Guide to Aberrant Drug-Related Behavior When Prescribing Opioids

for Pain Management

Lynn R. Webster, MD

Vice President of Scientific Affairs

PRA International

Salt Lake City, UT

March 12, 2015

Accreditation

• The American Academy of Pain Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

• Credit Designation: The American Academy of Pain Medicine designates this live webinar for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Dr Webster: Disclosures

• 12-Month disclosures of financial relationships with commercial interests:

• This presentation does not contain off-label or investigational use of drugs or products

Honorarium: Consultant Honorarium: Advisory Board Travel Expenses

Acura Pharmaceuticals Depomed Acura Pharmaceuticals

AstraZeneca Egalet AstraZeneca

BioDelivery Sciences International Inspirion Pharmaceuticals BioDelivery Sciences International

CVS Caremark Insys Therapeutics Bristol-Myers Squib (BMS)

Grunenthal USA Kaleo Depomed

Mallinckrodt Pharmaceuticals Mallinckrodt Pharmaceuticals Grunenthal USA

Nevro Corporation Signature Therapeutics Inspirion Pharmaceuticals

Synchrony Healthcare Teva Pharmaceuticals Insys Therapeutics

Travena Jazz Pharmaceuticals

Kaleo

Mallinckrodt Pharmaceuticals

Nektar Therapeutics

Nevro Corporation

Orexo Pharmaceuticals

Teva Pharmaceuticals

Travena

Planning Committee, Disclosures

• Vitaly Gordin, MD Director of Pain Division Penn State Hershey Medical Center Hershey, PA

No relevant financial relationships

• Jennifer Westlund, MSW Director of Education American Academy of Pain Medicine

No relevant financial relationships

• Angela Casey VP, Medical Director PharmaCom Group

No relevant financial relationships

Target Audience

• The overarching goal of PCSS-O is to offer evidence-based

trainings on the safe & effective prescribing of opioid

medications in the treatment of pain &/or opioid addiction

• Our focus is to reach providers &/or providers-in-training

from diverse healthcare professions including physicians,

nurses, dentists, physician assistants, pharmacists, &

program administrators

Educational Objectives

• At the conclusion of this activity participants should be able to:

1. Understand how to assess for & interpret

aberrant drug-related behaviors

2. Devise a plan to incorporate common risk

assessment tools into clinical practice

3. Utilize information from risk assessment in order to

stratify patients’ risk

Definition of Terms

• Use of a medication (for a medical purpose) other than as directed or as indicated, whether willful or unintentional, & whether harm results or not

Misuse

• Any use of an illegal drug

• The intentional self administration of a medication for a non-medical purpose, such as altering one’s state of consciousness, eg, getting high

Abuse

• The intentional removal of a medication from legitimate distribution & dispensing channels Diversion

Addiction

• A primary, chronic, neurobiological disease, with genetic, psychosocial, & environmental factors influencing its development & manifestations

• Behavioral characteristics include one or more of the following: Impaired control over drug use, compulsive use, continued use despite harm, craving

Katz NP, et al. Clin J Pain 2007;23:648-60.

Comparison of DSM-IV & DSM-5 Criteria for Opioid Use Disorder

DSM-IV

Abuse DSM-IV

Dependence

DSM-5 Opioid Use

Disorder

Recurrent use in physically hazardous situations ≥1

criteria in

12-mo period*

-

≥3

criteria in

12-mo period

≥2 criteria

in 12-mo period

Social/interpersonal problems related to use - Neglected major roles at work, school, or home due to use -

Recurrent substance-related legal problems - -

Withdrawal -

Tolerance -

Used larger amounts or for longer than intended - Desired or unsuccessful attempts to quit/control use -

Much time spent obtaining, using, or recovering - Continued use despite physical/psychological problems -

Social/occupational/recreational activities given up/reduced due to use -

Craving or a strong desire or urge to use opioids - -

*And no diagnosis of dependence American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR®). Washington, DC: APA, 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: APA, 2013.

DSM-5 Opioid Use Disorder

• Severity of the disorder is based on the number of criteria endorsed:

Mild: 2 to 3 criteria

Moderate: 4-5 criteria

Severe: ≥6 criteria

• These 3 DSM-5 categories broadly correlate with:

Misuse (mild)

Abuse (moderate)

Addiction (severe)

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: APA, 2013.

Who Misuses/Abuses Opioids & Why?

