Who requires opiates?

Participants used the BWH PainApp each day to score their moods, the intensity of their pain, whether it interfered with activities or sleep, and whether their situations had improved, grown worse, or kept the same over the previous 24 hours in a study conducted by Jamison and colleagues (Journal of Pain, Vol. 20, No. 3, 2019). That last question is a great method to figure out what you're looking for.

People who are constantly worried about what might happen, according to Jamison. "Despite any attempts to aid them, these folks don't do well," he says. However, thanks to the app's two-way messaging feature, psychologists or other pain management specialists can intervene with relaxation exercises, cognitive-behavioral therapy, or other methods.

While the BWH PainApp is an example of a novel tool developed by psychologists to assess the risk of opioid usage, psychologists are also repurposing traditional tests to combat the opioid pandemic. The Millon Behavioral Medicine Diagnostic (MBMD) and the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) are two tests that can be used to determine whether patients are psychologically prepared for potentially painful treatments like spinal or bariatric surgery. Furthermore, Pearson's Battery for Health Improvement 2 (BHI-2) can detect elements that may obstruct pain rehabilitation.

"For example, depression can have a significant impact on someone's recovery," says Paul Williams, PsyD, a health-care solutions analyst at Pearson Clinical Assessment. "If you're already depressed and go through a procedure and end up even more unhappy because you're in pain, the signs of depression—pessimism, loss of interest and drive, poor energy, low appetite—aren't conducive to rehabilitation." Anxiety, a tendency to avoid difficulties, sedentariness that may inhibit physical treatment, and a lack of social support are among the other concerns that may require presurgical intervention by a psychologist, he adds.

The Screener and Opioid Assessment for Patients in Pain (SOAPP)—and its updated version, the SOAPP-R—assists physicians and psychologists in determining if opioid medication is suitable. The assessment, which was created by psychologist Stephen Butler, PhD, Jamison, and colleagues, assesses patients' mood-related traits such as mood swings, tension in the home, and boredom, as well as past behaviors that could indicate opioid misuse, such as running out of medications early or having had previous legal problems or arrests. The Current Opioid Misuse Measure (COMM) is a sister survey that analyzes risky behaviors during the previous month, such as how often the patient battled to manage his or her anger.

The SOAPP and the COMM, as well as a patient's personal and family history of mental health disorders, can be used by psychologists and physicians to evaluate whether it is safe to give opioids. According to Butler, who is now a consultant for Inflexxion, an integrated behavioral health company that offers free, web-based versions of the SOAPP and the COMM as part of a clinical evaluation system for pain patients, these tools also help ensure that objective assessment data rather than physicians' own biases drive decision-making when it comes to treating patients in pain and deciding when, to whom, and how to prescribe opioids. (For more information, go to www.paincas.com/Account/RegisterFreeOrg.)

According to pain specialist Beverly E. Thorn, PhD, ABPP, a professor emerita of psychology at the University of Alabama, clinicians typically "push down" patients' self-reported pain if they've had it for a long time or are members of particular groups. "For African Americans, the presumption is that they will misuse pharmaceuticals or sell their medications," adds Thorn. "The gender bias is that women are more hypochondriacs and complainers than men. 'You won't be able to buy these meds, so I'm not going to prescribe them for you,' people have told my Hispanic patients."

Jamison's Opioid Compliance Checklist can assist doctors assess their patients' adherence to their prescribed opioid regimens and identify patients who may be misusing opioids or who are at risk of misusing them in the future once they have been prescribed opioids (Journal of Pain, Vol. 17, No. 4, 2016). Patients are asked if they have misplaced their prescription, missed medical appointments, or utilized illegal narcotics, among other things.

Other screening methods, such as the Substance Abuse Subtle Screening Inventory (SASSI-4), focus on patients who have already established difficulties with opioid usage. It can even identify clients who are unable or reluctant to admit that they have a problem. Furthermore, Pearson's Quality of Life Inventory (QOLI) can assist physicians and patients in tracking development in areas such as health, self-esteem, relationships, and overall well-being. "It's on the positive psychology side; it's not looking for deficits like pain or sorrow," Williams explains. "It's incredibly inspiring."

Unfortunately, according to Butler, many physicians do not use any exams. "We've discovered it may be incredibly difficult to get doctors and their nurses to use these assessments," he says, whether the issue is clinicians' reliance on their own instincts or a reluctance to modify work patterns. Butler and other psychologists are striving to shorten and computerize exams to assist overcome this problem. For example, a new version of the SOAPP produced by Butler, Jamison, and other researchers decreases the number of questions from 24 to just eight while maintaining its usefulness (Pain Medicine, Vol. 19, No. 10, 2018).

However, according to psychologists, there are still significant gaps in the study on pain assessment. There's no way to tell the difference between someone whose suffering is legitimately untreated and someone who simply wants pills. Another unsolved problem is determining how to assess chronic pain outcomes. "Almost by definition, chronic pain isn't supposed to get better, so what constitutes a successful outcome?" Butler wonders.