Transcript Journal Club

Journal Club
Alcohol, Other Drugs, and Health: Current Evidence
May-June 2007
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Featured Article
Persistent pain is associated with
substance use after detoxification:
a prospective cohort analysis
Larson MJ, et al. Addiction. 2007;(Online Early Articles):
doi: 10.1111/j.1360-0443.2007.01759.x.
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Study Objective
To examine whether persistent pain is
associated with…
• an increased odds of substance use
after detoxification
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Study Design
• This was a secondary analysis of 397 subjects
who had participated in a randomized clinical trial.
• All subjects had been admitted to an urban,
residential drug and alcohol detoxification unit and
interviewed periodically over 24 months.
• Researchers assessed pain with the SF-36 Health
Survey and substance use with the Addiction
Severity Index.
• Analyses were adjusted for potential confounders.
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Assessing Validity of an
Article about Prognosis
• Are the results valid?
• What are the results?
• How can I apply the results to
patient care?
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Are the Results Valid?
• Was the sample representative?
• Were the subjects sufficiently homogeneous with
respect to prognostic risk?
• Was follow-up sufficiently complete?
• Were objective and unbiased outcome criteria
used?
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Was the sample representative?
• The sample was a cohort of adults admitted to an urban,
residential alcohol and drug detoxification unit.
– It is unclear how many were referred; 470 of 642
consented to enroll in the randomized trial.
• Because the primary study evaluated efforts to link
patients to primary care after detoxification, patients who
already had a primary care provider were excluded.
– This somewhat limits the representativeness of the sample.
• Other important exclusions included being pregnant, not
being able to list 3 contacts, and not providing consent.
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Were the subjects sufficiently homogeneous
with respect to prognostic risk?
 All patients received standard detoxification
services.
 Randomization occurred after detoxification,
indicating that the risk of relapse should have
been similar in all subjects.
 No information was provided on the distribution
of pain disorders across the two study arms.
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Was follow-up
sufficiently complete?
•
Subjects were assessed every 6 months over
24 months.
•
69% completed the 24-month interview.
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Were objective and unbiased
outcome criteria used?
• Self-reported outcomes (in the past 30 days) were assessed
with the Addiction Severity Index and included...
– Heavy alcohol use (>3 drinks on at least 1 day or
intoxication)
– Cocaine use
– Heroin/opioid use
– Any substance use (i.e., heavy alcohol use or illicit use of
cocaine or opioids)
• There was no mention of blinding to the primary
independent variable of pain as assessed by the SF-36.
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What are the Results?
• How likely are the outcomes over time?
• How precise are the estimates of
likelihood?
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How likely are the outcomes over time?
Results (prospectively assessed):
• 16% reported persistent pain (moderate-to-higher pain
levels at all available interviews) in the 24 months after
detoxification.
• Subjects reporting persistent pain were more likely than
those with mild or no pain to have (in the past 30 days at
the 24-month follow-up)…
–
–
–
–
used any substance (odds ratio [OR], 4.21);
used heroin/opioids not prescribed for pain (OR, 5.36);
consumed >3 drinks on at least 1 day or been intoxicated (OR, 2.15);
used cocaine (OR, 2.05).
• All results, except for cocaine use, were significant.
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How precise are the estimates
of likelihood?
• Confidence Intervals [CI] are wide:
– For any substance use: OR, 4.21; 95% CI, 1.90-9.33
– For heroin/opioid use: OR, 5.36; 95% CI, 2.09-13.75
– For heavy alcohol use: OR, 2.15; 95% CI, 1.03-4.51
– For cocaine use: OR, 2.05; 95% CI, 0.91-4.62
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How Can I Apply the Results to
Patient Care?
• Were the study patients and their
management similar to those in my practice?
• Was the follow-up sufficiently long?
• Can I use the results in the management of
patients in my practice?
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Were the study patients similar
to those in my practice?
• Subjects are fairly representative of patients
receiving residential detoxification.
• However, patients with existing primary care
providers were excluded.
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Was the follow-up
sufficiently long?
• Follow-up occurred over 24 months.
• This timeframe is clinically important.
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Can I use the results in the
management of patients in my practice?
• These results should be primarily used to heighten
clinicians’ concern about the risk of relapse to any
substance–particularly opioids or alcohol–in their
patients discharged from detoxification.
• Next steps should include exploring various
strategies (nonopioid vs. opioid) for treating pain in
patients with persistent complaints of pain after
detoxification.
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