Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
CHRONIC PAIN RECOMMENDATION 3: RISK OF SUBSTANCE USE DISORDER SCREENING Recommendation 3.1: Screen for Risk of Opioid Use Disorder Use a validated screening tool to assess the patient’s risk of opioid use disorder prior to prescribing an opioid medication long-term for chronic pain. Long-term use of opioid medications to treat chronic pain safely requires the commitment of adequate resources to regularly monitor and evaluate outcomes and identify occurrence of adverse consequences. The screening tool results are intended to assist the prescriber in determining whether opioid therapy is appropriate and in determining the level of monitoring appropriate for the patient’s level of risk. Prescribers may use one of the standardized screening forms to help determine personal and family risks: • Patient Health Questionnaire (PHQ-4) or (PHQ-9) • Opioid Risk Tool (ORT©) • Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R®) • Current Opioid Misuse Measure (COMM®) • Alcohol, Smoking, and Substance Screening Test (ASSIST) These forms can be found in the Tools and Resources section. Recommendation 3.2: Obtain a Urine Drug Screen Urine drug screening is strongly recommended before initiating opioid treatment for chronic pain. Research and experience have shown that drug testing can identify problems, such as use of undisclosed medications, non- use of reported medications (i.e., drug hoarding or diversion), undisclosed use of alcohol, or use of illicit substances. It is recommended that drug testing be conducted, especially when other factors suggest a patient is at risk for opioid misuse, abuse, or overdose. If the condition started with acute pain and there is consideration for chronic use, at least one drug screen in approximately 1-2 months is advised. A positive drug screen indicates the need for caution but does not preclude opioid use for treatment of pain. Consideration should be given to referring the patient to substance abuse counseling and/or to a pain management specialist. If urine drug screening is positive for drugs that were not prescribed, are Utah Clinical Guidelines on Prescribing Opioids for the Treatment of Pain illegal, or for the absence of the prescribed meds, document this in the patient’s record and counsel the patient about adherence to a drug treatment plan or initiating a drug contract.
Opioid medications are not the appropriate first line of treatment for most patients with chronic pain. Other non- pharmacologic and non-opioid pharmacologic therapies should be tried and the outcomes of those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies are proven inadequate. Care should be taken to assure that use of opioid pain treatment does not interfere with early implementation of functional restoration programs, such as exercise and physical therapy. Recommendation 1.2: Identify if Benefits Outweigh the Risks Proactively consider initial and ongoing risks associated with opioid exposure based on age of the patient, history of substance use disorder, or psychiatric, physical, or medical comorbidities. Prescribers should only consider opioid therapy for a patient when expected benefits of pain improvement, function, and quality of life are anticipated to outweigh the risks. Identify if benefits outweigh the risks by completing recommendation sections 2. Comprehensive Evaluation and 3. Screening for Risk of Substance Use Disorder and by determining desired treatment outcomes. CHRONIC PAIN RECOMMENDATION 2: COMPREHENSIVE EVALUATION Recommendation 2.1: Complete a Comprehensive Patient Evaluation A comprehensive evaluation should be performed before initiating opioid treatment for chronic pain. The comprehensive evaluation consists of the patient’s social/ work history, medical history, mental health/substance use history, and physical examination. The goal of the comprehensive evaluation is to determine the nature of the patient’s pain; evaluate how the pain is impacting the patient’s job requirements, activities of daily living, and quality of life; identify other conditions or circumstances that could affect the choice of treatment or the approach to managing that treatment; assess and evaluate prior approaches to pain management; and serve as a basis in establishing a treatment plan and evaluation of treatment outcomes. For more specific information about what the comprehensive evaluation includes, see the Tools and Resources section. Recommendation 2.2: Check Disease-specific Guidelines Prescribers should refer to disease-specific guidelines for recommendations of treatment for specific diseases or conditions of chronic pain.
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