The Intersection of Pain Management
and
Addictive Illness

Topics: click on a blue title below to be taken to that section
Introduction

• The Great Divide
• About this resource page
  • Newest content
    

Terminology: Definitions and Discussion
Opioids for Chronic/Persistent Pain: Promise, Problems, and Questions
Addictive Illness/Substance Abuse in Patients with Pain

• Investigating the problem
• Treating pain in patients with addictive illness

Introduction to Addictive Illness
Risk Management: Appropriately Treating those in Pain while Managing Substance Abuse Risk
Risk Estimation: Behavioral Screening and Monitoring
Opioid Treatment Agreements

• Sample documents
• Articles that discuss treatment agreements and informed consent

Urine or Tissue Screening and Monitoring
Assessing Progress/Outcome
Organizing the Practice
Communication, Communication, Communication
Persistent Pain & Psychiatric Comorbidity
Ethical Issues
Drug Control Policy
Resources for Patients/Families
Organizations that Study Substance Abuse and Addictive Illness
Organizations/Resource Devoted to Addictive Illness-Related Treatment, Advocacy,         Education, and Support
Professional Membership Organizations
Meetings/Conferences/Symposia
Continuing Education

Introduction
The Great Divide
There is a great divide among the general public and among health care practitioners about the relationship between two major public health issues: widespread under treated pain, and abuse of prescription analgesics. While there is no evidence that simple exposure to opioids "causes" addictive iillness, our deep-seated societal aversion to addiction has added new layers of complexity to an already complex problem: adequate assessment, diagnosis, and treatment of pain.

Paradoxically, the science of addictive illness is rapidly evolving in a social, medical, and legal/regulatory environment that is mired in old beliefs about the nature of addiction. Similarly, progress is being made in multimodality approaches to pain management, but residual fears about addiction continue to interfere with management of both acute and persistent pain. "Iatrogenic addiction" is a theoretical construct that has not been demonstrated in actual patients.

Prescription drug abuse has overshadowed illicit drug abuse in recent years. It is an important, and apparently growing, public health problem that all clinicians need to take seriously. In spite of media hype about celebrities who "confess" to addiction to pain-killers, or the undue attention given to high profile prosecutions of doctors accused of trafficking in opioids, there is little evidence that the current epidemic is fueled by appropriate prescribing, nor would it end if restrictions on prescribing were increased.

Another socio-political wrinkle is the rise in "opioid advocacy" organizations, web sites and blogs, in counter-point to those who would dramatically increase the restrictions on opioid prescribing. These advocates seem to suggest that opioid treatment is a right.

Almost lost in the loud conversation is the rational treatment of pain, especially persistent pain. The principle remains the same as it has for years: treatment decisions are driven by individual assessment. No known modality is appropriate as a single intervention for all types of pain. Multimodality, multidisciplinary approaches appear to hold the most promise. Constant reassessment and adjustment to the treatment plan are essential. Opioid analgesics may be an integral part of the treatment plan for many patients, but important questions remain unanswered about long-term efficacy (that is, improved analgesia, improved functional levels and quality of life, and minimized side effects). Some patients appear to do very well, while others stop opioid therapy because of lack of efficacy. There are no tools for prospectively differentiating these patients. A subset of patients develop "aberrant" behaviors suggestive of substance abuse. How to interpret these behaviors is controversial. They may indicate attempts to improve pain relief. They may be manifestations of psychiatric comorbidity, which is common in patients with persistent pain. They may be indications of attempts to obtain drugs for diversion or to "self-medicate" for symptoms other than pain.

The challenges are complex, time-consuming, and frustrating. Some clinicians have responded by choosing not to prescribe opioids; imposing arbitrary ceilings on doses, or similar restricitions on practice. Paradoxically, others have chosen to simply continue opioid therapy without adequate reassessment. In either case, practice and treatment decisions are streamlined, but ethically questionable, and without scientific merit.

The extreme medical and social complexity and changing legal/regulatory landscape strongly suggest that a systematic, structured, and multidisciplinary approach is likely to be superior to a "go-it-alone" approach. Partnering is essential if the patient has a history of substance abuse.

About this resource page
This resource evolved from literature searches and conversations in preparation for a workshop, The Intersection of Pain Management and Addictive Illness: Where Do We Start the Conversation? and a presentation, Building Partnerships to Address Pain Management in Persons with Addictive Illness.

The primary intended audience is clinicians caring for patients with pain, especially those with persistent pain, or those caring for patients with addictive illness who have either acute or persistent pain. Most entries are from peered-reviewed professional literature. A few are books, monographs, web sites, or continuing education programs. The intent is to provide a representative, not comprehensive, resource. It includes clinical trials and other research, as well as clinical tools and guidelines for practice. The goal is to encourage continued conversation, stimulate research, and facilitate responsible prescribing of opioids. Responsible prescribing is driven by patient assessment, reassessment, and awareness of the problem of prescription opioid abuse.

In each section, web sites, monographs and books are listed first, then peer-reviewed articles. The icon, [O], found in some citations, indicates a free, full text article.

Newest Content (Items added during the past 60 days)
Added 4 January 2008

• Compton P. Should Opioid Abusers Be Discharged From Opioid-Analgesic Therapy? From the Pain Treatment Topics web site; January 2, 2008. (Topic: Treating pain in patients with addictive illness)
• Moeller KE, et al.  Urine Drug Screening: Practical Guide for Clinicians.  Mayo Clinic Proceedings.  2008;83:66-76. (Topic: Urine Screening and Monitoring)

Added 28 December 2007

• Compton P.  The Role of Urine Toxicology in Chronic Opioid Analgesic Therapy.  Pain Management Nursing.  Dec. 2007;8(4):139-172. (Topic: Urine Screening and Monitoring)

Added 14 December 2007

• Drug Enforcement Administration.  Issuance of Multiple Prescriptions for Schedule II Controlled Substances:  Final Rule (effective 19 December 2007).  Federal Register: 19 Nov 2007;72(222): 64921-64930. (Topic: Drug Control Policy)
• Gilson AM, Joranson DE. Is the DEA’s New “Prescription Series” Regulation Balanced?  Accessed 14 Dec 2007. (Topic: Drug Control Policy)
• Gilson AM, Joranson DE, Martha A. Maurer MA.  Improving State Pain Policies:  Recent Progress and Continuing Opportunities.  CA:  A Cancer Journal for Clinicians 2007 Nov/Dec;57(6):341–353. (Topic: Drug Control Policy)

Terminology: Definitions and Discussion
A major barrier to improving pain management is polarization between advocates and critics of opioid therapies for peristent pain. The conversation is complicated by a lack of consensus on the meaning of various terms associated with addictive illness in the context of treating patients with pain. Some attempts, as noted below, have been made to achieve consensus, but language and the concepts language supports remains problematical. Still unanswered, for example, is what is meant by "substance abuse?" Further, what are the important clinical distinctions between substance abuse and addictive illness?

