated, we need more data!

Several data analyses have estimated that opioid abuse among patients receiving drugs for chronic pain ranges from 18% to 41%. Remember that opioid “abuse” may or may not mean addiction (see below). Additionally, depression and other mood disorders are seen in over 1/3 of patients with chronic pain by some estimates.

This may sound complex or something you aren’t used to doing as part of your routine history-taking, but many studies show that a personal or family history of mental illness and/or substance misuse increases the risk that a patient may misuse controlled substances prescribed for the treatment of their chronic pain. Screening for alcohol, tobacco and drug use can be accomplished by formal validated tools or by taking a thorough social history. This is where your Screening, Brief Intervention & Referral to Treatment (SBIRT) training comes in handy!

Screening tools and instruments

Talking about Substance Use

Asking questions about substance use can be uncomfortable for physicians and patients alike. Often the discomfort stems from a misunderstanding about why the questions are being asked. In the best scenario, a physician may be attempting to thoroughly understand the health habits of the patient. In the worst scenario, the patient may assume the physician is trying to label the patient as an “addict.” Clearly stating why such questions are being asked, avoiding labeling a patient and explaining the difference among terms such as tolerance, dependence, and addiction can help clear up misconceptions and improve trust between the physician and the patient. Formal screening instruments may help destigmatize as well- since you “Ask Everyone”.

Some evidence-based tools exist that help quantify the risk of opioid misuse in a particular patient. The Opioid Risk Tool is one such screen that can help guide management by assessing the potential risk of opioid misuse.

Screening for mental health problems such as depression using validated tools such as PHQ-9 or other methods can help you coordinate care more appropriately and potentially avoid the “pill for every ill” trap of treating each disorder separately. Co-treatment of chronic pain and mental health disorders may improve patient outcomes. Patients with unrecognized or untreated mood disorders may be less motivated to participate fully in a multimodality pain management program.

These assessments should be done initially and periodically thereafter. Patients found to be “high risk” on opioid misuse screens or who have significant mental illness are typically not appropriate patients for chronic opioid therapy, especially in the primary care setting.

 

Mr. Hawkins defaultClient Case: Mr. Hawkins

After discussing your initial impressions with the patient, your prescribe physical therapy reassessment, obtain consent for medical records from his previous primary care physician and prescribe meloxicam and cyclobenzaprine. You schedule a visit in 8 weeks for reassessment.
Mr. Hawkins returns in 8 weeks reporting little improvement in his pain, noting that his pain still “spikes to 8 out of 10 sometimes” but slight improvement in his overall ability to tolerate walking and doing work around the house since starting physical therapy and using the cyclobenzaprine. He finds that he has 3 or 4 days a week when it is difficult for him to get out of bed due to the pain. He asks you for “something stronger” for these days.

Knowledge Check

Best practices in the care of this patient involve which of the following:

a. Perform a brief psychosocial assessment b. Screen for alcohol and substance use c. Discuss the risks and benefits of treatment with opioid narcotics d. Write a limited number of short-acting opioid narcotics that includes 1 refill