Patient Risk Assessment by Interview

Patient Risk Assessment By Interview The Brief Risk Interview: An Emerging New Risk Assessment Tool

Disclosures Dr. Jones has received funding from the following corporations over the last year: –Consultant/Independent Contractor: AFTS Labs, Pain Centre of Arizona; –Grant/Research Support: Dominion Diagnostics, AFTS Labs; –Honoraria: Alere, AFTS Labs

Learning Objectives Compare current risk assessment tools with the Brief Risk Interview Describe the areas of risk that should be evaluated during the Brief Risk Interview Explain how the Brief Risk Interview can be applied to first time pain patients

Introductions & This Presentation Who are you? I’m going to offer you a good deal of information today, and I’m not sure what you are already familiar with or not (and whether you came to my previous talk here) Please ask questions as we go along, and we can work to get on the same page as we go along

Introductions: Me  I am a clinical psychologist in private practice in Knoxville, TN. I have been in practice for 30 years  I am “embedded” inside a private pain practice, currently with two Board-certified pain physicians and six nurse practitioners  My entire practice is with chronic pain patients, and I have been working in the field of chronic pain since 1998  Before that I was working in various areas, including research and program evaluation and also substance abuse

A Quick Review of Risk Assessment

Opioid Risk Assessment: The Current Standard of Care  “A thorough risk assessment and stratification is appropriate in every case” American Pain Society and the American Academy of Pain Medicine, 2009

 “Risk stratification pertaining to outcomes associated with the abuse liability of opioids - misuse, abuse, addiction and diversion - is a vital but relatively undeveloped skill for many clinicians” American Pain Society and the American Academy of Pain Medicine, 2009

 Risk assessment is a legislated requirement for all patients seen at a registered pain clinic in Tennessee, as of 2012

We Started With “Red Flag” Lists  Smoking  On welfare  Normal blood pressure  Does not have a PCP  Has had an MVA, fall or fire  Leaves blanks on forms  Calls staff by first name

 Multiple dose escalations  Obtains medications from multiple sources  Sells medications  Steals another pt’s medications  Forges prescriptions

Current Risk Assessment Tools  Opioid Risk Tool (ORT)  Screener and Opioid Assessment for Patients with Pain (SOAPP); Screener and Opioid Assessment for Patients with Pain Short Form SOAPP-SF); Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R)  Pain Medication Questionnaire (PMQ)  Screening Instrument for Substance Abuse Potential (SISAP)  Drug Use Questionnaire (DAST-20)

Overall Status of the Current Tools  …more validation and prospective outcome studies are needed to understand how their use affects predicts and affects clinical outcomes.” (APS & AAPM)  Passik SD, Kirsh KL, and Casper D. Addiction-related assessment tools and pain management: instruments for screening, treatment planning, and monitoring compliance  Pain Med 2008; 9(2): S145-S166: – “Studies showing that the use of a risk prediction or monitoring instrument alters clinician behavior and improves patient outcomes would provide strong evidence to support its use. At this time, there are no such studies”

How About Clinical Judgment?

A recent study by Bronstein found that clinicians’ current ability to predict future inappropriate urine drug tests (UDT’s) is only slightly better than chance

The False Dichotomy  Almost all current risk assessment tools were based on the original dichotomous thinking: “Real Pain Patients” versus “Drug Addicts.”

Thus, “We need something to tell the difference between the two”  This dichotomous thinking leads to: – “If a patient has ‘real’ pain, then they are not an addict and I can treat him or her without worry” – Also: “If the patient is an addict or alcoholic, then I should not treat him or her at all. I’d be feeding his/her addiction”

 Almost all risk assessment tools were created to identify addicted persons and those with substance abuse disorders

Some Literature  Ives et al 2006. Found that predictors of medication misuse at a pain clinic were: – Hx of cocaine – Hx of drug charges or DUI – Hx of alcohol abuse – Younger age – Smoking THC

 Turk et al 2008 – The data is very poor overall – But hx of alcohol or drug abuse seems to be a factor

But Then Data On Overdoses Finds…  Hall et al 2008 found: – That the majority of fatal overdoses involved people who did NOT have an rx for opioids. Doctor shopping is less common but involves a different subset of patients: female, older, and not engaging in illegal activities.

 Dunn et al 2010 found: – Overdoses (both fatal and serious) are associated with: • older age (>65) • hx of depression • hx of substance abuse • being prescribed a higher dose of opioids.