• Addiction, physical dependence and tolerance [Consensus definitions of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine)
• Definitions Related to the Use of Opioids for the Treatment of Pain
• Savage SR, Joranson DE, Covington EC, Schnoll SH, Heit HA, Gilson AM.  Definitions related to the medical use of opioids: evolution towards universal agreement.  Journal of Pain & Symptom Management. 2003 Jul;26(1):655-67.
• Aberrant drug-taking behaviors
  • McCaffery M, et al.  On the meaning of "drug seeking".  Pain Management Nursing. 2005 Dec;6(4):122-36. [Free full text also available on Medscape]
  • Passik SD.  Pain management misstatements: ceiling effects, red and yellow flags.  Pain Medicine. 2006 Jan-Feb;7(1):76-7.
  • Passik SD, et al.  Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.  Clinical Journal of Pain. 2006 Feb;22(2):173-81.
  • Passik SD, Kirsh KL.  Assessing aberrant drug-taking behaviors in the patient with chronic pain.  Current Pain & Headache Reports. 2004 Aug;8(4):289-94.
  • Passik SD, Kirsh KL.  The need to identify predictors of aberrant drug-related behavior and addiction in patients being treated with opioids for pain.  Pain Medicine. 2003 Jun;4(2):186-9.
  • Passik SD, et al. Pain clinicians' rankings of aberrant drug-taking behaviors.  Journal of Pain & Palliative Care Pharmacotherapy. 2002;16(4):39-49.
  • Passik SD, et al.  A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients.  Journal of Pain & Symptom Management. 2000 Apr;19(4):274-86
• "Drug seeking"
  • McCaffery M, et al.  On the meaning of "drug seeking".  Pain Management Nursing. 2005 Dec;6(4):122-36 [Free full text also available on Medscape]
• Pseudoaddiction
  "Pseudoaddiction," a term coined by Weissman & Haddox in 1989, refers to behaviors that may mimic those commonly associated with opioid abuse but which instead are indicative of unrelieved pain. The behaviors are extinguished when pain is adequately treated.
  • Elander J, et al.  Understanding the causes of problematic pain management in sickle cell disease: evidence that pseudoaddiction plays a more important role than genuine analgesic dependence.  Journal of Pain & Symptom Management. 2004 Feb;27(2):156-69.
  • Kowal N.  What is the issue?: pseudoaddiction or undertreatment of pain.
    Nursing Economics. 1999 Nov-Dec;17(6):348-9.
  • Lusher J, et al.  Analgesic addiction and pseudoaddiction in painful chronic illness.  Clinical Journal of Pain. 2006 Mar-Apr;22(3):316-24.
  • Porter-Williamson K, et al.  Pseudoaddiction.  Journal of Palliative Medicine. 2003 Dec;6(6):937-9.
  • Weissman DE.  Understanding pseudoaddiction.  Journal of Pain & Symptom Management. 1994 Feb;9(2):74.
  • Weissman DE, Haddox JD.  Opioid pseudoaddiction--an iatrogenic syndrome.  Pain. 1989 Mar;36(3):363-6.
  • Porter-Williamson K, Heffernan E, Von Gunten CF.  Pseudoaddiction.  Journal of Palliative Medicine. 2003 Dec;6(6):937-9.
• Tolerance
  Tolerance to the analgesic effect of opioids is a puzzling and controversial phenomenon. It surely exists, but just as surely it is not a universal phenomenon. It's development cannot be predicted in a specific patient. Clinical implications and management are unclear. Dose increase or opioid rotation are rational responses, but reasons for a diminution in analgesic effect must be investigated to rule out other reasons, such as progression of the underlying disease or psychosocial influences that may aggravate the pain experience. There is no pharmacological ceiling dose (the dose beyond which no additional analgesic effect will be acheived in an opioid-responsive condition) for most mu receptor agonists.
  • Definitions Related to the Use of Opioids for the Treatment of Pain (AAPM, APS, ASAM)
    • Savage SR, et al. Definitions related to the medical use of opioids: evolution towards universal agreement.  Journal of Pain & Symptom Management. 2003 Jul;26(1):655-67.
  • Adriaensen H, et al.  Opioid tolerance and dependence: an inevitable consequence of chronic treatment?  Acta Anaesthesiolica Belgica. 2003;54(1):37-47.
  • Chang G, et al.  Opioid tolerance and hyperalgesia.  Medical Clinics of North America. 2007 Mar;91(2):199-211.
  • Collen M.  In my opinion . . . Opioid tolerance.  Journal of Pain & Palliative Care Pharmacotherapy. 2007;21(1):35-7.
  • Collett BJ.  Opioid tolerance: the clinical perspective.  British Journal of Anaesthesia. [O] 1998 Jul;81(1):58-68.
  • Jage J.  Opioid tolerance and dependence -- do they matter?  European Journal of Pain. 2005 Apr;9(2):157-62.
  • Mao J.  Opioid tolerance and neuroplasticity. Novartis Found Symposium. 2004;261:181-6; discussion 187-93.
  • Mao J,et al.  Neuronal apoptosis associated with morphine tolerance: evidence for an opioid-induced neurotoxic mechanism.  Journal of Neuroscience. 2002 Sep 1;22(17):7650-61.
  • Mao J.  NMDA and opioid receptors: their interactions in antinociception, tolerance and neuroplasticity.  Brain Research. Brain Research Reviews. 1999 Nov;30(3):289-304.
  • Passik SD, Kirsh KL.  Will the number of milligrams of an opioid dose ever re-achieve the truly meaningless status it deserves?  Journal of Pain & Palliative Care Pharmacotherapy. 2007;21(1):39-41.
  • Price DD, et al.  NMDA-receptor antagonists and opioid receptor interactions as related to analgesia and tolerance.  Journal of Pain & Symptom Management. 2000 Jan;19(1 Suppl):S7-11.
  • Rich BA.  A Chronic Pain Patient's Perspective on Opioid Tolerance.
    Journal of Pain & Palliative Care Pharmacotherapy . 2007;21(1):43-5.
  • South S & Smith MT.  Analgesic tolerance to opioids.  Pain Clinical Updates [O] (IASP) Dec 2001;IX(5).
  • Thompson AR, Ray JB.  The importance of opioid tolerance: a therapeutic paradox.  Journal of the American College of Surgeons. 2003 Feb;196(2):321-4.

Opioids for Chronic/Persistent Pain: Promise, Problems, and Questions
Opioids have been demonstated to be effective in acute pain and in several chronic and neuropathic pain syndromes, especially in the short term. In longer term treatment (several months to years) the picture is less clear. A subset of patients do very well. Others do not respond, develop tolerance and/or toxicity and ultimately stop opioid treatment. There are currently no clinically applicable explanations for the dramatic differences in response to opioids, nor are there tools for prospectively screening patients to determine responsivity to opioids.

• Opioid Analgesia Toolkit: A Resource for Managing your Patients with Chronic Pain. (Online interactive program; PainKnowledge.org/National Initiative on Pain Control--NIPC)

• Ballantyne JC.  Opioid misuse in oncology pain patients. Current Pain and Headache Reports. 2007 Aug;11(4):276-82.
• Ballantyne JC.  Opioid analgesia: perspectives on right use and utility.  Pain Physician. [O] 2007 May;10(3):479-91.
• Ballantyne JC.  Opioids for chronic nonterminal pain.  Southern Medical Journal. 2006 Nov;99(11):1245-55. [Free full text also available on Medscape]
• Ballantyne JC, Mao J.  Opioid therapy for chronic pain.  New England Journal of Medicine. 2003 Nov 13;349(20):1943-53
• Brown RT, et al.  Adverse effects and cognitive function among primary care patients taking opioids for chronic nonmalignant pain.  Journal of Opioid Management. 2006 May-Jun;2(3):137-46.
• Burton AW, et al.  Chronic pain in the cancer survivor: a new frontier.  Pain Medicine. 2007 Mar;8(2):189-98.
• Coupe ME, Stannard C. Opioids in persistent non-cancer pain. Continuing Education in Anaesthesia, Critical Care & Pain. 2007;7(3): 100-103.
• Eriksen J, et al.  Critical issues on opioids in chronic non-cancer pain: an epidemiological study.  Pain. 2006 Nov;125(1-2):172-9.
• Fleming MF, et al.  Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy.  Journal of Pain. 2007 Jul;8(7):573-82
  • See summary and comment on Pain Treatment Topics web site.
• Friedman DP.  Perspectives on the medical use of drugs of abuse.  Journal of Pain & Symptom Management. 1990 Feb;5(1 Suppl):S2-5.
• Furlan AD, et al.  Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects.  CMAJ. [O] 2006 May 23;174(11):1589-94.
• Ives TJ, et al.  Predictors of opioid misuse in patients with chronic pain: a prospective cohort study.  BMC Health Services Research. [O] 2006 Apr 4;6:46.
• Jovey RD, et al.  Use of opioid analgesics for the treatment of chronic noncancer pain--a consensus statement and guidelines from the Canadian Pain Society, 2002.  Pain Research & Management. [O] 2003 Spring;8 Suppl A:3A-28A.
• Kahan M, et al.  Misuse of and dependence on opioids: study of chronic pain patients.  Canadian Family Physician. 2006 Sep;52(9):1081-7.
• Maclaren JE, et al.  Impact of opioid use on outcomes of functional restoration.  Clinical Journal of Pain. 2006 May;22(4):392-8.
• Manchikanti L, et al.  Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables.  Pain Physician. [O] 2006 Jul;9(3):215-25.
• National Institute on Drug Abuse, National Institutes of Health.  Pain, Opioids, and Addiction:  An Urgent Problem for Doctors and Patients.  Journal of Pain & Palliative Care Pharmacotherapy. 2007;21(4):45-49.
• Nedeljkovic SS, et al.  Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential.  Clinical Journal of Pain. 2002 Jul-Aug;18(4 Suppl):S39-51.
• Portenoy RK, et al.  Long-term use of controlled-release oxycodone for noncancer pain: results of a 3-year registry study.  Clinical Journal of Pain. 2007 May;23(4):287-99.
• Portenoy RK.  Opioid therapy for chronic nonmalignant pain: a review of the critical issues.  Journal of Pain & Symptom Management. 1996 Apr;11(4):203-17.
• Portenoy RK, Foley KM.  Chronic use of opioid analgesics in non-malignant pain: report of 38 cases.  Pain. 1986 May;25(2):171-86.
• Reid MC, et al.  Use of opioid medications for chronic noncancer pain syndromes in primary care.  Journal of General Internal Medicine. [O] 2002 Mar;17(3):173-9.
• Rowbotham MC, Lindsey CD.  How effective is long-term opioid therapy for chronic noncancer pain?  Clinical Journal of Pain. 2007 May;23(4):300-2.
• Turk DC.  Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain.  Clinical Journal of Pain. 2002 Nov-Dec;18(6):355-65.
• Twycross RG.  Clinical experience with diamorphine in advanced malignant disease.  International Journal of Clinical Pharmacology. 1974 Apr;7(3):184-98.

