Risk Assessment: Safe Opioid Prescribing Tools
Over the past several decades, medically prescribed opioid analgesics have been promoted as a key component of a comprehensive treatment program for patients with chronic pain. Ongoing debate, however, surrounds the efficacy and safety of prescription opioids for patients with chronic noncancer pain (CNCP), especially when used long term and at high doses. While a subgroup of appropriately selected patients with CNCP can benefit from opioid therapy, there has been a dramatic increase in prescription opioid misuse, opioid abuse, and opioid-related morbidity and mortality.1-4
In an effort to balance effective pain management and safety when prescribing opioids, a number of expert-consensus guidelines for opioid prescribing in patients with CNCP were developed, including the recently released Centers for Disease Control and Prevention (CDC) guidelines.5,6 The majority of the guidelines recommend that clinicians who prescribe opioids to patients with CNCP employ strategies such as querying the state prescription drug monitoring program (PDMP), ensuring proper dosing of opioids, assessing for sleep disordered breathing (SDB), and using risk assessment instruments.
Risk Assessment Instruments
Three types of risk assessment instruments have been designed to detect different dangers: (1) opioid misuse prior to initiating long-term opioid therapy, (2) signs of misuse in patients currently using opioids, and (3) nonopioid general substance abuse (Table 1).7-16
Screening for Risk of Opioid Misuse Prior to Initiating Long-Term Opioid Therapy
The most frequently recommended instruments for assessing the risk of opioid misuse before initiating long-term opioid therapy include the Opioid Risk Tool (ORT); the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R); the Screening Instrument for Substance Abuse Potential (SISAP); and the Diagnosis, Intractability, Risk, and Efficacy (DIRE) score.7-10
The DIRE is a clinician-rated instrument designed for use by primary care physicians to predict the efficacy of analgesia and adherence with long-term opioid therapy. The DIRE score can range from 7 to 21, with a score of 13 or below suggesting that a patient is not a suitable candidate for long-term opioid therapy.
The SISAP, ORT, and SOAPP-R are patient self-administered instruments. The SISAP is a 5-item questionnaire developed to predict the risk of opioid misuse. In the author’s experience, it is used less frequently in practice than the ORT or the SOAPP-R. The ORT is a 5-item validated questionnaire designed to predict the risk of problematic drug-related behaviors (PDRB). A score of 8 or higher is considered high risk for opioid misuse. The SOAPP-R is a well-validated 24-item instrument constructed to predict the development of PDRB. A score of 18 or greater indicates a patient is at risk for misusing prescribed opioids.
Monitoring for Signs of Opioid Misuse in Patients Receiving Long-Term Opioid Therapy
When patients have transitioned to long-term opioid therapy, typically defined as consistent use for more than 90 days, there are a number of instruments that can help the clinician monitor for the development of PDRB. Patient self-administered instruments include the Prescription Drug Use Questionnaire-patient version (PDUQ-p), which evolved out of the original clinician-completed PDUQ; the Current Opioid Misuse Measure (COMM); and the Patient Medication Questionnaire (PMQ).11-14 Clinician-administered instruments include the Pain Assessment and Documentation Tool (PADT) and the Addiction Behavior Checklist (ABC).15-16
The PDUQ-p is a 31-item instrument intended to predict the potential for opioid abuse at a cutoff value of 10 or greater. The COMM is a 17-item questionnaire designed to identify patients who may be misusing their prescription opioids. A score of 9 or greater is suggestive of current PDRB. With a sensitivity of 0.76 and a specificity of 0.66, the COMM is one of the most commonly used tools for patients on long-term opioid therapy. Again, higher scores suggest opioid misuse or PDRB on the 26-item PMQ. The PADT is a 41-item clinician-administered instrument, and the ABC is a 20-item clinician-completed questionnaire. While the PADT has no cutoff score, a score greater than 3 on the ABC is indicative of PDRB.
Many pain management clinicians recommend the ORT and SOAPP for prescreening patients being considered for long-term opioid therapy, and the COMM for monitoring of PDRB in patients currently prescribed long-term opioid therapy.17 However, further research is needed.
Screening for Nonopioid General Substance Abuse
Both the COMM and PDRB, however, still do not include assessment of tobacco, alcohol, or other substances of abuse.18 When considering the initiation or continuation of opioid therapy, it is important to screen for illicit or nonprescribed drug use and alcohol misuse or abuse. Any of these could pose life-threatening consequences when combined with prescribed opioid therapy. In addition to drug monitoring, there are many commonly used instruments to screen for drug and alcohol abuse (Table 1).19-24
Mental Health Screening
Although beyond the scope of this article, the judicious clinician will not only assess for the risk of opioid and nonopioid misuse or abuse but also for concomitant mood and anxiety disorders (see Chapter 4, Part 1). There is a high prevalence of mood and anxiety disorders in patients with CNCP, and leaving these disorders undetected and untreated can contribute to opioid misuse or abuse. Opioids can have strong anxiolytic and hedonic effects, leading to chemical coping.25 There are a number of brief, well-validated instruments to assess mood and anxiety disorders (such as the Patient Health Questionnaire [PHQ-9] and the Generalized Anxiety Disorder [GAD] tool).26
While debate remains regarding the accuracy of various risk assessment instruments in detecting current misuse and abuse of prescription opioids, these instruments can provide important information as one component of a comprehensive risk assessment, monitoring, and mitigation process.6,27