Non-Medical Use o Recreational

abusers

o Patients with the disease of addiction

Medical Use

o Pain patients seeking more

pain relief

o Pain patients escaping emotional

pain

Spectrum of Behaviors

Nonmedical users Pain patients (nonpatients)

Passik SD, Kirsh KL. Exp Clin Psychopharmacol 2008;16:400-4.

SUD = substance-use disorder

Routes of Prescription Opioid Misuse/Abuse

• Most early misusers/ abusers ingest them orally

• As abuse progresses, users increasingly modify route of ingestion for a faster onset of action

• Even among individuals admitted to substance abuse treatment, 58.5% reported oral use

Oral 58.5%

Smoked 2.8%

Inhaled 20.7%

Injected 17.0%

Other 1.0%

Amongst those entering substance abuse treatment:

Katz N, et al. Am J Drug Alcohol Abuse. 2011;37:205-17. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2002-2012. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-71, HHS Publication No. (SMA) 14-4850. Rockville, MD: SAMHSA, 2014.

Major Opioid Risks

• Opioid use disorder

Misuse

Abuse

Addiction

• Diversion

• Overdose

Significant Risk Factors for Abuse & Overdose

• Pharmacologic substance

Potency

Tmax

Cmax

Availability

• Patient risk factors

Individual risk factors

Environmental risk factors

• Prescriber behavior

Improper patient selection, dosing, & titration

Improper patient counseling & management

Problem

Total chronic pain

population

ADRB (misuse)

40%

Abuse 20%

Addiction 2%-5%

Webster LR, Webster RM. Pain Med. 2005;6:432-42.

ADRB = aberrant drug-related behavior

Prevalence of Opioid Use Disorder Among Chronic Pain Patients

Study N Prevalence

Boscarino et al,

2011

705 • Lifetime opioid-use disorder as defined by DSM-5: 34.9%

(21.7% moderate; 13.2% severe)

• Lifetime opioid dependence as defined by DSM-IV: 35.5%

Noble et al, 2010 4,893* • Opioid use disorder†: 0.27%

Fleming et al,

2007

801 • Opioid use disorder: 3.8%

o Past 30 days opioid dependence as defined by DSM-IV: 3.1%

o Past 30 days opioid abuse as defined by DSM-IV: 0.6%

Von Korff et al,

2011 (reference

to Fleming et al,

2007 article)

801 • Purposeful over-sedation: 26%

• Increasing dose without prescription: 39%

• Obtaining extra opioids from other doctors: 8%

• Use for purposes other than pain: 18%

• Drinking alcohol to relieve pain: 20%

• Hoarding pain medications: 12%

Boscarino JA, et al. J Addict Dis 2011;30:185-94. Noble M, et al. Cochrane Database Syst Rev 2010;CD006605. Fleming MF, et al. J Pain 2007;8:573-582. Von Korff M, et al. Ann Intern Med 2011;155:325-8.

*Meta-analysis of 26 studies that enrolled a total of 4893 participants †As defined by each study

Aberrant Behaviors in Pain Patients With & Without Prescription Drug Use Disorder

0

10

20

30

40

50

60

70

80

90

≥ 1 ≥ 2 ≥ 3 ≥ 4 ≥ 5

Perc

en

t o

f p

ati

en

ts

Minimum number of aberrant behaviors

Cumulative number of aberrant behaviors

PDUD

No Disorder

Meltzer EC, et al. Pain Med 2012;13:1436-43.

N=264

Aberrant Behaviors Among Chronic Pain Patients

Total number of aberrant

behaviors reported

Percent of patients

(N=388)

0 55.4%

1 to 2 25.3%

3 to 4 8.5%

5 to 7 6.7%

≥8 4.1%

Passik SD, et al. J Opioid Manag. 2005;1:257-66.

44.6% of

respondents

engaged in

≥1 behavior

Aberrant Behaviors in Patients with Cancer & AIDS-Related Pain

0

10

20

30

40

50

60

70

0 1 to 2 3 to 4 ≥5

Perc

en

t o

f p

ati

en

ts

Number of aberrant behaviors

Cancer (n=100)

AIDS (n=73)

Passik SD, et al. Clin J Pain. 2006;22:173-81.