Addictive Illness/Substance Abuse in Patients with Pain
Investigating the problem
Pain and addictive illness can co-occur. The precise relationship between the two is the subject of ongoing research.

• The Interface Between Pain and Chemical Dependency (StopPain.org); International Association for Pain and Chemical Dependency.
• Adams EH, et al.  A comparison of the abuse liability of tramadol, NSAIDs, and hydrocodone in patients with chronic pain.  Journal of Pain & Symptom Management. 2006 May;31(5):465-76.
• Compton P, Athanasos P.  Chronic pain, substance abuse and addiction.  Nursing Clinics of North America. 2003 Sep;38(3):525-37.
• Compton P, Estepa CA.  Addiction in patients with chronic pain.  Lippincotts Primary Care Practitioner. 2000 May-Jun;4(3):254-72.
• Compton WM, et al.  Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry. 2007 May;64(5):566-76.
• Edlund MJ, et al.  Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain.  Pain. 2007 Jun;129(3):355-62.
• Eriksen J, et al.  Critical issues on opioids in chronic non-cancer pain: an epidemiological study.  Pain. 2006 Nov;125(1-2):172-9.
• Fanciullo GJ, et al.  An observational study on the prevalence and pattern of opioid use in 25,479 patients with spine and radicular pain.  Spine. 2002 Jan 15;27(2):201-5.
• Fleming MF, et al.  Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy.  Journal of Pain. July 2007;8(7):573-82
  • See summary and comment on Pain Treatment Topics web site.
• Hariharan J, et al.  Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. Journal of General Internal Medicine. 2007 Apr;22(4):485-90.
• Hojsted J, Sjogren P.  Addiction to opioids in chronic pain patients: A literature review.  European Journal of Pain. 2007 Jul;11(5):490-518.
• Jamison RN, et al.  Characteristics of methadone maintenance patients with chronic pain.  Journal of Pain & Symptom Management. 2000 Jan;19(1):53-62.
• Kirsh KL, et al.  Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study.  Clinical Journal of Pain. 2002 Jul-Aug;18(4 Suppl):S52-60.
• Manchikanti L, et al.  Evaluation of abuse of prescription and illicit drugs in chronic pain patients receiving short-acting (hydrocodone) or long-acting (methadone) opioids.  Pain Physician. [O] 2005 Jul;8(3):257-61.
• Martell BA, et al.   Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.  Annals of Internal Medicine. [O] 2007 Jan 16;146(2):116-27.
• Michna E, et al.  Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history.  Journal of Pain & Symptom Management. 2004 Sep;28(3):250-8.
• Morgan BD.  Knowing how to play the game: hospitalized substance abusers' strategies for obtaining pain relief.  Pain Management Nursing. 2006 Mar;7(1):31-41.
• Owens P, et al. (2007) Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals, 2004. HCUP Fact Book No. 10. Agency for Healthcare Research and Quality.
• Passik SD, et al.  Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.  Clinical Journal of Pain. 2006 Feb;22(2):173-81.
• Passik SD, et al.  Psychiatric and pain characteristics of prescription drug abusers entering drug rehabilitation.  Journal of Pain & Palliative Care Pharmacotherapy. 2006;20(2):5-13.
• Rosenblum A, et al.  Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities.  JAMA. [O] 2003 May 14;289(18):2370-8.
• Wasan AD, et al.  Iatrogenic addiction in patients treated for acute or subacute pain: a systematic review.  Journal of Opioid Management. 2006 Jan-Feb;2(1):16-22.

Treating pain in patients with addictive illness
Unfortunately, few pain specialists have cross-training in managing addictive illness. Probably even fewer addiction specialists have cross-training in pain management. Developing collaborative treatment and monitoring plans between the specialties is essential to successful outcomes. Structured, systematic approaches using standardized instruments is almost certainly the most fruitful approach, but there has been no research to compare these strategies.

• The Addiction Topics and Opioid Safety & Risk Management pages of the Pain Treatment Topics web site has collected many useful references, most of them online.
• Pain Management in Patients with Addictive Disease. Position Statement of the American Society for Pain Management Nursing.(2002)
• Alford DP, et al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annals of Internal Medicine [O] 2006 Jan 17;144(2):127-134.
• Compton P. Should Opioid Abusers Be Discharged From Opioid-Analgesic Therapy? From the Pain Treatment Topics web site; January 2, 2008.
• D'Arcy Y.  Managing pain in a patient who's drug-dependent. Nursing. 2007 Mar;37(3):36-40.
• Kirsh KL, Passik SD.  Palliative care of the terminally ill drug addict. Cancer Investigation. 2006 Jun-Jul;24(4):425-31.
• Grant MS, et al.  Acute Pain Management in Hospitalized Patients With Current Opioid Abuse.Topics in Advanced Practice Nursing eJournal. [O] Posted 06/06/2007 [accessed 12 Jun 2007]
• Jage J, Bey T. Postoperative analgesia in patients with substance abuse disorders: Part I. Acute Pain 2000 September 2000;3(3):29-44.
• Jage J, Bey T. Postoperative analgesia in patients with substance abuse disorders: Part II. Acute Pain 2000 December 2000;3(4):20-28.
• Lindroth JE, et al. The management of acute dental pain in the recovering alcoholic. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003 Apr;95(4):432-436.
• May JA, et al. The patient recovering from alcohol or drug addiction: special issues for the anesthesiologist. Anesthesia & Analgesia 2001 Jun;92(6):1601-1608.
• Nedeljkovic SS, et al.  Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential.  Clinical Journal of Pain. 2002 Jul-Aug;18(4 Suppl):S39-51.
• Passik SD, Kirsh KL.  Managing pain in patients with aberrant drug-taking behaviors.
  Journal of Supportive Oncology. [O] 2005 Jan-Feb;3(1):83-6.
• Passik SD, Kirsh KL.  Opioid therapy in patients with a history of substance abuse.  CNS Drugs. 2004;18(1):13-25.
• Passik SD, Theobald DE.  Managing addiction in advanced cancer patients: why bother? Journal of Pain & Symptom Management. 2000 Mar;19(3):229-34.
• Peng PW, et al. Review article: Perioperative pain management of patients on methadone therapy.  Canadian Journal of Anaesthesia 2005 May;52(5):513-523.
• Scimeca MM, Savage SR, Portenoy R, Lowinson J. Treatment of pain in methadone-maintained patients. Mt Sinai Journal of Medicine 2000 Oct-Nov;67(5-6):412-422.
• Tucker C.  Acute pain and substance abuse in surgical patients.  Journal of Neuroscience Nursing Dec 1990;22(6):339-349.
• Weaver M, Schnoll S.  Abuse liability in opioid therapy for pain treatment in patients with an addiction history.  Clinical Journal of Pain 2002 Jul-Aug;18(4 Suppl):S61-9.
• Weaver MF, Schnoll SH.   Opioid treatment of chronic pain in patients with addiction.  Journal of Pain & Palliative Care Pharmacotherapy. 2002;16(3):5-26.
• Whitcomb LA, et al.  Substance abuse issues in cancer pain.  Current Pain & Headache Reports. 2002 Jun;6(3):183-90.
• Ziegler PP. Safe treatment of pain in the patient with a substance use disorder. Psychiatric Times. 2007 Jan;24(1).

