Screening tools. The APS/AAPM guidelines recommend empirically derived screening questionnaires (TABLE 2)8 to help you identify misuse potential before initiating opioid therapy. Instruments also are available to monitor misuse for individuals already in treatment. The Screener and Opioid Assessment for Patients with Pain (SOAPP) appears to be the most predictive of misuse potential, although selecting a screening instrument may depend on particular practice needs.14 These tools are most valuable when used within a comprehensive evaluation that includes the clinical interview with history and pain assessment.
TABLE 2
Questionnaires for screening and opioid misuse risk identification8
| Risk assessment tools | |
| Screener and Opioid Assessment for Patients with Pain (SOAPP) http://www.painedu.org/soapp.asp | Predicts how much monitoring a patient will need on long-term opioid therapy |
| Opioid Risk Tool (ORT) http://www.partnersagainstpain.com/printouts/ Opioid_Risk_Tool.pdf | Assesses for known conditions that indicate higher risk for medication misuse, including history of substance abuse, age, history of sexual abuse, and psychiatric disorders |
| Diagnosis, Intractability, Risk, Efficacy (DIRE) http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5& ved=0CEgQFjAE&url=http%3A%2F%2Fwww.fmdrl.org%2Findex.cfm%3Fevent%3Dc .getAttachment%26riid%3D6613&ei=vJ7lULDHFqKc2AWCiIGwAQ&usg=AFQjCNECSYFnam9UATA-Xm_JQ0cjm6Xdiw& bvm=bv.1355534169,d.b2I | Assigns the patient a score of 1 to 3 for each of 4 factors: diagnosis, intractability, risk (psychological, chemical health, reliability, social support), and efficacy |
| Monitoring tools during long-term opioid therapy | |
| Pain Assessment and Documentation Tool (PADT) http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/maperc/online/Documents/Pain Assessment Documentation Tool %28PADT%29.pdf | Assesses pain relief, daily functioning, and opioid-related adverse events; also whether patient appears to be engaging in potential aberrant drug-related behaviors |
| Current Opioid Misuse Measure (COMM) http://www.painedu.org/soapp.asp | Assists in identifying patients exhibiting aberrant drug-related behaviors |
When you identify someone at high risk of opioid misuse, proceed carefully using multiple sources of clinical information. Balance appropriate pain care with safeguarding against misuse. In the absence of evidence of current misuse, the decision depends on clinical judgment. You might try alternative pain treatments to avoid opioid exposure or consider opioid analgesics with additional monitoring of prescribing (TABLE 3).8
TABLE 3
Practical strategies for addressing opioid misuse8
Before treatment
|
During treatment
|
When things go wrong
|
Managing risk during treatment
Opioid trial. The APS/AAPM panel8 and the World Health Organization analgesic ladder for treating cancer pain15 recommend an opioid trial before long-term opioids are prescribed. This approach assumes that opioid therapy may not be universally effective and appropriate for all patients and all pain complaints for which opioids are indicated.
By agreeing to an evaluation period, such as 30 days, you and your patient understand that opioid treatment may not continue beyond the trial without an accompanying treatment response. Whereas you may tailor specific outcomes to the individual, a successful response should include:
-
reduced pain
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increased function (such as return to work or other valued activities)
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and improved quality of life.
If the agreed-upon outcomes are not met, consider discontinuing the opioid trial and trying alternative treatments. Full discussion of the well-documented strategies for managing opioid therapy is beyond the scope of this article. (See other sources for information about strategies such as opioid rotation, which involves switching from one opioid to another in an effort to increase therapeutic benefit or reduce harm.16,17 )
Monitoring aids. In addition to screening and monitoring questionnaires, urine drug screens and prescription monitoring programs (PMPs) can help you objectively monitor for aberrant drug-related behaviors that may indicate misuse.