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 Screen for risk of opioid addiction Screen for risk of opioid addiction Screen for risk of opioid addiction
Patient self-report
17 items
Diagnosis, Intractability, Risk, Efficacy (DIRE)
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
Use drug monitoring programs PDMPs have been implemented in 49 of 50 states, the District of Columbia, and 1 United States territory (Guam). Information available through PDMPs varies based on reporting requirements and restrictions, but may include DEA schedules reported, timeliness of pharmacy dispensing information, access, and required reviews. Recommendations for using a PDMP include: ● Check the PDMP before starting anyone on opioid therapy. ● Review the PDMP periodically throughout opioid therapy (at least every 3 months). ● Look for prescriptions for other controlled substances, like benzodiazepines, that can increase risk of overdose death. ● Review the total MMED (Morphine Milligram Equivalent Dose). Some states have specific requirements for PDMP use, such as requiring review prior to initial prescription or any time a specific prescription is written, such as for hydrocodone ER (Zohydro), therefore clinicians should remain updated about the specific requirements of their state PDMPs.
The Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based tool used to facilitate screening patients for OUD, which typically takes 5-10 minutes to administer. 29 SBIRT has been endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA), but should always be paired with referral to treatment. 30 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 contrast, universal screening with urine, blood, or oral fluid tests are not recommended. 30 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) Urine drug testing Urine drug testing (UDT) is recommended before prescribing any opioid and at least annually thereafter. 31 Providers using urine drug screens should be familiar with the metabolites and expected positive results based on the opioid prescribed. For example, a patient taking oxycodone may test positive for both oxycodone and oxymorphone (a metabolite). 34 UDT often involves both presumptive (screen) testing, and definitive (quantitative) testing because many synthetic and semisynthetic opioids cannot be detected by presumptive testing alone. 35,36
If the prescribed opioid is not detected, discuss the finding with the patient and, if diversion is confirmed or suspected, re-evaluate the pain management strategy or taper the opioid. If the patient tests positive for unprescribed drugs, schedule more frequent follow-up visits, consider opioid discontinuation, offer naloxone, or refer for treatment for substance use disorder. Decision tools and help with interpreting urine drug testing results are available at: http://mytopcare.org/udt-calculator/interpret-opiates- test-result .
Book Code: MDAZ1124
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