Introduction to Addictive Illness
Addictive illness (in all its names and variations) is complex and often difficult and frustrating to manage. The scientific investigation of addictions is advancing rapidly; clinical practice may not be keeping up. This section will feature review articles they may help the non-addictionologist to begin to grasp the nature of this disease.

• Erickson CK. (2007)  The Science of Addiction: From Neurobiology to Treatment.  New York:  W.W. Norton.
• The Addiction Topics page of the Pain Treatment Topics web site and the companion Addiction Treatment Forum web site have collected many useful references, most of them online.
• No, Really, This Is Your Brain on Drugs. Interview with Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), on National Public Radio's Fresh Air [broadcast 10 July 2007; accessed 11 July 2007]
• Mouse Party. A simplified, animated depiction of the chemical changes in the brain cause by abuse of various drugs, including opioids. From the University of Utah Genetic science Learning Center.

• Ballantyne JC, LaForge KS.  Opioid dependence and addiction during opioid treatment of chronic pain.  Pain. 2007 Jun;129(3):235-55.
• Camí J, Farré M.  Drug addiction.  New England Journal of Medicine. [O] 2003 Sep 4;349(10):975-86.
• Hyman SE.  Addiction: A Disease of Learning and Memory.  Focus 2007;5(2):220-228.
  
• Kalivas PW, Volkow ND.  The Neural Basis of Addiction: A Pathology of Motivation and Choice. Focus 2007;5(2):208-219.
• McLellan AT, et al.  Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation.  JAMA. [O] 2000 Oct 4;284(13):1689-95.

Risk Management: Appropriately Treating those in Pain while Managing Substance Abuse Risk
Some of the interventions used in managing pain in patients with addictive illness have been adapted for treating persistent pain with chronic opioid therapy. Diagnosing addictive illness is not a precise science. Like pain, there is no physical marker; diagnosis is made on the basis of history and behavior. It is difficult to identify patients prior to initiating opioid therapy who may be substance abusers or at risk. Similarly, there are no clear signs that a patient has "become" addicted during the course of treatment. A prudent, rational approach that several experts recommend includes using a standard screening instrument, monitoring medication compliance, and assessing progress toward therapeutic goals.

• The Addiction Topics and Opioid Safety & Risk Management pages of the Pain Treatment Topics web site has collected many useful references, most of them online.
• American Pain Society (2006). Pain Control in the Primary Care Setting. Glenview, IL: American Pain Society.
• Opioid Analgesics and Stimulant Medications: A Clinician Guide to Prevent Misuse: February 2007. The Medical Foundation [Laminated pocket card; includes SOAPP, CRAFFT ] Order from Massachusetts Health Promotion Clearinghouse.
• VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain [Department of Veterans Affairs evididence-based guideline,2003]
• McCaffery M, Pasero C. (1999) Pain: Clinical Manual (2nd Ed.) St. Louis: Mosby. [Especially pages 50-54 & Chapter 10]
• Webster LR, Dove B. (2007) Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MN: Sunrise River Press.
• Ziegler PP.  Chronic Pain Conundrums in Primary-Care Practice.  [Pain Treatment Topics, posted July 2007; accessed 7/15/2007]
  

• Ballantyne JC.  Opioid misuse in oncology pain patients. Current Pain and Headache Reports. 2007 Aug;11(4):276-82.
• Bruckenthal P.  Controlled substances: principles of safe prescribing.  Nurse Practitioner. 2007 May;32(5):7-11.
• Burton AW, et al.  Chronic pain in the cancer survivor: a new frontier.  Pain Medicine. 2007 Mar;8(2):189-98.
• Chelminski PR, et al.  A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity.  BMC Health Services Research. [O] 2005 Jan 13;5(1):3.
• Cicero TJ, et al.  The development of a comprehensive risk-management program for prescription opioid analgesics: researched abuse, diversion and addiction-related surveillance (RADARS). Pain Medicine. 2007 Mar;8(2):157-70.
• Coluzzi F, et al.  Opioid therapy for chronic noncancer pain: practice guidelines for initiation and maintenance of therapy.  Minerva Anestesiologica. 2005 Jul-Aug;71(7-8):425-33.
• Compton WM, Volkow ND.  Abuse of prescription drugs and the risk of addiction.  Drug & Alcohol Dependence. 2006 Jun;83 Suppl 1:S4-7.
• Dahl JL.  How to reduce fears of legal/regulatory scrutiny in managing pain in cancer patients.  Journal of Supportive Oncology. 2005 Sep-Oct;3(5):384-8.
• Fields HL.  Should we be reluctant to prescribe opioids for chronic non-malignant pain?  Pain. 2007 Jun;129(3):233-4.
• Gourlay DL, et al.  Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.  Pain Medicine. 2005 Mar-Apr;6(2):107-12.
• Jung B, Reidenberg MM. Doctors being deceived. Pain Medicine 2007 (published online 21 June)
• Kirsh KL, Passik SD. Managing Drug Abuse, Addiction, and Diversion in Chronic Pain. Medscape Medscape Neurology & Neurosurgery. 2005 [Posted 2 Sep 2005; Accessed 14 Jun 2007]
• Gourlay DL, Heit HA. Universal Precautions in Pain Medicine: The Treatment of Chronic Pain With or Without the Disease of Addiction. (Medscape; Posted 28 Apr 2005; accessed 14 Jun 2007)
• Gourlay DL, Heit HA.  Risk management is everyone's business. Pain Medicine. 2007 Mar;8(2):125-7.
• Kuehn B. Scientists probe ways to curb opioid abuse without hindering pain treatment. JAMA. 2007 May 9;297(18):1965-7.
• Katz N. (2007) The PainEDU Supplement: Patient Level Opioid Risk Management. Inflexxion, Inc.: Needham, MA. [Electronic resource (PDF); accessed 12 Jun 2007] [Free registration required].
• Katz NP, et al.  Foundations of opioid risk management. Clinical Journal of Pain.  2007 Feb;23(2):103-18.
• Manchikanti L, et al.  Does adherence monitoring reduce controlled substance abuse in chronic pain patients?  Pain Physician. [O] 2006 Jan;9(1):57-60.
• Nicholson B. Responisble presribing of opioids for the management of chronic pain. Drugs. 2003;63(1):17-32.
• Passik SD, Kirsh, KL.  Special Considerations in the Management of Breakthrough Pain With Rapid-Onset Opioids: Abuse, Addiction, and Diversion.  Medscape Neurology & Neurosurgery.  2007 [Posted 06/27/2007; accessed 3 July 2007]
• Passik SD, et al. (2007) Substance abuse issues in palliative care. In Berger A. et al, Eds. Principles and Practice of Palliative Care and Supportive Oncology. 3rd Ed. Philadelphia: Lippincott Williams & Wilkins. pp 457-466
• Sullivan MD, et al.  Brief report: Training internists in shared decision making about chronic opioid treatment for noncancer pain.  Journal of General Internal Medicine. [O] 2006 Apr;21(4):360-2.
• Wilson JF.  Strategies to Stop Abuse of Prescribed Opioid Drugs.  Annals of Internal Medicine.  19 Jun 2007;146(12):897-900.

