Just five days' worth of data collected via a new smartphone app is all it takes to identify people who "catastrophize" their pain and may thus be at risk for future opioid misuse, says Robert Jamison, PhD, chief psychologist at the Pain Management Center at Brigham and Women's Hospital (BWH).
In a study conducted by Jamison and colleagues, participants used the BWH PainApp each day to rate their moods, the intensity of their pain, whether it interfered with activity or sleep, and whether their situations had improved, gotten worse or stayed the same over the past 24 hours (Journal of Pain, Vol. 20, No. 3, 2019). That last question is an extremely effective way to identify
people who indulge in recurrent worries about what might happen, says Jamison. "These people tend not to do well despite any attempts to help their pain," he says. But thanks to the app's two-way messaging feature, psychologists or other providers can intervene with relaxation exercises, cognitive-behavioral therapy or other approaches to pain management.
While the BWH PainApp is an example of a new tool psychologists have developed to assess risk of opioid misuse, psychologists are also using classic assessments in new ways to respond to the opioid epidemic. For example, the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and the Millon Behavioral Medicine Diagnostic (MBMD) can help assess whether patients are psychologically ready for potentially painful procedures, such as spinal or bariatric surgeries. In addition, Pearson's Battery for Health Improvement 2 (BHI-2) can identify factors that may impede recovery from pain.
"Depression, for example, can very much affect a person's recovery," says Paul Williams, PsyD, a health-care solutions analyst at Pearson Clinical Assessment. "If you're already depressed, go through a procedure and come out even more depressed because now you're in pain, the symptoms of depression—pessimism, loss of interest and drive, low energy, low appetite—aren't good for recovery." Other issues that may warrant presurgical intervention by a psychologist include anxiety, a tendency to avoid problems, sedentariness that may prevent physical therapy and a lack of social support, he adds.
Another widely used assessment, the Screener and Opioid Assessment for Patients in Pain (SOAPP)—and an updatedversion called the SOAPP-R—helps physicians and psychologists determine whether opioid therapy is appropriate. Developed by psychologist Stephen Butler, PhD, Jamison and colleagues, the assessment evaluates patients' mood-related traits, such as mood swings, tension in the home and boredom, and looks at past behaviors that might hint at potential opioid misuse, such as running out of medications early or having had previous legal problems or arrests. A sister survey, the Current Opioid Misuse Measure (COMM), assesses risky behaviors over the past month, such as how often the patient struggled to control his or her anger.
Psychologists and physicians can use the SOAPP and the COMM, along with a patient's personal and family history of mental health issues, to determine when it is safe to prescribe opioids. 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, says Butler, now a consultant to 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. (The system is available at www.paincas.com/Account/RegisterFreeOrgopens in new window.)
These often-unconscious biases can leave some populations undertreated for their pain, says pain specialist Beverly E. Thorn, PhD, ABPP, a professor emerita of psychology at the University of Alabama, who explains that physicians often "bump down" patients' self-reported pain if they've had the pain for a long time or are members of certain groups. "For African Americans, the bias is they're going to misuse medications or they're going to sell their medications," says Thorn. "For women, the bias is that women are more hypochondriacal and more complaining. And people have said to my Hispanic patients, 'You're not going to be able to afford these medications, so I'm not going to prescribe them for you.'"
Once patients are prescribed opioids, Jamison's Opioid Compliance Checklist can help clinicians monitor their patients' adherence to their prescribed regimens and identify patients who may be misusing opioids or be at risk of misusing them in the future (Journal of Painopens in new window, Vol. 17, No. 4, 2016). The checklist asks whether patients have lost their medication, missed medical appointments or used illegal substances, for example.
Other assessment tools focus on patients who have already developed problems with opioid misuse, including the Substance Abuse Subtle Screening Inventory (SASSI-4), which can identify even clients who are unable or unwilling to acknowledge that they have a problem. And Pearson's Quality of Life Inventory (QOLI) can help clinicians and patients track progress in such areas as health, self-esteem, relationships and overall well-being. "It's not looking for deficits like pain or anguish; it's on the positive psychology side," says Williams. "It's very motivating."
Unfortunately, many clinicians don't use any assessments, says Butler. Whether the problem is clinicians' reliance on their own instincts or a reluctance to change work flows, "we've found it can be really difficult to get doctors and their nurses to use these assessments," he says. To help overcome that challenge, Butler and other psychologists are working to shorten and computerize assessments. A new version of the SOAPP developed by Butler, Jamison and other researchers, for instance, reduces the number of questions from the original 24 down to just eight without losing its effectiveness (Pain Medicineopens in new window, Vol. 19, No. 10, 2018).
But there are still major gaps in the research on pain assessment, psychologists say. There's no way to differentiate between someone whose pain is genuinely undertreated and someone who just wants drugs, for example. Another ongoing dilemma is how to measure outcomes when it comes to chronic pain. "Almost by definition, chronic pain is not expected to get better, so, what does a good outcome look like?" asks Butler.
