Nancy A. Melville

June 01, 2016

AUSTIN, Texas — Amid heightened efforts to try to prevent pain and surgical patients from developing long-term opioid use or misuse, one research team has come up with a handy alternative to time-consuming screening tools for identifying patients at risk, while other researchers report on key risk factors linked to long-term use.

In the first of the studies presented here at American Pain Society (APS) 35th Annual Scientific Meeting, researchers sought to allow primary care and other practices to streamline the identification of patients at risk for opioid abuse with the use of just one screening score.

The item — the Catastrophizing Subscale from the Single Item Form of the Coping Strategies Questionnaire (CSQ3 Catastrophizing Subscale) — prompts patients to rate their agreement with the following statement from 0 (not at all) to 4 (all the time) regarding their pain: "It is terrible and I feel it is never going to get better."

This score has been shown in previous research to be among the strongest of predictors of pain catastrophizing, a leading risk factor for opioid abuse.

"Catastrophizing is associated with a lot of bad outcomes, including increased pain and risk of opioid abuse, and previous research has identified that one item as being nearly as strong as all of the other items put together in indicating catastrophizing," Richard T. Gross, PhD, from the Department of Behavioral Medicine and Psychiatry at West Virginia University, Morgantown, told Medscape Medical News.

"So we wanted to see if use of that one item could represent a quick and easy screening method with clinical utility in places like primary care practices, spine centers, or orthopedic surgery centers, where clinicians can be alerted of the potential for abuse if the score is high."

For the study, the researchers looked at data on a clinical sample of 119 patients referred for screening for possible long-term opioid therapy. They compared the predictive ability of the CSQ3 item with the 13-item Pain Catastrophizing Scale (PCS), the current gold standard for measuring catastrophizing, in predicting a high risk for abuse on the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), a validated tool used in the clinical practice setting for predicting opioid medication misuse.

The results showed the CSQ3 item did have good predictive ability for suggesting the potential for abuse on the SOAPP-R, with an area under the receiving-operator curve (AUC) of 0.72, suggesting a large predictive ability.

The CSQ3 had an R2 value of 0.30 for continuous SOAPP-R, again indicating good predictive utility. However, when compared with PCS, CSQ3 has less utility, with a partial R2 of 0.014.

"What we found was that a high score on this one pain catastrophizing item predicted high scores on the SOAPP-R," Dr Gross said.

"Not surprisingly, it wasn't quite as strong as the longer PCS, but it's still good. So it's a small study but shows this item does have utility as a useful screening tool for places like primary care practices as an alternative to the longer instrument."

"The use of the item could be particularly useful in places like spine centers, where long questionnaires are needed for many other aspects of pain-related disability and surgeons may want an alternative to a 13-item measure of catastrophizing," Dr Gross added.

"It's also useful for people who aren't used to various psychological variables because it's just one item, it's understandable, and the score can help guide clinicians on opioid management."

Factors Linked to Long-term Opioid Use

Another study presented at the meeting offers additional guidance in opioid management, reporting on factors associated with long-term opioid use in a large, prospective cohort of pain patients presenting to a tertiary pain clinic.

The study involved 423 pain patients older than age 18 years presenting to the Stanford Pain Management Center, Palo Alto, Calif., who completed questionnaires via the Stanford Collaborative Health Outcomes Information Registry. The study excluded patients with chronic pain due to malignancy.

Retrospective chart reviews showed that among the patients, about half (n=212 [51%]) were still taking opioids 6 months after their first clinical visit.

A multivariate analysis showed the strongest factors associated with opioid use at 6 months included the use of any prescription opioid at the initial clinic visit (odds ratio [OR], 9.13; 95% confidence interval [CI], 5.68 - 14.68; P < .0001) and aberrant drug-related behaviors (OR, 14.95; 95% CI, 3.07 - 72.91; P = .0008).

Patients with self-reported physical functioning were meanwhile associated with a decreased opioid use at 6 months (OR, 0.48; 95% CI, 0.34 - 0.68; P < .0001).

"We found that every 10-point increase in physical functioning at the initial visit decreased the odds of prescription opioid use at 6 months," the authors explained.

The evaluation of patients at a tertiary center was important, first author Jennifer Hah, MD, from the Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California, told Medscape Medical News.

"We wanted to determine risk factors for chronic opioid use in patients with noncancer pain despite this best-case scenario of interdisciplinary pain management accompanied by a conservative approach to medication management with minimal opioids and use of alternative nonopioid analgesics."

The rate of aberrant drug-related behaviors was notably high, she added.

"Patients with aberrant drug-related behaviors had a 14.9 times increased odds of continued opioid use 6 months after their initial presentation to the pain clinic," Dr Hah said.

"These findings are concordant with previous research showing an independent association of nonmedical opioid use with chronic pain and pain interference in US adults and veterans."

"Whether or not pain is the primary motivation behind nonmedical prescription opioid use and long-term opioid therapy, our research highlights the need to develop potent nonopioid analgesics and alternative psychotherapeutic strategies to target pain relief."

The findings underscore the need for clinicians and others to keep risk factors such as any previous prescription opioid use or aberrant drug-related behaviors on their radar, Dr Hah added.

"Patients, families, providers, and the general public should be educated on the risks associated with long-term opioid therapy, including misuse, abuse, addiction, and diversion," she said.

"As part of a comprehensive, interdisciplinary pain management approach, strategies to minimize the risks of long-term opioid therapy should be weighed against the potential benefits of increased function and adequate pain relief."

Dr Gross has disclosed no relevant financial relationships. Dr Hah's research was supported by grants from the National Institute on Drug Abuse.  

American Pain Society (APS) 35th Annual Scientific Meeting Abstracts 139 and 197. Presented May 13, 2016.

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