• AIDS patients reported a mean of 6.14 aberrant behaviors/patient

Compared with a mean of 1.42 behaviors/patient among cancer patients

Patient Risk Factors for Aberrant Behaviors/Harm

Biological Psychiatric Social

• Age ≤45 years

• Gender

• Family history of prescription drug or alcohol abuse

• Cigarette smoking

• Physical Illnesses

• Pain severity

• Pain duration

• Sleep disorders

• Substance use disorder

• Preadolescent sexual abuse (in women)

• Major psychiatric disorder (eg, personality disorder, anxiety or depressive disorder, bipolar disorder)

• Depression

• Prior legal problems

• History of motor vehicle accidents

• Poor family support

• Involvement in a problematic subculture

• Unemployed

• Isolation

Katz NP, et al. Clin J Pain. 2007;23:103-18. Manchikanti L, et al. J Opioid Manag. 2007;3:89-100. Webster LR, Webster RM. Pain Med. 2005;6:432-42. Cheatle MD. Pain Med. 2011;12(s2):S43-8. Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.

Assessments of Aberrant Behaviors

• Urine drug testing

• Prescription-monitoring programs

• Predictive assessment tools

• Patterns of Use

• Family & friends

• Pharmacists

Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.

Assessment Tools

• Use prior to prescribing opioids

Screener and Opioid Assessment for Patients in Pain

(SOAPP)

Opioid Risk Tool (ORT)

Diagnosis, Intractability, Risk, Efficacy (DIRE)

• Use during prescribing of opioids

Current Opioid Misuse Measure (COMM)

Webster LR. Pain Med. 2013;14:959-61. Webster LR, Webster RM. Pain Med. 2005:6:432-42. Butler SF, et al. Pain. 2004;112:65-75. Belgrade MJ, et al. J Pain. 2006;7:671-81. Butler SF, et al. Pain. 2007;130:144-56.

Limitations of Familiar Screening Tools

• Designed to identify patients who already have problems managing substance intake, not to predict who may develop problems

• Not designed to screen specifically for opioid abuse

• Often take a long time to administer & require unique skills to interpret

Smith HS, Passik SD. Chapter 47. Screening for the risk of substance abuse in pain management. In: Pain and Chemical Dependency. 1st ed. New York, NY: Oxford University Press; 2008. Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.

Screener and Opioid Assessment for Patients with Pain (SOAPP): V.1.0-SF (5Q)

The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.

Please answer the questions below using the following scale:

0 = Never 1 = Seldom 2 = Sometimes 3 = Often 4 = Very Often

1. How often do you have mood swings? 0 1 2 3 4

2. How often do you smoke a cigarette within an hour after you wake up?

0 1 2 3 4

3. How often have you taken medication other than the way that it was prescribed?

0 1 2 3 4

4. How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past five years?

0 1 2 3 4

5. How often, in your lifetime, have you had legal problems or been arrested?

0 1 2 3 4

Please include any additional information you wish about the above answers. Thank you.

To score the SOAPP V.1.0-SF, add ratings of

all questions:

A score of ≥4 is considered positive

Sum of questions

SOAPP indication

4 +

<4 -

SOAPP is available in 3 formats: 5Q, 14Q, & 24Q

PainEDU. Screener and Opioid Assessment for Patients with Pain (SOAPP)® Version 1.0-SF. www.painedu.org/load_doc.asp?file=SOAPP_5.pdf

Opioid Risk Tool (ORT)

Mark each box that applies Female Male

1. Family history of substance abuse

Alcohol

Illegal drugs

Prescription drugs

1

2

4

3

3

4

2. Personal history of substance abuse

Alcohol

Illegal drugs

Prescription drugs

3

4

5

3

4

5

3. Age (mark box if 16-45 years) 1 1

4. History of preadolescent sexual abuse

3 0

5. Psychological disease

ADD, OCD, bipolar, schizophrenia

Depression

2

1

2

1 ADD = attention deficit disorder; OCD = obsessive-compulsive disorder

• Exhibits high degree of

sensitivity & specificity

• 94% of low-risk patients

did not display an

aberrant behavior

• 91% of high-risk patients

did display an aberrant

behavior

Total score

Risk % with

aberrant behavior

0-3 Low 6%

4-7 Moderate 28%

≥8 High 91%

Webster LR, Webster RM. Pain Med. 2005;6:432-42.

N=185

Level of Abuse in Stressful Environments

Low Moderate High

Patient stress level

Dru

g-a

bu

sin

g b

eh

avio

r

Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.

