Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
The Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based tool that screens for OUD and takes 5-10 minutes to administer [11]. SBIRT, endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA), should always be paired with referral to treatment [12]. 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 the context of pain care, however, the 2022 CDC guidelines recommend urine drug testing before initiating opioid therapy and probably at least annually when prescribing opioids for chronic pain. 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) DRUG MONITORING PROGRAMS Prescription drug monitoring programs (PDMPs) have been implemented in 49 of 50 states, the District of Columbia, and one U.S. territory (Guam). Information available through PDMPs varies based on reporting requirements and restrictions but may include Drug Enforcement Agency (DEA) schedules reported, timeliness of pharmacy dispensing information, access, and required reviews.
TYPES OF PAIN Nociceptive and neuropathic pain respond differently to pain treatments. Neuropathic pain may respond poorly to both opioid analgesics and nonsteroidal anti-inflammatory (NSAID) agents. Other classes of medications, such as anti- epileptics, antidepressants, or local anesthetics, may provide more effective relief for neuropathic pain [8]. CHRONIC PAIN THAT DEVELOPS AFTER ACUTE PAIN Factors associated with an increased risk for chronic pain following acute pain or surgery include older age, psychological problems, higher levels of pre-procedural pain or pain sensitivity, type and duration of surgery, severity and number of comorbidities, and use of post-procedural radiation or chemotherapy [9]. SCREENING FOR OPIOID ABUSE RISK FACTORS Evaluations of the physical and psychological history can identify risk factors for substance misuse and overdose 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. These approaches enable providers to identify high-risk patients so that that they can consider whether to prescribe opioids, engage substance misuse and mental health interventions, and provide education materials to mitigate opioid misuse (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
Patient self-report
17 items
Diagnosis, Intractability, Risk, Efficacy (DIRE)
Screen for risk of opioid addiction Screen for risk of opioid addiction Screen for risk of opioid addiction
Clinician
7 items
Opioid Risk Tool (ORT)
Clinician or patient self-report
5 yes/no questions
Screener and Opioid Assessment for Patients with Pain, Version 1 and Revised (SOAPP, and SOAPP-R)
Patient self-report
24 items
Source [9]
Table 1
4
MDUT1125
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