Risk Estimation: Behavioral Screening and Monitoring
Quite a few instruments that assess abuse potential in individual patients have been developed. Several of these have been introduced in recent years. There is insufficient clinical experience with any of them, and no head-to-head comparison studies to guide selection. However, judicious use of a standardized instrument is recommended by most experts.

• Assessing the Risk of Problematic Drug Use (StopPain.org)
• Babor TF & Kadden RM. Screening and Interventions for Alcohol and Drug Problems in Medical Settings: What Works? Journal of Trauma Sep 2005;59(3), Supplement:S80-S87.
• Katz NP, et al.  Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy.  Anesthesia & Analgesia. 2003 Oct;97(4):1097-1102.
• Savage, S.  Assessment for Addiction in Pain-Treatment Settings.  Clinical Journal of Pain.  2002;18(4 Supp):S28-38.
• Webster LR. Assessing Abuse Potential in Pain Patients. Medscape Neurology & Neurosurgery 2004;6(1)
• ABC (Addiction Behaviors Checklist)
  • Wu SM, et al.  The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain.  Journal of Pain & Symptom Management.  2006 Oct;32(4):342-51.
    • Kenreigh CA, Wagner LT. Checklist Helps Identify Inappropriate Opioid Use [Commentary on ABC on Medscape]
• ASI (Addiction Severity Index)
  • Saffier K, et al.  Addiction Severity Index in a chronic pain sample receiving opioid therapy.  Journal of Substance Abuse Treatment. 2007 Oct;33(3):303-11.
• CAGE-AID [CAGE Adapted to Include Drugs] (Cut down, Annoyed, Guilty, Eye-opener)
  • Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin Medical Journal. 1995;94(3):135-40.
  • Brown RL, et al.  A two-item conjoint screen for alcohol and other drug problems.  Journal of the American Board of Family Medicine. [O] 2001 Mar-Apr;14(2):95-106.
• COMM (Current Opioid Misuse Measure)
  • Butler SF, et al.  Development and validation of the Current Opioid Misuse Measure.  Pain 2007 July;130(1-2):144-156.
• CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)
• Knight JR, et al.  Validity of the CRAFFT substance abuse screening test among adolescent clinic patients.  Archives of Pediatric & Adolescent Medicine. 2002 Jun;156(6):607-14.
• DIRE (Diagnosis, Intractability, Risk, Efficacy)
  • Belgrade MJ, et al.  The DIRE score: predicting outcomes of opioid prescribing for chronic pain.  Journal of Pain. 2006 Sep;7(9):671-81.
  • Brennan MJ.  DIRE: a tool to assess risks of maintaining opioid treatment.  Journal of Pain. 2007 Feb;8(2):185.
• DAST (Drug Abuse Screening Test)
  • Yudko E, et al.  A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment. 2007 Mar;32(2):189-98.
• MMPI-2 (Addiction Acknowledgment Scale (AAS) and Addiction Potential Scale (APS))
  • Greene RL, et al. A cross-validation of MMPI-2 substance abuse scales. Journal of Personality Assessment. 1992;58:405–410.
• ORT (Opioid Risk Tool)
  • Webster LR, Webster RM.  Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.  Pain Medicine. 2005 Nov-Dec;6(6):432-42.
• PADT (Pain Assessment and Documentation Tool)
  • Passik SD et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clinical Therapeutics.  2004; 26(4):552-61.
  • Passik SD, et al.  Monitoring outcomes during long-term opioid therapy for noncancer pain: results with the Pain Assessment and Documentation Tool.  Journal of Opioid Management. 2005 Nov-Dec;1(5):257-66.
• PMQ (Pain Medication Questionnaire)
  • Holmes CP et al.  An Opioid Screening Instrument: Long-Term Evaluation of the Utility of the Pain Medication Questionnaire. Pain Practice. 2006 Jun;6(2):74–88
    • Passik SD, Kirsh KL.  An opioid screening instrument: long-term evaluation of the utility of the pain medication questionnaire by Holmes et al.  Pain Practice. 2006 Jun;6(2):69-71.
• PDUQ (Prescription Drug Use Questionnaire)
  • Compton P, et al. Screening for addiction in patients with chronic pain and “problematic” substance use: evaluation of a pilot assessment tool. Journal of Pain and Symptom Management 1998;16:355-363.
• SASSI (Substance Abuse Subtle Screening Inventory)
  • Lazowski LE, Miller FG, Boye MW, Miller GA. Efficacy of the Substance Abuse Subtle Screening Inventory-3 (SASSI-3) in identifying substance dependence disorders in clinical settings. Journal of Personality Assessment. 1998 Aug;71(1):114-28.
    
• SISAP (Screening Instrument for Subsatnce Abuse Potential)
  • Coambs RB, Jarry JL. The SISAP: a new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain in general medical practice. Pain Research and Management 1996;1:15-162.
• SOAPP (Screener and Opioid Assessment for Patients with Pain )
  • Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN.  Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP).  Journal of Pain & Symptom Management. 2006 Sep;32(3):287-93.
  • Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004 Nov;112(1-2):65-75.

Opioid Treatment Agreements
The use of opioid treatment agreements is controversial and not well studied. Before designing or adapting an agreement, careful reading of the available literature and consulting with an attorney specializing in health care is advisable. The following statement about current preferred terminology is excerpted from an Indian Health Board discussion list:
“There are two words that certified pain specialists avoid when discussing patients with pain. They are contract and narcotic. Instead, we use the words, agreement and opioid. The former words are avoided for good reason ... Here is the rationale: If we use the word contract on our documents or in our speech, we can be held accountable, under state contract laws, should we fail any of our contract responsibilities. Providers who have used contracts have been sued, by patients, who have won such contract suits. Provider failure might include such things as not being available 24/7 to write for new opioid fills or to evaluate for new pain onsets. Thus, the American Academy of Pain Management recommends using the term, agreement, and not contract”

Related to, but different from, a contract is a consent agreement that spells out the potential risks and benefits of the proposed treatment.

Sample documents

• MGH Pain Center: Controlled Medication Agreement
• MGH Primary Care: Patient-Provider Contract for the Use of Chronic Opioids
• American Academy of Pain Medicine: Long-term Controlled Substances Therapy
  for Chronic Pain [see also Spanish version)
• American Academy of Pain Medicine: Consent for Chronic Opioid Therapy [see also Spanish version]
• National Initiative on Pain Control: Patient Medication Management Agreement (PainEDU.org)

Articles that discuss treatment agreements and informed consent

• Emerging Solutions in Pain [Register, then navigate to ESP Tool Kit, then Practice Management, then Opioid Agreement]
• Using an Opioid Contract (StopPain.org)
• Arnold RM, Han PK, Seltzer D.  Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties.  American Journal of Medicine. 2006 Apr;119(4):292-6.
• Bolen J. A Treatment Agreement Establishes Boundaries With Patients. Pain Medicine News. [O] Aug 2005:(3)4.
• Bolen J. Informed Consent Facilitates Use of Controlled Substances. Pain Medicine News. [O] Apr 2005:(3)2.
• Fishman SM, Mahajan G, Jung SW, et al. The trilateral opioid contract: Bridging the pain clinic and the primary care physician through the opioid contract. J Pain Symptom Manage. 2002;24:335-344.
• Fishman SM, Kreis PG. The Opioid Contract. Clinical Journal of Pain. 18(4 Supp):S70-S75, July/August 2002.
• Fine P, Portenoy RK: A clinical guide to opioid analgesia. [O] New York: McGraw Hill, 2004.  (Chapter 10, p 96-99)
• Hariharan J, et al.  Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. Journal of General Internal Medicine. 2007 Apr;22(4):485-90.
• Heit HA.  Creating and Implementing Opioid Agreements. Journal of Care Management [O]
• Kulich R.  Screening for Chronic Opioid Therapy.  Pain Management Rounds [O] 2004;1(4).
• Passik S, Kirsh KL.  Managing Pain in Patients With Aberrant Drug-Taking Behaviors.  Journal of Supportive Oncology [O] Jan/Feb 2005;3(1):83-86.
• Roskos SE, et al.  Literacy Demands and Formatting Characteristics of Opioid Contracts in Chronic Nonmalignant Pain Management.  Journal of Pain. 2007 Oct;8(10):753-8
• Wallace LS, et al.  Development and Validation of a Low-Literacy Opioid Contract.  Journal of Pain. 2007 Oct;8(10):759-66.

