Robert N. Jamison

Development and validation of the Current Opioid Misuse Measure

Abstract Clinicians recognize the importance of monitoring aberrant medication‐related behaviors of chronic pain patients while being prescribed opioid therapy. The purpose of this study was to develop and validate the Current Opioid Misuse Measure (COMM) for those pain patients already on long‐term opioid therapy. An initial pool of 177 items was developed with input from 26 pain management and addiction specialists. Concept mapping identified six primary concepts underlying medication misuse, which were used to develop an initial item pool. Twenty‐two pain and addiction specialists rated the items on importance and relevance, resulting in selection of a 40‐item alpha COMM. Final item selection was based on empirical evaluation of items with patients taking opioids for chronic, noncancer pain (N = 227). One‐week test–retest reliability was examined with 55 participants. All participants were administered the alpha version of the COMM, the Prescription Drug Use Questionnaire (PDUQ) interview, and submitted a urine sample for toxicology screening. Physician ratings of patient aberrant behaviors were also obtained. Of the 40 items, 17 items appeared to adequately measure aberrant behavior, demonstrating excellent internal consistency and test–retest reliability. Cutoff scores were examined using ROC curve analysis and reasonable sensitivity and specificity were established. To evaluate the COMM’s ability to capture change in patient status, it was tested on a subset of patients (N = 86) that were followed and reassessed three months later. The COMM was found to have promise as a brief, self‐report measure of current aberrant drug‐related behavior. Further cross‐validation and replication of these preliminary results is pending.

Validation of a screener and opioid assessment measure for patients with chronic pain

Abstract There has been a need for a brief assessment tool for providers who treat chronic pain patients to determine potential risk of abuse when prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a self‐administered screening tool (Screener and Opioid Assessment for Patients with Pain, SOAPP) for chronic pain patients considered for long‐term opioid therapy. A consensus of 26 pain and addiction experts was obtained on important characteristics of chronic pain patients that predict future medication misuse using concept mapping. A 24‐item SOAPP (version 1.0) was developed based on this consensus and was administered to 175 patients who were taking opioids for chronic pain. After 6 months, 95 of these patients were re‐evaluated. Validation of the SOAPP was conducted by identifying those patients exhibiting aberrant drug‐related behavior as determined by any of the following: a positive score on the Prescription Drug Use Questionnaire (PDUQ) interview, positive urine toxicology screen, and/or ratings by staff as to whether patients had a serious drug problem. Of the original 24 items, 14 SOAPP items appeared to predict subsequent aberrant behaviors. Coefficient α for these 14 items was acceptable for a short scale (0.74). Receiver operating characteristics curve analysis yielded an area under the curve of 0.881 (P<0.001), suggesting adequate sensitivity and specificity for a screening device. These reliability and predictive validity results suggest that the SOAPP is a promising step toward screening risk potential for substance misuse among persons with chronic pain.

Validation of the Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R)

UNLABELLED The original Screener and Opioid Assessment for Patients with Pain (SOAPP) is a conceptually derived self-report questionnaire designed to predict aberrant medication-related behaviors among chronic pain patients considered for long-term opioid therapy. The purpose of this study was to develop and validate an empirically derived version of the SOAPP (SOAPP-R) that addresses some limitations of the original SOAPP. In successive steps, items were reduced from an initial pool of 142 to a 97-item beta version. The beta version was administered to 283 chronic pain patients receiving long-term opioid therapy. Items were evaluated based on data collected at follow-up, including correlation with the Aberrant Drug Behavior Index (ADBI), derived from interview data, physician ratings, and urine toxicology screens. Twenty-four items were retained and comprise the final SOAPP-R. Coefficient alpha was .88, and receiver operating characteristics curve analysis yielded an area under the curve of .81 (P < .001). A cutoff score of 18 showed adequate sensitivity (.81) and specificity (.68). The obtained psychometrics, along with the use of a predictive criterion that goes beyond self-report, suggest that the SOAPP-R is an improvement over the original version in screening risk potential for aberrant medication-related behavior among persons with chronic pain. PERSPECTIVE There is a need for a screener for abuse risk in patients prescribed opioids for pain. This study presents a revised version of the SOAPP-R that is empirically derived with good reliability and validity but is less susceptible to overt deception than the original SOAPP version 1.

