M. Carrington Reid

Use of Opioid Medications for Chronic Noncancer Pain Syndromes in Primary Care

AbstractOBJECTIVES: To define the spectrum of chronic noncancer pain treated with opioid medications in 2 primary care settings, and the prevalence of psychiatric comorbidity in this patient population. We also sought to determine the proportion of patients who manifested prescription opioid abuse behaviors and the factors associated with these behaviors. DESIGN: A retrospective cohort study. SETTING: A VA primary care clinic and an urban hospital-based primary care center (PCC) located in the northeastern United States. PATIENTS: A random sample of VA patients (n=50) and all PCC patients (n=48) with chronic noncancer pain who received 6 or more months of opioid prescriptions during a 1-year period (April 1, 1997 through March 31, 1998) and were not on methadone maintenance. MEASUREMENTS: Information regarding patients’ type of chronic pain disorder, demographic, medical, and psychiatric status, and the presence of prescription opioid abuse behaviors was obtained by medical record review. MAIN RESULTS: Low back pain was the most common disorder accounting for 44% and 25% of all chronic pain diagnoses in the VA and PCC samples, respectively, followed by injury-related (10% and 13%), diabetic neuropathy (8% and 10%), degenerative joint disease (16% and 13%), spinal stenosis (10% and 4%), headache (4% and 13%) and other chronic pain disorders (8% and 22%). The median duration of pain was 10 years (range 3 to 50 years) in the VA and 13 years in the PCC sample (range 1 to 49 years). Among VA and PCC patients, the lifetime prevalence rates of psychiatric comorbidities were: depressive disorder (44% and 54%), anxiety disorder (20% and 21%), alcohol abuse/dependence (46% and 31%), and narcotic abuse/dependence (18% and 38%). Prescription opioid abusive behaviors were recorded for 24% of VA and 31% of PCC patients. A lifetime history of a substance use disorder (adjusted odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4 to 10.8) and age (adjusted OR, 0.94; 95% CI, 0.89 to 0.99) were independent predictors of prescription opioid abuse behavior. CONCLUSIONS: A broad spectrum of chronic noncancer pain disorders are treated with opioid medications in primary care settings. The lifetime prevalence of psychiatric comorbidity was substantial in our study population. A significant minority of patients manifested prescription opioid abusive behaviors, and a lifetime history of a substance use disorder and decreasing age were associated with prescription opioid abuse behavior. Prospective studies are needed to determine the potential benefits as well as risks associated with opioid use for chronic noncancer pain in primary care.

Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system

The improved management of pain among veterans seeking care in Veterans Health Administration (VHA) facilities has been established as a priority. This study documents the high prevalence of reports of pain among a convenience sample of 685 veterans seeking care in a VHA primary care setting. Also reported are associations of pain complaints with self-rated health, an index of emotional distress, health-risk behaviors such as tobacco and alcohol use, health-related concerns about diet and weight, and perceptions of the availability of social support. The relationship between the presence of pain and use of outpatient and inpatient medical and mental health services is also examined. Nearly 50% of the sample reported that they experience pain regularly and that they were concerned about this problem at the time of the index visit to their primary care provider. Persons acknowledging the presence of pain, relative to those not reporting pain, were younger, reported worsening health over the past year, had greater emotional distress, used tobacco, had diet and/or weight concerns, and were found to use more outpatient medical, but not inpatient medical or mental health services. Results support the goals of the VHA National Pain Management Strategy designed to reduce unnecessary pain and suffering among veterans receiving care in VHA facilities.

Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis.

This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse and misuse potential of opioids as treatment for chronic noncancer pain in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80–7/1/09) with a mean study population age of 60 and older. Forty‐three articles were identified and retained for review (40 reported safety and efficacy data, the remaining 3 reported misuse or abuse outcome data). The weighted mean subject age was 64.1 (mean age range 60–73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), and other pain‐producing disorders (17%). The mean duration of treatment studies was 4 weeks (range 1.5−156 weeks), and only five (12%) lasted longer than 12 weeks. In meta‐analyses, effect sizes were −0.557 (P<.001) for pain reduction, −0.432 (P<.001) for physical disability reduction, and 0.859 (P=.31) for improved sleep. The effect size for the Medical Outcomes Study 36‐item Health Survey was 0.191 (P=.17) for the physical component score and −0.220 (P=.04) for the mental component score. Adults aged 65 and older were as likely as those younger than 65 to benefit from treatment. Common adverse events included constipation (median frequency of occurrence 30%), nausea (28%), and dizziness (22%) and prompted opioid discontinuation in 25% of cases. Abuse and misuse behaviors were negatively associated with older age. In older adults with chronic pain and no significant comorbidity, short‐term use of opioids is associated with reduction in pain intensity and better physical functioning but poorer mental health functioning. The long‐term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.

