ABSTRACT
Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the "true" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid.
Similar content being viewed by others
References
Tsang AM, Von Korff S, Lee J, Alonso E, Karam MC, Angermeyer GL, et al. Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9(10):883-891.
IOM (Institute of Medicine). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press; 2011.
Breuer B, Cruciani R, Portenoy RK. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey. South Med J. 2010;103(8):738-747.
Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21(6):652-655.
Patient Protection and Affordable Care Act. Public Law No: 111-148: H.R. 3590. March 23, 2010.
American Academy of Pediatrics Council on Pediatric Practice. Pediatric records and a ‘medical home’. Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967.
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4.
American College of Physicians. The advanced medical home: A patient-centered, physician-guided model of health care. Philadelphia: American College of Physicians; 205: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106).
Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the new millennium. Health Aff. 2009;28(1):75-85.
Portenoy RK. Opioid therapy for chronic nonmalignant pain: A review of the critical issues. J Pain Symptom Manage. 1996;11:203-217.
American Academy of Pain Management and the American Pain Society. The use of opioids for the treatment of chronic pain: A consensus document. Glenview, IL; 1997.
Savage S. Opioid use in the management of chronic pain. Med Clin North Am. 1999;83:761-785.
Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349(20):1943-1953.
Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9(4):444-459.
Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4856Findings). Rockville, MD; 2010.
Johnston LD, O’Malley PM, Bachman J, Schulenberg JE. Monitoring the Future national results on adolescent drug use: Overview of key findings, 2010. Ann Arbor: Institute for Social Research, The University of Michigan; 2011.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Drug Abuse Warning Network, 2008: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. SMA 11-4618. Rockville, MD; 2011.
Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999–2006. NCHS Data Brief. 2009;22:1-8.
Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618-627.
Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31(6):506-511.
Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-1321.
Cheatle MD. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med. 2011;12(Suppl 2):S43-S48.
Reid MC, Engles-Horton LL, Weber MB, Kerns RD, Rogers EL, O'Connor PG. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002;17(3):173-179.
Katz N, Sherburne S, Beach M, Rose RJ, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97(4):1097-1102.
Ives TJ, Chelminski PR, Hammett-Stabler CA, Malone RM, et al. Predictors of opioid misuse in patients with chronic pain: A prospective cohort study. BMC Health Serv Res. 2006;6:46.
Martell BA, O'Connor PG, Kerns RD, Becker WC, et al. Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116-127.
Ballantyne JC, LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. Pain. 2007;129(3):235-255.
Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6:432-442.
Fleming M, Davis J, Passik S. Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients. Pain Med. 2008;9(8):1098-1106.
Heit HA. Addiction, physical dependence, and tolerance: Precise definitions to help clinicians evaluate and treat chronic pain patients. J Pain Palliat Care Pharmacother. 2003;17(1):15-29.
Cheatle MD, O'Brien CP. Opioid therapy in patients with chronic noncancer pain: Diagnostic and clinical challenges. Adv Psychosom Med. 2011;30:61-91.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
Boscarino JA, Rukstalis MR, Hoffman SN, Han JJ, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: Comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30(3):185-194.
Schieffer BM, Pham Q, Labus J, Baria A, et al. Pain medication beliefs and medication misuse in chronic pain. J Pain. 2005;6(9):620-629.
Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clin J Pain. 2008;24(6):497-508.
Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007;129(3):355-362.
Manchikanti L, Pampati V, Damron KS, Beyer CD, Barnhill RC. Prevalence of illicit drug use in patients without controlled substance abuse and interventional pain management. Pain Physician. 2003;6(2):159-166.
Reisfield GM, Wasan AD, Jamison RN. The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: A review of the extant literature. Pain Med. 2009;10(8):1434-1441.
Jamison RN, Kauffman J, Katz NP. Characteristics of methadone maintenance patients with chronic pain. J Pain Symptom Manage. 2000;19(1):53-62.
Larson MJ, Paasche-Orlow M, Cheng DM, Lloyd-Travaglini C, Saitz R, Samet JH. Persistent pain is associated with substance use after detoxification: A prospective cohort analysis. Addiction. 2007;102(5):752-760.
Brands B, Blake J, Sproule B, Gourlay D, Busto U. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend. 2004;73(2):199-207.
Trafton JA, Oliva EM, Horst DA, Minkel JD, Humphreys K. Treatment needs associated with pain in substance use disorder patients: Implications for concurrent treatment. Drug Alcohol Depend. 2004;73(1):23-31.
Roshanov PS, Misra S, Gerstein HC, Garg AX, Sebaldt RJ, Mackay JA, et al. Computerized clinical decision support systems for chronic disease management: A decision-maker-researcher partnership systematic review. Implement Sci. 2011;6(1):92.
