ISSUES IN THE ASSESSMENT AND TREATMENT OF CO-OCCURRING OPIATE DEPENDENCE AND CHRONIC PAIN

Colloquium PresentationJuly 19th, 2013

Victoria Marrow, MA

Opiate Dependence & Chronic Pain• 1/3 Americans experience chronic pain• Prescribing opiates for chronic pain is the treatment of

choice (Rosenblatt & Mekhail, 2005)

• Opiate treatment does not completely eradicate pain & there is controversy about whether the costs outweigh the benefits for some.

• Although addiction is not an expected reaction, physical dependence and tolerance are expected physiological reactions with long-term opiate treatment (Naliboff, Wu, & Pham, 2006)

Prevalence of Opiate Prescription Abuse• Lifetime prevalence of the “non-medical use”

of prescription opioid medications 12 yrs or olderincreased from 11.6 million in 1998 to 31.2 million in 2003

• In 2008, people aged 12+ new Rx drug abuse(2.2 million) was roughly even with that of marijuana. 3.0% past-month use in 12-17 yr-olds

• 2.4 million total new nonmedical use 2010. 6,600 initiates per day. • >1/2 females and about 1/3 aged 12 to 17. • Females more likely to abuse Rxs in 12-17 range, but males have higher rates in all other age

ranges• Highest rate is 18-24 yr-olds. 5.9% in past month• Elderly account for 1/3 prescription drug sales, but only 13% of population

• With multiple medications, cognitive decline, fixed income – misuse of rx potential is higher• More potential for drug-drug interactions

• (NIDA, 2010; Tetrault et al., 2007)

Pervasiveness of Opiate Prescription Abuse

RELAPSE PREVENTION• Among 12th-graders, 8 of the

13 most commonly abused drugs (excluding tobacco and alcohol) were prescription or over-the-counter medications• Over half of which were given to

them or were purchased from a friend or relative

• 1 in 10 high school seniors reported past-year nonmedical use of Vicodin

• 1 in 20 abused OxyContin• More likely to abuse other drugs• (Tetrault, et al, 2007)

Addiction in Chronic Pain Patients• Similar addiction rates for general population and those

with chronic pain (3-27%). NIDA 2013 said 3-40%• Not many studies have been done to date on addiction rates amongst chronic pain patients.• Substance use disorders are often under-identified in health-care settings. • Possibly an Underestimate

(Rosenblatt & Mekhail, 2005; www.drugabuse.gov/publications/research-reports/prescription-drugs/chronic-pain-treatment-addiction [NIDAwebsite, 2013])

Pain• Chronic vs. acute pain –

• Acute pain can be very intense and serve a protective function, such as warn of potential tissue damage.

• Chronic pain is non-protective and does not go away.

• It may be disproportionate to the injury or • last longer than expected. • Chronic pain is often undertreated and • can lead to medical complications or • drug-seeking behavior. (Schnoll, & Weaver, 2003)

Assessing Pain• Perception of pain is

subjective• Chemically addicted

patients may have lower pain thresholds and lower pain sensitivity

• (Rosenblatt & Mekhail, 2005).

•

Hyperalgesia: (increased

pain sensitivity) is a risk for long-term pain treatment (NIDA website, 2013)

The Dilemma• Opiate use can predispose a

client to tolerance and physical dependence

• Pain management is important, but we know that addiction can lead to detrimental life consequences.• 2009 - Roughly 343,000

emergency department visits involved prescription opioid pain relievers, a rate more than double that of 5 years prior.

• More than ½ ed visits for Rx drug abuse involved multiple Rx drugs(Rosenblatt & Mekhail, 2005).

The Dilemma• Clark, Stoller, and Brooner (2008) reported that people

with opioid dependency are significantly more likely to have chronic pain than people with heroin dependency. • Of prescription opioid-dependent patients studied, 84% reported

pain was the reason they started taking opioids. • Of the opioid-dependent patients that started taking prescription

opioids and later switched to heroin, 62% reported pain as the primary reason they began using opioids.

• What is your experience of clients with Opiate addiction or with chronic pain?