Management of Persistent Pain in the Older Patient A Clinical Review

IMPORTANCE Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE Treatment planning for persistent pain in later life requires a clear understanding of the patients treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.

Psychological resilience predicts decreases in pain catastrophizing through positive emotions.

The study used a daily process design to examine the role of psychological resilience and positive emotions in the day-to-day experience of pain catastrophizing. A sample of 95 men and women with chronic pain completed initial assessments of neuroticism, psychological resilience, and demographic data, and then completed short diaries regarding pain intensity, pain catastrophizing, and positive and negative emotions every day for 14 consecutive days. Multilevel modeling analyses indicated that independent of level of neuroticism, negative emotions, pain intensity, income, and age, high-resilient individuals reported greater positive emotions and exhibited lower day-to-day pain catastrophizing compared with low-resilient individuals. Mediation analyses revealed that psychologically resilient individuals rebound from daily pain catastrophizing through experiences of positive emotion. Implications for research on psychological resilience, pain catastrophizing, and positive emotions are discussed.

Depressive Symptoms and Suicidal Ideation among Older Adults Receiving Home Delivered Meals

Homebound older adults may be vulnerable to the deleterious impact of untreated depression. Yet because these elders are difficult to reach, there is little data on the rates of depressive symptoms and suicidal ideation among this group. The objective of this study is to document the rates of depression and correlates among a population of homebound elders.

Self‐Management Strategies to Reduce Pain and Improve Function among Older Adults in Community Settings: A Review of the Evidence

CONTEXT Self-management strategies for pain hold substantial promise as a means of reducing pain and improving function among older adults with chronic pain, but their use in this age group has not been well defined. OBJECTIVE To review the evidence regarding self-management interventions for pain due to musculoskeletal disorders among older adults. DESIGN We searched the Medline and Cumulative Index to Nursing and Allied Health Literature databases to identify relevant articles for review and analyzed English-language articles that presented outcome data on pain, function, and/or other relevant endpoints and evaluated programs/strategies that could be feasibly implemented in the community. Abstracted information included study sample characteristics, estimates of treatment effect, and other relevant outcomes when present. RESULTS Retained articles (N = 27) included those that evaluated programs sponsored by the Arthritis Foundation and other programs/strategies including yoga, massage therapy, Tai Chi, and music therapy. Positive outcomes were found in 96% of the studies. Proportionate change in pain scores ranged from an increase of 18% to a reduction of 85% (median = 23% reduction), whereas change in disability scores ranged from an increase of 2% to a reduction of 70% (median = 19% reduction). Generalizability issues identified included limited enrollment of ethnic minority elders, as well as non-ethnic elders aged 80 and above. CONCLUSIONS Our results suggest that a broad range of self-management programs may provide benefits for older adults with chronic pain. Research is needed to establish the efficacy of the programs in diverse age and ethnic groups of older adults and identify strategies that maximize program reach, retention, and methods to ensure continued use of the strategies over time.

Functional self-efficacy and pain-related disability among older veterans with chronic pain in a primary care setting.

&NA; We examined the relationship between functional self‐efficacy and pain‐related disability in a sample of older veterans with chronic pain. A total of 1045 veterans aged 65 years or older who received primary care at the VA Connecticut Healthcare System in West Haven, CT, were assessed for the presence of chronic pain (i.e. pain due to a non‐cancer cause for ≥3 consecutive months in the past 12 months); 303 (26%) screened positive; and 245 (81%) participated. Using a ten‐item functional self‐efficacy questionnaire (scale: 0–40), participants were categorized into three functional self‐efficacy groups: low, score ≤26; moderate, score 27–38; and high, score 39–40. Pain‐related disability was defined as having one or more days of restricted activity due to pain in the past month. The mean age was 75 years (s.d.=5.1) and most participants were male (84%) and Caucasian (96%). Twenty‐five percent of the sample had low, 50% had moderate, and 25% had high functional self‐efficacy. The prevalence of pain‐related disability was 56%. After adjusting for potential confounders, the likelihood of pain‐related disability was significantly higher for those with moderate vs. high (OR=2.05, 95% CI 1.03–4.06) and low vs. high (OR=4.77, 95% CI 1.96–11.61) functional self‐efficacy. Functional self‐efficacy was a strong and independent factor associated with pain‐related disability among older veterans with chronic pain.

