6/9/2017. Assessment, Treatment, and Outcome of Pain Patients at Risk for Prescription Opioid Abuse: A Naturalistic Study

Transcription

1 6/9/7 Assessment, Treatment, and Outcome of Pain Patients at Risk for Prescription Opioid Abuse: A Naturalistic Study Stacey McCaffrey, PhD, Research Scientist Stephen F Butler, PhD, Chief Science Officer Purpose: To evaluate how patients who are at high risk for problematic opioid behavior differ initially and over the course of treatment from those at low risk Observational study using data collected from pain treatment centers around the United States from an electronic self-report assessment of pain and functioning (PainCAS) The PainCAS: Clinical Assessment System (PainCAS) is a comprehensive scientifically developed web-based clinical tool used during painrelated treatment

2 6/9/7 PainCAS includes assessment of: pain medical/family history medications and other treatments social and emotional functioning interference with activities of daily living opioid risk Assessments Initial pain assessment 5 core questions -5 minutes Follow up pain assessment core questions - minutes Screener and Opioid Assessment for Patients with Pain (SOAPP) Current Opioid Misuse Measure (COMM) Sample Assessment Screen

3 6/9/7 Sample Assessment Screen Sample Assessment Screen Reports Provider Reports Pertinent positive information prioritized in at-a-glance graphic format Graphically displays change over time Monitoring recommendations based on opioid risk assessment Links to PainEDU.org educational content Patient Reports Report card format Change in pain and function over time Links to painaction.com educational content

4 6/9/7 Sample Patient Report Clinical Utility Standardizes assessments Reduces paperwork Assessments can be completed by patients at home or in the clinic Significantly increases the likelihood that a risk assessment is included in the EMR Risk Assessment Documentation % of charts with documentation of a risk assessment Baseline (w/out PainCAS) Post-Intervention (w/ PainCAS) % Change % 8% 9% Clinical Utility Encourages dialogue and transparency Increase in discussion of clinically relevant topics during clinic visits, such as substance abuse history and medication misuse At-a-glance reports for streamlined clinical interpretation Offers patient and provider education on pain management Generates monitoring recommendations based on the patient s level of opioid risk

5 6/9/7 Why use a standardized screener for abuse risk? Measuring opioid abuse risk Abuse risk = f((# of missing teeth + # of tattoos + # of family members in the waiting room)/age) Thanks to Dr. Ted Jones Who is at risk for nonmedical opioid use? 5

6 6/9/7 Screener and Opioid Assessment for Patients with Pain (SOAPP) SOAPP is a self-report screener to identify chronic pain patients who may be at risk for problematic long-term opioid use Misuse, abuse, diversion activities, and drug-seeking behaviors SOAPP has exhibited strong sensitivity and specificity in predicting aberrant opioid-related behavior 5 months later, as measured by urine toxicology screening, self-report, and clinician report Current Opioid Misuse Measure (COMM) COMM is a self-report screener to monitor aberrant medication related behaviors in chronic pain patients who are already on long-term opioid therapy COMM has exhibited strong sensitivity and specificity in predicting aberrant behavior months later, as measured by urine toxicology screening, self-report, and clinician report Clinical Sites As of October 6, the PainCAS database includes 858 assessments across 7689 unique patients Patients completed assessments from 9 clinics across 8 states De-identified PainCAS data are automatically uploaded to the PainCAS database 6

7 6/9/7 Participant Demographics (n=7689 unique patients) Valid Percent Female 6. Gender Male 9.9 Hispanic 6. Ethnicity Non-Hispanic 9.9 White 8.9 African American 8. Race Native American.8 Asian/Pacific Islander. Other/Mixed Race years.7 5- years 6.5 Age 5-5 years years years. Patient Information At their first assessment, 5.% of patients were determined to be at high risk for problematic opioid-related behavior Patients completed as many as assessments over the course of treatment Research Question How do patients at high risk for aberrant-related drug behavior differ from those who are at low risk when initially presenting for treatment? 7

8 Percent Percent Percent 6/9/ Gender Male Female Ethnicity Hispanic Non-Hispanic Race White African American Native American Asian/Pacific Islander Other/Mixed Race 8

9 Mean Pain Rating Percent Percent 6/9/ Age History of Family Substance Abuse parent sibling spouse child Pain Ratings Pain Now Pain Least Pain Worst Pain Average 9

10 Percent Percent Percent 6/9/7 8 Location of Pain Head Back and/or Neck Shoulder and/or Arm Hip and/or Leg Torso 9 Psychological/Emotional Distress Depression Anxiety Irritability Concentration Social Isolation Fatigue Forgetfulness Interference with Daily Activities

