improving opioid prescription practices and reducing patient risk in the primary care setting

Abstract: Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting

Mental defeat and suicidality in chronic pain : a prospective analysis

Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n=371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between ‘low’ and ‘high’ suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention

Prevalence of Suicidal Ideation in Patients with Chronic Non-Cancer Pain Referred to a Behaviorally Based Pain Program

Background: Patients with chronic pain often experience co-occurring depression and in some cases suicidal ideation. It is critical to discover risk factors for suicide in this vulnerable patient population. Objective: To assess the prevalence of suicidal ideation and identify potential risk factors in patients with chronic non-cancer pain. Study Design: Retrospective chart review. Setting: Four hundred and sixty-six patients with chronic non-cancer pain referred to a behaviorally based pain program in a community health system. Methods: Data collected included pain intensity and level of pain interference (Brief Pain Inventory), pain duration, pain site, depression level (Beck Depression Inventory Fast Screen for Medical Patients), anxiety (Beck Anxiety Inventory), personal and family psychiatric and substance use disorder history, level of isolation, and demographic data. Univariate and logistic regression analyses were performed. Results: Results showed a high rate of suicidal ideation in this patient population (28%). Univariate analyses stratified by level of suicide (no suicidal ideation or passive/active suicidal ideation) revealed statistically significant group differences on pain location (extremity P = 0.046, generalized P = 0.047), work disruption (P = 0.049), social withdrawal (P &lt; 0.001), pre-pain history of depression (P &lt; 0.001), family history of depression (P &lt; 0.001), and history of sexual/physical abuse (P &lt; 0.001). Logistic regression revealed that history of sexual/physical abuse (Beta = 0.825; P = 0.020; OR = 2.657 [95% CI = 1.447 – 4.877]), family history of depression (Beta = 0.471; P = 0.006; OR = 1.985 [95% CI = 1.234 – 3.070]), and being socially withdrawn (Beta = 0.482; P &lt; 0.001; OR = 2.226 [95% CI = 1.431 – 3.505]) were predictive of suicidal ideation. Limitations: Measure of depression was not included in data analysis to reduce effect of colinearity. Also the study population was a specialty pain clinic allowing for possible subject selection bias. Conclusions: Results of this study are consistent with the prevailing literature on pain and suicide demonstrating a high prevalence of suicidal ideation in the chronic pain population. Novel predictive variables were also identified that will provide the basis for developing a risk stratification model that can be further tested prospectively in chronic pain patients. Key words: Chronic pain, suicide, depression</jats:p