PAIN MEDICINEVolume 4 • Number 2 • 2003

CLINICAL NOTE

Treating Pain Patients at Risk: Evaluation of a Screening Tool inOpioid-Treated Pain Patients With and Without Addiction

Robert Friedman, MD, FACP,* Victor Li, MD,† and Deepak Mehrotra, MD‡

Department of †Anesthesiology and ‡Pain Medicine, *Temple University Hospital, Philadelphia, Pennsylvania

A B S T R A C T

Patients receiving opioid treatment for chronic pain, many of whom were hospitalized with medicalcomplications of substance abuse, were asked to complete a screening questionnaire to help vali-date a simple self-administered survey. Questions relating to tobacco abuse and prior treatment fordrug and alcohol abuse distinguished patients with addiction and pain from opioid-treated chronicpain patients.

Key Words. Pain; Substance Use; Opioids; Screening Tool; Addiction

© American Academy of Pain Medicine 1526-2375/03/$15.00/182 182–185

Reprint requests to: Robert Friedman, MD, FACP, Depart-ment of Anesthesiology, Cooper Hospital, 1 Cooper Plaza,Camden, NJ 08037. E-mail: DrRFriedman@aol.com

Victor Li, MD, is currently a fellow in pain medicine atthe Hospital of the University of Pennsylvania. DeepakMehrotra, MD is currently an attending anesthesiologistin pain medicine at the Albert Einstein Medical Center.Robert Friedman, MD, FACP, is currently an attendinganesthesiologist in pain medicine at UMDNJ@CooperHospital.

Introduction

A ddiction is a chronic lifelong disease, with hos-pitalizations for trauma, infections, and pain

[1]. The transition from frequent abuse of sub-stances to addiction, in which the patient is unableto control the adverse medical and legal conse-quences of substance abuse, is not understood [2].Physicians are ill prepared to evaluate substance useand abuse in pain patients [3]. Undertreatment ofpain in patients with a history of substance use maylead to addiction. On the other hand, patients witha history of addiction, when surveyed, said theywould abuse drugs to achieve adequate pain control[4]. Moreover, those patients identified their priorpain treatment as a contributing cause for theiraddiction [5]. There are growing concerns thateasier availability of controlled substances for pain

treatment may be fueling an epidemic of drug abuse[6]. The ability to identify patients at risk beforeinitiating opioid treatment might help to provideearlier treatment to addicted patients at risk forproblems with opioid therapy.

Medication compliance with opioid therapy anduse of illegal substances is an underrecognizedproblem in chronic pain patients. In a series ofpatients with chronic pain who submitted to drugscreening, 21% had concealed their use of psy-chotropic substances from their physicians [7].The relationship between compliance and possi-ble substance abuse and addiction is particularlycomplex in patients with chronic pain takingopioids. Noncompliance with opioid treatmentmay be a warning of possible active substanceabuse. In fact, while the incidence of drug addic-tion may be low as a consequence of opioidtherapy, the likelihood of substance abuse occur-ring in a population of pain patients treated withopioids may be as high as 27% [8].

Opioids have an important role in the treatmentof noncancer chronic pain [9]. While small serieshave documented successful methadone treatmentfor pain in patients with substance abuse, less isknown about the identification and managementof substance abuse as a complication of opioidtreatment [10]. Chronic pain patients who are notable to control their use of prescribed opioids may

Addiction Screening Tool in Opioid-Treated Pain Patients 183

request specific opioids for treatment. Patientswho develop substance abuse during pain treat-ment often request specific short-acting opioids.Oxycodone preparations have been identified as the “drugs of choice” for substance-abusingpatients [11]. However, the failure of a particularopioid to control a patient’s pain does not neces-sarily imply that that patient has active substanceabuse. Pseudoaddiction can occur in some chronicpain patients who are prescribed subanalgesicdoses of short-acting opioids [12]. These patientsoften demonstrate behaviors similar to those ofsubstance-abusing patients in their search for adequate pain control.

It may be more useful in the treatment of thepain patient with a history of substance abuse toidentify how the opioid is used rather than whichopioid is used [13]. The inability of a pain patientto control their use of pain medication suggestspossible reactivation of substance abuse. Patientswho are unable to comply with treatment guide-lines, who lose prescriptions, who miss appoint-ments, and whose pain complaints escalate asopioid doses are increased may be developingactive substance abuse. Random drug screeningfor the presence of prescribed and absence of othernonprescribed substances may be necessary toidentify potential problems with opioid therapy inpatients with a history of pain and substance abuse[14]. However, drug testing in an office settingrequires a number of chain-of-custody proceduresto prevent adulteration and misinterpretation ofscreening results. Opioid treatment agreements,while used to provide information for patientsabout the risks of opioid treatment, how treatmentwill be monitored, and referral for substance-abuse treatment if substance abuse occurs, may notdeter chronic pain patients with who are activelyabusing opioids [15].

Screening interviews have been useful in identifying patients with substance abuse andaddiction. When interviewed by experienced

counselors, patients with mental health problemsreported their own substance use and abuse inmore than 70% of cases [16]. Pain patients withaberrant prescription behavior also identifiedthemselves as substance abusers when interviewedby trained substance abuse counselors [17]. Innonpsychiatric settings, patients with substanceabuse/addiction may sometimes not report theirproblems with drugs. For patients with alcoholabuse, simple self-administered screening tools,like the Michigan Alcohol Screening Test(MAST), have helped primary care physiciansintervene to prevent complications associated withharmful and hazardous alcohol consumption.These tools have been validated by testing onpopulations of people convicted of “driving underthe influence” [18]. The development of simpler,more easily administered screening tools mightallow the development of a MAST-like tool toidentify pain patients at risk for substance abusebefore opioid treatment was initiated.

