A TREATMENT IMPROVEMENT PROTOCOL Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders TIP 54 A TREATMENT IMPROVEMENT PROTOCOL Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders TIP 54 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments This publication was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., under contract numbers 270-04-7049 and 270-09-0307, with SAMHSA, U.S. Department of Health and Human Services (HHS). Christina Currier served as the Government Project Officer. Disclaimer The views, opinions, and content of this publication are those of the authors and do not neces­ sarily reflect the views, opinions, or policies of SAMHSA or HHS. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be ordered from SAMHSA’s Publications Ordering Web page at http://www.store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). The document can be downloaded from the KAP Web site at http://www.kap.samhsa.gov. Recommended Citation Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. Originating Office Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. HHS Publication No. (SMA) 12-4671 Printed 2012 ii Contents Consensus Panel ............................................................ vii What Is a TIP? ..............................................................ix TIP Format .................................................................ix TIP Development Process . ix Foreword ...................................................................xi 1—Introduction ............................................................. 1 Chronic Pain Impact .......................................................... 1 Audience.................................................................... 2 Purpose..................................................................... 2 Definitions ................................................................. 2 Pain and Addiction Basics ...................................................... 4 Neurobiology of Pain .......................................................... 4 Chronic Pain ................................................................ 6 Pain’s Effect on Health ........................................................ 7 Neurobiology of Addiction ..................................................... 7 Risk Factors for Addiction ..................................................... 8 Cross-Addiction.............................................................. 9 The Cycle of Chronic Pain and Addiction ......................................... 9 Summary of TIP ............................................................ 11 Key Points ................................................................. 11 2—Patient Assessment ....................................................... 13 Elements of Assessment....................................................... 13 Assessment Tools ............................................................ 13 Assessing Pain and Function ................................................... 15 Screening for Substance Use Disorders ........................................... 20 Referring for Further Assessment ............................................... 23 Psychiatric Comorbidities ..................................................... 24 Assessing Ability To Cope With Chronic Pain .................................... 27 Evaluating Risk of Developing Problematic Opioid Use ............................. 28 Ongoing Assessment ......................................................... 30 Treatment Setting ........................................................... 31 Key Points ................................................................. 32 iii 3—Chronic Pain Management ................................................ 33 Overview of Pain Management ................................................ 33 The Treatment Team ......................................................... 33 Treating Patients in Recovery .................................................. 35 Nonpharmacological Treatments ................................................ 37 Treating Psychiatric Comorbidities .............................................. 39 Opioid Therapy ............................................................. 40 Treating Patients in Medication-Assisted Recovery ................................. 43 Tolerance and Hyperalgesia ................................................... 44 Treating Pain in Patients Who Have Active Addiction............................... 45 Acute Pain Episodes.......................................................... 46 Assessing Treatment Outcomes ................................................. 46 Key Points ................................................................. 48 4—Managing Addiction Risk in Patients Treated With Opioids ..................... 49 Promoting Adherence ........................................................ 49 Urine Drug Testing .......................................................... 51 Inclusion of Family, Friends, and Others ......................................... 54 Nonadherence .............................................................. 54 Tools To Assess Aberrant Drug-Related Behaviors.................................. 56 Documenting Care........................................................... 58 Managing Difficult Conversations............................................... 59 Workplace Safety ............................................................ 59 Discontinuation of Opioid Therapy ............................................. 61 Key Points ................................................................. 63 5—Patient Education and Treatment Agreements................................. 65 The Value of Patient Education................................................. 65 Providing Effective Education .................................................. 66 The Internet as a Source of Patient Education ..................................... 68 Education Content........................................................... 69 Opioid Information .......................................................... 69 Methadone Maintenance Therapy Information..................................... 71 Treatment Agreements ....................................................... 71 Key Points ................................................................. 74 iv Contents Appendix A—Bibliography .................................................... 75 Appendix B—Assessment Tools and Resources .................................... 87 Appendix C—CFR Sample Consent Form and List of Personal Identifiers .............. 91 Appendix D—Resources for Finding Complementary and Alternative Therapy Practitioners. 93 Appendix E—Field Reviewers.................................................. 95 Appendix F—Acknowledgments ................................................ 97 Index...................................................................... 99 Exhibits Exhibit 1-1 Statistics on Substance Use and Chronic Pain in the United States ............ 1 Exhibit 1-2 The Pain Pathways .................................................. 5 Exhibit 1-3 Pain Types......................................................... 6 Exhibit 2-1 Elements of a Comprehensive Patient Assessment ........................ 14 Exhibit 2-2 Tools To Assess Pain Level........................................... 17 Exhibit 2-3 Tools To Assess Several Dimensions of Pain ............................. 18 Exhibit 2-4 Tools To Assess Pain Interference With Life Activities and Functional Capacities........................................... 19 Exhibit 2-5 Items To Include in Substance Use Assessment........................... 20 Exhibit 2-6 DSM-IV-TR Criteria for Substance Abuse and Substance Dependence ................................................. 21 Exhibit 2-7 Steps Following Substance Abuse Assessment............................ 22 Exhibit 2-8 Tools To Screen for Substance Use Disorders ............................ 22 Exhibit 2-9 Elements of Screening, Brief Intervention, and Referral to Treatment ......... 23 Exhibit 2-10 Federal Protection of Patient Health Information ........................ 24 Exhibit 2-11 Tools To Assess Emotional Distress, Anxiety, Pain-Related Fear, and Depression............................................ 26 Exhibit