Practical Pain Assessment- Screening for Psychosocial Risk. Session #3 Roman D. Jovey, MD

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2 Practical Pain Assessment- Screening for Psychosocial Risk Session #3 Roman D. Jovey, MD

3 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

4 Learning Objectives Discuss the concept of psychosocial risk as it pertains to pain. Review the research linking psychosocial risk factors to pain outcomes. Describe the use of some specific screening instruments to assess risk

6 Comprehensive Pain History 1. Current pain descriptions (including pain scoring) 2. Previous pain history (including treatments & results) 3. Other concurrent medical / psych problems 4. Current treatments, effectiveness and side effects 5. Psychosocial factors (coping, family, work, income, relationships) 6. Screening for substance misuse risk 7. Current functioning (sleep, activity, libido) 8. Patient s beliefs and expectations

7 Screening for Mental Health Co- morbidity and Psychosocial Contributors to Suffering

8 Chronic Pain: Mental Health Disorders Prevalence of diagnosed concurrent mental health disorders: Depression: 27.9% Anxiety: 25.0% Both: 16.4% CPS Nanos Survey

9 Chronic Pain: Mental Health Disorders Prevalence of diagnosed concurrent mental health disorders (POINT cohort): Mod/severe depression: 46.6% Mod/severe GAD: 22.8% PTSD: 15.3% Lifetime suicidal attempt: 20.3% Campbell G et al. Pain 2015;156(2):231-42

10 Screening for MH Disorders Screening for Anxiety 1. Generalized Anxiety Disorder Score (GAD-7) Arch Intern Med. 2006;166: Screening for Depression 2. The Patient Health Questionnaire PHQ 9 Screening for Both 3. Hospital Anxiety & Depression Scale HADs Acta Psychiatr Scand Jun;67(6): J Psychosom Res Feb;52(2):69-77.

11 HADS Anxiety Depression

physical disease, stress Maintaining Causes -

12 Understanding Psych Comorbidity... Predisposing Causes - preexisting susceptibility, genetics, learned beliefs Precipitating Causes - triggering circumstances death of a loved one, physical disease, stress Maintaining Causes - perpetuating consequences withdrawal from friends, irregular sleep patterns, expectations, rewards

13 The stress cycle...

14 Psychosocial Factors Yellow Flags Psychosocial indicators suggesting increased risk of progression to longterm distress, disability and pain

15 Psychosocial Factors Yellow Flags Mood Attitudes and beliefs Behaviours (e.g. fear avoidance, catastrophising, passive/sick role ) Marital and family status, social class, education Workplace, compensation, litigation

16 Fear Avoidance in Pain Injury Pain experience Disuse Depression Disability Hypervigilance Avoidance Recovery Confrontation Fear of re-injury Catastrophizing No Fear

17 Plays a vital and robust role in predicting both pain and disability across a wide variety of patient samples suffering pain. Pain Catastrophizing...

19 Pain Catastrophizing Associated with: Increased pain intensity Exaggerated pain behavior Decreased physical function Prolonged disability Increased risk for substance misuse??

20 Pain Catastrophizing Treatment with a multimodal approach: Cognitive Behavioural Therapy Emotional disclosure Graded exposure to activity Neurophysiology education

21 Perceived Injustice high scores on a measure of perceived injustice were associated with greater pain, more severe depressive symptoms, and more pronounced disability Dealing with these issues as part of your interactions as physicians may contribute to better outcomes Sullivan MJ et al. J Occup Rehabil Sep;18(3): Scott W et al. Pain 154(2013):

23 James MH Screen HADs-A score is 9 = non-significant anxiety symptoms HADs-D score is 14 = significant depressive symptoms His PCS score is 26 = some degree of fear avoidance behaviour related to his pain He is angry that his company did not provide the proper safety equipment to offload his cargo fell multiple times as a result

conditions such as depression, suicide, drug and alcohol abuse, high risk behaviours, and

24 As a consequence, abused children are at increased risk for a wide range of physical health conditions including obesity, heart disease, and cancer, as well as psychiatric conditions such as depression, suicide, drug and alcohol abuse, high risk behaviours, and violence. Mehta D, et al. Proceedings for the National Academy of Sciences, 110(20):

25 What is the Adverse Childhood Experiences (ACE) Study? Decade long - 17,000 people involved. Looked at effects of adverse childhood experiences over the lifespan. Largest study ever done on this subject.