The Relationship Between Psychological Factors and Disabling Musculoskeletal Pain in Community-Dwelling Older Persons

OBJECTIVES: To determine the relationship between two psychological factors (depressive symptoms and low functional self‐efficacy) and the occurrence of disabling musculoskeletal pain in community‐dwelling older persons.

Outpatient Management of Patients with Alcohol Problems

Clinical Presentation of Alcohol Problems A 45-year-old secretary comes to see you as a new patient. She is concerned that she might have hypertension because her friend, a nurse, has been checking her blood pressure and has noted several elevated readings. She fills out a new-patient questionnaire and reports that she drinks two to three glasses of wine every day. Could This Patient Have an Alcohol Problem? It can be easy to miss patients with alcohol problems in clinical practice (1). However, early recognition of and intervention for alcohol problems can prevent or reduce long-term consequences of excessive consumption (2). Alcohol problems occur across a spectrum. The categories and definitions established by federal and international agencies are described in Table 1 (3-5). These criteria classify patients into diagnostic categories on the basis of the amount of alcohol that they consume per day or the alcohol-related social or physical consequences that they experience. For example, patients who regularly exceed the recommended limits for alcohol intake but do not meet criteria for alcohol abuse or dependence exhibit hazardous (5) or at-risk (3) drinking. In contrast, the criteria for alcohol abuse and dependence used by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) (4) and the criteria for harmful drinking used by the World Health Organization are based on the effect of alcohol on social or physical functioning (4, 5). Table 1. Categories and Definitions for Patterns of Alcohol Use Population-based estimates for hazardous drinking in the United States range from 4% to 5% among women and 14% to 18% among men (6, 7). Population-based surveys of current drinkers have found rates of 7% to 16% for alcohol abuse or dependence (8, 9). The prevalence of alcohol problems increases in primary care settings, and large screening studies report prevalence rates of 9% to 34% for hazardous drinking (10, 11), 2% to 8% for lifetime alcohol dependence (12-15), and 9% to 36% for a current or lifetime diagnosis of alcohol abuse or dependence (16-21). Is Hazardous Drinking Really Hazardous? The patient reports that she enjoys cooking and usually has a glass of wine while preparing her meal, one with dinner, and an occasional drink on nights when she needs something to help her sleep. She has heard that wine is good for your heart and hopes that it may help her if she does have hypertension. A large body of evidence (22-71) suggests that alcohol-related morbidity and mortality increase at doses below those considered diagnostic for alcohol abuse or dependence. Heavy drinking may progress to alcohol abuse and dependence and increase the risk for a variety of health outcomes, including cardiovascular events, stroke, breast cancer, and all-cause mortality events. Although prospective studies have shown that moderate alcohol consumption (one to two drinks per day) is associated with reduced fatal and nonfatal coronary events in men (22-27) and women (25-31), these benefits are generally lost at higher doses. Heavy alcohol consumption may lead to adverse effects on blood pressure (32-37) and cardiac muscle function (40, 41) and may contribute to arrhythmia (38, 39, 42, 44). Consumption of more than two drinks per day increases the risk for hypertension in men (32-35) and women (34-37), and increased alcohol intake is associated with greater risk for new (42, 43) and recurrent atrial fibrillation (44), as well as fatal arrhythmia (38, 39). In addition, a dose-dependent relationship has been demonstrated between cumulative lifetime consumption of alcohol and increased risk for cardiomyopathy, particularly among women (40). Consumption of at least three drinks per day is associated with greater risk for hemorrhagic stroke in men (45-48) and women (49). Greater alcohol consumption may also increase risk for ischemic stroke (45, 49, 50). Drinking pattern may modify the relationship between alcohol and stroke risk. For example, one study (51) found that men who reported drinking five or more drinks per occasion had an elevated risk for ischemic stroke (relative risk, 1.6 [95% CI, 1.1 to 2.5]) compared with nondrinkers. Numerous studies have examined the relationship between alcohol consumption and breast cancer, and many (52-59) but not all (60-63) found that greater alcohol consumption was associated with increased risk. In a pooled analysis of six studies (59), women consuming three to five drinks per day had an increased relative risk for breast cancer (1.41 [CI, 1.18 to 1.69]) compared with nondrinkers. The relative risk for breast cancer increased by 1.09 (CI, 1.04 to 1.13) for each 10 g/d increase (approximately one drink) in alcohol intake. Several studies (22, 31, 64-69) have shown that consumption