Managing patients with chronic pain without initiating or exacerbating substance use disorders is a significant challenge in healthcare. The latest criteria for all substance use disorders can be found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.1 A study of 705 adult patients receiving care in a health network in Northeastern Pennsylvania (who were prescribed opioid medications for nonmalignant pain four or more times in a 12-month period) found the lifetime prevalence of opioid use disorders to be 35%.2 Furthermore, overdose deaths quadrupled between 1999 and 2015.3
Despite the fact that a family history of substance use disorder is an established risk factor for personal problems with substance use, a survey conducted by the Hazelden Betty Ford Foundation found that 46% of those (N = 1,028) who were prescribed pain medications in the previous year reported that prescribers did not ask about their personal or family substance use history.4,5
Often, individuals with chronic pain and substance use problems believe that only severe cases of addiction need to be addressed. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, comprehensive, integrated approach for providing intervention and services to individuals with, or at risk for developing, substance use disorders. SBIRT is designed to be used in healthcare, including trauma centers and inpatient or outpatient care settings to identify individuals with substance use issues. Effective use of SBIRT has demonstrated considerable benefit to individuals and has led to healthcare cost reductions.6
The purpose of this article is to describe the use of family history of substance use disorder as a component of comprehensive care in evaluating and managing a patient with chronic pain. This case-based approach will highlight important considerations, describe the use of SBIRT in a chronic pain rehabilitation program, and discuss the process of NPs providing evaluation, education, discussion, and support focused on family history risk.
Case example information
Mr. K, a 30-year-old male, presents for admission to a 3-week interdisciplinary pain rehabilitation program. He reports he has had persistent chronic pain on the right side of his neck, shoulder, and upper back since age 24 following a motor vehicle accident. He rates his pain intensity on a scale of 0 to 10 (with 10 being the worst pain imaginable) at 4 (least severe) after taking opioid medication to the worst 10 (almost unbearable)without medication. His medical diagnoses are congenital lobar emphysema (which is a rare respiratory disorder causing hyperinflation of the lobes of the lungs) and recurrent bouts of pneumonia. A right upper pulmonary lobectomy was performed 2 years earlier and did not reduce his chronic pain.
Prior pain management treatments included spinal and trigger point injections, numerous pain medication trials, physical therapy, biofeedback, heat, ice, and herbal and mineral supplements. Pulmonary experts determined that there were no further medical interventions to relieve Mr. K's chronic pain and a pain rehabilitation program would be his best course of action. On admission to the pain rehabilitation program, Mr. K stated he had been prescribed hydromorphone for the past 4 years with a current 4 mg oral dose every 6 hours as needed, gabapentin 2,100 mg per day in divided doses, lidocaine patch 5% topically once per week (both gabapentin and the lidocaine patch are FDA off-label for chronic pain), and albuterol sulfate inhalation aerosol 108 mcg/actuation 2 puffs via inhalation once daily as needed.
In addition, Mr. K has a complex mental health history, including major depression, generalized anxiety disorder, posttraumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD), and polysubstance use including cannabis (about one joint daily to help with pain relief and stress management in addition to consuming four to five alcoholic drinks most Fridays and Saturdays with roommates). He reports that his mother was a “severe alcoholic” who was emotionally, verbally, and physically abusive, leading to his diagnosis of PTSD. Following his father's suicide when Mr. K was 15 years of age, he was hospitalized on a psychiatric unit.
Mr. K subsequently received mental health counseling and therapy a number of times over the years, but he is not currently meeting with any psychiatric provider. He denies thoughts or plans related to suicide. Psychiatric medications prescribed by his primary care provider include lorazepam 0.5 mg at bedtime as needed, which he takes most nights, and amphetamine salt combination 30 mg daily for ADHD.
He is single, never married, and does not have any children. He lives in a house with two roommates. Mr. K is not close to any family members except for his paternal grandmother. He states that his “foster family,” who unofficially provided shelter and supported him off and on over the years, is still supportive of him, although he has not maintained steady contact with them. Mr. K worked hard to attain a bachelor's degree with the hope of becoming a teacher but is currently working full time in customer service for a telephone company, which he finds stressful and unfulfilling.
Mr. K's goals for the pain rehabilitation program are to taper off of opioid medication and learn behavioral skills to manage his chronic pain, increase his ability to physically function, and gain a much better quality of life. On admission, he stated his future looked “bleak” if he is unable to make changes in his life.
