● History of legal problems. ● History of SUD treatment. ● Craving for prescription drugs. ● Mood swings/disorders. ● Childhood adversity, adverse childhood experiences. ● Social environments that encourage illicit substance use.
The HHS Inter-Agency Task Force on best practices in pain management emphasizes sleep disturbances, mood disorders, and stress as factors that put patients at risk for poorer outcomes and substance use. 1 HCPs may identify risk factors from patient and family history and current biopsychosocial evaluation.
Table 5: Patient Behaviors Suggestive of Opioid Misuse, Diversion, Abuse, and Addiction (list not exhaustive) Behavior Category Behavior Observed clinically: 116 • Over-sedated/intoxicated. • Opioid overdose. Laboratory findings: 116 • Abnormal (i.e., inconsistent) urine or blood screen. Unusual healthcare utilization: 116 • Reports multiple pain causes. • Resists therapeutic changes/alternatives.
• Cancels/no shows pain clinic visits. • Has persistent/nonmodifiable pain. • Requests refills instead of clinic visit. • Gets prescriptions from multiple practitioners without their coordination or knowledge.
Risk factors for getting prescriptions from multiple
• Age ≤65. • Concurrent use of benzodiazepines. • Mood disorders. • Back pain. • Abuse of nonopioid drugs.
practitioners without their coordination or knowledge: 116
Patient reported (primary care population): 117
• Requested early refills. • Increased dose on own. • Felt intoxicated from pain medication. • Purposely over-sedated oneself. • Used opioids for purpose other than pain relief. • Lost or had medication stolen.
• Tried or succeeded in obtaining extra opioids from other doctors. • Used alcohol or other non-prescribed substances to relieve pain. • Hoarded pain medication.
Assessing for risk of overdose Respiratory depression leading to fatal or nonfatal overdose is a chief risk with opioids. Risk factors for overdose in people taking opioids medically or nonmedically include: 119-123 ● Middle age. ● History of SUD. ● Comorbid mental and medical disorders. ● High opioid dose (>90 mg morphine equivalents, although risk is present at any dose). ● Recent upward titration of opioids (within the first 2 weeks). ● Recent opioid rotation. ● Methadone use. ● Benzodiazepine use. ● Antidepressant use. ● Unemployment. ● Use of non-prescribed illicit substances. ● Recent release from jail or prison. ● Recent release from substance treatment program. ● Sleep apnea. ● Heart or pulmonary complications (e.g., respiratory infections, asthma). ● Pain intensity.
Higher dose adds risk for opioid-related overdose but other risk factors contribute, and no dose is completely safe. 124 Although the CDC guideline identified a dose limit of 90 morphine milligram equivalents (MMEs) daily after which caution is advised, another study involving 2.2 million North Carolinians did not show evidence of a distinct risk threshold and found much of the risk at higher doses to be associated with co-prescribed benzodiazepines. 122 Evidence is strong that prescribing opioids together with benzodiazepines increases risk for overdose, 20 and evidence suggests that co-prescription of opioids and gabapentinoids also may increase overdose risk. 20 Consider use of the Veterans Administration- developed Risk Index for Overdose or Serious Opioid- induced Respiratory Depression (RIOSORD) to assess for the risk of a serious opioid-related respiratory depression event in patients treated with medical opioids (available here: https://paindr.com/wp- content/uploads/2015/09/RIOSORD-tool.pdf).
Book Code: MDCO1025
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