of at least three drinks per day increases risk for all-cause mortality among both men (64-68) and women (22, 31, 69); a U- or J-shaped association was found between alcohol consumption and all-cause mortality. However, these estimates fail to provide important information about cause-specific mortality and mortality rates from various types of cancer (31, 66, 68, 70), liver disease (22, 31, 69), and fatal injuries (31, 66, 70, 71), which increase substantially among persons with greater exposure to alcohol. Screening for Alcohol Problems The patients review of systems is notable for occasional insomnia, and she often awakens at 2:00 a.m. for no reason. Her medical history is significant for allergic rhinitis. She denies problems with her gastrointestinal system or liver. She has no history of psychiatric diagnoses. She reports a 15 pack-year history of tobacco use but has been abstinent for the past 5 years. Her mother has diabetes mellitus, and her father has cirrhosis. On examination, her blood pressure is 145/90 mm Hg and her heart rate is 85 beats/min. Results on the remainder of the examinations, including her abdominal examination, are normal. Test results include normal findings for sodium, potassium, blood urea nitrogen, creatinine, glucose, hematocrit, mean corpuscular volume, aspartate aminotransferase, and alanine aminotransferase; her -glutamyltransferase level is 1.75 kat/L (normal range, 0.18 to 0.85 kat/L). What Are Effective Methods for Screening Patients for Alcohol Problems? Formal screening instruments, such as the CAGE questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), or the Michigan Alcoholism Screening Test (MAST) (72-74), are the most effective methods for screening for alcohol problems in primary care (75) (Table 2). These instruments focus on the social and behavioral aspects of alcohol problems and provide greater accuracy than quantity and frequency questions, laboratory tests, or clinical detection (75). Among common screening instruments, AUDIT seems to have the best operating characteristics for identifying patients with hazardous drinking (sensitivity, 57% to 97%; specificity, 78% to 96%) (11, 74, 76, 77). The CAGE questionnaire, which includes four brief questions (Have you ever felt you should C ut down on your drinking? Have people A nnoyed you by criticizing your drinking? Have you ever felt bad or G uilty about your drinking? Have you ever taken a drink first thing in the morning [E ye-opener] to steady your nerves or to get rid of a hangover?), performs best among common screening instruments for identifying patients with alcohol abuse and dependence. In primary care settings, CAGE scores of 2 have a sensitivity of 77% to 94% and a specificity of 79% to 97% for a current diagnosis of alcohol abuse or dependence (11, 15, 77). A cutoff of 1 positive CAGE response has a sensitivity of 21% to 71% and a specificity of 84% to 95% (21, 84, 85). When used to screen for a lifetime diagnosis of alcohol abuse or dependence, CAGE scores of 2 have a sensitivity of 21% to 74% and a specificity of 70% to 96% (11, 18-20, 84, 85). Table 2. Sensitivity and Specificity of Screening Tests for Alcohol Problems in Primary Care The performance of screening instruments can be affected by patient characteristics (10, 20, 21) and interview style (86). For example, the accuracy of the CAGE questionnaire varies according to ethnicity and sex (20, 21). In one study, the area under the receiver-operating characteristic (ROC) curve, a measure of a tests ability to discriminate between diseased and nondiseased patients, was 0.67 for Mexican-American women, 0.76 for white women, and 0.88 for African-American women (20). Sex also affected the performance of the CAGE questionnaire in this study. Areas under the ROC curve varied from 0.69 for African-American men to 0.88 for African-American women (20). Test performance may also vary according to the way the test is introduced. One study found that the sensitivity of the questionnaire increased when the questions were prefaced by the phrase, Please tell me about your drinking, rather than by a closed-ended introduction inquiring about quantity and frequency of alcohol consumption (86). Clinicians commonly ask patients to report the quantity and frequency of alcohol consumption (87). Evidence supports the validity of patient self-report of alcohol consumption (88, 89), but these reports can be influenced by characteristics of the patient, provider, or clinical encounter and may lead to both underreporting and overreporting (88, 89). In particular, clinicians should question the validity of self-report in patients who have recently consumed alcohol (88). Although the quantity and frequency questions efficiently identify patients whose alcohol consumption is above the levels recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (Table 1), they are not as sensitive as the CAGE questionnaire, AUDIT, or MAST for detecting patients with alcohol abuse and dependence. One study found that a cutoff score of four drinks per day resulted in a sensitivity of 47% and a specificity of 96% for a diagnosis of alcohol abuse and d