The Basic Terminology• Part of the trouble is the difference

in the use of concepts amongst medical and psychological field. • Physical Dependence• Tolerance• Withdrawal Syndrome• Nonmedical Use• Substance Abuse• Substance Dependence• Addiction• Opiophobia• Psuedoaddiction

• (Naliboff, Wu, & Pham, 2006)

The Basic Terminology• Physical Dependence – “a state of adaptation that often includes tolerance and is

manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.” Definition in the medical field. • Neuroadaptation - is present if a withdrawal syndrome occurs with cessation of or reduction in use

of a substance.

• Both physical dependence, tolerance , and withdrawal are expected physical adaptations in patients on long-term opiate treatment.

• Addiction is not an expected reaction • (Naliboff, Wu, & Pham, 2006;O’Brien, 2003).

(American Academy of Pain Medicine, American Pain Society, & American Society of Addiction Medicine, 2001, p. 2).

The Basic Terminology• Nonmedical use of prescription drugs - SAMHSA, 2006

on defining NMUPD:• “Use without a prescription from a doctor or solely for the feeling or

experience caused by the drug” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2006).

• Interchangeable with “prescription drug abuse” (NIDA website, 2013)

Substance AbuseSubstance Abuse Criteria - A. “A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:• (1) recurrent substance use resulting in a failure to

fulfill major role obligations at work, school, or home• (2) recurrent substance use in situations in which it is

physically hazardous• (3) recurrent substance-related legal problems• (4) continued substance use despite having

persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

B. The symptoms have never met the criteria for Substance Dependence for this class of substance” (APA, 2000)

Which of these can you see being met with appropriate prescribed use of opiates for pain?

Substance DependenceSubstance Dependence Criteria– “A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:• (1) tolerance, as defined by either of the following:

• (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect• (b) markedly diminished effect with continued use of the same amount of the substance

• (2) withdrawal, as manifested by either of the following:• (a) the characteristic withdrawal syndrome for the substance • (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

• (3) the substance is often taken in larger amounts or over a longer period than was intended

• (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use• (5) a great deal of time is spent in activities necessary to obtain the substance, use the

substance, or recover from its effects• (6) important social, occupational, or recreational activities are given up or reduced

because of substance use• (7) the substance use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (APA, 2000) Which of these can you see being met with appropriate prescribed use of opiates

for pain?

Substance Abuse & Dependence• Agent-host-environment model of addictions states that

the interaction between variables that affect the progression from use to abuse to dependence (O’Brien, 2003).

• Substance Abuse – Person takes drug and drug takes drug stage

• Substance Dependence – Drug takes person stage

The Basic Terminology• DSM-IV-TR emphasizes the presence of physical

dependence & tolerance, which may over-diagnose non-problematic patients on long-term opiate treatment (Naliboff, Wu, & Pham, 2006).

• Because we tend to think of “dependence” as tolerance & withdrawal, the medical field prefers to use the term “addiction” to differentiate between patients that have these expected biological changes and those with problematic use (O’Brien, 2003).

The Basic Terminology• Addiction - Short Definition of Addiction: “Addiction is a

primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” (http://www.asam.org; updated 4/12/2011).

The Basic Terminology

• Opiophobia - the fear of inducing addictive disease with opioid exposure (Rosenblatt &Mekhail, 2005).

• Pseudoaddiction - a term which has been used to describe patient behaviors that may occur when pain is undertreated.

Identifying Problematic Use/ “Red Flags”• In the case of patients on long-term opiate

treatment, where tolerance & physical dependence are expected, more emphasis is placed on drug use behaviors.

• It is necessary to keep these distinctions clear in evaluating pain patients

• Many behaviors can signify multiple conditions. • Ex – early prescription refills can point to disease progression,

physical tolerance, or a drug problem(NIDA website, 2013)

• (Naliboff, Wu, & Pham, 2006).

