____________________________ Responsibilities and Requirements of Prescribing Schedule II Opioid Drugs
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
Low Risk Definable physical pathology with objective signs and reliable symptoms Clinical correlation with diagnostic testing, including MRI, physical examination, and interventional diagnostic techniques With or without mild psychological comorbidity With or without minor medical comorbidity No or well-defined and controlled personal or family history of alcoholism or substance abuse Age 45 years or older High levels of pain acceptance and active coping strategies High motivation and willingness to participate in multimodal therapy and attempting to function at normal levels Medium Risk Significant pain problems with objective signs and symptoms confirmed by radiologic evaluation, physical examination, or diagnostic interventions Moderate psychological problems, well controlled by therapy Moderate coexisting medical disorders that are well controlled by medical therapy and are not affected by chronic opioid therapy (e.g., central sleep apnea) Develops mild tolerance but not hyperalgesia without physical dependence or addiction History of personal or family history of alcoholism or substance abuse Pain involving more than three regions of the body
Defined pathology with moderate levels of pain acceptance and coping strategies Willing to participate in multimodal therapy, attempting to function in normal daily life High Risk Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of alcoholism or drug misuse, abuse, addiction, diversion, dependency, tolerance, or hyperalgesia Major psychological disorders Age younger than 45 years HIV-related pain High levels of pain exacerbation and low levels of coping strategies Unwilling to participate in multimodal therapy, not functioning close to a near normal lifestyle HIV = human immunodeficiency syndrome, MRI = magnetic resonance imaging. Source: [17; 28]
Table 1
Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1]: • Pain indications for opioid therapy • Nature and intensity of pain • Past and current pain treatments and patient response • Comorbid conditions • Pain impact on physical and psychological function • 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
If substance abuse is active, in remission, or in the patient’s history, consult an addiction specialist before starting opioids [1]. In active substance abuse, do not prescribe opioids until the patient is engaged in treatment/recovery program or other arrangement made, such as addiction professional co- management and additional monitoring. When considering an opioid analgesic (particularly those that are extended-release or long-acting), one must always weigh the benefits against the risks of overdose, abuse, addiction, physical dependence and tolerance, adverse drug interactions, and accidental exposure by children [10; 16]. Screening and assessment tools can help guide patient stratifica- tion 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 tools used to help determine patient risk level, most tools have not been extensively evaluated, validated, or compared to each other, and evidence of their reliability is poor [17; 28].
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