The PEG scale can be very useful in primary care or busy practices to assess pain, functioning, and quality of life. Assessing Mental Health Screening tools to assess patients with pain for mental health disorders ahead of prescribing opioids include: • Patient Health Questionnaire-2 (PHQ-2), a two-item screen for depressive disorder that leads to more detailed assessment if either item is positive. 109 The PHQ-2 is available at the following link: https://www.hiv.uw.edu/ page/mental-health-screening/phq-2 • Patient Health Questionnaire-9 (PHQ-9), this nine-item screen for depressive disorder may be used initially or as a follow-up to the PHQ-2. 110 This tool and its variations are brief, reliable, valid, and easy to score. The PHQ-9 is available at the following link: https://www.hiv. uw.edu/page/mental-health-screening/phq-9 • The reliable and valid Beck Depression Inventory-II (BDI-II) is a self-report measure of depression severity. 111 This 21-item tool is available here: http://www.hpc-educ.org/Files/ Danz/BDII.pdf • Suicidal ideation is addressed by items on the PHQ-9 and BDI-II. This is an important assessment for patients with chronic pain. • The Beck Anxiety Inventory (BAI) emphasizes somatic components of anxiety 112 and can be found here: https://www.gphealth.org/ media/1087/anxiety.pdf • The Generalized Anxiety Disorder-7 (GAD) and GAD-2 are validated and recommended to assess for generalized, panic, and social anxiety disorders, and PTSD. 61,113,114 These tools are available here: PMID: 32582485
Newer systems such as the Stanford-developed and implemented Collaborative Health Outcomes Information Registry offer more in-depth pain assessment through the use of item banks that capture many physical, psychological, and social functioning domains. 115 Assessing Social History, Including Substance Use Patients to be treated with opioid therapy should be screened for the risk of opioid misuse and OUD and monitored regularly. Misuse of prescription opioids is common whether from casual sharing of prescription pills, recreational or experimental use by non-patients (including adolescents), all the way up to and including development of OUD in at-risk populations. Yet clinically it is not always easy to differentiate between appropriate use of prescribed opioids and behavior that may indicate a problem. There is reason to suspect that a pattern of seeking opioids from multiple sources is a strong indicator of misuse and possible OUD. 116 A list of behaviors suggestive of opioid misuse is shown in Table 5. 116,117 A number of risk factors are associated with poorer outcomes in opioid therapy. 101 These factors include: 118 • Nonfunctional status (e.g., severe physical debility) due to pain • Exaggeration of pain • Unclear etiology for pain • History of rapid opioid dose escalation • Young age (<30 years) • Tobacco use • Poor social support
• Psychological stress • Psychological trauma • Psychological disease • Psychotropic substance use • Focus on opioids • Sexual trauma
• 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. 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
• Personal history of SUD • Family history of SUD
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/non-modifiable pain Requests refills instead of clinic visit Gets prescriptions from multiple practitioners without their coordination or knowledge
Risk factors for getting prescriptions from multiple practitioners without their coordination or knowledge: 116
Age ≤65 Concurrent use of benzodiazepines Mood disorders Back pain Abuse of non-opioid drugs
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
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