Identifying Problematic Use/ “Red Flags”• Using pain meds other than to control pain,

“psychological dependence” – loss of control, compulsive use, use regardless of self-harm

Things we can observe or query for in inmates:

• Repeated resistance to therapy despite clear adverse effects

• Can’t control use or follow guidelines, lose scripts, miss appointments

• Multiple dose increases despite warnings• Report no improvement despite increase in

dosage• Requesting specific meds (esp short-

acting, euphoric meds like OxyContin) • Decreased ability to work

Identifying Problematic Use/ “Red Flags”

• 3 predictors for addiction in chronic pain patients

• Patients believes he/she is addicted• Patient requests increases in dose or

frequency

• Patient has route of administration preference

(Rosenblatt & Mekhail, 2005)

Aberrant Drug Seeking Behaviors (cont.)

• Behaviors that are more suggestive of addiction include:• Using heroin, buying opiates from street • Forging & selling scripts• Doctor/pharmacy shopping

• “Prescription Drug Monitoring Programs allow physicians and pharmacists to track prescriptions and help identify patients who are "doctor shopping.“”

(NIDA website, 2013)

• Frequent emergency room visits• Current illicit drug or alcohol abuse• Injecting oral drugs• Stealing/ borrowing drugs from others (Passick, 2009; Rosenblatt & Mekhail, 2005)

•These can be queried for in inmate’s history to assess the addiction history. If they have had addiction in the past and are now on opiate medication for chronic pain during incarceration, they should be considered at greater risk of future addiction and treatment should address this.

Possible Pseudoaddiction• Pseudoaddiction - a term which has been used to

describe patient behaviors that may occur when pain is undertreated.

• Patients with unrelieved pain may • become focused on obtaining medication• “clock watch,”• may otherwise seem inappropriately

“drug seeking.” Even such behaviors as

• illicit drug use and • deception can occur in the

patient’s efforts to obtain relief.Pseudoaddiction can be distinguished from true addiction in that the

behaviors resolved when pain is effectively treated (Rosenblatt &Mekhail, 2005).

Possible Pseudoaddiction• Behaviors that are less suggestive of addiction include:

• Aggressive complaining about need for more drugs• Drug hoarding during periods of reduced symptoms• Openly acquiring similar drugs from other medical sources• Requesting specific drugs• Resistance to therapy associated with tolerable adverse effects• Unapproved use of a drug to treat another symptom• Unapproved dose increase on 1 or 2 occasions

• (Passick, 2009)

Risk FactorsAgent-Host-Environment Model Of Addiction

• Agent variables • Psychopharmacology

• rapid onset, quick euphoria• Route of administration – IV• Interactions with other substances

• Environment Variables• childhood abuse• lack of family support• availability (on street or by doctor)• other family/friends that have Rx opiates• Price & purity• Societal/peer pressure• Modeling • (O’Brien, 2003; Rosenblatt & Mekhail, 2005).

What else? (speculation…not much research found here)• Cultural perspective on prescriptions

Risk Factors• Host variables

• Personality• Individual response to drug• Noncompliance - cheeking• Heredity – family history of addiction

or psychiatric disorders• History of addiction

• History of prior drug/alcohol treatment significantly predicted addiction in chronic pain patients

• Current or past history of substance abuse or dependence increases the potential for becoming dependent on opiate medication

• Early onset of non-medical use of prescription opiates • Family history of substance abuse• Other psychiatric disorders (talk more about this in a moment)(McCabe, West, Morales, Cranford, & Boyd, 2007; Rosenblatt & Mekhail, 2005)

Anxiety & Opiates• A significant relationship has been

found between anxiety disorders and opioid dependence.

• Opioids decrease the experience of anxiety and anxiety-related symptoms by lowering blood pressure and slowing down heartbeat and breathing. Some people abuse opioids in order to reduce anxiety or cope with stress. (Scorzelli & Chaundhry, 2009)

Co-occurring Psychopathology• Approximately 60% of people with chronic pain have at least two psychological diagnoses.

•Pain can be made much worse with Some psychological and environmental factors (medicinenet.com/chronic_pain/article.htm)

• Depression, anxiety, and a history of substance abuse

were associated with increased use of prescription opioids. (Wilsey et al., 2008)

• Comorbid psychiatric and medical disorders were found to predict poorer outcomes for substance abuse treatment (Clark et al., 2008).

