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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

What types of risk screening tests are available to clinicians prescribing opioid therapy?

A guide to risk-assessment tests clinicians can use before starting a patient on chronic opioid therapy for pain.

The CDC recommends that risk screenings be utilized for all patients under consideration for receiving opioid therapy and/or already receiving opioid therapy.1 As depicted in Table I, there are numerous validated tools readily available for clinicians; some are to be administered by the healthcare provider while others may be completed by the patient.

While having a patient complete a screening may ease the office visit and keep the patient involved in the treatment plan, there is potential for misreported or under-reported information. In some cases, a patient may already have a screening in the electronic health record which may be used for comparison. Due to the sensitivity of some of the screening questions (eg, family history of substance-use disorder, illegal actions), it is important to have a strong patient-provider relationship in tact before issuing a screening. It is also important to provide regular or follow-up risk screenings for patients on long-term opioid therapy. Best practice calls for screens every 3 months to every 12 months, depending on the patient. More often than not, and for a variety of reasons, however, such follow-ups tend to fall through the cracks. Below are more specific recommendations to ensure these gaps are filled.

Source: 123RFPatient-reported or provider-reported risk assessment tools and tests should be administered before prescribing opioids.

For the Opioid-Naïve Patient

Self-screens

For the opioid naïve patient, a clinician may prefer to use a self-reported screen such as the Drug Abuse Screening Test (DAST) or the Screener & Opioid Assessment for Patients with Pain (SOAPP). The DAST was originally published in 1982 by Harvey Skinner, PhD, modified from the Michigan Alcoholism Screening Test (MAST). The DAST is available in three versions varying in the number of questions within, including the DAST-10, DAST-20, & DAST-28. Scores greater than 12 on the DAST-28 indicate a definitive substance abuse problem. Scores greater than 5 on the DAST-10 indicate a substantial/severe level of drug abuse.2 The SOAPP was more recently revised to be less susceptible to overt deception and is recognized as the SOAPP-r. The SOAPP-r includes 24 questions with a 5-point scale, where scores greater than 18 indicate a high risk for opioid misuse.3 The DAST may be more useful when considering overall drug usage as compared to the targeted medication class of opioid medications.

Provider screens

Provider screens for the opioid-naïve include the Opioid Risk Tool (ORT) and the Diagnosis, Intractability, Risk, & Efficacy Score (DIRE). The ORT is one of the most widely accepted and utilized opioid risk screenings tools for its validity, and ease of use.4 The ORT includes five questions with scores ranging from 0 to 26. Scores between 4 and 7 are considered moderate risk, whereas scores greater than 7 are considered high risk. The DIRE was developed after the Minnesota Board of Medicine took corrective action on one prescriber based on prescribing patterns. Scores ranging from 7 to 13 indicate that a patient may not be suitable for long-term opioid utilization, while scores ranging from 14 to 21 indicate a patient may be a candidate for long-term opioid utilization.5

 

For the Opioid-Experienced Patient

Self-screens

Available self-assessments for patients on long-term opioid therapy include the Current Opioid Misuse Measure (COMM), Pain Medication Questionnaire (PMQ), and the Prescription Drug Use Questionnaire for patient reporting (PDUQp). The COMM, which includes 17 questions on a 5-point scale, is widely accepted and utilized based on its high level of sensitivity and specificity. The COMM aims to identify patients who may be misusing opioid medications, which is suggested by a score greater than 8. The PMQ includes 26 questions on a 4-point scale, but does not have a recommended “cut-off” that identifies the level of risk for opioid abuse.6 The PDUQp was redesigned in 2008 based on the 1998 version, while taking both the COMM and the PMQ into consideration. The PDUQp includes 31 questions, and while it includes a specific discussion on medication agreement violation-related discontinuation, it also does not offer a “cut-off” score.7

Provider screens

Provider-based screening tools for the opioid experienced patient include the Prescription Drug Use Questionnaire (PDUQ). The PDUQ includes 42 questions (only 39 are scored). Like the PDUQp and PMQ self-screens, the PDUQ does not provide a “cut-off” score for guidance on high-risk patients. As a result, many clinicians end up using the COMM tool.8

Of note, the PDUQ and PDUQp provide a simplified yes/no answering system, while the COMM and PMQ screenings utilize a 5-point scale, which allows for more variability and specificity.9

After the Assessment

There is no specific guidance that states a provider should avoid the utilization of opioid medications if a patient is determined to be at moderate or high risk after taking a screening test, yet clinicians should proceed with caution in such instances. If a patient screens as a very high risk, the decision-making process to prescribe opioid therapy should take into consideration the “entire patient” in regards to his/her historical and current situation. For instance, if a patient reporting misusing or abusing any medication 20 years ago, but has been compliant since that time, a provider’s view may be distorted. Conversely, if a patient has multiple psychiatric conditions, and has experienced a recent opioid overdose, the question of whether to utilize opioid medications may be more easily answered.

In any case, patient agreements for opioid therapy, such as those recommended by the FDA,10 should be put into place. More frequent monitoring of the Prescription Drug Monitoring Program database, and other tools, such as clinical drug monitoring as recommended by the CDC, and abuse-deterrent opioids, should also be considered. Overall, when opioid risk screenings are used in conjunction with an overall risk-management plan, not only is patient care improved and risk minimized but also, the liability risk of the healthcare professional is subsequently reduced.

 

See also our Guide to Clinical Drug Monitoring in Primary Care

Last updated on: November 7, 2018
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