Urine Screening and Monitoring
The precise role of urine toxicolgy in pain management is unclear and controversial. Most experts caution that is should be employed as one part—not the only component—of a monitoring strategy.

• Gourlay DL, et al.  (2006) Urine Drug Testing in Clinical Practice:  Dispelling the Myths & Designing Strategies (3rd Ed.).  California Academy of Family Physicians Monograph Series.  Published by PharmaCom Group. 
• Compton P.  The Role of Urine Toxicology in Chronic Opioid Analgesic Therapy.  Pain Management Nursing.  Dec. 2007;8(4):139-172.
• Cone EJ, et al.  Evidence of morphine metabolism to hydromorphone in pain patients chronically treated with morphine.  Journal of Analytical Toxicology. 2006 Jan-Feb;30(1):1-5.
• Fishman SM, et al.  Adherence monitoring and drug surveillance in chronic opioid therapy.  Journal of Pain & Symptom Management. 2000 Oct;20(4):293-307.
• Katz NP, et al.  Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy.  Anesthesia & Analgesia. 2003 Oct;97(4):1097-1102.
• Katz N & Fanciullo G. Role of urine toxicolgy testing in the management of chronic opioid therapy. Clinical Journal of Pain Jul-Aug 2002;18(4;Supp):S76-S82.
• Manchikanti L, et al.  Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids?  Pain Physician. [O] 2006 Apr;9(2):123-9.
• Manchikanti L, et al.  Does adherence monitoring reduce controlled substance abuse in chronic pain patients?  Pain Physician. [O] 2006 Jan;9(1):57-60.
• Michna E, et al.  Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings.  Clinical Journal of Pain. 2007 Feb;23(2):173-9.
• Mittal MK, et al.  Toxicity From the Use of Niacin to Beat Urine Drug Screening.  Annals of Emergency Medicine. 2007 Apr 4; [Epub ahead of print]
• Moeller KE, et al.  Urine Drug Screening: Practical Guide for Clinicians.  Mayo Clinic Proceedings.  2008;83:66-76.
• Passik SD, et al.  A chart review of the ordering and documentation of urine toxicology screens in a cancer center: do they influence patient management?  Journal of Pain & Symptom Management. 2000 Jan;19(1):40-4.
• Tennant F. Urine and blood tests: Why and when to use each test in pain treatment. Practical Pain Management 2007;7(5):18, 26-27.
• Von Seggern RL, et al.  Laboratory monitoring of OxyContin (oxycodone): clinical pitfalls.  Headache. 2004 Jan;44(1):44-7.

Assessing Progress/Outcome
Until recently, tools to assess treatment goal progress or outcomes have lagged behind instruments for assessing substance abuse risk prior to therapy. Very recent outcome measures include a focus on assessing patients for appropriateness of opioid use. Progress measures also need to include assessment of analgesia, functional levels, and side effects of treatment.

• Belgrade MJ, et al.  The DIRE score: predicting outcomes of opioid prescribing for chronic pain.  Journal of Pain. 2006 Sep;7(9):671-81.
• Brennan MJ.  DIRE: a tool to assess risks of maintaining opioid treatment.  Journal of Pain. 2007 Feb;8(2):185
• Butler SF, et al.  Development and validation of the Current Opioid Misuse Measure.  Pain 2007 July;130(1-2):144-156.
• Gironda RJ, et al.  Preliminary evaluation of reliability and criterion validity of Actiwatch-Score.Journal of Rehabilitation Research & Development.  [O] 2007;44(2):223-230.
• Hariharan J, et al.  Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. Journal of General Internal Medicine. 2007 Apr;22(4):485-90.
• Jamison RN, et al.  Neuropsychological effects of long-term opioid use in chronic pain patients.  Journal of Pain & Symptom Management. 2003 Oct;26(4):913-21.  
• Kalso E, et al.  Opioids in chronic non-cancer pain: systematic review of efficacy and safety.  Pain. 2004 Dec;112(3):372-80.
• Nedeljkovic SS, et al.  Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential.  Clinical Journal of Pain. 2002 Jul-Aug;18(4 Suppl):S39-51.
• Nishimori M, et al.  Successful and unsuccessful outcomes with long-term opioid therapy: a survey of physicians' opinions.  Journal of Palliative Medicine. 2006 Feb;9(1):50-6.
• Passik SD et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clinical Therapeutics.  2004; 26(4):552-61.
• Passik SD, et al.  Monitoring outcomes during long-term opioid therapy for noncancer pain: results with the Pain Assessment and Documentation Tool.  Journal of Opioid Management. 2005 Nov-Dec;1(5):257-66.
• Saffier K, et al.  Addiction Severity Index in a chronic pain sample receiving opioid therapy.  Journal of Substance Abuse Treatment. 2007 Oct;33(3):303-11
• Savage, S.  Assessment for Addiction in Pain-Treatment Settings.  Clinical Journal of Pain.  2002;18(4 Supp):S28-38.

Organizing the Practice
A recently emerging phenomenon—too soon to call a trend—is a recognition that the organizational structure of the practice or clinic can have an impact on outcomes and satisfaction of practitioners.

• Emerging Solutions in Pain [Register, then navigate to ESP Tool Kit, then Practice Management]
• TOTA: Texas Opioid Treatment Alliance Involving MMT Patients in Their Treatment & Recovery [Addiction Treatment Forum]
• Bolen J. A Letter to Your Patients. Pain Medicine News [O] Aug 2006;4(4)
• Chelminski PR, et al.  A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity.  BMC Health Services Research. [O] 2005 Jan 13;5(1):3.
• Jamison RN, et al.  Disease management for chronic pain: barriers of program implementation with primary care physicians.  Pain Medicine. 2002 Jun;3(2):92-101.
• Pembrook L. Advice on Building A Multidisciplinary Pain Network. Pain Medicine News [O]April 2007;5(4)
• Pembrook L. Opioid Renewal Clinic Reduces Unscheduled Office Visits. Pain Medicine News [O] Aug 2006;4(4) [See Wiedemer article, below]
• Pembrook L. No Phone Refill Policy for Opioids Improves Efficiency. Pain Medicine News [O] Aug 2006;4(4)
• Shurman J, et al. Share the Risk Model. Practical Pain Management Oct 2006;6(7):10-20.
• Vlessides M. Resource Kit Improves Management, Documentation of Chronic Pain Patients. Pain Medicine News [O] Aug 2006;4(4)
  • Chronic Pain Network Resource Center [requires free registration]
• Wiedemer N, et al.  The Opioid Renewal Clinic: A Primary Care, Managed Approach to Opioid Therapy in Chronic Pain Patients at Risk for Substance Abuse.  Pain Medicine Oct 2007;8(7):573-84

Communication, Communication, Communication
Collaborative practice requires clear and timely communication. The patient and family should be regarded as part of the team, and the patient's current understanding of treatment goals and knowledge about the treatment regularly confirmed. Who else should be involved, how often, and the type of communication used is determined by the patient's particular circumstances.

• Effective Communication Between Clinicians and Patients in Chronic Pain Management (panel discussion) [media player required] [Medscape--free registration required]
• TOTA: Texas Opioid Treatment Alliance Involving MMT Patients in Their Treatment & Recovery [Addiction Treatment Forum]
• Bruckenthal P.  Controlled substances: principles of safe prescribing.  Nurse Practitioner. 2007 May;32(5):7-11.
• Pembrook L. Advice on Building A Multidisciplinary Pain Network. Pain Medicine News [O] April 2007;5(4)
• Pembrook L. Improving Communication Between Primary Care Physicians and Pain Specialists Part 1: The Pain Specialist's Perspective. Pain Medicine News [O] 2006 Aug;4(4)
• Pembrook L. Primary Care Physicians Speak Up On Communicating With Pain Specialists Part 2: The Primary Care Physician’s Perspective. Pain Medicine News [O] 2006 Oct;4(5)
• Sullivan MD, et al.  Brief report: Training internists in shared decision making about chronic opioid treatment for noncancer pain.  Journal of General Internal Medicine. [O] 2006 Apr;21(4):360-2.