Comprehensive pain rehabilitation program
The pain rehabilitation program is a comprehensive, interdisciplinary, 3-week outpatient program with the primary goal of increasing overall functional ability for a quality lifestyle. The 5-day (Monday through Friday) 8-hour program includes physical and occupational therapy and participation in educational groups focused on cognitive behavioral therapy (CBT), elimination of pain behaviors, relaxation and stress management; management of depressive and anxiety symptoms, strategies for enhancing quality sleep, moderation and modification of daily activities, use of appropriate nonaddictive medications for pain management, and reducing risks for problematic substance use. RN care managers and advanced practice registered nurses (APRNs) are integral members of the interdisciplinary treatment team.
Although Mr. K was skeptical about tapering off of opioid medication and replacing this with behavioral strategies, he was willing to try this approach, as he felt like the pain rehabilitation program was his “last hope” for a better life. He was gradually tapered off of hydromorphone over a 10-day period and experienced minimal opioid withdrawal symptoms. His topical analgesic was also discontinued, as he stated it did not seem to be helpful.
Mr. K continued taking 2,100 mg of gabapentin daily even though this medication has some potential for abuse but has less negative long-term effects and better evidence for managing chronic pain.7 Additionally, lorazepam and amphetamine salt combination were discontinued, as he became proficient with CBT, mindful relaxation techniques, and sleep enhancement. Mr. K participated in all program activities and gained a sense of hope as he increased his physical strength and endurance as well as positive coping strategies to manage his chronic pain condition. Mr. K's positive experience is similar to most of the pain rehabilitation program participants.8
As per the program's admission process, Mr. K was asked by his RN care manager, “In your opinion, have you had family members who had problems with alcohol, drugs, or prescription medication that caused health, relationship, job, or legal issues?” He reported that his mother had severe alcohol use disorder and was abusive and that his only sibling (sister) had a lot of problems with alcohol, marijuana, and prescription medications. Mr. K stated that his maternal grandmother and an aunt and uncle, as well as his paternal grandfather, had problems with alcohol.
According to the program's established criteria of two first-degree family members (or one first-degree and at least two second-degree family members with substance use concerns), Mr. K had a high-risk family history and was referred to a program that provides additional focus on substance use risk reduction.9 Individuals are referred to this track based on family history risk as well as personal substance use risk factors, and Mr. K had both.
Mr. K did not think his family history of substance use and his own personal use of prescribed opioids, benzodiazepines, stimulants, daily use of cannabis, and weekend use of alcohol were problematic. He justified this belief by stating that he did not drink alcohol to the point of intoxication like his mother and that he was employed. As part of the pain rehabilitation program, Mr. K attended groups led by APRNs on substance use risk reduction and shared that he was surprised that the heritability estimates for nicotine, alcohol, and drug dependence are 50% to 60%; family pedigrees shared and diagrammed in the groups really made him think about his genetic risks (see Targeted family pedigree for substance use disorders).10
Stigma related to substance use disorders is reduced by understanding that everyone has genetic risks for a number of medical problems, and for some individuals, that is substance use. Mr. K was intrigued by education and discussion on brain functioning and how some individual's brains have a number of inherited variations of genes in the dopamine reward system that can increase their risk for substance use disorders.11 In addition, exposure to any substances, even prescribed opioid medications, can increase risk for ongoing substance use problems.12
APRNs are vigilant about keeping substance use risk reduction groups confidential, nonjudgmental, supportive, and positive. Powerful participant life stories are shared during groups to personally illustrate genetic and environmental risk factors and how individual resilience and behavioral changes can support reducing risks for problems with substance use. Mr. K shared his life story in group and stated it was enlightening and helpful for him to understand how his family history of substance use disorders and the traumatic events of his childhood and life had impacted him.
Participants with chronic pain agree on admission to the pain rehabilitation program to abstain from using any mood-altering substances during the 3 weeks of intensive programming. For Mr. K, an admission urine drug abuse survey (DAS) confirmed the presence of hydromorphone and lorazepam, which were prescribed; tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, which he reported smoking almost daily, was also confirmed. A follow-up DAS obtained at the beginning of the program's third week was negative for opioids and lorazepam but positive for THC at a level higher than on admission. This was an unexpected finding and indicated a risk of an ongoing problem with substance use.
An APRN was able to use motivational interviewing, focusing on Mr. K's high-risk family history of substance use disorders and his own personal use, including the use of cannabis during the program. Having information on multiple risk factors, including family history, helped make a more compelling case for behavior change. Mr. K was initially resistant to focused attention on his substance use but gradually acknowledged that he was at high risk for ongoing problems.
