Q&A with Robert Jamison, PhD

With the crusade against the over-prescription of opioids, medical professionals are finding it difficult to ascertain if and when they should ever prescribe the medications to clients.

The chief psychologist at the Pain Management Center of Chestnut Hill, Mass., Robert Jamison,Ph.D has worked with pain management for close to 30 years and has witnessed the rise and fall of opioids as the go-to medication for treatment. As his team realized how detrimental the drugs could be to some patients, they began to search for a way to predict just who may be at risk for abusing opioids and to see if those risks could be ameliorated.

Jamison, who is also a professor at Harvard Medical School and Brigham and Women’s Hospital, teamed up with colleagues at the Pain Management Center to create a series of questionnaires that can help medical professionals identify candidates who may not do well with opioids.

He spoke with Catherine Robertson Souter of New England Psychologist about the work they have done to help fight the opioid crisis, his career in pain management, and several other technological advances they have been working on.

Can you tell us about the questionnaires that you developed?

I kind of backed in to the opioid crisis. Like others, we were also pretty liberal about offering medication to anyone with cancer pain but we began to realize over time that it just causes more trouble.

Doctors are not good detectives and they can’t tell who is going to take their pain medication or who is going to misuse it. So, we developed studies through some NIH grants to determine if we can come up with a self-report measure to identify those people that are at risk.

There have been several generations of the questionnaires over time. How have they evolved?

The first was the Screener and Opioid Assessment for Pain Patients, or SOAPP. We initially developed that with questions that were pretty obvious. As you can imagine, if you are asked “yes” or “no” if you have ever abused or misused opioids there is a tendency to under report. We revised that to include more subtle answers, so now the questionnaire answers are all from “never” to “very often” on each question. But, of course, you can answer “seldom” but we see that as basically a “yes.”

We were also able to determine scores for each question and to add them up to help determine people who really over time misuse their medication. We found that anyone scoring 18 or higher pretty much captured 90% of the people who are going to misuse their prescription.

Then we developed a companion questionnaire called the Current Opioid Misuse Measure which is basically the same type of format but looking at how often in the last 30 days.

In the process, we developed a third questionnaire called the Opioid Compliance Checklist, a yes/no questionnaire to do with what is found in an opioid agreement typically operant at any pain center.

The questionnaires have seen widespread use since first introduced in 2004. They have really become integral in various practices.

We have been quite surprised at how wide-spread this has become and how much interest there has been in using them. I see it all the time in clinical reports and trials that incorporate these questionnaires.

They help providers get more confident in terms of managing people that are really perceived to be low risk.

We know that long term use of chronic opioid therapy is probably not a good thing but there are some people prescribed opioids post operatively with hip or knee replacements surgery or back surgery who are really just not that high a risk.

If they are determined to be a high risk, what are the options?

We did another study to show that if you have someone who is higher risk, careful attention and very close monitoring seems to help in terms of getting them to be more compliant with their opioid use.

They can also be informed that we do this questionnaire and, just like some people are at risk for heart disease, they would be informed that they have risk factors that suggest we might need to keep careful monitoring and be paying careful attention.

And some people use these measures to say, “We are going to try to treat your pain but you are probably not a good candidate for narcotics.”

Do you find some people appreciate knowing that they may be at risk?

I think it is good for them to be informed that they have some qualities or characteristics that place them at risk and that monitoring is indicated. And so, I think you are right, some people are grateful that they get that information.

The tools you developed, are they available for general use?

Yes, they are available for anyone who wants to use them for free and they are pretty easy to score.

Who is typically using them?

Certainly, in specialty pain management centers they tend to be used a lot. But now we are finding them in virtually all clinics, primary care, gerontology, oncology, and a whole lot of places that feel they want to document any risk factors.

Since these are self-reported questionnaires, it is very possible that people can under-report or falsify but I have always said that anything you can document that they actually did themselves and they sign, if you show they were not honest or reliable, that is more indication that they were probably not good candidate for opioids.

And, I expect that also showing due diligence would help protect the practitioner legally if someone does become addicted.

I think it has helped reassure some providers that they are really doing diligence to track people when they prescribe these medications.

You have been working in pain management for close to three decades. What has changed in how we understand or treat it?

There has been a real change in terms of how we see chronic pain. Medicine has done a good job of keeping people alive for a long time so basically, we tend to die with chronic illnesses and most of those are associated with pain.

With chronic pain, people still hold on to a medical model; they want to know what the problem is and they want someone to make it all go away. But those options are limited.

It boils down to how to help people deal with a chronic condition that interferes with all aspects of their life. That is where psychology can play a role. There is a lot of evidence that cognitive behavioral therapy in particular or acceptance commitment therapy or some behavioral strategies can be helpful in getting people to cope with their conditions.

Your team has been working on several sideline projects as well, a smartphone pain app and studying teletherapy?

We have been interested in using technology to help people track their progress. If you could track how you are doing and have line graphs, you can share that with your provider. It gives you more objective information about your progress.

And we have been experimenting now with telemedicine. We found that people who did the remote groups were more compliant, they were able to make more sessions. The online groups were found to be equally as beneficial as the in-person groups. I think that is going to be happening in the future much more, to be able to connect with people using technology and these programs.

What else can you share about your work with our readers?

I think what we discovered for psychologists is that there is a lot of specializing within the field for which they can be very valuable. It is not just a mental health center kind of occupation any more.

For instance, psychologists can play a real role with people with chronic pain and with chronic illnesses where they can offer behavioral interventions that help people cope and manage. This field didn’t exist when I was training so this is going to be something that will go continue to expand.

I think there is a lot of excitement around having psychology as a background.