Persistent Pain & Psychiatric Comorbidity
A disproportionate number of patients with persistent pain have co-occuring or pre-existing psychiatric diagnoses. Some of these are manifested by behaviors that make pain management very difficult and frustrating. This is another population in which collaborative practice and systematic approaches are more likely to result in positive outcomes.

• Demyttenaere K, et al.  Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys.  Pain. 2007 Jun;129(3):332-42.
• Douaihy AB, et al.  Psychiatric aspects of comorbid HIV/AIDS and pain, Part 2.
  AIDS Reader. 2007 Jul;17(7):350-2, 357-61.
• Douaihy AB, et al.  Psychiatric aspects of comorbid HIV/AIDS and pain, Part 1.
  AIDS Reader. 2007 Jun;17(6):310-4.
• Fishbain DA, et al.  Chronic pain and the measurement of personality: do states influence traits?  Pain Medicine. 2006 Nov-Dec;7(6):509-29. 
• Fishbain DA, et al.    Chronic pain-associated depression: antecedent or consequence of chronic pain? A review.  Clinical Journal of Pain. 1997 Jun;13(2):116-37.
• Gureje O, et al.   The relation between multiple pains and mental disorders: Results from the World Mental Health Surveys.  Pain. 2007 Jun 12; [Epub ahead of print]
• Hay JL, Passik SD.  The cancer patient with borderline personality disorder: suggestions for symptom-focused management in the medical setting.  Psychooncology. 2000 Mar-Apr;9(2):91-100.
• Manchikanti L, et al.  Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients.  Journal of Opioid Management. 2007 Mar-Apr;3(2):89-100.
• Strain, E.  Assessment and Treatment of Comorbid Psychiatric Disorders in Opioid-Dependent Patients.  Clinical Journal of Pain.  2002;18(4 Supp):S14-27.
• Sullivan MD, et al.  Association between mental health disorders, problem drug use, and regular prescription opioid use.  Archives of Internal Medicine. 2006 Oct 23;166(19):2087-93.
• Sullivan MD, et al.  Regular use of prescribed opioids: association with common psychiatric disorders.  Pain. 2005 Dec 15;119(1-3):95-103.
• Twillman RK.  Mental Disorders in Chronic Pain Patients.  Journal of Pain & Palliative Care Pharmacotherapy.  2007;21(4):13-19.
• Wasan AD, et al.  Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clinical Journal of Pain. 2007 May;23(4):307-15.
• Wasan AD, et al.  Dealing with difficult patients in your pain practice.  Regional Anesthesia & Pain Medicine. 2005 Mar-Apr;30(2):184-92.

Ethical Issues
Ethical dilemmas and conflicts are inherent in this complex discussion. Unfortunately, they are rarely discussed in either the pain management literature or the ethics literature.

• Lachman V.D.(Ed.) (2006). Applied Ethics in Nursing. Springer Publishing Company.
• Schatman ME (Ed.) (2007) Ethical Issues in Chronic Pain Management.  New York:  Informa Healthcare.
  • Book review:  Hays RM.  Ethical Issues in Chronic Pain Management.  New England Journal of Medicine. 2007 June 14;356(24):2551.
  • Author interview on PainEDU web site
• Ballantyne JC.  Opioids for chronic nonterminal pain.  Southern Medical Journal. 2006 Nov;99(11):1245-55. [Free full text also available on Medscape]
• Ballantyne JC.  Opioid analgesia: perspectives on right use and utility.  Pain Physician. [O] 2007 May;10(3):479-91.
• Brennan F, et al.  Pain management: a fundamental human right.  Anesthesia & Analgesia. 2007 Jul;105(1):205-21.
  • Fishman SM.  Recognizing pain management as a human right: a first step.  Anesthesia & Analgesia. 2007 Jul;105(1):8-9.
  • Johnson SH.  Legal and ethical perspectives on pain management. Anesthesia & Analgesia. 2007 Jul;105(1):5-7.
  • Scholten W, et al.  The World Health Organization paves the way for action to free people from the shackles of pain.  Anesthesia & Analgesia. 2007 Jul;105(1):1-4.
  • White PF, Kehlet H.  Improving pain management: are we jumping from the frying pan into the fire?  Anesthesia & Analgesia. 2007 Jul;105(1):10-2.
• Cohen M, et al.  Ethical Perspectives: Opioid Treatment of Chronic Pain in the Context of Addiction.  Clinical Journal of Pain.  2002;18(4 Supp):S99-107.
• Geppert CM.  To help and not to harm: ethical issues in the treatment of chronic pain in patients with substance use disorders. Advances in Psychosomatic Medicine. 2004;25:151-71.
• McCaffery M, et al.  On the meaning of "drug seeking". Pain Management Nursing. 2005 Dec;6(4):122-36 [Free full text also available on Medscape]
• Pappagallo M, Heinberg LJ.  Ethical issues in the management of chronic nonmalignant pain.  Seminars in Neurology. 1997;17(3):203-11.
• Sullivan M, Ferrell B.  Ethical challenges in the management of chronic nonmalignant pain: negotiating through the cloud of doubt.  Journal of Pain. 2005 Jan;6(1):10-1.

Drug Control Policy
In theory, regulators and clinicians share the goal of ensuring safe and appropriate treatment of pain (including opioid treatment) while minimizing diversion and illegal prescribing. However, there has rarely been more tension between the two camps as there is at this time, and efforts to reach consensus have met with limited results.

• Achieving Balance in State Pain Policy: A Progress Report Card (3rd Ed, 2007). Pain and Policy Studies Group
• Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (4th Ed, 2007) Pain and Policy Studies Group
• Pain and Policy Studies Group, University of Wisconisin
  • Diversion of Prescription Opioids
  • Prescription Monitoring Programs
• Model Policy for the Use of Controlled Substances for the Treatment of Pain (Federation of State Medical Boards of the United States)
• Public Policy Statement on the Rights and Responsibilities of Healthcare Professionals in the use of Opioids for the Treatment of Pain. (American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine)
• Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing Act. (A Joint Statement From 21 Health Organizations and the Drug Enforcement Administration; the DEA disavowed the statement 3 months later)
• Agency Medical Directors Group (Washington State) Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain.
• Drug Enforcement Administration.  Final Rule: Issuance of Multiple Prescriptions for Schedule II Controlled Substances (effective 19 December 2007).  Federal Register: 19 Nov 2007;72(222): 64921-64930
• Drug Enforcement Administration. Proposed Rule:  Issuance of multiple prescriptions for Schedule II controlled substances. Federal Register. 2006;71(172):52724-52726.
• Drug Enforcement Administration. Practitioners Manual: An Informational Outline of the Controlled Substances Act. 2006 Edition. (Downloadable PDF also available) [Accessed 7/16/2007]
• A Q & A with the DEA: Part 1 [Interview by Pain Medicine News with Karen Tandy, DEA Administrator; posted February 2007; accessed 7/16/07]
• A Q & A with the DEA: Part 2 [Interview by Pain Medicine News with Karen Tandy, DEA Administrator; posted April 2007; accessed 7/16/07]
• The Legal Side of Pain: web resource on all aspects of legal and regulatory issues related to pain and pain management. Includes both free and subscribed content.

