Remove Mental Health Barriers to Fully Treat Patients With Chronic Pain

Painful chronic conditions often are accompanied by equally debilitating comorbidities such as depression, substance use disorders, and suicidal ideation. Unfortunately, there are significant barriers to accessing mental health services that need to be addressed to adequately treat these complex patients.

That was the advice from Martin Cheatle, PhD, who is director of the Pain and Chemical Dependency Program at the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia.

“There is a preponderance of evidence that depression and suicidal ideation are very common in patients with chronic pain and patients with substance use disorders, and those patients who suffer from both pain and substance use disorders are particularly vulnerable to developing a major depressive disorder and experiencing suicidal ideation and behavior,” Dr. Cheatle told PainWeek News.

He further explained that this evidence points to a need to routinely screen for depression and suicide in patients with pain.

While there has been considerable focus on the misuse and abuse of prescription opioids and the rising rate of opioid-related overdoses, both depression and suicidal ideation in patients with pain and patients with pain and substance use disorders have become “silent epidemics,” Dr. Cheatle said.

In discussing ways to identify patients who may be at risk for depression, Dr. Cheatle discussed use of the PHQ9 (9-item patient health questionnaire), which is a self-administered survey derived from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) classification system to document typical vegetative signs of depression including  anhedonia,  depressed mood, trouble sleeping, feeling tired, change in appetite, feelings of guilt or worthlessness, trouble concentrating, and feeling slowed down or restless.

A number of risk assessment tools have also been developed and validated to assess the risk of misusing or abusing prescription opiates, Dr. Cheatle said.  These include the ORT (Opioid Risk Tool), SOAPP® (Screener and Opioid Assessment for Patients with Pain®), COMM® (Current Opioid Misuse Measure®), and PDUQ (Prescription Drug Use Questionnaire).

Additionally, a number of instruments are available to assess for substance use disorders that are not specific to the pain patient population. Examples of these include the AUDIT-C (Alcohol Use Disorders Identification Test Consumption), CAGE-AID (Cut down, Annoyed, Guilty, Eye-opener Tool Adjusted to Include Drugs), and the DAST (Drug Abuse Screening Test).

But many of these tools depend upon patient self-assessment, which is always susceptible to response bias and the influence of social desirability, Dr. Cheatle warned.

He offered this pearl: “The clinician should always attempt to gather corroborating information from family members and from medical records to obtain an accurate assessment of the potential for a substance use disorder.”

He said that clinics that manage these complex patients should have a plan of action if a patient’s screening is suggestive of possible substance use disorder, severe depression, and/or suicide.

Interventions could be office based or involve referral to a local behavioral health or addiction specialist or a pain self-management program.

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