Responsible and Effective Opioid Prescribing _ ____________________________________________________
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
Low Risk Definable physical pathology with objective signs and reliable symptoms Clinical correlation with diagnostic testing, including MRI, physical examination, and interventional diagnostic techniques With or without mild psychologic comorbidity With or without minor medical comorbidity No or well-defined and controlled personal or family history of alcoholism or substance abuse Age 45 years or older High levels of pain acceptance and active coping strategies High motivation and willingness to participate in multimodal therapy and attempting to function at normal levels Medium Risk Significant pain problems with objective signs and symptoms confirmed by radiologic evaluation, physical examination, or diagnostic interventions Moderate psychologic problems, well controlled by therapy Moderate coexisting medical disorders that are well controlled by medical therapy and are not affected by chronic opioid therapy (e.g., central sleep apnea) Develops mild tolerance but not hyperalgesia without physical dependence or addiction History of personal or family history of alcoholism or substance abuse Pain involving more than three regions of the body Defined pathology with moderate levels of pain acceptance and coping strategies Willing to participate in multimodal therapy, attempting to function in normal daily life High Risk Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of alcoholism or drug misuse, abuse, addiction, diversion, dependency, tolerance, or hyperalgesia
Major psychologic disorders Age younger than 45 years HIV-related pain High levels of pain exacerbation and low levels of coping strategies Unwilling to participate in multimodal therapy, not functioning close to a near normal lifestyle HIV = human immunodeficiency syndrome, MRI = magnetic resonance imaging. Source: [33; 34]
Table 1
Screening Instrument or Substance Abuse Potential (SISAP) The Screening Instrument or Substance Abuse Potential (SISAP) tool is a self-administered, five-item questionnaire addressing history developed used to predict the risk of opioid misuse. The SISAP is used to identify patients with a history of alcohol/substance abuse and improve pain management by facilitating focus on the appropriate use of opioid analgesics and therapeutic outcomes in the majority of patients who are not at risk of opioid abuse, while carefully monitoring those who may be at greater risk [36]. CAGE and CAGE-AID The original CAGE (Cut down, Annoyed, Guilty, and Eye- opener) Questionnaire consisted of four questions designed to help clinicians determine the likelihood that a patient was misusing or abusing alcohol. These same four questions were modified to create the CAGE-AID (adapted to include drugs), revised to assess the likelihood of current substance abuse [38].
Diagnosis, Intractability, Risk, and Efficacy (DIRE) Score The Diagnosis, Intractability, Risk, and Efficacy (DIRE) risk assessment score is a clinician-rated questionnaire that is used to predict patient compliance with long-term opioid therapy [36; 39]. Patients scoring lower on the DIRE tool are poor candidates for long-term opioid analgesia.
INFORMED CONSENT AND TREATMENT AGREEMENTS
The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [1]. This agreement should address potential side effects, tolerance and/or physical dependence, drug interactions, motor skill impairment, limited evidence of long-term benefit, misuse, dependence, addiction, and overdose. Informed consent documents should include information regarding the risk/ benefit profile for the drug(s) being prescribed. The prescribing policies should be clearly delineated, including the number/ frequency of refills, early refills, and procedures for lost or stolen medications.
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