Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ Screener and Opioid Assessment for Patients with Pain–Revised
Low-risk patients receive the standard level of moni- toring, 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 con- sultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations [21]. SAFETY PRECAUTIONS A simplified approach to opioid prescribing safety, based on the core concept of universal precautions but designed with high specificity for opioid analge- sics, was presented at the 2013 annual conference of the AAPM. The eight principles are specifically intended to reduce fatalities with opioid analgesic prescribing and are now incorporated in the AAPM Safe Opioid Prescribing Initiative [122]. They may be recalled using the acronym RELIABLE: • R espiratory: If a patient on long-term opioids develops a respiratory condition (e.g., asthma, pneumonia, flu), reduce the opioid dose by 20% to 30%. • E xperience: Assess the patient before prescribing opioids to explore biologic, social, and psychiatric risk factors. • L ong-term: Extended-release opioids should not be used for acute pain. • I nitiating methadone: Never start methadone at a dose ≥15 mg/day. • A pnea: Screen for hypoxemia and obstructive or central sleep apnea, especially in patients who are taking 150 mg/day MED or who are obese, infirm, or elderly. • B enzodiazepines: Avoid these agents if possible because they enhance opioid toxicity. • L ook for comorbidities: Patients often misuse opioid analgesics for their mental health disorder instead of their pain, so assess patients for a history of bipolar disorder, post- traumatic stress disorder, depression, stress, and general anxiety disorder.
The Screener and Opioid Assessment for Patients with Pain–Revised (SOAPP-R) is a patient-admin- istered, 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 [118]. CAGE and CAGE-AID The original CAGE (Cut down, Annoyed, Guilty, and Eye-opener) Questionnaire consists of four questions designed to help clinicians determine the likelihood that a patient is misusing or abusing alcohol. These same four questions were adapted to include drugs (CAGE-AID), and this tool may be used to assess the likelihood of current substance abuse [119]. Diagnosis, Intractability, Risk, Efficacy Tool The Diagnosis, Intractability, Risk, Efficacy (DIRE) tool is a clinician-rated questionnaire used to predict patient compliance with long-term opioid therapy [120]. Patients scoring lower on the DIRE tool are poor candidates for long-term opioid analgesia. Mental Health Screening Tool The Mental Health Screening Tool is a five-item screen that asks about a patient’s feelings of hap- piness, calmness, peacefulness, nervousness, and depression in the past month [121]. A lower score on this tool is an indicator that the patient should be referred to a specialist for pain management. PATIENT RISK STRATIFICATION Common to most clinical practice guidelines, and discussed in the FSMB 2017 Guidelines, is patient stratification by level of risk [113]. All practice guide- lines for opioid analgesic prescribing recommend assessing the risk of misuse, abuse, or addiction in all patients before initiating long-term (≥90 days) opioid therapy and in high-risk patients prior to acute pain therapy. Patient risk level is designated as low, medium, or high based on background and clinical characteristics ( Table 9 ) [97].
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MDMS1526
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