In Summary  Misuse and overdose involve people who have or have had a history of drug addiction  But the problem ALSO involves people with: – Hx of alcohol abuse – Hx of criminal charges – Older persons – Depression, and – Diversion

 There is not one set or type of “bad guys” to look for. The problem is multi-faceted

The Findings On Risk Assessment To Date * Moore ’09 (N=48)

Jones ’11 (N=51)

Jones ’12 (N=132)

Jones ’12 (N=263)

Jones ’12 (N=196)

77%

-

70%

71%

76%

-

-

-

43%

-

73%

-

-

-

-

-

-

32%

39%

60%

45%

30%

29%

35%

48%

ORT by interview

-

57%

-

-

-

PMQ

-

-

44%

51%

-

DIRE

17%

-

-

-

-

-

-

-

-

76%

Clin. Intrvw – me Clin. Intrvw – not me SOAPP SOAPP-R ORT

BRI

Why? Two Reasons Clin. Intrvw

SOAPP-R

PMQ

Sex/Age

DIRE

X

Pain Dx / Type Behavior with meds

ORT

X X

X

Engagement in Tx

X

X X

X

Mental Health Dx

X

X

X

X

X

Substance Abuse Hx

X

X

X

X

X

Family Hx SA

X

Social Environment

X

Literacy

X

Theft Hx

X

Legal Hx

X

Content Tapped by Each Risk Measure

X X

And An Interview Beats Written Measures  Remember ORT written versus ORT asked?

– 30% correct versus 57% correct

 In that study, looking at the ORT items that were discrepant, – Personal Hx of Substance Abuse was discrepant – But also Family Hx of Substance Abuse and Depression were significantly discrepant – Age was discrepant 14% of the time (“Mark box if between 16-45”)

 BOTH literacy/carefulness AND non-revealing/lying were factors

The Brief Risk Interview 

The Artist Formerly Known as The RABI

Building a Better Mousetrap  Since 2006 I have evaluated every patient at our practice prior to opioids being started  That’s clinical risk assessment on 5000+ patients, in a geographical area with a high rate of addiction / medication misuse

Psychology Interview (90801)

Brief Risk Interview

Creating a New Risk Interview Taking the essential risk elements from the well-studied 45’ interview and creating a short risk-focused interview

The Areas of Risk Past discharge Overtaking medication Street use Pushes for a specific med Depression & anxiety Bipolar / ADHD

Medication security Substance abuse Parental history of SA Legal history Cognitive / literacy issues Dishonesty

The Continua of 12 Variables

Past Discharge from Treatment No past discharge from a physician practice for aberrant drug-taking behavior

Past discharge from opioid medication treatment but was poorly educated about what to do or not do, and it appears this an honest mistake

Discharge from another medical practice for significant aberrant drug-taking behavior but patient admits it and knows what he/she did was wrong. Patient admits it was wrong to do and won’t do it again

Discharge from more than one past pain treatment practice for aberrant drug-taking behavior, or minimizes or denies his or her actions in any past discharge (“It wasn’t my fault.”). It does not appear to be “an honest mistake”

Is dishonest about past pain treatment (e.g., denies seeing a physician for pain treatment before but records say otherwise)

Overtaking of Medication No current or past misuse or overtaking of medication

Some overtaking of current or past opioids but this appears to be pseudoaddiction as pain may well have been undertreated

Has overtaken opioids multiple times in the past and/or is currently significantly overtaking opioid medication

Has overtaken opioids multiple times in the past and/or is currently significantly overtaking opioid.

Has basically taken medications as he/she sees fit and not at all as prescribed

Has overtaken opioids multiple times in the past and/or is significantly overtaking medication now. It appears this is not pseudoaddiction as patient seems to have had adequate opioids from legitimate providers but got more any way

Street Use Patient has not obtained medications from the streetfamily-friends

Has obtained opioids from the streetfamily-friends a few times, though this appears to be pseudoaddiction.

Patient knows this was wrong and expresses guilt about it

Has obtained opioids from the streetfamily-friends several times, though this appears to be pseudoaddiction.

Patient knows this was wrong and expresses guilt about it

Has obtained opioids from street-familyfriends many times, though this may be pseudoaddiction.

States he/she will get medication from the street again if he/she “has to�

Patient is regularly obtaining pain medication from street-family-friends.