Gender Findings• 4.5% of women and 5.2% of men reported non-medical use of

prescription opioids in the past year • Women are more likely to identify prescriptions as their primary

substance of abuse. • Non-medical use of prescription opioids in the past year was associated

with:• For men- past-year inhalant use • For women- illicit drug use beginning at 24 years old or older, serious mental illness,

and cigarette smoking in women • For both men & women- illicit drug use and alcohol abuse/dependence (Tetrault et al.,

2007) • With pain:

• estrogen lowers threshold for pain, but women also more likely to not let pain control their lives due to seeking help early, recover more quickly, use variety of coping resources (http://www.medicinenet.com/chronic_pain/page5.htm)

Assessment Approaches & Tools• Complete a thorough evaluation of pain symptoms, opiate

and other substance use patterns including social context of use, social & family risk factors, family & personal history of substance abuse, and psychiatric history (Rosenblatt & Mekhail, 2005)

Assessment Approaches & Tools• 4 A’s of Pain Treatment

• Ongoing assessment of the 4 A’s of pain treatment is a way to monitor a clients pain.

• They include:

• Analgesia (i.e., pain relief)• Activities of daily life (i.e., psychosocial functioning)• Adverse effects (i.e., side effects)• Aberrant drug taking (Passick, 2009)

• This should be the minimal list of things to always ask when working with a chronic pain or dually addicted person

• Also ask about secondary motivations for prolonging pain symptoms or drug taking, such as litigations and addiction. (Rosenblatt & Mekhail, 2005)

Assessment Approaches & Tools• Use a non-judgmental attitude in order to get a more

accurate history. • Clients who feel judged are unlikely to be open about their substance use. • Use a matter-of-fact tone that is consistent with other medical questioning about nutrition, exercise, etc.

• In one study, chronic pain patients were drug screened and 21% lied to their physicians about taking other psychotropic substances (Rosenblatt & Mekhail, 2005)

Assessment Approaches & Tools• AUDADIS-IV operationalizes DSM-IV criteria for SUD’s

(Hasin, Carpenter, McCloud, Smith, & Grant, 1997) • Adult Substance Abuse Subtle Screening Inventory – 3

(SASSI-3)• Screener that identifies high or low probability of substance dependence disorder • Also measures level of defensiveness, willingness to acknowledge problems, and the desire for change.• Available in Adolescent and Spanish language versions

Assessment Approaches & Tools• CAGE-AID

• Originally developed for to screen for alcoholism the questions have been adapted into the CAGE-AID, a more general instrument for screening drug.

• In the past have you ever: • Tried to Cut down or Change your pattern of drinking or drug use? • Been Annoyed or Angry by others' concern about your drinking or drug use?• Felt Guilty about the consequences of your drinking or drug use? • Had a drink or used a drug in the morning (Eye-opener) to decrease hangover or

withdrawal symptoms? • This is a popular screening instrument; however, it is clear from the

information presented that a chronic pain patient who uses opiates as prescribed will likely answer “yes” to one or more of these questions

• With complicated cases, you can refer to a clinical health psychologist that has specialized training in pain management (Naliboff, Wu, & Pham, 2006).

Interventions• For all direct care staff:• The goal is to maximize efficacy & limit unwanted side

effects. We can play a pivotal role in reaching both goals (Naliboff, Wu, & Pham, 2006).

• If safe opioid therapy can’t be established, non-opioid medication or other modalities should be explored (Rosenblatt & Mekhail, 2005).

Interventions for Pain Treatment• Pharmacological options:

• Opiate treatment• Analgesic (aspirin, ibuprophen, acetaminophen) • Anticonvulsant (carbamazepine, gabapentin)• Antidepressants, neuroleptics (Lithium), Benzodiazepines• Antimigraine (ex – Imitrex)• Cannabis (controversial) (http://www.medicinenet.com, pgs 4, 11)

Interventions for Pain Treatment• Physical options:

• Self-administered therapies (eg., bandages, exercise, heat or cold application)

• Limitation of activity• Physical medicine (eg., massage) • Mechanical devices (eg. splints)• Physical and occupational

therapy (Passick, 2009)

• R.I.C.E. – rest, ice, compression, elevation (http://www.medicinenet.com/chronic_pain/page4.htm)