• Ballantyne JC.  Regulation of opioid prescribing.  BMJ. 2007 Apr 21;334(7598):811-2.
• Compton WM, Volkow ND.  Abuse of prescription drugs and the risk of addiction.  Drug & Alcohol Dependence. 2006 Jun;83 Suppl 1:S4-7.
• Dahl JL.  How to reduce fears of legal/regulatory scrutiny in managing pain in cancer patients.  Journal of Supportive Oncology. 2005 Sep-Oct;3(5):384-8.
• Gilson AM, Joranson DE, Martha A. Maurer MA.  Improving State Pain Policies:  Recent Progress and Continuing Opportunities.  CA:  A Cancer Journal for Clinicians 2007 Nov/Dec;57(6):341–353.
• Gilson AM, Joranson DE. Is the DEA’s New “Prescription Series” Regulation Balanced?  Accessed 14 Dec 2007.
• Gilson AM, Joranson DE.  The Federal Drug Enforcement Administration “Prescription Series” Proposal:  Continuing Concerns.  Journal of Pain & Palliative Care Pharmacotherapy. 2007;21(4):21-24.
• Gilson AM, et al.  State policy affecting pain management: recent improvements and the positive impact of regulatory health policies. Health Policy. 2005 Oct;74(2):192-204.
• Gilson AM, et al.  A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. Journal of Pain & Symptom Management. 2004 Aug;28(2):176-88.
• Jung B, Reidenberg MM. Doctors being deceived. Pain Medicine 2007 (published online 21 June)
• Manchikanti L.  National drug control policy and prescription drug abuse: facts and fallacies.  Pain Physician. [O] 2007 May;10(3):399-424.
• Manchikanti L.  Prescription drug abuse: what is being done to address this new drug epidemic? Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources.  Pain Physician. [O] 2006 Oct;9(4):287-321.
• Manchikanti L, et al.  Evolution of the National All Schedules Prescription Electronic Reporting Act (NASPER): a public law for balancing treatment of pain and drug abuse and diversion. Pain Physician. [O] 2005 Oct;8(4):335-47.
• Paulozzi LJ, et al. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and Drug Safety. 2006 Sep;15(9):618-27.
  • Response to Paulozzi: Fishman SM.  Commentary in response to Paulozzi et al.: prescription drug abuse and safe pain management. Pharmacoepidemiology and Drug Safety. 2006 Sep;15(9):628-631.
  • Response to Paulozzi: Joranson DE, Gilson AM. Wanted: a public health approach to prescription opioid abuse and diversion. Pharmacoepidemiology and Drug Safety. 2006 Sep;15(9):632-634.
• Zacny J, Bigelow G, Compton P, Foley K, Iguchi M, Sannerud C.  College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement.  Drug & Alcohol Dependence. 2003 Apr 1;69(3):215-32.

Resources for Patients/Families

• The Intractable Pain Patient's Handbook for Survival. (Free; PainTopics.org)
• Kannerstein D & Whitman SM.  Surviving a Loved One's Chronic Pain.  Practical Pain Management Jan/Feb 2007;7(1):48-53.  Free full text also available via the PainTopics.org web site.
• Treatment Options: A Guide for People Living with Pain. American Pain Foundation. Available for free download on APF web site.
• HBO Addiction Project (National Institute on Drug Abuse--NIDA)
• HBO Addiction web site.
• NIDA publication, “Drugs, Brains, and Behavior - The Science of Addiction”
• Addiction, Tolerance, and Dependence:  article on National Pain Foundation web site. [Accessed 7/19/2007]

Organizations that Study Substance Abuse and Addictive Illness

• National Institutes of Health
  • National Institute on Alcohol Abuse and Alcoholism (NIAAA)
  • National Institute on Drug Abuse (NIDA)
    • NIDA for Teens
  • Substance Abuse and Mental Health Services Administration (SAMHSA)
    • National Survey on Drug Use & Health, 2006
    • National Clearinghouse for Alcohol and Drug Information
    • Drug Abuse Warning Network [DAWN], 2005: National Estimates of Drug-Related Emergency Department Visits
• National Center on Addiction and Substance Abuse at Columbia University (CASA)
• Inflexxion, Inc.

Organizations/Resources Devoted to Addictive Illness-Related Treatment, Advocacy, Education, and Support

• Addiction Resource Center (Medscape)
• Addiction Treatment Forum [E-mail newsletter available]
• Network for the Improvement of Addiction Treatment (NIATx)
• Robert Wood Johnson Foundation
• Center for Substance Abuse Treatment (CSAT/SAMHSA)
• Massachusetts Organization of Addiction Recovery (MOAR)

Professional Membership Organizations

• American Academy of Addiction Psychiatry (AAAP)
• American Academy of Pain Medicine (AAPM)
• American Osteopathic Academy of Addiction Medicine (AOAAM)
• American Pain Society (APS)
• American Society of Addiction Medicine (ASAM)
• American Society for Pain Management Nursing (ASPMN)
• International Nurses Society On Addictions (IntNSA)

Meetings/Conferences/Symposia
Future

Past

• American Pain Society Nursing SIG presentation, May 9, 2008. [Click her for slides of the presentation "The Intersection of Pain Management and Addictive Illness"]
• Massachusetts Pain Initiative Quarterly Meeting. October 25, 2007. [Click here for slides of the presentation "The Intersection of Pain Management and Addictive Illness"]
• 31st Annual International Nurses Society on Addictions Conference, October 11-13, 2007
• Alliance of State Pain Initiatives, June 21 - 23, 2007 [Click here for slides of presentation "Building Partnerships to Address Pain Management in Persons with Addictive Illness"]
• The 7th International Conference on Pain & Chemical Dependency, June 21-24, 2007
• Pain, Opioids, and Addiction: An Urgent Problem for Doctors and Patients. Two-day conference sponsored by National Institute on Drug Addiction (NIDA), March 5-6, 2007.
  • Agenda & Speakers
  • Day 1 description & video of proceedings
  • Day 2 description & video of proceedings
  • A NIDA-authored report on the meeting can be found in: National Institute on Drug Abuse, National Institutes of Health.  Pain, Opioids, and Addiction:  An Urgent Problem for Doctors and Patients.  Journal of Pain & Palliative Care Pharmacotherapy. 2007;21(4):45-49.
• Materials prepared for the MGH Continuing Education Course, The Intersection of Pain Management & Addictive Illness: Where Do We Start the Conversation? Offered January 18 & May 30, 2006.

Continuing Education
NOTE: The following is a non-exhaustive list of professional continuing education offerings available on the Web. They are listed here for the convenience of readers; they are not endorsed by Massachusetts General Hospital or MGH Cares About Pain Relief. Readers should be aware that most free continuing educational offerings are financially supported by the pharmaceutical industry. Many web sites require free registration.

• Treating Pain and Preventing Abuse and Diversion. CME; Expires 31 Aug 2008
• Strategic Management of Pain Patients at Risk for Abuse or Diversion. CME; CNE;CPE; Expires 25 Sep 2007
• Pain Patients at Risk of Abuse and Those with Comorbid Psychopathology: A Guide to Identification and Treatment. CME; CNE;CPE; Expires 19 Jul 2007
• Opioids for Pain: Risk Management. CME; Expires 30 June 2007 (fee)
• Controlled Substance Prescriptions and Pain Management: Striking a Balance. CPE; Expires 21 Jun 2009
• Managing pain in a patient who's drug-dependent. CNE; Expires 3/31/09
• Update on opioid analgesics for patients with chronic pain: Receptors, Research, and Regulations. CME; Expires 30 Nov 2007
• Opioid Analgesia: Risk Management Strategies And Emerging Therapies. CME; Expires 31 Jul 2007
• Pain and Addiction 101. CME;CNE;CPE; expires 18 May 2008
• Gourlay DL, et al.  (2006) Urine Drug Testing in Clinical Practice:  Dispelling the Myths & Designing Strategies (3rd Ed.).  California Academy of Family Physicians Monograph Series.  Published by PharmaCom Group.  CME; Expires 1 Nov 2008
  

Resource Page developed by
Thomas E. Quinn, RN, MSN, AOCN, CHPN
tquinn1 [at] partners [dot] org

Sponsored by MGH Cares About Pain Relief
For additional information,
contact Paul Arnstein, PhD, RN
617-724-8517
pmarnstein [at] partners [dot] org

This page last updated 4 January 2008