Monitoring outcomes during long-term opioid therapy for noncancer pain: results with the Pain Assessment and Documentation Tool.

The increasingly common practice of long-term opioid therapy for chronic noncancer pain must be guided by ongoing assessment of four types of outcomes: pain relief, function, side effects, and drug-related behaviors. Our objective was to gather initial pilot data on the clinical application of a specialized chart note, the Pain Assessment and Documentation Tool (PADT), which was developed and tested with 27 physicians. This pilot test provided the means to collect cross-sectional outcome data on a large sample of opioid-treated chronic pain patients. Each of the physician volunteers (located in a variety of settings across the United States) completed the PADT for a convenience sample of personally treated chronic pain patients who had received at least three months of opioid therapy. Completion of the PADT required a clinical interview, review of the medical chart, and direct clinical observation. Data from the PADTs were collated and analyzed. The results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all four relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality was generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common but viewed as an indicator of a problem (i.e., addiction or diversion) in only approximately 10 percent of cases. Using the PADT physician ratings can be developed in four domains. In this sample, outcomes suggested that opioid therapy provided meaningful analgesia.

A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy.

BACKGROUND: Opioid analgesics are the cornerstone of management for malignant pain. Their use in managing chronic, nonmalignant pain, albeit controversial, has increased in recent years. The decisions about whether to initiate opioid therapy or continue it over time should be guided by a comprehensive patient assessment. During long-term treatment, this assessment should focus on a broad range of outcomes, each of which should be documented in the medical record. OBJECTIVE: The goal of this study was to develop an instrument, the Pain Assessment and Documentation Tool (PADT), to focus on key outcomes and provide a consistent way to document progress in pain management therapy over time. METHODS: Items that assess 4 domains (pain relief, patient functioning, adverse events, and drug-related behaviors) were generated with input from a MEDLINE literature search and experts in pain and addiction management. The original tool was field tested by clinicians who applied it to the assessment of patients receiving long-term opioid therapy for the management of chronic, nonmalignant pain. Data analysis and debriefing telephone interviews with a formalized set of questions were then used to rephrase, delete, and refine items to create the final tool. RESULTS: A 6-member expert panel contributed to the initial development of the PADT. Twenty-seven clinicians completed the preliminary version of PADT for 388 patients. The original 59-item tool was modified to create a 41-item tool. The revised PADT was formatted for use as a chart note designed to assist clinicians in assessing and documenting 4 main outcome domains during long-term opioid use. CONCLUSIONS: In this study, the PADT appeared to be a useful tool for clinicians to guide the evaluation of several important outcomes during opioid therapy and provide a simple means of documenting patient care.

An unsuccessful attempt to develop a single-item screen for insomnia in cancer patients.

The focus of this pilot study was to examine issues of criterion validity and detection of insomnia utilizing a single item from the Zung Self-Rating Depression Scale (ZSDS) as a means to rapidly screen cancer patients in ambulatory oncology clinics. In our previous work, we have demonstrated the usefulness of other single items for screening purposes, such as for fatigue. The sleep item reads "I have trouble sleeping through the night" and is rated on a 4-point Likert scale ranging from "none or little of the time" to "most or all of the time." Fifty-two oncology patients were administered the ZSDS and further evaluated with the Pittsburgh Sleep Quality Index (PSQI). The sensitivity and specificity of various cutoffs on the ZSDS sleep item were investigated as predictors of the PSQI. Results revealed that the ZSDS single-item screen has poor sensitivity and specificity for detecting insomnia in cancer patients, and that the relationship between insomnia and depression is more complicated than anticipated. The use of this single item, or perhaps any single item, as a means of screening for sleep disturbances in cancer patients may be problematic. A better understanding of insomnia and its measurement are worthwhile areas of study.

Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study.