Differential Diagnosis: Aberrant Drug-Taking Attitudes & Behavior

• Addiction

• Pain-relief seeking

• Pain-relief seeking & substance-use disorder

• Other psychiatric diagnosis

Organic mental syndrome

Personality disorder

Chemical coping

Depression/anxiety/situational stressors

• Criminal intent (diversion)

Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007. Passik SD, Kirsh KL. Curr Pain Headache Rep. 2004;8:289-94.

Aberrant Medication Taking Behaviors Pain-Relief Seeking: Differential Diagnosis

• Disease progression

• Poorly opioid responsive pain

• Withdrawal mediated pain

• Opioid-induced hyperalgesia

• Opioid analgesic tolerance

Drug Seeking: Addiction

• A clinical syndrome presenting as…

Loss of Control

Compulsive use

Continued use despite harm

Craving

• Addiction is NOT the same as physical dependence

Biological adaptation with signs & symptoms of withdrawal

(eg, pain) if opioid is abruptly stopped

Savage SR, et al. J Pain Symptom Manage. 2003;26:655-67.

Aberrant medication-

taking behaviors

(pattern & severity)

Behaviors Concerning for Addiction The Spectrum: Yellow to Red Flags

Portenoy RK. J Pain Symptom Manage. 1996;11:203-14. Passik SD, et al. Oncology (Williston Park ) 1998;12:517-21, 524.

○ Requests for increased opioid dose

○ Requests for specific opioid by name, “brand name only”

○ Unsanctioned dose escalation or other noncompliance with therapy on 1 or 2 occasions

○ Nonadherence with other recommended therapies (eg, physical therapy)

○ Resistance to change therapy despite adverse effects (eg, over-sedation)

○ Deterioration in function at home & work

○ Multiple dose escalations or other noncompliance with therapy despite warnings

○ Nonadherence with monitoring (eg, pill counts, urine drug testing)

○ Multiple “lost” or “stolen” opioid prescriptions

○ Illegal activities (eg, forging prescriptions, selling prescription opioids)

Discussing Possible Addiction

• Give specific & timely feedback why patient’s behaviors raise your concern for possible addiction, eg, loss of control, compulsive use, continued use despite harm

• Remember patients may suffer from both chronic pain & addiction

• May need to “agree to disagree” with the patient

• Benefits no longer outweighing risks

“I cannot responsibly continue prescribing opioids as I feel it

would cause you more harm than good”

• Always offer referral to addiction treatment

• Stay 100% in “Benefit/Risk” mindset

When to Refer to an Addiction Medicine Specialist

• When a patient:

Is using illicit drugs

Is experiencing problems with other prescription drugs

− eg, benzodiazepines

Has an addiction or abuse to alcohol

Agrees they have an opioid addiction & wants help

Has a dual or a trio diagnosis of pain, addiction, &

psychiatric disease

Diversion

• Drug diversion is defined as a supply of prescription medication intended for one person being given, bartered or sold to another

• Patients who have had medications stolen, lost, or otherwise taken unintentionally also qualify as participants in drug diversion

Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62. Bell J. Addiction. 2010:105:1531-7. Inciardi JA, et al. Pain Med. 2009:10:537-48.

Frequency & Type of Diversion Among a Pain Clinic Population

# of

incidents

Type of diversion

Sharing Selling Stolen Lost

n=340 n=336 n=338 n=342

0 304 (89.4%) 330 (98.2%) 238 (70.4%) 272 (80.0%)

1 16 (4.7%) 4 (1.2%) 54 (16.0%) 42 (12.3%)

2 4 (1.1%) 1 (0.3%) 26 (7.7%) 21 (6.1%)

3 5 (1.5%) 0 10 (3.0%) 5 (1.5%)

4 0 0 2 (0.6%) 1 (0.3%)

≥5 11 (3.2%) 1 (0.3%) 8 (2.4%) 1 (0.3%)

≥1 36 (10.6%) 6 (1.8%) 100 (29.6%) 70 (20.5%)

Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.

