Review Article
Adherence Monitoring with Chronic Opioid Therapy for Persistent Pain: A Biopsychosocial-Spiritual Approach to Mitigate Risk

https://doi.org/10.1016/j.pmn.2012.08.008Get rights and content

Abstract

Opioids represent a mainstay in the pharmacologic management of persistent pain. Although these drugs are intended to support improved comfort and function, the inherent risk of abuse or addiction must be considered in the delivery of care. The experience of living with persistent pain often includes depression, fear, loss, and anxiety, leading to feelings of hopelessness, helplessness, and spiritual crisis. Collectively, these factors represent an increased risk for all patients, particularly those with a history of substance abuse or addiction. This companion article to the American Society for Pain Management Nursing “Position Statement on Pain Management in Patients with Substance Use Disorders” (2012) focuses on the intersection of persistent pain, substance use disorder (SUD), and chronic opioid therapy and the clinical implications of monitoring adherence with safe use of opioids for those with persistent pain. This paper presents an approach to the comprehensive assessment of persons with persistent pain when receiving opioid therapy by presenting an expansion of the biopsychosocial model to include spiritual factors associated with pain and SUD, thus formulating a biopsychosocial-spiritual approach to mitigate risk. Key principles are provided for adherence monitoring using the biopsychosocial-spiritual assessment model developed by the authors as a means of promoting sensitive and respectful care.

Section snippets

Persistent Pain Requires a Comprehensive Approach

According to the American Academy of Pain Medicine (2012), at least 100 million Americans suffer from persistent pain, which is more than the number affected by diabetes, heart disease, and cancer combined. Undertreatment or mismanagement of pain can cause delays in healing as well as changes to the central nervous system (Cheatle & O’Brien, 2011). This problem is exacerbated by a lack of consideration of the complex biologic interplay with psychologic, social, and spiritual issues involved

SUD and Persistent Pain

Preliminary research of SUD in persistent pain patients has cited a wide range of prevalence from 0%–50%, depending how a SUD is defined (Hojsted & Sjogren, 2007). However, most authorities believe the rate of SUD in persistent pain patients is relatively low if the patient has no significant risk factors for SUD and if opioid treatment is conducted using adherence monitoring strategies (Cheatle & O’Brien, 2011; Gallagher & Rosenthal, 2008; Gourlay, Heit, & Almahrezi, 2005). It is important to

The Biopsychosocial Approach

The biopsychosocial model has been internationally accepted as the model for pain management (Fillingim, 2009; Jacobson & Mariano, 2001; Melzack & Wall, 1996). There are three overlapping components of the biopsychosocial model that have been well studied, and these are physical pain, psychologic pain, and social/cultural pain (Altilio & Otis-Green, 2011; Grinstead, 2007; Keefe, Rumble, Scipio, Giordano, & Perri, 2004; Merskey & Bogduk, 1994; Merskey & Spear, 1967; Turk & Melzack, 2011).

Incorporating Risk Stratification into the Biopsychosocial-Spiritual Model

Risk stratification is designed to assess a person's risk for misusing or abusing opioid medications, or for developing or relapsing into addiction. Evaluating risk requires the clinician to assess two main areas: behavior related to pain and opioid use, and mental health.

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    Acknowledgement of the grant: Portions of this work were prepared by Barbara St. Marie during a postdoctoral traineeship on an NIH T32 in Pain and Associated Symptoms (NR011147).

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