Benjamin J. Morasco

Health problems and medical utilization associated with gambling disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

Objective: Pathologic gambling is believed to be associated with adverse health consequences, but no prior studies have rigorously evaluated these relationships. We sought to examine medical disorders and health service utilization associated with problem and pathologic gambling. Method: A total of 43,093 adults aged 18 years and older were evaluated in the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions. Self-reported medical diagnoses and past-year medical services used were assessed. Results: Pathologic gamblers were more likely than low-risk individuals to have been diagnosed with tachycardia (odds ratio [OR] = 1.77; 95% confidence interval [CI] = 1.05–2.97), angina (OR = 2.35; 95% CI = 1.33–4.15), cirrhosis (OR = 3.90; 95% CI = 1.11–13.72), and other liver disease (OR = 2.98; 95% CI = 1.07–8.26). Gambling severity was also associated with higher rates of medical utilization with pathologic gamblers more likely than low-risk individuals to have been treated in the emergency room in the year before the survey (OR = 1.98; 95% CI = 1.27–3.09). Significant effects of gambling severity remained even after controlling for demographic characteristics (age, gender, ethnicity, marital status, education, income, and region of the country) and behavioral risk factors such as body mass index, alcohol abuse and dependence, nicotine dependence, and mood and anxiety disorders. Conclusions: A lifetime diagnosis of pathologic gambling is associated with several medical disorders and increased medical utilization, perhaps leading to a burden on healthcare costs in the United States. AUDADIS-IV = Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV; BMI = body mass index; CI = confidence interval; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition; ER = emergency room; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; NIAAA = National Institute on Alcohol Abuse and Alcoholism; OR = odds ratio; SES = socioeconomic status; SF-12v2 = Short-Form Health Survey, Version 2.

Clinical Characteristics of Veterans Prescribed High Doses of Opioid Medications for Chronic Non-Cancer Pain

&NA; Little is known about patients prescribed high doses of opioids to treat chronic non‐cancer pain, though these patients may be at higher risk for medication‐related complications. We describe the prevalence of high‐dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non‐cancer pain prescribed high doses of opioids (≥ 180 mg/day morphine equivalent; n = 478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional‐dose (5–179 mg/day; n = 500) or no opioid (n = 500). High‐dose opioid use occurred in 2.4% of all chronic pain patients and in 8.2% of all chronic pain patients prescribed opioids long‐term. The average dose in the high‐dose group was 324.9 (SD = 285.1) mg/day. The only significant demographic difference among groups was race (p = 0.03) with black veterans less likely to receive high doses. High‐dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high‐dose prescriptions. High‐dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short‐acting opioids, urine drug screens were administered to only 25.7% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high‐dose usage, as well as the efficacy and safety of such dosing.

A randomized trial of brief interventions for problem and pathological gamblers.

Limited research exists regarding methods for reducing problem gambling. Problem gamblers (N = 180) were randomly assigned to assessment only control, 10 min of brief advice, 1 session of motivational enhancement therapy (MET), or 1 session of MET plus 3 sessions of cognitive-behavioral therapy. Gambling was assessed at baseline, at 6 weeks, and at a 9-month follow-up. Relative to assessment only, brief advice was the only condition that significantly decreased gambling between baseline and Week 6, and it was associated with clinically significant reductions in gambling at Month 9. Between Week 6 and Month 9, MET plus cognitive-behavioral therapy evidenced significantly reduced gambling on 1 index compared with the control condition. These results suggest the efficacy of a very brief intervention for reduction of gambling among problem and pathological gamblers who are not actively seeking gambling treatment.

Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain

OBJECTIVE The goal of this paper was to examine the relationship between history of substance use disorder (SUD) and self-reported prescription medication misuse in 127 primary care patients who receive opioid medications for treatment of chronic pain. METHOD Participants completed measures of pain location, pain intensity, disability due to pain, and misuse of prescription medications. Other measures included demographic characteristics, psychiatric symptomatology and quality of life. RESULTS Seventy-eight percent of participants reported at least one indicator of medication misuse in the prior year. After adjusting for age and clinical factors (pain severity, depression severity, current alcohol or substance use disorder), participants with SUD history were significantly more likely than participants without SUD history to report borrowing pain medications from others (OR=6.62, 95% CI=1.4-30.7) and requesting an early refill of pain medication (OR=3.86, 95% CI=1.5-9.6). CONCLUSIONS Misuse of prescription medications is a concern among primary care patients with chronic pain. Participants with a lifetime history of SUD are more likely to endorse some aberrant medication-related behaviors. Patients with SUD histories should be carefully evaluated for medication misuse potential and may require more intense assessment and follow-up.

Systematic Review of the Literature on Pain in Patients with Polytrauma Including Traumatic Brain Injury

OBJECTIVE To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes. DESIGN Systematic review. METHODS We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies. RESULTS One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder. CONCLUSIONS Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.

Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder

&NA; Recent data suggest that comorbid substance use disorders (SUDs) are common among chronic non‐cancer pain (CNCP) patients; however, prevalence rates vary across studies and findings are limited regarding treatment options for CNCP patients with comorbid SUD. The purpose of this systematic review is to assess the prevalence, associated demographic and clinical characteristics, and treatment outcomes for CNCP patients with comorbid SUD. We conducted searches from Ovid MEDLINE, PsychINFO, and PubMED from 1950 through February 2010 and retrieved the references. Thirty‐eight studies met inclusion criteria and provided data that addressed our key questions. Three to forty‐eight percent of CNCP patients have a current SUD. There are no demographic or clinical factors that consistently differentiate CNCP patients with comorbid SUD from patients without SUD, though SUD patients appear to be at greater risk for aberrant medication‐related behaviors. CNCP patients with SUD are more likely to be prescribed opioid medications and at higher doses than CNCP patients without a history of SUD. CNCP patients with comorbid SUD do not significantly differ in their responses to treatment compared to CNCP patients without SUD, though the quality of this evidence is low. Limited data are available to identify predictors of treatment outcome. Although clinical experience and research suggests that SUDs are common among CNCP patients, only limited data are available to guide clinicians who treat this population. Research is needed to increase understanding of the prevalence, correlates, and responses to treatment of CNCP patients with comorbid SUDs.

Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain.

Objectives:Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent noncancer pain. Methods:Using Veterans Affairs administrative data, we identified 5961 veterans from the Pacific Northwest with persistent elevated pain intensity scores who had not been prescribed opioids in the prior 12 months. We compared veterans not prescribed opioids over the subsequent 12 months with those prescribed any opioid and to those prescribed COT (>90 consecutive days). Results:During the study year, 35% of the sample received an opioid prescription and 5% received COT. Most first opioid prescriptions were written by primary care clinicians. Veterans prescribed COT were younger, had greater pain intensity, and high rates of psychiatric and substance use disorders compared with veterans in the other 2 groups. Among patients receiving COT, 29% were prescribed long-acting opioids, 37% received 1 or more urine drug screens, and 24% were prescribed benzodiazepines. Adjusting for age, sex, and baseline pain intensity, major depression [odds ratio 1.24 (1.10-1.39); 1.48 (1.14-1.93)], and nicotine dependence [1.34 (1.17-1.53); 2.02 (1.53-2.67)] were associated with receiving any opioid prescription and with COT, respectively. Discussion:Opioid initiations are common among veterans with persistent pain, but most veterans are not prescribed opioids long-term. Psychiatric disorders and substance use disorders are associated with receiving COT. Many Veterans receiving COT are concurrently prescribed benzodiazepines and many do not receive urine drug screening; additional study regarding practices that optimize safety of COT in this population is indicated.

Smoking Cigarettes as a Coping Strategy for Chronic Pain Is Associated With Greater Pain Intensity and Poorer Pain-Related Function

UNLABELLED Smoking cigarettes is prevalent among individuals with chronic pain. Some studies indicate nicotine reduces pain and others suggest it may cause or exacerbate pain. Participants in this cross-sectional study were 151 chronic pain patients from a large, urban VA medical center. Patients were divided into 3 groups: 1) nonsmokers; 2) smokers who deny using cigarettes to cope with pain; and 3) smokers who report using cigarettes to cope with pain. Patients who reported smoking as a coping strategy for chronic pain scored significantly worse compared with the other 2 groups on the majority of measures of pain-related outcome. Nonsmokers and smokers who denied smoking to cope did not differ on any variable examined. After controlling for the effects of demographic and clinical factors, smoking cigarettes as a coping strategy for pain was significantly and positively associated with pain intensity (P = .04), pain interference (P = .005), and fear of pain (P = .04). In addition to assessing general smoking status, a more specific assessment of the chronic pain patients reasons for smoking may be an important consideration as part of interdisciplinary pain treatment. PERSPECTIVE This paper describes the relationship between smoking cigarettes as a mechanism to cope with chronic pain and pain-related outcome. Understanding this relationship may illuminate the broader relationship between smoking and chronic pain and provide new directions for effective interdisciplinary pain treatment.

Prophylactic Antidepressant Treatment in Patients With Hepatitis C on Antiviral Therapy: A Double-Blind, Placebo-Controlled Trial

Background Approximately one-third of patients undergoing interferon- α (IFN- α ) therapy for treatment of the hepatitis C virus (HCV) develop major depression, which decreases functioning and may lead to the reduction or discontinuation of treatment. Objective The authors examined the efficacy of citalopram in preventing IFN- α -induced depression in HCV patients. Method This was a randomized, controlled trial comparing citalopram with placebo in 39 HCV patients. Results The rate of IFN- α -induced depression in the sample was 15.4% (6/39). Randomization to citalopram did not decrease the statistical likelihood of developing IFN- α -induced depression (10.5% for citalopram vs. 20.0% for placebo). Conclusion Citalopram does not prevent depression onset; however, an empirically-supported treatment recommendation for IFN- α -induced depression includes monitoring depressive symptoms throughout antiviral therapy and initiating psychiatric treatment at the initial signs of depression.

Brief motivational interventions for college student problem gamblers.

AIMS College students experience high rates of problem and pathological gambling, yet little research has investigated methods for reducing gambling in this population. This study sought to examine the efficacy of brief intervention strategies. DESIGN Randomized trial. SETTING College campuses. PARTICIPANTS A total of 117 college student problem and pathological gamblers. INTERVENTIONS Students were assigned randomly to: an assessment-only control, 10 minutes of brief advice, one session of motivational enhancement therapy (MET) or one session of MET, plus three sessions of cognitive-behavioral therapy (CBT). The three interventions were designed to reduce gambling. MEASUREMENTS Gambling was assessed at baseline, week 6 and month 9 using the Addiction Severity Index-gambling (ASI-G) module, which also assesses days and dollars wagered. FINDINGS Compared to the assessment-only condition, those receiving any intervention had significant decreases in ASI-G scores and days and dollars wagered over time. The MET condition decreased significantly ASI-G scores and dollars wagered over time, and increased the odds of a clinically significant reduction in gambling at the 9-month follow-up relative to the assessment-only condition, even after controlling for baseline indices that could impact outcomes. The Brief Advice and MET+CBT conditions had benefits on some, but not all, indices of gambling. None of the interventions differed significantly from one another. Conclusions These results suggest the efficacy of brief interventions for reducing gambling problems in college students.