Interventions for Pain Treatment• Medical options to treat chronic pain include:

• Bracing• Injection and radiation therapy• Nerve blocks• Neurodestructive surgical techniques (Passick, 2009)

•Chemonucleolysis (herniated lumbar)•Electrical stimulation•Low power lasers•Magnets•Placebos (controversial)•Surgery•http://www.medicinenet.com/chronic_pain/page4.htm

Interventions for Pain Treatment• Alternative therapies:

• Acupuncture • Chiropractic Treatment • Massage• Nutritional Supplements• Capsaicin (chemical in chili peppers)

• (www.medicinenet.com/chronic_pain/page4.htm)

Interventions for Pain Treatment• Psychological options:

• Biofeedback – learning to control biological reactions by observing changes in biological data

• Cognitive-behavioral therapy• Desensitization• Guided therapy• Hypnosis• Patient education• Psychotherapy for comorbid• Relaxation training

• Relaxation technique relieves pain or keeps it from getting worse by reducing muscle tension.(Passick, 2009) Relaxation for pain & Healing Script:

(http://www.innerhealthstudio.com/pain-management.html) http://www.innerhealthstudio.com/healing-relaxation.html )

•Increasing endorphins through various methods http://www.medicinenet.com/chronic_pain/page6.htm)

Interventions for Opioid Dependence• Research shows a combined approach is better than

pharmacological alone. Not sure if its better than behavioral alone. • Pharmacological options to treat opioid dependence include:

• Naltrexone – antagonist. Keeps opioids from activating receptors• Long-lasting form (Vivitrol) approved for alcohol dependence

• Methadone – synthetic opioid agonist acts on same receptor sites as opioids• Buprenorphine – partial opioid agonist partial antagonist.

• Behavioral options to treat opioid dependence include:• Individual counseling, group or family counseling, contingency management, and

cognitive-behavioral therapies• Take into account type of drug used, individualize treatment to their needs • strategies to function without drugs, deal with cravings, avoid drugs and situations

that could lead to drug use, and handle a relapse should it occur.• also can help patients improve their personal relationships and their ability to

function at work and in the community. (NIDA website, 2013)

Multidisciplinary Interventions• For researchers:• “The development of effective, nonaddicting pain medications

is a public health priority.”• Elderly population• Injured military• Children/teens• People with abuse potential• Research –

• being done on alternative medications that can alleviate pain but have less abuse potential.

• More needed on effective chronic pain management, • including identifying factors that predispose some patients to addiction and developing

measures to prevent abuse.

• (NIDA website, 2013)

Multidisciplinary InterventionsFor all direct care staff:

Always assess for underlying pathology• Understand the need to take a good history w/ a non-judgmental

attitude• Understand that opiates are rewarding substances & be mindful of

risk factors.• Individualize each patient’s pain treatment

• Be consistent with patients while individualizing treatment. • Have strict rules & regulations about treating • chronic pain patients with opiates (HSU)

• Change drugs, dose, frequency, & route • as needed

(Rosenblatt & Mekhail, 2005)

Multidisciplinary Interventions• For HSU: • Use least invasive route and least dosage necessary with

least side effects• Avoid IV or inhaled opiates for patients with current of

history of addiction, as exposure to these routes can be a trigger for relapse• Long-acting opiates are preferred• Less risky routes are oral, rectal, topical, transmucosal, and

transdermal• We want less euphoria and more steady blood levels • Euphoria can be a trigger for relapse• Intrathecal (implanted pumps) route can be considered(Rosenblatt & Mekhail, 2005)

Multidisciplinary Interventions• For the doctor:• Opioid Contract• Don’t undermedicate, as it

could lead to addiction• Random drug screening to

check for opiate levels as well as others substances of abuse

• Refer for substance abuse evaluation & treatment if addiction is suspected

(Rosenblatt & Mekhail, 2005)