26 Childhood Experiences Underlie Chronic Depression % With a Lifetime History of Depression >=4 ACE Score Women Men

27 ACE Score and Intravenous Drug Use % Have Injected Drugs or more ACE Score N = 8,022 p<0.001

30 Screening for Addiction / Misuse Risk

31 Sleep disturbance Secondary Discomforts Drug Dependence Pain Addiction Depression Anxiety Functional Disability Increased Stresses Savage, 2004

32 An active concurrent addiction disorder will interfere with the optimum treatment of pain

33 Prescribed opioids are diverted to the street and can do harm

36 Substance Use & Addictive Disorders DSM-5 May 2013 Use à consequences Repeated use in hazardous situations Repeated use despite interpersonal harm Tolerance Withdrawal Use for longer or more than intended Unsuccessful attempts to cut down use Long periods spent obtaining or recovering Neglecting other life activities Use despite ongoing health consequences Craving Mild = 2-3 Moderate = 4-5 Severe=6-11 has to cause clinically significant impairment / distress

37 The 4 C s of Addiction Loss of Control Compulsive Use Craving Consequences (Use Despite Harm) Consensus Statement on Pain and Opioids ASAM, APS, AAPM, April

38 Population of Rx Opioid Users Is Heterogeneous Nonmedical users Pain patients SUD=substance use disorder Passik 2008

41 Screening for Opioid Misuse Risk Initial Screening Questions: Ask in a routine, straightforward manner

42 How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? Once = Sensitivity: 100% Specificity: 73.5% Smith P.C. et al Arch Int Med 2010; 170(13):

43 I only have 1 drink per day, doc.

44 Screening for Opioid Misuse Risk Initial Screening Questions: Ask in a routine, straightforward manner Ask about number of drinks per day and per week and sedative use CAGE, SOAPP-R, Opioid Risk Tool

46 46

47 Ellen Addiction Screen Previous heavy drinking after divorce from 1st husband now under control Reluctant to specify current drinking level but admits to ~ 2 glasses wine daily with supper Tried marijuana as a youth, no illicit drugs Occasional use of lorazepam for sleep Father alcoholic died of his disease 47

48 Ellen X X X 5 48

49 Ellen MH Screen HADs-A score is 14 = consistent with significant anxiety Further questioning suggests no history of anxiety until her divorce; she is quite worried about her future finances She admits to using alcohol to help her cope HADs-D score is 6 = non-significant depressive symptoms Her PCS score is 26 indicating some degree of fear avoidance behaviour related to her pain 49

Primary Care Triage of Patients With Chronic Pain Group 3 High Risk Specialist Co-Management Active addictive disorder, Hx of opioid addiction Major untreated

psychiatric disorder No active addictive disorder and no major untreated psychiatric disorder Group 1 Low Risk - Primary Care Lacks major psychiatric comorbidity No

50 Primary Care Triage of Patients With Chronic Pain Group 3 High Risk Specialist Co-Management Active addictive disorder, Hx of opioid addiction Major untreated psychiatric disorder Get a specialist s help Group 2 Elevated Risk Get specialist opinion Previously treated SUD, strongly positive family history, treated psychiatric disorder No active addictive disorder and no major untreated psychiatric disorder Group 1 Low Risk - Primary Care Lacks major psychiatric comorbidity No history of substance related problems Tried non-pharm and non-opioid treatments Get a specialist s opinion Manage in Primary Care Adapted from Gourlay D. & Heit H. Pain Med 2005

51 Elements of a Good Pain History: CNCP 1. Current pain descriptions (including pain scoring) 2. Previous pain history (including treatments and results) 3. Current treatments, effectiveness and adverse effects 4. Other concurrent medical / psych problems 5. Psychosocial factors (coping, family, work, income, relationships) 6. Addiction screening 7. Current functioning and future goals

52 CNCP - Diagnostic Formulation Anatomic location of pain Pathophysiologic mechanism (if known) Mechanism of pain (neuropathic vs. nociceptive) (? central centralization) Contributing physical factors (atrophy, deconditioning) Contributing psychosocial factors (mood, catastrophizing, environment) Risk of addiction / misuse Squire 2006

53 ELLEN: 67 y.o. woman 1. Moderate to severe L knee OA Myofascial neck and shoulder girdle and knee pain Some evidence of central sensitization left leg 2. Mild renal insufficiency, hypertension, DM II, (high NSAID GI and CV risk); L quadriceps muscle wasting and weakness; TrPts bil. trapezii and lev. Scapulae and left knee 3. MDD in remission; sig. anxiety symptoms;? SUD EtOH 4. Moderate catastrophizing and passive approach to pain; previous divorce with loss of financial security and isolation 5. Moderate addiction/misuse risk ORT (5) 6. Moderately severe impact on function (PDI = 42/70) 53

54 Summary Psychosocial factors are important predictors of the outcomes of pain management Asking the right questions is still the best way we have to assess for risk Using standard tools can help to make the pain assessment more thorough and time efficient

55 Questions?