The assessment of addiction-related outcomes is crucial to the management of chronic pain with opioid drugs in all patients. Pain management for patients who have concomitant drug abuse or addiction issues is a particularly complex task involving a need for a common nomenclature as well as empirically derived data to support management strategies during treatment regimens. Complicating the issue is the notion of pseudoaddiction, which is an abuse of medications driven by unrelieved pain that appears on the surface to be very similar to the behavior patterns of addicts. For proper adherence to medical therapy and safety during treatment, it is necessary to address and manage substance abuse-related behaviors. Aberrant drug-taking behavior presents many threats to the integrity of pain treatment. Unfortunately, the current state of the art still has a long way to go before clear guidelines for treatment and management can emerge. What is ultimately needed is a broad-based spectrum of research that highlights the epidemiology of drug-taking behaviors for different medical illnesses ranging from cancer to back pain. This article focuses on some of these issues as well as recounting attempts by our research group to address these issues systematically in hopes of shedding light on the nature of abuse issues in the medically ill. Although advances have been made, there is a definite need for large-scale studies that address the issues of identification and treatment of aberrant behavior in medically ill patients in the effort to provide the best possible outcomes for patients with chronic pain.

A pilot study of oncology staff perceptions of palliative care and psycho-oncology services in rural and community settings in Indiana.

Although there has been an increased interest in health care delivery for rural community populations, concerns remain regarding the lack of access to primary health care and specialty services (such as palliative care), particularly in rural areas that are medically underserved (MU). This survey was conducted to examine the perceptions of palliative care services in rural communities and toward identifying perceived barriers that interfere with accessing palliative care services. In conducting the study, personnel from various disciplines throughout the Community Cancer Care (CCC) network (the largest private provider of oncology services in Indiana) completed a survey that assessed their perceptions of the strengths and weaknesses of the available palliative care services in their communities. These responses, which indicate discrepancies in perceptions among staff within sites, suggest problems of integration of palliative care in given locations. Results revealed three particularly problematic areas: accessing pain control, accessing psychological or psychiatric services or both, and overcoming barriers to hospice care. Although no significant differences were found for any variables between MU and adequately medically served (AMS) areas, in general palliative care is limited and unintegrated into oncology care. Confusion among staff at a particular oncology program likely contributes to the haphazard delivery and poor integration of palliative care. Conclusions are tempered by important study limitations but the results suggest the need for programs that improve delivery of palliative care in rural Indiana.

Substance abuse issues in cancer pain.

It is estimated that 40% to 50% of patients with metastatic disease and 90% of patients with terminal cancer experience unrelieved pain. Furthermore, inadequate treatment of cancer pain is a greater possibility if the patient is a substance abuser. In this paper, we will explore pertinent conceptual and clinical aspects of addiction that can assist in improving the identification and treatment of patients with substance use disorders.

Pain clinicians' rankings of aberrant drug-taking behaviors.

A pilot study was conducted to examine experienced pain physicians' perceptions of aberrant drug taking behaviors. One hundred pain physicians attending a meeting on pain management were asked to rank order (from most aberrant = 1 to least aberrant = 13) a list of aberrant drug-taking behaviors. The sample was comprised mainly of anesthesiologists (50%) and half of the group had 10 or more years of pain management experience. The group prescribed an average of 19-96 opioid medications per week. Practice variables were not related to the rank ordering of the behaviors. All of the various behaviors appeared in all 13 of the rank ordering slots, suggesting a great deal of individual difference in the perception of these behaviors. By examining the average ranking of the behaviors, we noted that physicians' focus on illegal behaviors as the most aberrant followed by the alteration of route of delivery and self-escalation of dose. This survey suggests that an experienced group of pain clinicians does not view aberrant drug related behaviors uniformly. Average rankings suggest clinicians seem to view illegal behavior as the most worrisome. These results must be interpreted with caution due to the small convenience sample, the lack of data on the level of addiction medicine training of the respondents and the lack of data on those physicians who chose not to respond. Further inquiry could be used to guide clinicians' responses to aberrant behaviors when encountered in patients on controlled substances for pain.