It appears this is not pseudoaddiction as patient seems to have had adequate opioids from legitimate providers but got more any way

Relationship with Opioids Does not ask in some way for a particular pain medication. Might mention a specific medication but shows no strong motivation for it

Pushes provider for a particular opioid medication but states he/she will accept whatever is prescribed. Pushes for opioids being prescribed today

Pushes provider for a particular opioid medication but grudgingly and hesitantly states he/she will accept whatever is prescribed “as long as it works like my old medication did�

Patient is very specific about the particular brand or type of pain medication he/she wants. Patient states he/she will refuse any other medication or form of pain treatment

Depression and Anxiety No significant mental health disorder. Some depression or anxiety present.

Mild depression at most About average for a pain patient

Significant anxiety or depression present. Refers to pain with words such as “horrible,” “unbearable,” or “agonizing”

Bipolar Disorder or Attention Deficit Hyperactivity Disorder (ADHD) No Bipolar Disorder or Attention Deficit Hyperactivity Disorder (ADHD) present

Has possible Bipolar Disorder and/or ADHD. Stable now.

Has Bipolar Disorder and/or ADHD but is relatively stable

Has Bipolar Disorder and/or ADHD. Patient shows some impulsivity, poor judgment or erratic behavior

Has Bipolar Disorder and/or (ADHD). Is not behaviorally stable today. Shows impulsivity or erratic behavior today

Social Environment and Medication Security No people with untreated pain are in the social environment.

Medication is secure or medication is not secure but patient states he/she will lock it up very soon

One past theft in the last year. Currently patient has little contact with addicts or those who have stolen medication in the past. Medication is secure or medication is not secure but patient states he/she will lock it up very soon.

Overall, there seems little risk for future thefts

One past theft in the past year.

Medications are in common hiding places and are not locked up. There is some question if patient will lock them up. Or there are others in the home who have untreated pain. Overall, there seems to be some risk for future thefts

More than one past theft. Medication is not secure (locked up). Patient still has ongoing contact with addicts or those who have stolen medication in the past. Overall, there is moderate risk for future thefts

Repeated past thefts of medications and the circumstances are not significantly different. Living with or having frequent contact with active addicts or those who have stolen medication in the past, and pain medication is not secure (locked up).

Overall, it is likely that there will be future thefts

Substance Abuse Disorder .

No current or past substance abuse disorder (complaints from spouse, DUI’s, legal charges, job problems, or medical problems). Might have one past DUI as a teen or young adult that appears to be an isolated incident

Has a substance abuse disorder history (complaints from spouse, DUI’s, legal charges, job problems, or medical problems), or using illegal drugs.

Went to substance abuse treatment or AA (or should have gone). No signs of a drug or alcohol problem in the last five years

Has a substance abuse disorder history (complaints from spouse, DUI’s, legal charges, job problems, or medical problems).

Went to substance abuse treatment or AA (or should have gone), or using illegal drugs. Has had signs of a drug or alcohol problem between five years ago and one year ago. OR reports a past addiction to heroin or morphine

Has a substance abuse disorder history (complaints from spouse, DUI’s, legal charges, job problems, or medical problems), or using illegal drugs.

Went to substance abuse treatment or AA (or should have gone). Has had signs of a drug or alcohol problem in the last year but not in the last week

Has a significant substance abuse problem. Not sober today or has drank/used in the last week. Has an active substance abuse disorder

Biological Family History of Addiction No significant parental history of substance abuse in biological family

At least one parent positive for alcohol or drug addiction

Both parents positive for alcohol or drug addiction

Legal Issues No significant past legal charges

Past incarceration for a month or more, or has a significant history of legal problems. Presents as behaviorally stable today.

Has social support. Has made a significant life change

Long history of legal troubles or incarceration.

Presents as behaviorally stable today. Has social support. Has made a significant life change

Long history of legal trouble or incarceration.

Does not appear behaviorally stable or highly trustable today. Has not made a life change and doesn’t plan to

Intellectual / Cognitive / Literacy Abilities Normal IQ and .literate

Low average IQ. Some literacy . problems but has help from others

Significant cognitive problems (dementia, post-TIA, mental retardation) but has strong social support and much oversight of medication use

Significant cognitive problems (dementia, post-TIA, mental retardation). Has some social support and medication oversight

Significant cognitive problems (dementia, post-TIA, mental retardation). Limited to no social support or medication oversight

Dishonesty Honest and revealing in the interview. There are no significant discrepancies between what the patient says and what the record or other documents say

. Dishonest about some . issues on interview, such as underreporting or forgetting recent drug/ alcohol use. This seems to be more denial and the overall sense is that the patient will be truthful in the future if educated

Dishonest about recent medications or drugs used.