Opioid therapy for chronic noncancer back pain : a randomized prospective study

Study Design. A randomized, open, long‐term, repeated‐dose comparison of an anti‐inflammatory drug and two opioid regimens in 36 patients with back pain. Objectives. To examine the long‐term safety and efficacy of chronic opioid therapy in a randomized trial of patients with back pain. Methods. All participants underwent a 4‐week washout period of no opioid medication before being randomly assigned to one of three treatment regimens for 16 weeks: 1) naproxen only, 2) set‐dose oxycodone, or 3) titrated‐dose oxycodone and sustained‐release morphine sulfate. All patients then were assigned to a titrated dose of opioids for 16 weeks and then gradually tapered off their medication for 12 weeks. Finally, all participants were monitored for a 1‐month posttreatment washout period. Each patient was called once a week for a report on pain, activity, mood, medication, hours awake, and adverse effects and was monitored carefully for signs of abuse and noncompliance. Results. Weekly reports during the experimental phase showed the titrated‐dose group to have less pain (P < 0.001) and less emotional distress (P < 0.001) than the other two groups. Both opioid groups were significantly different from the naproxen‐only group. During the titration phase, patients also reported significantly less pain and improved mood. Few differences were found in activity or hours asleep, or between average pretreatment and posttreatment phone‐interview and questionnaire variables. No adverse events occurred and only one participant showed signs of abuse behavior. Conclusions. The results suggest that opioid therapy has a positive effect on pain and mood but little effect on activity and sleep. Opioid therapy for chronic back pain was used without significant risk of abuse. However, tapered‐off opioid treatment is palliative and without long‐term benefit.

Characteristics of methadone maintenance patients with chronic pain

Chronic pain patients who have limited access to opioids may be redirected to methadone maintenance centers for management of their pain. Unfortunately, little information exists on the incidence and characteristics of methadone maintenance patients with chronic pain. The aim of this study was to survey individuals at methadone maintenance centers in order to determine the prevalence of chronic pain and to explore differences between patients with and without pain in this treatment setting. Of 248 participants interviewed at three centers, 152 (61.3%) reported chronic pain. Compared with patients without pain, those with pain reported significantly more health problems (P < 0.001), more psychiatric disturbance (P < 0.05), more prescription and nonprescription medication use (P < 0.001), and greater belief that they were undertreated (P < 0.001); 44% of those with pain believed that opioids prescribed for their pain had led to an addiction problem. Most of the methadone maintenance patients stated that they had always required some substance (alcohol or opioids) to feel normal. These results raise many questions about chronic-pain treatment policies and resources for persons with a history of substance abuse. Further investigations are needed to define the needs of this population and to improve their access to effective pain management.

Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ)

Abstract This manuscript describes the development and initial validation of a self‐report questionnaire designed to assess an individuals readiness to adopt a self‐management approach to their chronic pain condition. Theory and preliminary empirical work informed the development of a pool of items that were administered to a sample of individuals reporting chronic pain. Analyses of the data support a four factor measure that is consistent with the transtheoretical model of change and associated stages of change model. Each of the four factors, precontemplation, contemplation, action, and maintenance, was found to be internally consistent and stable over time. There was also substantial support for each factors discriminant and criterion‐related validity.

Electronic diaries for monitoring chronic pain : 1-year validation study

&NA; Electronic data collection for monitoring pain has become increasingly popular in clinical research. However, no direct comparison has been made between electronic diaries and self‐report paper diaries or phone interviews. We asked 36 patients with chronic low back pain to monitor their pain for 1 year; 20 of them used both a palmtop computer and paper diaries, and 16 used paper diaries alone. All patients were called once a week and asked to rate their pain. Regression analyses with a measurement error model were run on hourly pain scores recorded by both palmtop computer and paper diaries. Ratings of pain intensity were highly reliable between data recorded with a palmtop computer and with data from paper diaries. Patients who monitored their pain with the palmtop computer entered data on average 6.75 times a week and were 89.9% compliant with daily monitoring throughout the year. Two‐way messaging available through the palmtop computer seemed to encourage continued use of the device. Internal consistency of reporting and correlations with phone reports and standardized measures were highly significant, suggesting that data from electronic diaries are both reliable and valid. Patients using electronic diaries preferred them to paper diaries and showed much higher rates of compliance and satisfaction over the 1‐year trial.