Ghitza UE, Sparenborg S, Tai B. Improving drug abuse treatment delivery through adoption of harmonized electronic health record systems. Subst Abuse Rehabil. 2011;2011(2):125-131.
Michel M, Trafton J, Martins S, Wang D, Tu S, Johnson N, Goldstein MK. Improving patient safety using athena-decision support system technology: The opioid therapy for chronic pain experience. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches (Vol. 4: Technology and Medication Safety). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.
Trafton JA, Martins SB, Michel MC, Wang D, Tu SW, Clark DJ, et al. Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain. Implement Sci. 2010;5:26.
VA/DoD Opioid Therapy for Chronic Pain Working Group. The management of opioid therapy for chronic pain. Washington DC: Office of Quality and Performance, VA and Quality Management Directorate, US Army MEDCOM; 2003.
Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
Tracey I, Bushnell MC. How neuroimaging studies have challenged us to rethink: Is chronic pain a disease? J Pain. 2009;10(11):1113-1120.
American Society of Addiction Medicine. The definition of addiction. Available at http://www.asam.org/DefinitionofAddiction-LongVersion.html. Accessibility verified July 10, 2011.
Passik S, Kirsh K. Screening for opioid abuse potential. Clin Updates IASP. 2008;26(7):1-4.
Butler S, Budman S, et al. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112(1–2):65-75.
Belgrade M, Schamber C, Lindgren B. The DIRE score: Predicting outcomes of opioid prescribing for chronic pain. J Pain. 2006;7(9):671-681.
Skinner HA. The drug abuse screening test. Addict Behav. 1982;7(4):363-371.
Passik S, Kirsh KL, Whitcomb L, Portenoy RK, Katz NP, Kleinman L, Dodd SL, Schein JR. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2004;26(4):552-561.
Butler S, Budman SH, Fernandez KC, Houle B, Benoit C, Katz N, Jamison RN. Development and validation of the current opioid misuse measure. Pain. 2007;130(1–2):144-156.
Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: Prediction and identification of aberrant drug-related behaviors: A review of the evidence for an American pain society and American academy of pain medicine clinical practice guideline. J Pain. 2009;10(2):131-146.
Michna E, Jamison RN, Pham LD, Ross EL, Janfaza D, Nedeljkovic SS, Narang S, Palombi D, Wasan AD. Urine toxicology screening among chronic pain patients on opioid therapy: Frequency and predictability of abnormal findings. Clin J Pain. 2007;23(2):173-179.
Starrels JL, Becker WC, Alford DP, et al. Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152(11):712-720.
Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163(20):2433-2445.
Miller LR, Cano A. Comorbid chronic pain and depression: Who is at risk? J Pain. 2009;10(6):619-627.
Smith MT, Edwards RR, Robinson RC, Dworkin RH. Suicidal ideation, plans, and attempts in chronic pain patients: Factors associated with increased risk. Pain. 2004;111(1–2):201-208.
Braden JB, Sullivan MD. Suicidal thoughts and behavior among adults with self-reported pain conditions in the national comorbidity survey replication. J Pain. 2008;9(12):1106-1115.
Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Pain and suicidal thoughts, plans and attempts in the United States. Gen Hosp Psychiatry. 2008;30(6):521-527.
Ratcliffe GE, Enns MW, Belik SL, Sareen J. Chronic pain conditions and suicidal ideation and suicide attempts: An epidemiologic perspective. Clin J Pain. 2008;24(3):204-210.
Tang NK, Crane C. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psychol Med. 2006;36(5):575-586.
Dworkin R, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, IMMPACT, et al. Core outcome measures for chronic pain trials: IMMPACT recommendations. Pain. 2005;113(1–2):9-19.
Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571.
McNair D, Lorr M, Droppleman L. Profile of Mood States. San Diego, CA: Educational and Industrial Testing Service; 1971.
Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112.
Substance Abuse and Mental Health Services Administration Substance Abuse Treatment Facility Locator. Available at http://findtreatment.samhsa.gov. Accessibility verified July 10, 2011.
Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1–3):280-295.
Manchikanti L. CBT for low-back pain in primary care. Lancet. 2010;375(9718):869-870. 13.
Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V. Group cognitive behavioral treatment for low-back pain in primary care: A randomized controlled trial and cost-effectiveness analysis. Lancet. 2010;375:916-923.
Thieme K, Flor H, Turk D. Psychological pain treatment in fibromyalgia syndrome: Efficacy of operant behavioral and cognitive behavioral treatments. Arthritis Res Ther. 2006;8(4):R121.
Linton SJ. A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: A randomized, controlled trial. Spine. 2006;31(8):853-858.
Keefe FJ, Caldwell DS. Cognitive behavioral control of arthritis pain. Med Clin North Am. 1997;81:277-290.
Chen E, Cole SW, Kato PM. A review of empirically supported psychosocial interventions for pain and adherence outcomes in sickle cell disease. J Pediatr Psychol. 2004;29:1997-2009.