Patient reports taking a certain medication but the UDT finds that the patient is really taking more than that or using illegal drugs

Dishonest about significant issues such as past pain providers and legal issues.

Goes beyond minimizing patient is outright lying for whatever reason

The Brief Risk Interview Form速

Brief Risk Interview – Page 1

Brief Risk Interview – the Interview Form

Page 2 - The Interview Form

Research on the BRI  Submitted for publication (as of this writing):  A comparison of predictive ability for the ORT, SOAPP-R, a clinical interview (me) and the Brief Risk Inventory (also completed by me)  The clinical interview and the BRI overlapped at a 90% level. 98% of the ratings were within one level on a six level scale (Low, Low Medium, Medium, Medium High, High and Very High)  Ratings were collapsed into “Low” (Low, Low Medium) and “High” (Medium and higher)  Six month follow-up of 196 patients, as to the presence of medication aberrant behavior and discharge due to medication aberrant behavior

The Data: % “Correct” For Each Measure Treated with Opioids & No MAB

Treated with Opioids & had MAB

ORT Low Risk

57%

53%

ORT High Risk

43%

48%

SOAPP-R Low Risk

62%

47%

SOAPP-R High Risk

38%

53%

BRI Low Risk

43%

27%

BRI High Risk

57%

73%

Ongoing Research  Thanks to an unrestricted grant by AFTS Labs, there is field test of the BRI underway at this time  Four pain practices are field testing the Brief Risk Interview (formerly the RABI) with 100 new pain patients each  We will be gathering six month follow-up data on the presence of medication aberrant behavior and compare that with the risk level assessed by the Brief Risk Interview, the ORT and the SOAPP-R  Feedback from the providers so far is that the BRI is helpful and not time consuming. It also seems easy to learn

If This Interests You… See me afterwards so we can discuss it further We may be interested in testing this risk assessment technique in other locations and practice settings

A Walk Through With Cases

Mary  42 year old MWF with low back and right leg pain. Pain for 3 years. Lumbar fusion two years ago and recent compression fracture. Scans support her dx and pain complaint

Limps Mother was Bipolar Mildly depressed and anxious now No makeup Father absent Mildly suspicious Data supports her report Hx of physical assault Stays home a lot No social life No hx of thefts of medication Distant hx of suicide attempts Not Bipolar or ADHD Meds well hidden by overdose Live alone in an apartment No intimate relationship now Taking meds (oxycodone) as rx now. No street use Grandfather and three uncles Hx of professional job were alcoholics Disabled five years Quit smoking 15 years ago Broke up a 21 year Several significant medical issues now relationship last year College educated.

Chronic steroid use for lung sx Depressed and anxious since Takes trazadone and Fluoxetine childhood Functional alcoholic for 28 years Sober 9 years No past discharge Severely dysfunctional family No substance abuse tx of origin Hx of AA Sees a psychiatrist and psychotherapist now Stressed about money and health now Not asking for particular med No arrest hx

The Areas of Risk to Assess Past discharge Overtaking medication Street use Pushes for a specific med Depression & anxiety ✔ Bipolar / ADHD

Medication security Substance abuse ✔ Parental history of SA Legal history Cognitive / literacy issues Dishonesty

Edith  78 year old WWF with pervasive joint pain due to arthritis. Pain for 50 years, worse the last six years. She has had numerous joint surgeries to date. Scans and blood work support her dx and pain complaint

Risk assessment by interview reveals:  Past discharge: No. Treated by her PCP for many years but now he wants to d/c all opioids in his practice  Overtaking medication: No. Has been prescribed 6 HC 10 mg a day and 6 PCT 10 mg a day  Street use: None  Pushes for a specific med: No, though she feels her current regime works well for her  Depression & anxiety: Denied  Bipolar / ADHD: Denied

And… Substance abuse: Denied Parental history of SA: None Legal history: None Cognitive / literacy issues: None Dishonesty: Honest. PMP matches her report

But… Medication security: Thefts “lots of times” by her two daughters. Keeps her medication in her pocket or a pillow. Says getting a lockbox is inconvenient as she needs to get to her medication every two hours. Both daughters live at home and both have pain conditions.

Both overtake their own medication

Let’s Practice Video Cases

Ms. Roberts

Ms. Wheels

Discussion & Questions