Responsibilities and Requirements of Prescribing Schedule II Opioid Drugs _ ___________________________
modified to create the CAGE-AID (adapted to include drugs), revised to assess the likelihood of current substance abuse [20].
Despite limited evidence for reliability and accuracy, screening for opioid use is recommended by the American Society of Interventional Pain Physicians, as it will identify opioid abusers and reduce opioid abuse.
Diagnosis, Intractability, Risk, and Efficacy (DIRE) Score
The Diagnosis, Intractability, Risk, and Efficacy (DIRE) risk assessment score is a clinician-rated questionnaire that is used to predict patient compliance with long-term opioid therapy [18; 21]. Patients scoring lower on the DIRE tool are poor candidates for long-term opioid analgesia.
(https://painphysicianjournal.com/2012/july/ 2012;%2015;S67-S116.pdf. Last accessed January 24, 2024.) Level of Evidence : Limited (Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality trials, important flaws in trial design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.)
INFORMED CONSENT AND TREATMENT AGREEMENTS
The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [1]. This agree- ment should address potential side effects, tolerance and/ or physical dependence, drug interactions, motor skill impairment, limited evidence of long-term benefit, misuse, dependence, addiction, and overdose. Informed consent documents should include information regarding the risk/ benefit profile for the drug(s) being prescribed. The prescribing policies should be clearly delineated, including the number/ frequency of refills, early refills, and procedures for lost or stolen medications. The treatment agreement also outlines joint physician and patient responsibilities. The patient agrees to using medica- tions safely, refraining from “doctor shopping,” and consent- ing to routine urine drug testing (UDT). The prescriber’s responsibility is to address unforeseen problems and prescribe scheduled refills. Reasons for opioid therapy change or dis- continuation should be listed. Agreements can also include sections related to follow-up visits, monitoring, and safe storage and disposal of unused drugs. PERIODIC REVIEW AND MONITORING When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [1]. This can include input from family members and/or the state PDMP. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. At every visit, chronic opioid response may be monitored according to the “5 A’s” [1; 23]: • Analgesia
RISK ASSESSMENT TOOLS
Opioid Risk Tool (ORT) The Opioid Risk Tool (ORT) is a five-item, patient-adminis- tered assessment to help predict aberrant drug-related behavior. The ORT is also used to establish patient risk level through categorization into low, medium, or high levels of risk for aber- rant drug-related behaviors based on responses to questions of previous alcohol/drug abuse, psychological disorders, and other risk factors [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 patient-administered, 24-item screen with questions addressing history of alcohol/substance use, psychological status, mood, cravings, and stress. Like the ORT, the SOAPP-R helps assess risk level of aberrant drug-related behaviors and the appropriate extent of monitoring [18; 19].
Screening Instrument or Substance Abuse Potential (SISAP)
The Screening Instrument or Substance Abuse Potential (SISAP) tool is a self-administered, five-item questionnaire addressing history developed used to predict the risk of opioid misuse. The SISAP is used to identify patients with a history of alcohol/substance abuse and improve pain management by facilitating focus on the appropriate use of opioid analgesics and therapeutic outcomes in the majority of patients who are not at risk of opioid abuse, while carefully monitoring those who may be at greater risk [18]. 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
• Activities of daily living • Adverse or side effects • Aberrant drug-related behaviors • Affect (i.e., patient mood)
Signs and symptoms that, if present, may suggest a problem- atic response to the opioid and interference with the goal of functional improvement include [24; 29]: • Excessive sleeping or days and nights turned around
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