We evaluated questionnaires that had been usedto screen patients with possible substance abuseand used questions about mental health status,employment, family history of drug abuse, as wellas prior treatment for drug abuse in pain patients.We also used screening questions regardingtobacco abuse derived from the CAGE [19]. Ourgoal was to develop a simple self-administeredscreening tool that would identify pain patients atrisk before they received opioid treatment.

Methods

After obtaining Internal Review Board approval, ascreening tool for addiction risk (STAR) consist-ing of 14 true-or-false questions (Table 1) wasevaluated in a convenience sample of 48 chronicpain patients, 14 of whom were pain patients witha recent history of substance abuse and were hos-pitalized for treatment for chronic infectionsand/or AIDS (Table 2). These patients had more

Table 1 Temple STAR questionnaire

1. Have you felt depressed or anxious over the last 6 months? 10. Have you been to a pain clinic before?2. Have you noticed frequent mood swings over the last 6 months? 11. Have you visited an emergency room for pain treatment 3. Are you currently unemployed? in the past year?4. Do you smoke cigarettes? 12. Has anyone in your family (relatives you don’t live with) 5. Do you feel that you smoke too much? had problems with drug or alcohol abuse?6. Do you drink more than three alcohol drinks/day? 13. Has anyone in your household (partner, children) had 7. Have you used recreational drugs during the last year? problems with drug or alcohol abuse?8. Have you ever been treated in a drug or alcohol rehabilitation facility? 14. Did any family member physically or verbally abuse you 9. Do you get pain medicines from more than one doctor? when you were a child?

All questions required yes/no answers.

184 Friedman et al.

than three DSM-IV criteria for addiction.Answers from pain patients with substance abusewere then compared with answers from chronicpain patients with no history of active substanceabuse using chi-square analysis. Differences insurvey answers between the two groups of patientswere examined by multiple logistic regression andfactor analysis.

All but one patient received opioids for theirpain. This patient, with a past history of metham-phetamine addiction, refused an opioid trial forintractable facial pain. Patients with active sub-stance abuse were treated only with methadone.Chronic pain patients with addiction historieswere treated with methadone as well as other sustained-release opioid preparations. Results ofopioid treatment were examined by chart reviewfor both groups of patients at 2 months.

Results

Chi-square analysis of screening questions revealedthat questions relating to tobacco abuse, priortreatment in a drug or alcohol rehabilitation facil-ity, or treatment in another pain clinic were signifi-cantly (P < 0.05) more common in respondents whohad used or were currently using heroin or cocaine(addicts). Logistic regression showed that historyof treatment in a drug or alcohol rehabilitationfacility was a significant predictor of addiction witha positive predictive value of 93% and a negativepredictive value of 5.9%. Factor analysis revealed aclose relationship among cigarette smoking, afeeling of smoking too much, and a history of treat-ment in a drug or alcohol rehabilitation facility.

Discussion

In this preliminary evaluation of a screening tool,we found that questions related to prior treatmentof substance abuse and cigarette dependence coulddistinguish patients who had pain and substance

abuse with dependence from patients who hadpain without a substance abuse history.

Questions that related to smoking helped identify substance abusers from pain patients onchronic opioids. Our findings support other obser-vations, which showed greater polysubstanceabuse in methadone-treated patients who abusedtobacco [20]. Since substance abuse is a chronicrelapsing disease, it is not surprising that theSTAR question about prior substance abuse treatment helped to identify pain patients withsubstance abuse. We also confirmed earlier obser-vations that prior treatment for substance abuse isa risk factor for the development of opioid abusein chronic pain patients.

Psychosocial factors associated with depend-ence disorders were not different in the twogroups of pain patients. History of emotional orphysical abuse, family history of substance abuse,mood disorders, and unemployment were similarin both groups of patients we tested. We foundthat many risk factors for substance abuse did notdistinguish chronic pain patients from those withpain and substance abuse. Our patients, many ofwhom were hospitalized with complications ofintravenous drug abuse, still failed to show any differences from chronic pain patients in manypsychosocial areas associated with drug addiction.

Our sample of chronic pain patients gatheredfrom a large inner-city hospital may not be repre-sentative of other outpatient chronic pain prac-tices. It is also possible that our group of patientswith pain and substance abuse self-selected to par-ticipate in the survey. This sampling bias mightoverrepresent patients who admitted to priortreatment for drug abuse. Nevertheless, the STARquestionnaire supported observations from otherscreening studies that suggest tobacco abuse ispredictive for active substance abuse.

We took the questions that had the highest pre-dictive value for substance abuse and incorporatedthem into our pain intake questionnaire. Askingpatients about their concerns over excessivesmoking and if they had prior treatment for a sub-stance abuse disorder identified pain patients atrisk that we would have otherwise missed in ourpractice. By identifying patients at risk, appropri-ate evaluation of the status of their addictive dis-orders can be recorded as part of their pain history.

This self-administered survey tool has beenhelpful in identifying chronic pain patients at riskfor subsequent problems with opioid treatment.We hope that further interest in this area willeventually lead to better self-administered screen-

Table 2 Patient characteristics

Substance No Substance Abuse Abuse

Total number 14 34Age range, years (mean) 27–78 (53) 34–67 (45)Opioid treatment 11 15Treatment failures 6 0Prescription problems 2 0Left pain center 8 5

Addiction Screening Tool in Opioid-Treated Pain Patients 185

ing tools to detect the potential for active sub-stance abuse in patients with chronic pain.

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