11 6/9/7 Profile of Patients At for Misuse Logistic regressions were employed to evaluate the extent to which demographic/clinical variables, pain severity and location, psychological/emotional distress, and interference with daily activities predicted risk classification ( high risk vs. low risk ) Profile of Patients At for Misuse Profile of Patients At for Misuse Hip/Leg Pain Front Torso Pain Hx Parent Hx Sibling Hx Spouse Substance Abuse Substance Abuse Substance Abuse

12 6/9/7 Profile of Patients At for Misuse Patients who reported: pain in their front torso pain in their hip and/or leg irritability social isolation forgetfulness interference with relationships were approximately.5 times as likely to be at high-risk Patients who reported: depression anxiety History of sibling substance abuse were approximately times as likely to be at high-risk Patients who reported: History of parent substance abuse History of spouse substance abuse were approximately.5 times as likely to be at high-risk Research Question How do patients at high risk for aberrant-related drug behavior differ from those who are at low risk over the course of treatment? Tracking Patients Over Time PainCAS initial and follow-up assessments can be used to track individual or aggregate outcomes over time. Exploratory analyses of treatment outcomes for those at high and low risk for aberrant opioidrelated behavior on: pain ratings impairment in daily activities psychological/emotional distress

13 Mean Pain Rating Mean Pain Rating PainCAS Functional Impairment score (lower score is better) 6/9/ Pain Ratings Over Four Follow-up Visits Pain at worst Pain now Pain at least Initial visit Follow-up visit Follow-up visit Follow-up visit Follow-up visit Pain Ratings Over Four Follow-up Visits Pain at worst Pain now Pain at least Initial visit Follow-up visit Follow-up visit Follow-up visit Follow-up visit 9 Functional Impairment Over Four Follow-up Visits Initial visit Follow-up visit Follow-up visit Follow-up visit Follow-up visit

14 Psychological/Emotional Distress score (lower score is better) Psychological/Emotional Distress score (lower score is better) 6/9/7 Psychological/Emotional Distress Over Four Follow-up Visits Initial visit Follow-up visit Follow-up visit Follow-up visit Follow-up visit.5 Psychological/Emotional Distress Over Four Follow-up Visits Interaction significant at second visit: greater improvement for high-risk patients (p <.) Initial visit Follow-up visit Follow-up visit Follow-up visit Follow-up visit Patients determined to be at high-risk at the initial assessment evidenced a greater decrease in psychological/emotional distress from initial assessment to follow-up than patients at low-risk for problematic opioid behavior If these high-risk patients are showing improvement in psychological/emotional distress, does their risk status also change? How does change in psychological/emotional distress vary based on high-risk patients risk status at follow-up? Initial Assessment: High-Risk Follow-Up Assessment: 9 at High-Risk (.8%) 8 at Low-Risk (58.%)

15 Psychological/Emotional Distress score (lower score is better) Psychological/Emotional Distress score (lower score is better) 6/9/7.5 Patients Determined to be at Initial Assessment: Change in Psychological/Emotional Distress based on Risk Status at Follow-Up Still high risk at second visit No longer high risk at second visit First visit Follow up visit.5.5 Patients Determined to be at Initial Assessment: Change in Psychological/Emotional Distress based on Risk Status at Follow-Up 8.9% decrease.8% decrease Still high risk at second visit No longer high risk at second visit First visit Follow up visit Conclusions Electronic collection of patient self-report data allows for a number of benefits: Ensures inclusion of required patient information in the EMR (e.g., risk assessment) Allows for tracking of individuals response to treatment Allows for aggregate analyses of patient presentation and follow-up data to uncover patterns of responses and differences among patient subgroups. 5

16 6/9/7 Limitations Real-word data from clinical sites Lack of follow-up data for patients, incomplete data N at the sub-group level does not allow for more granular sub-group analyses at this time Data are being collected on an on-going basis (check back with us soon!) Need to explore these trends more fully What might account for the wide CI for patients with a history of spouse substance abuse? What are protective factors? What variables mediate this relationship? Future Directions Aggregate electronic collection of self-report and other variables can be used to: Understand how chronic pain patients and subgroups of patients respond to treatment Develop benchmarks for treatment outcomes Develop more accurate screeners for aberrant opioid-related behaviors (e.g., include non-selfreport variables) Thank You Stacey McCaffrey, PhD, Research Scientist smccaffrey@inflexxion.com Stephen F Butler, PhD, Chief Science Officer sfbutler@inflexxion.com These data have not been published A subscription to the PainCAS can be purchased through Inflexxion, Inc. 6