Pretreatment Psychosocial Variables as Predictors of Outcomes Following Lumbar Surgery and Spinal Cord Stimulation: A Systematic Review and Literature Synthesis

BACKGROUND In the multimodal treatment approach to chronic back pain, interventional back procedures are often reserved for those who do not improve after more conservative management. Psychological screening prior to lumbar surgery or spinal cord stimulation (SCS) has been widely recommended to help identify suitable candidates and to predict possible complications or poor outcome from treatment. However, it remains unclear which, if any, variables are most predictive of pain-related treatment outcomes. OBJECTIVE The intent of this article is to perform a systematic review to examine the relationship between presurgical predictor variables and treatment outcomes, to review the existing evidence for the benefit of psychological screening prior to lumbar surgery or SCS, and to make treatment recommendations for the use of psychological screening. RESULTS Out of 753 study titles, 25 studies were identified, of which none were randomized controlled trials and only four SCS studies met inclusion criteria. The methodological quality of the studies varied and some important shortcomings were identified. A positive relationship was found between one or more psychological factors and poor treatment outcome in 92.0% of the studies reviewed. In particular, presurgical somatization, depression, anxiety, and poor coping were most useful in helping to predict poor response (i.e., less treatment-related benefit) to lumbar surgery and SCS. Older age and longer pain duration were also predictive of poorer outcome in some studies, while pretreatment physical findings, activity interference, and presurgical pain intensity were minimally predictive. CONCLUSIONS At present, while there is insufficient empirical evidence that psychological screening before surgery or device implantation helps to improve treatment outcomes, the current literature suggests that psychological factors such as somatization, depression, anxiety, and poor coping, are important predictors of poor outcome. More research is needed to show if early identification and treatment of these factors through psychological screening will enhance treatment outcome.

Psychiatric History and Psychologic Adjustment as Risk Factors for Aberrant Drug-related Behavior Among Patients With Chronic Pain

ObjectiveTo investigate the role of psychiatric history and psychologic adjustment on aberrant drug-related behavior among patients prescribed opioids for noncancer pain. MethodsTwo hundred twenty-eight patients prescribed opioids for chronic pain were classified as either high or low on psychiatric morbidity on the basis of their responses on the psychiatric subscale of the Prescription Drug Use Questionnaire (PDUQ). They also completed the Brief Pain Inventory (BPI), Screener and Opioid Assessment for Pain Patients (SOAPP), and the Current Medication Misuse Measure (COMM). Patients were followed for 5 months and submitted a urine toxicology screen, and their treating physician completed the Prescription Opioid Therapy Questionnaire (POTQ). On the basis of the results from the SOAPP, COMM, POTQ, and urine screens, patients were classified as positive or negative on the Drug Misuse Index (DMI). ResultsOne hundred and three (N=103) of the patients (45%) were classified in the low psychiatric group (Low Psych) whereas 55% (N=125) were classified in the high psychiatric morbidity group (High Psych). High Psych patients were significantly younger than Low Psych patients and had been taking opioids longer (P<0.05). The High Psych group showed significantly higher SOAPP and COMM scores than the Low Psych patients (P<0.001), had a greater frequency of abnormal urine toxicology screens (P<0.01), and significantly higher scores on the DMI (P<0.001). A consistent association was found between psychiatric morbidity and prescription opioid misuse in chronic pain patients. DiscussionPsychiatric factors, such as a history of mood disorder, psychologic problems, and psychosocial stressors, may place patients at risk for misuse of prescription opioids. Future studies to elucidate the risk of medication misuse and aberrant drug behavior among this patient population are needed.

Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings.

ObjectiveTo examine the incidence of abnormal urine toxicology screening among chronic pain patients prescribed opioids for their pain and to relate these results to patient descriptors and type, number, and dose of prescribed opioids. MethodsA retrospective analysis of data from 470 patients who had urine screening at a pain management program in an urban teaching hospital was performed. Urine samples were analyzed using gas chromatography-mass spectrometry. Patients were categorized as having urine screens that were “normal” (expected findings based on their prescribed drugs) or abnormal. Abnormal findings were those of (1) absence of a prescribed opioid, (2) presence of an additional nonprescribed controlled substance, (3) detection of an illicit substance, and (4) an adulterated urine sample. ResultsForty-five percent of the patients were found to have abnormal urine screens. Twenty percent were categorized as having an illicit substance in their urine. Illicit substances and additional drugs were found more frequently in younger patients than in older patients (P<0.001). No other variables were found to predict abnormal urine screen results. DiscussionThese results confirm past findings that random urine toxicology screens among patients prescribed opioids for pain reveal a high incidence of abnormal findings. Common patient descriptors, and number, type, and dose of prescribed opioids were found to be poor predictors of abnormal results.