• Most common type of drug diversion was loss due to theft 29.6% of respondents

Frequency of Stolen Medications Per Age Group

Age group

(years)

How many times medications stolen (%) % of responses

≥1 0 1 2 3 4 5

18-24

(n=2)

2

(100.0%)

0

(0.0%)

0

(0.0%)

0

(0.0%)

0

(0.0%)

0

(0.0%)

0%

25-34

(n=29)

19

(65.5%)

5

(17.2%)

1

(3.4%)

2

(6.9%)

0

(0.0%)

2

(6.9%)

34.5%

35-44

(n=62)

38

(61.3%)

14

(22.6%)

6

(9.7%)

1

(1.6%)

0

(0.0%)

3

(4.8%)

38.7%

45-54

(n=119)

76

(63.9%)

18

(15.1%)

16

(13.4%)

5

(4.2%)

2

(1.68%)

2

(1.68%)

36.1%

>55

(n=101)

81

(80.2%)

14

(13.9%)

3

(3.0%)

2

(2.0%)

0

(0.0%)

1

(1.0%)

19.8%

Total

(n=313) 216 51 26 10 2 8 31.0%

Frequency missing = 14

Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.

Frequency of Stolen Medications Per Marital Status

Marital status How many times medications stolen (%) % of

responses ≥1 0 1 2 3 4 5

Never married

(n=28)

19

(67.9%)

3

(10.7%)

3

(10.7%)

0

(0.0%)

0

(0.0%)

3

(10.7%) 32.1%

Divorced

(n=63)

39

(61.9%)

12

(19.0%)

3

(4.8%)

4

(6.3%)

0

(0.0%)

5

(7.9%) 38.1%

Widowed

(n=11)

7

(63.6%)

2

(18.2%)

2

(18.2%)

0

(0.0%)

0

(0.0%)

0

(0.0%) 36.4%

Married

(n=206)

148

(71.8%)

33

(16.0%)

17

(8.3%)

6

(2.9%)

2

(1.0%)

0

(0.0%) 28.2%

Total

(n=308) 213 50 25 10 2 8 30.8%

Frequency missing = 19

Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.

Suicide

161.6 151.6

182.8

197.1 199.5 198.4

212.7

228.4

16.9 17.8 24.5

29.9 26.8 29.6 32.9 31.7

0

25

50

75

100

125

150

175

200

225

250

2004 2005 2006 2007 2008 2009 2010 2011

Nu

mb

er

of

ED

vis

its f

or

dru

g-

rela

ted

su

icid

e a

ttem

pts

(t

ho

usan

ds)

All drugs Opioid analgesics

87% increase in opioid suicide attempts

41% increase in drug suicide attempts

Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: SAMHSA, 2013.

ED = emergency department

Why Suicide? Non-Pain Patients

Escape from severe suffering Only option

Permanent solution Hopelessness

Kraft TL, et al. Arch Suicide Res. 2010;14:375-82.

Suicide Ideation in Chronic Pain Patients

• Hitchcock

50% chronic pain

patients had suicidal

thoughts due to pain

• Fishbain

Pain severity

Severe comorbidity

(depression)

19%

13%

5% 5%

0%

5%

10%

15%

20%

Passive suicide ideation

Actual thoughts

Current plan

Previous attempt

Planned suicide

N=153

Hitchcock LS, et al. J Pain Symptom Manage. 1994;9:213-8. Fishbain DA. Semin Clin Neuropsychiatry. 1999;4:221-7. Smith MT, et al. Pain. 2004;111:201-8.

Risk for Suicide Among Pain Patients

Family history of suicide

History of childhood

abuse

Previous suicide attempts

History of mental disorder, particularly depression

Hopelessness

History of substance abuse

Impulsive & aggressive

behaviors

Losses such as work, family, self-esteem

Isolation

Physical illness

+1: Access to potentially lethal doses of prescription medications (ie, opioids)

Fishbain DA. Semin Clin Neuropsychiatry. 1999;4:221-7. Tang NK, Crane C. Psychol Med. 2006;36:575-86.

Risk Stratification

Lower Risk Moderate Risk Higher Risk

Primary care patients Primary care patients with

specialist support Pain specialist patients

ORT Score 0-3 ORT Score 4-7 ORT Score ≥8

No past or current

history of substance use

disorders

No family history of past

or current substance

use disorders

No major or untreated

psychopathology

Consistent UDT results

Consistent PDMP

results

Mild to moderate pain

May be a past history of

substance use disorders

May be a family history of

problematic drug use

May have past or

concurrent

psychopathology

Not actively addicted

Usually consistent UDT

results

Consistent PDMP results

Mild to severe pain

Active substance

use disorders

Major, untreated

psychopathology

Poor social support

Actively addicted

Inconsistent UDT

results

PDMP multiple

prescribers

Moderate to severe

pain

Gourlay DL, et al. Pain Med. 2005;6:107-12. Webster LR Webster RM. Pain Med. 2005;6:432-42.

