• 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). This tool showed nearly 90% predictive accuracy in a Veterans Administration case–control analysis of close to 9,000 veteran patients 125 and was subsequently validated in the commercial insurance records of a nonveteran population of approximately 18 million medical users of prescription opioids. 126
Screening for Opioid Misuse Risk Several screening tools are available to help HCPs detect current opioid misuse or risk that a patient may develop misuse or OUD during the course of opioid therapy. None has been associated with a high degree of predictive accuracy; 1,61 however, they are generally recommended in expert guidelines for their clinical utility (Table 6). Most of the tools in Table 6 are specific to opioid-treated patients with pain. The HHS Inter-Agency Task Force has also cited the Drug Abuse Screening Test 127 and the Alcohol Use Disorders Identification Test 128 as validated tools. 1 HCPs should select the tool that fits best into their clinical practice, treating assessment as routine and encouraging patients to share information honestly. Even single questions, such as, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” can be effective means of screening for drug use if implemented consistently. 129 An answer to the single question of one or more is considered positive and was found in a primary care setting to be 100% sensitive and 73.5% specific for the detection of a drug-use disorder compared with a standardized diagnostic interview. 61,129 The information gained from screening is documented in the patient record and used to assist selection of the best treatments, including medication classes and delivery systems, to facilitate ongoing monitoring to help mitigate potential opioid misuse, and to inform whether SUD treatment and mental-health referrals are warranted. A baseline urine drug test (UDT) should take place before opioids are prescribed or continued. 20,61,77 Usefulness of a UDT includes identifying the presence of prescribed medications as well as unauthorized prescription and illegal drugs, helping to guide clinical decisions, and serving as an alert to potential drug-drug interactions.
Immunoassay testing done at the point of care (POC) can help quickly establish whether a new patient has recently ingested illegal drugs or other opioid and prescription drugs but typically cannot isolate specific opioids. 137 If POC test results are inconsistent with medical direction, the next step is a quantitative evaluation, usually via gas chromatography/mass spectrometry (GC/ MS) technology or liquid chromatography dual mass spectrometry (LC/MS/MS). These tests can detect actual drugs and their metabolites. Some laboratories offer definitive testing via LC-MS/MS that may be given as the initial test; however, most guidelines still suggest immunoassay ahead of confirmatory testing due to cost concerns. 137 A query of the state prescription drug monitoring program (PDMP) should also take place before opioids are initiated or continued. 20,61,77 These importance checks of the patient’s past and present opioid prescriptions are done at initial assessment and during the monitoring phase. PDMP data can help to identify patients who have had multiple practitioner episodes or potentially overlapping prescriptions that place them at risk of a misuse or drug interaction problem. The use of an PDMP is also aimed at stopping the spread of opioid misuse and diversion as a public health problem. If baseline UDT and PDMP checks indicate unauthorized prescriptions or there are other signs suggestive of opioid misuse, the results should be discussed with the patient and, if OUD or another substance-use issue is suspected, treatment should be offered and/or a specialist referral can be given. More will follow on using UDT and PDMP checks for periodic monitoring during the course of opioid therapy. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1 ON THE NEXT PAGE.
Table 6. Screening Tools for Risk of OUD in Opioid-Treated Patients
Tool
# of Items
Administered
Approximate Time to Complete
For Use Prior to Initiating Opioid Therapy Opioid Risk Tool (ORT) 130 Revised Screener and Opioid Assessment for Pa- tients with Pain (SOAPP-R) 131 Diagnosis, Intractability, Risk, Efficacy (DIRE) 132 Pain Medication Questionnaire (PMQ) 133 For Use During Opioid Therapy Current Opioid Misuse Measure (COMM) 134
5
Health-care practitioner
1 min 5 min
24*
Patient
7
Health-care practitioner
2 min
26
Patient
10 min
17
Patient
10 min
Patient Version Prescription Drug Use Questionnaire (PDUQp) 135
31
Patient
20 min
Brief Initial Drug Screenings Not Specific to Pain Population CAGE-AID (Adapted to Include Drugs) 136 4
Health-care practitioner
1 min
Drug Abuse Screening Test (DAST) 127 Alcohol Use Disorders Identification Test 128 *4- and 12-item SOAPP formats available
10 10
Health-care practitioner or patient versions 5 min Health-care practitioner or patient versions 5 min
33
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