Screen for opioid abuse risk factors Screening and monitoring in pain management seeks to identify patients at risk of substance misuse and overdose as well as improve overall patient care. Evaluations of patient physical and psychological history can screen for risk factors and help characterize pain to inform treatment decisions. Screening approaches include efforts to assess for concurrent substance use and mental health disorders that may place patients at higher risk for OUD and overdose. This includes screening for drug and alcohol use and the use of urine drug testing, when clinically indicated. These approaches enable providers to identify high-risk patients so that they can consider whether to prescribe opioids, engage substance misuse and mental health interventions, and education materials to mitigate opioid misuse. 16 Many tools have been developed for the formal assessment of a patient’s risk of having a substance misuse problem, some of which are appropriate for routine clinical use because they are relatively brief and easily implemented. Table 1 lists the tools that appear to have good content and construct validity for assessing patient risks related to chronic opioid therapy, although to date, no single tool has been widely endorsed or thoroughly validated. 28 The Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based tool used to facilitate screening patients for OUD, which typically takes 5-10 minutes to administer. 29 SBIRT has been endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA), but should always be paired with referral to treatment. 30 SAMHSA recommends universal screening with oral or writing-based tools because of the high prevalence of substance use disorders in patients visiting primary care settings. In contrast, universal screening with urine, blood, or oral fluid tests are not recommended. 30 In the context of pain care, however, the 2016 CDC guidelines recommend urine drug testing before initiating opioid therapy and probably at least annually when prescribing opioids for chronic pain. 31
Other tools for universal substance abuse screening include: • Single screening question screening tool for drug use • Drug Abuse Screening Test (DAST) 10 • Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) • Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) • the CAGE questionnaire adapted to include drugs (CAGE-AID) Use drug monitoring programs As of March, 2020, all U.S. states (except Missouri) and the District of Columbia have operational prescription drug monitoring programs (PDMPs). 32,33 Information available through PDMPs varies based on reporting requirements and restrictions, but may include DEA schedules reported, timeliness of pharmacy dispensing information, access, and required reviews. Recommendations for using a PDMP include: • Check the PDMP before starting anyone on opioid therapy. • Review the PDMP periodically throughout opioid therapy (at least every 3 months). • Look for prescriptions for other controlled substances, like benzodiazepines, that can increase risk of overdose death. • Review the total MMED (Morphine Milligram Equivalent Dose). Some states have specific requirements for PDMP use, such as requiring review prior to initial prescription or any time a specific prescription is written, such as for hydrocodone ER (Zohydro), therefore clinicians should remain updated about the specific requirements of their state PDMPs. Urine drug testing Urine drug testing (UDT) is recommended before prescribing any opioid and at least annually thereafter. 31 Providers using urine drug screens should be familiar with the metabolites and expected positive results based on the opioid prescribed. For example, a patient taking oxycodone may test positive for both oxycodone and oxymorphone (a metabolite). 34 UDT often involves both presumptive
(screen) testing, and definitive (quantitative) testing because many synthetic and semisynthetic opioids cannot be detected by presumptive testing alone. 35,36 If the prescribed opioid is not detected, discuss the finding with the patient and, if diversion is confirmed or suspected, re-evaluate the pain management strategy or taper the opioid. If the patient tests positive for unprescribed drugs, schedule more frequent follow-up visits, consider opioid discontinuation, offer naloxone, or refer for treatment for substance use disorder. Decision tools and help with interpreting urine drug testing results are available at: http://mytopcare.org/udt- calculator/interpret-opiates-test-result. Pain management overview Many pharmacologic and non-pharmacologic approaches to treating pain are available to primary care providers. These options should be employed using the following general principles: • Identify and treat the source of the pain, if possible, although pain treatment can begin before the source of the pain is determined • Select the simplest approach to pain management first. This generally means using non-pharmacologic approaches as much as possible and/or trying medications with the least severe potential side effects, and at the lowest effective doses • Establish a function-based, individualized treatment plan if therapy is expected to be long-term Non-drug approaches Many nonpharmacologic and self-management treatment options have been found to be effective alone or as part of a comprehensive pain management plan, particularly for musculoskeletal pain and chronic pain. 37 Examples include, but are not limited to, psychological, physical rehabilitative and surgical approaches, procedural therapies (e.g., injections, nerve blocks), complementary therapies, and use of approved/cleared medical devices for pain management.
Table 1. Tools for patient risk assessment
Tool
Use
Who Administers?
Length
Current Opioid Misuse Measure (COMM)
Monitor for misuse by patients currently on long-term opioid therapy Screen for risk of opioid addiction Screen for risk of opioid addiction
Patient self-report
17 items
Diagnosis, Intractability, Risk, Efficacy (DIRE)
Clinician
7 items
Opioid Risk Tool (ORT)
Clinician or patient self-report
5 yes/no questions 24 items
Screener and Opioid Assessment for Patients with Pain, Version 1 and Revised (SOAPP, and SOAPP-R)
Screen for risk of opioid addiction
Patient self-report
47
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