Lamb S, Hansen Z, Lall R, et al. Group cognitive behavioral treatment for low-back pain in primary care: A randomized control trial and cost-effectiveness analysis. Lancet. 2010;375:916-923.
Glombiewski JA, Hartwich-Tersek J, Rief W. Two psychological interventions are effective in severely disabled, chronic back pain patients: A randomized controlled trial. Int J Behav Med. 2010;17(2):97-107.
Turner JA, Manci L, Aaron LA. Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic tempromandibular disorder pain: A randomized, controlled trial. Pain. 2006;121(3):181-194.
Greco CM, Rudy TE, Manzi S. Effects of a stress-reduction program on psychological function, pain, and physical function of systemic lupus erythematosus patients: A randomized controlled trial. Arthritis Rheum. 2004;51(4):625-634.
Holder HD, Cisler R, Longabaugh R, Stout RL, Treno AJ, Zweben A. Alcoholism treatment and medical care costs from Project MATCH. Addiction. 2000;95(7):999.
Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry. 2008;165:179-187.
Osilla KC, Hepner KA, Muñoz RF, Woo S, Watkins K. Developing an integrated treatment for substance use and depression using cognitive-behavioral therapy. J Subst Abuse Treat. 2009;37(4):412-420.
Stuhlmiller C, Tolchard B. Computer-assisted CBT for depression and anxiety: increasing accessibility to evidence-based mental health treatment. J Psychosoc Nurs Ment Health Serv. 2009;47(7):32-39.
Cuijpers P, Marks IM, van Straten A, Cavanagh K, Gega L, Andersson G. Computer-aided psychotherapy for anxiety disorders: A meta-analytic review. Cogn Behav Ther. 2009;38:66-82.
Kay-Lambkin FJ, Baker AL, Lewin T, Carr VJ. Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: A randomized controlled trial of clinical efficacy. Addiction. 2009;104(3):378-388.
Tew J, Klaus J, Oslin D. The behavioral health laboratory: Building a stronger foundation for the patient-centered medical home. Fam Syst Health. 2010;28(2):130-145. 130.
National Institute for Health and Clinical Excellence. Guidance on the use of computerized cognitive behavioral therapy for anxiety and depression (Technology Appraisal 51). London: Author; 2002.
National Institute for Health and Clinical Excellence. Computerized cognitive behavior therapy for depression and anxiety: Review of technology appraisal 51 (Technology Appraisal 97). 2006; Available at http://www.nice.org.uk/nicemedia/pdf/TA097guidance.pdf. Accessibility verified August 17, 2011.
Liss HJ, Glueckauf RJ, Ecklund-Johnson EP. Research on telehealth and chronic medical conditions: Critical review, key issues, and future directions. Rehabil Psychol. 2002;47:8-30.
Cuijpers P, Marks IM, van Straten A, Cavanagh K, Gega L, Andersson G. Computer-aided psychotherapy for anxiety disorders: A meta-analytic review. Cogn Behav Ther. 2009;38:66-82.
Keogh E, Rosser BA, Eccleston C. e-health and chronic pain management: Current status and developments. Pain. 2010;151(1):18-21.
Sato AF, Clifford LM, Silverman AH, Davies W. Cognitive-behavioral interventions via telehealth: Applications to pediatric functional abdominal pain. Child Health Care. 2009;38(1):1-22.
Tuerk PW, Yoder M, Ruggiero K, Gros DF, Acierno R. A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology. J Trauma Stress. 2010;23:116-123.
Dobscha SK, Corson K, Pruitt S, Crutchfield M, Gerrity MS. Measuring depression and pain with home health monitors. Telemed e-Health. 2006;12(6):702-706.
Morasco BJ, Duckart JP, Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Intern Med. 2011;26(9):965.
Acknowledgments
MDC would like to acknowledge the support from Grant 5-P60-DA-005186-22 from the National Institute on Drug Abuse, National Institutes of Health in the writing of this manuscript.
Author information
Authors and Affiliations
Corresponding author
Additional information
Implications
Researchers: Explore the opportunity for translational and implementation research in the highly topical area of pain and opioid abuse in the primary care setting
Practitioners: Broaden knowledge on managing complex chronic pain patients employing the emerging patient-centered medical home model of care utilizing health information technology
Policymakers: Design reimbursement strategies and policies to incentivize healthcare institutions and practitioners to invest in health information technology to address the burgeoning public health crisis of opioid abuse and diversion
About this article
Cite this article
Cheatle, M.D., Klocek, J.W. & McLellan, A.T. Managing pain in high-risk patients within a patient-centered medical home. Behav. Med. Pract. Policy Res. 2, 47–56 (2012). https://doi.org/10.1007/s13142-012-0113-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13142-012-0113-z