_____________________________________________________ Responsible and Effective Opioid Prescribing
A lack of appropriate education and training in the assessment and management of pain has been noted to be a substantial contributor to ineffective pain management [29; 31]. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [29; 31]. Clinicians require a clear understanding of available medications to relieve pain, including appropriate dosing, safety profiles, and side effects. If necessary, clinicians should consult with pain specialists to develop an effective approach. Strong opioids are used for severe pain at the end of life [26; 27]. Morphine, buprenorphine, oxycodone, hydromorphone, fentanyl, and methadone are the most widely used in the United States [32]. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. For patients who are opioid-naïve or who have been receiving low doses of a weak opioid, the initial dose should be low, and, if pain persists, the dose may be titrated up daily until pain is controlled. More than one route of opioid administration will be needed by many patients during end-of-life care, but in general, opioids should be given orally, as this route is the most convenient and least expensive. The transdermal route is preferred to the parenteral route, although dosing with a transdermal patch is less flexible and so may not be appropriate for patients with unstable pain [27]. Intramuscular injections should be avoided because injections are painful, drug absorption is unreliable, and the time to peak concentration is long [27]. CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state prescription drug monitoring program (PDMP), and from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses ( Table 1 ) [33; 34]. Low-risk patients receive the standard level of monitoring, vigilance, and care. Moderate-risk patients should be considered for an additional level of monitoring and provider contact, and high-risk patients are likely to require intensive and structured monitoring and follow-up contact, additional consultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations [18; 35]. Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1]: • Pain indications for opioid therapy • Nature and intensity of pain • Past and current pain treatments and patient response • Comorbid conditions • Pain impact on physical and psychologic function
• Social support, housing, and employment • Home environment (i.e., stressful or supportive) • Pain impact on sleep, mood, work, relationships, leisure, and substance use • Patient history of physical, emotional, or sexual abuse If substance abuse is active, in remission, or in the patient’s history, consult an addiction specialist before starting opioids [1]. In active substance abuse, do not prescribe opioids until the patient is engaged in treatment/recovery program or other arrangement made, such as addiction professional co-management and additional monitoring. When considering an opioid analgesic (particularly those that are extended-release or long-acting), one must always weigh the benefits against the risks of overdose, abuse, addiction, physical dependence and tolerance, adverse drug interactions, and accidental exposure by children [18; 24]. Screening and assessment tools can help guide patient stratification according to risk level and inform the appropriate degree of structure and monitoring in the treatment plan. It should be noted that despite widespread endorsement of screening tools used to help determine patient risk level, most tools have not been extensively evaluated, validated, or compared to each other, and evidence of their reliability is poor [33; 34].
RISK ASSESSMENT TOOLS Opioid Risk Tool (ORT)
The Opioid Risk Tool (ORT) is a five-item, patient- administered assessment to help predict aberrant drug-related behavior. The ORT is also used to establish patient risk level through categorization into low, medium, or high levels of risk for aberrant drug-related behaviors based on responses to questions of previous alcohol/drug abuse, psychologic disorders, and other risk factors [36]. Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP-R) The Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP-R) is a patient-administered, 24-item screen with questions addressing history of alcohol/substance use, psychologic status, mood, cravings, and stress. Like the ORT, the SOAPP-R helps assess risk level of aberrant drug-related behaviors and the appropriate extent of monitoring [36; 37]. 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].
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MDTX1625
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