_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
during pregnancy [94]. A thorough clinical examination, including appropriate laboratory testing and other elements supporting the plan of care, should be documented in the medical record. When the use of controlled substances is required for management of chronic pain, patients should not be treated through telemedicine. Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1; 94]: • History of the patient’s pain condition and indications for opioid therapy, including nature and intensity of the pain, and impact on functioning ability and quality of life • Past and current pain treatments and patient response • Important comorbid conditions such as COPD, sleep apnea, diabetes, or congestive heart failure • Screening co-occurring anxiety, depression, and current or past substance use disorder • Social support, housing, and employment • Home environment (i.e., stressful or supportive) • Pain impact on sleep, mood, work, relationships, leisure, and substance use • Patient history of physical, emotional, or sexual abuse • The possibility of pregnancy, initially and on each subsequent visit The initial evaluation is intended to establish a current diagnosis that justifies the need for opioid medication. After this determination is made, it is important to assess the patient’s risk for drug misuse and develop and document a treatment plan, including a discussion of treatment goals. Opioid Misuse Risk Assessment Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state Controlled Substance Monitoring Database (CSMD), and According to the American Society of Interventional Pain Physicians, before starting opioid therapy, clinicians must take certain basic steps to prevent opioid abuse: distinguish individual opioid abuse risk factors; screen patients’ potential for addiction and abuse during their initial visit; categorize patients in accordance with their level of risk and implement an appropriate level of monitoring; and refrain from judgments before a thorough assessment. Combining the above strategies with point-of-care urine drug testing as a confirmatory tool have been shown to contribute significantly to the identification of inconsistencies. from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses ( Table 1 ). A UDT should be performed prior to initiating opioid treatment. Low-risk patients receive the standard level of monitoring, vigilance, and care. Moderate-risk patients should be considered for an additional level of monitoring and provider contact, and high-risk patients are likely to require intensive and structured monitoring and follow-up contact, additional consultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations [10; 26]. (https://www.painphysicianjournal.com/current/pdf?a rticle=NDIwNA%3D%3D&journal=103. Last accessed September 28, 2025.) Level of Evidence : Expert Opinion/Consensus Statement
If substance abuse is active, in remission, or in the patient’s history, one should consult an addiction specialist before starting opioids [1]. In the setting of active substance abuse, opioids should not be prescribed until the patient is engaged in a treatment/recovery program or other arrangement is made, such as addiction professional co-management and additional monitoring. When considering an opioid analgesic (particularly those that are extended-release or long-acting), it is important to weigh the benefits against potential risks, such as overdose, misuse, physical dependence, adverse drug interactions, and accidental exposure by children [10; 16]. Screening and assessment tools can help guide patient stratification according to risk level and inform the appropriate degree of structure and monitoring in the treatment plan. It should be noted that despite widespread endorsement of screening tool use to help determine patient risk level, most tools have not been extensively evaluated, validated, or compared to each other [17]. Information on some of the more commonly used risk assessment tools is provided in the following sections. Opioid Risk Tool (ORT) The Opioid Risk Tool (ORT) is a brief, 10-item written questionnaire completed by the patient, designed to elicit personal and family history of psychiatric illness and prior drug/alcohol abuse. The assessment is used to predict likelihood for aberrant drug-related behavior and classify patients as low-, medium-, or high-risk [18]. Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP-R) The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a 24-item, patient-administered questionnaire that assesses history of alcohol/substance use, psychological status, mood, impulsivity, cravings, and stress. It uses a five-point rating scale for each response and classifies patients as low or high risk in relation to potential aberrant drug-related behaviors and the appropriate extent of monitoring [19]. CAGE and CAGE-AID The original CAGE (Cut down, Annoyed, Guilty, and Eye- opener) Questionnaire consisted of four questions designed to help clinicians determine the likelihood that a patient was misusing or abusing alcohol. These same four questions were modified to create the CAGE-AID (adapted to include drugs), revised to assess the likelihood of current substance abuse [20]. Diagnosis, Intractability, Risk, and Efficacy (DIRE) Tool The Diagnosis, Intractability, Risk, and Efficacy (DIRE) risk assessment tool is a clinician/interviewer-derived rating scale based on the patient’s history, diagnosis, personal engagement in care, and psychiatric issues. The numerical score is used to predict patient compliance with long-term opioid therapy, and patients are classified as “not a suitable candidate” or “good candidate” for long-term opioid analgesia [21].
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MDTN1726
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