Multidisciplinary Interventions• For the pharmacist:• Help patients understand instructions• Watch for fake, altered Rxs• Log Rx fills on prescription drug monitoring program & be mindful of

what the database says about patient• For the patient:• Follow the prescription• NEVER change dosage without talking to provider• Aware of drug-drug interactions• NEVER use someone else’s prescription• ALWAYS inform provider of other drugs, supplements you’re taking• Discard unused medication properly to avoid possibility of family or

friend misusing your medication(NIDA website, 2013)

Take Home• In order to provide people the best treatment, it is imperative we take

a good history with a non-judgmental attitude, and monitor symptoms in a consistent fashion

• At minimum, ask about the 4 A’s of Pain Assessment (Analgesia, Activities of daily life, Adverse effects, Aberrant drug taking

• Screen for the risk factors the patients possesses and the red flags or aberrant drug-seeking behaviors

• Working with Chronic Pain patients on Opioid treatment can be difficult to assess for addiction, but there are aids available

• Treatment for Chronic Pain and Opiate Dependence requires a multidisciplinary approach

• Many psychological and non-opioid treatment options are recommended for chronic pain treatment – there is a lot we can do!

References• American Academy of Pain Medicine, American Pain Society, & American Society

of Addiction Medicine. (2001). Definitions related to the use of opioids for the treatment of pain. Glenview, IL: Author.

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author.

• Clark, M. R., Stoller, K. B., & Brooner, R. K. (2008). Assessment and management of chronic pain in individuals seeking treatment for Opioid dependence disorder. Canadian Journal of Psychiatry, 58(8), 496-508.

• Hasin, D., Carpenter, K. M., McCloud, S., Smith, M., & Grant, B. F. (1997). The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a clinical samples. Drug and Alcohol Dependence, 4, 133-141.

• http://www.innerhealthstudio.com/html • McCabe, S. E., West, B. T., Morales, M., Cranford, J. A., & Boyd, C. J. (2007).

Does early onset of non-medical use of prescription drugs predict subsequent prescription drug abuse and dependence? Results from a national study. Addiction, 102, 1920-1930.

• www.medicinenet.com/chronic_pain searched on 6/25/13

References• National Institute on Drug Abuse (2005, July). Prescription drugs:

Abuse and addition. Research Report Series. Bethesda, MD: United States Department of Health and Human Services, National Institutes of Health, National Institute of Drug Abuse.

• National Institute on Drug Abuse. (2009). NIDA launches drug use screening tools for physicians. News release. http://archives.drugabuse.gov/newsroom/09/NR4-20.html

• National Institute on Drug Abuse. (2009, September). Treatment approaches for drug addiction. NIDA Infofacts. Bethesda, MD: United States Department of Health and Human Services, National Institutes of Health, National Institute of Drug Abuse.

• National Institute on Drug Abuse. (2010, January). Nationwide trends. NIDA Infofacts. Bethesda, MD: United States Department of Health and Human Services, National Institutes of Health, National Institute of Drug Abuse.

References• O’Brien, C. P. (2003). Research advances in the understanding and treatment of

addiction. The American Journal on Addictions, 12, S36-47. • Passik, S. D. (2009). Issues in long-term opioid therapy: Unmet needs, risks, and

solutions. Mayo Clinic Proceedings, 84(7), 593-601. • Schnoll. S. H., & Weaver, M. F. (2003). Addiction and pain. The American Journal

on Addictions, 12, S27-S35. • Scorzelli, J. F., & Chaudhry, S. Z. (2009). Relationship between anxiety and

addiction to a depressant drug. Journal of Psychoactive Drugs, 41(1), 61-66. • Substance Abuse and Mental Health Services Administration. (2006). Results from

the 2005 National Survey on Drug Use and Health: National findings. Rockville, MD: Substance Abuse and Mental Health Services Administration.

• Tetrault, J. M., Desai, R. A., Becker, W. C., Fiellin, D. A., Concato, J., & Sullivan, L. E. (2007). Gender and non-medical use of prescription opioids: Results from a national US survey. Addiction, 103, 258-268.

• Wilsey, B. L., Fishman, S. M., Tsodikov, A., Ogden, C., Symreng, I., & Ernest, A. (2008). Psychological comorbidities predicting prescription opioid abuse among patients in chronic pain presenting to the emergency department. Pain Medicine, 9(8), 1107-1117.