ORT = Opioid Risk Tool; PDMP = Prescription Drug Monitoring Program; UDT = urine drug testing

Conclusion

• Aberrant drug-related behaviors must be assessed

• Risk assessment can be easily implemented into most clinical practices

• Risk assessment leads to risk stratification

• Risk stratification can help match appropriate monitoring to mitigate abuse, potential diversion, suicide, & overdoses

References • American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR®). Washington, DC: APA, 2000.

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: APA, 2013.

• Belgrade MJ, et al. J Pain. 2006;7:671-81.

• Bell J. Addiction. 2010:105:1531-7.

• Boscarino JA, et al. J Addict Dis 2011;30:185-94.

• Butler SF, et al. Pain. 2004;112:65-75.

• Butler SF, et al. Pain. 2007;130:144-56.

• Cheatle MD. Pain Med. 2011;12(s2):S43-8.

• Fishbain DA. Semin Clin Neuropsychiatry. 1999;4:221-7.

• Fleming MF, et al. J Pain 2007;8:573-582.

• Gourlay DL, et al. Pain Med. 2005;6:107-12.

• Hitchcock LS, et al. J Pain Symptom Manage. 1994;9:213-8.

• Inciardi JA, et al. Pain Med. 2009:10:537-48.

• Katz NP, et al. Clin J Pain. 2007;23:103-18.

• Katz NP, et al. Clin J Pain 2007;23:648-60.

• Katz N, et al. Am J Drug Alcohol Abuse. 2011;37:205-17.

• Kraft TL, et al. Arch Suicide Res. 2010;14:375-82.

• Manchikanti L, et al. J Opioid Manag. 2007;3:89-100.

• Meltzer EC, et al. Pain Med 2012;13:1436-43.

• Noble M, et al. Cochrane Database Syst Rev 2010;CD006605.

• PainEDU. Screener and Opioid Assessment for Patients with Pain (SOAPP)® Version 1.0-SF. www.painedu.org/load_doc.asp?file=SOAPP_5.pdf

• Passik SD, et al. Clin J Pain. 2006;22:173-81.

• Passik SD, et al. Oncology (Williston Park ) 1998;12:517-21, 524.

• Passik SD, Kirsh KL. Curr Pain Headache Rep. 2004;8:289-94.

• Passik SD, et al. J Opioid Manag. 2005;1:257-66.

• Passik SD, Kirsh KL. Exp Clin Psychopharmacol 2008;16:400-4.

• Portenoy RK. J Pain Symptom Manage. 1996;11:203-14.

• Savage SR, et al. J Pain Symptom Manage. 2003;26:655-67.

• Smith MT, et al. Pain. 2004;111:201-8.

• Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2002-2012. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-71, HHS Publication No. (SMA) 14-4850. Rockville, MD: SAMHSA, 2014.

• Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: SAMHSA, 2013.

• Tang NK, Crane C. Psychol Med. 2006;36:575-86.

• Utah Drug Overdose Mortality Report: Findings from interview with family and friends of Utah residents aged 13 and older who died of a drug overdose between October 26, 2008 and October 25, 2009. Prepared by the Utah Department of Health.

• Von Korff M, et al. Ann Intern Med 2011;155:325-8.

• Walker MJ, Webster LR. J Opioid Manag. 2012:8:351-62.

• Webster LR, Webster RM. Pain Med. 2005:6:432-42.

• Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MD: Sunrise River Press. 2007.

• Webster LR. Pain Med. 2013;14:959-61.

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PCSS-O Colleague Support Program

• PCSS-O Colleague Support Program is designed to offer general

information to health professionals seeking guidance in their clinical

practice in prescribing opioid medications.

• PCSS-O Mentors comprise a national network of trained providers with

expertise in addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be

unique and catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• Listserv: A resource that provides an “Expert of the Month” who will

answer questions about educational content that has been presented

through PCSS-O project. To join email: pcss-o@aaap.org.

For more information on requesting or becoming a mentor visit:

pcss-o.org/ask-colleague

PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in

partnership with: Addiction Technology Transfer Center (ATTC), American Academy of

Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of

Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA),

American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine

(AOAAM), American Psychiatric Association (APA), American Society for Pain Management

Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast

Consortium for Substance Abuse Training (SECSAT).

For more information visit: www.pcss-o.org

For questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The views expressed in written

conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names,

commercial practices, or organizations imply endorsement by the U.S. Government.