Mr. K was referred for a substance use disorder evaluation, which resulted in a recommendation for enrollment and participation in an intensive residential addiction program. He subsequently completed the program and was open to recommendations for follow-up care and community support groups to maintain sobriety.
Importance of family history
Milne and colleagues studied the predictive value of family history information on severity of illnesses with data collected at numerous points in time from 981 subjects in New Zealand between ages 11 and 32.13 The research focused on individuals with a diagnosis of depression, anxiety disorder, alcohol dependence, or drug dependence and concluded that a positive family history was associated with the presence of the disorder, a recurrent course of illness, worse impairment, and greater use of healthcare services. Study findings indicated that highlighting the importance of a high-risk family history and providing supportive, nonjudgmental interventions underpins improved overall outcomes.13 This study also supports taking a shared family environment into consideration.
Many individuals with chronic pain are unable to participate in extensive rehabilitative programs. Some individuals with risk factors for substance use disorders, including family history of substance use disorders, will benefit from an increased awareness of these risks and can make behavioral changes with brief motivational interventions. The SBIRT approach for early substance use disorder identification and appropriate intervention is endorsed by the Office of National Drug Control Policy.6 SBIRT screening can quickly assess risk factors, including problematic personal use of substances and family history of substance use disorders by using questions similar to the ones used in this case report.
Brief intervention focuses on increasing awareness of a problem or potential problem by nonjudgmentally summarizing problematic personal use of substances and/or family history risks; this is followed by providing educational interventions, such as the supportive and informative publications available at the Substance Abuse and Mental Health Services Administration (SAMHSA) website (www.samhsa.gov). Motivational interviewing can help to facilitate referral to appropriate evaluation and treatment for those who need more extensive interventions.6 Information regarding treatment locations, admission criteria, and cost is also available at the SAMHSA website.
Bernstein and colleagues found evidence that using even brief interventions that raise awareness of problems supported abstinence from heroin and cocaine use at a 6-month follow-up interview without specialty addiction treatment.14 Shetty and colleagues concluded that personalized, motivational intervention for patients with facial injuries reduced existing substance use behaviors.15
Mr. K came to the pain rehabilitation program with persistent chronic pain for the past 6 years, and the intensity had gradually increased. He also had a complex mental health history, including multiple psychiatric diagnoses and problematic polysubstance use. He reported a high-risk family history for substance use disorders and daily use of an opioid, benzodiazepine, and cannabis. His goals for the pain rehabilitation program were to taper off of opioid and benzodiazepine medications and to learn behavioral skills to increase his ability to physically function and gain a better quality of life.
After successful discontinuation of targeted medications and participation in all program activities, Mr. K had positive improvements in his physical functioning, endurance, and cognitive coping skills. However, a DAS near the end of the program revealed an increase in his THC level, which was incompatible with the program expectation of no mood altering substance use. Motivational interviewing focused on his high-risk family history of substance abuse, his past and present personal use, and the need for additional support to maintain a healthy, substance-free lifestyle.
Mr. K was initially resistant to attention focused on his substance use and offered excuses, but he gradually gained awareness of the need for evaluation for substance use disorder treatment. Mr. K was referred for evaluation and subsequently completed an intensive residential addiction program. He completed the program and was open to recommendations for follow-up care and community support groups. Comprehensive evaluation and treatment related to chronic pain and substance use gave Mr. K the best chance for long-term, successful management of his chronic conditions.
Implications for practice
Using family history of substance use disorder as part of a chronic pain assessment may provide important data for multimodal treatments. A recent study of individuals with chronic pain by Pestka and colleagues found that response to just one question related to family history of substance use indicating high risk is associated with other substance use risk factors, including a higher depression screening score, higher pain catastrophizing screening score, and more frequently reported past and current use of substances.16
Efforts to identify patients with chronic pain at high risk of poor outcomes, including risk for a substance use disorder, can offer an opportunity for brief motivational interviewing and a means to direct patients who may benefit from further interventions to appropriate risk reduction or treatment resources.
Given the current opioid crisis, it is imperative that APRNs embrace strategies to help reduce opioid use disorder and only prescribe these medications appropriately for short-term use. The CDC has established guidelines for prescribing opioid medications (www.cdc.gov/drugoverdose/prescribing/guideline.html). When providing care for a patient who has been exposed to opioid medications for an extended period of time, it is important to consider motivational interviewing to guide them in the direction of comprehensive pain rehabilitation centers or other supportive resources.
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