Special Topics in Pain: Opioids

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Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse: Part 2.

Author(s): Kaye A D, et al.
Journal: Pain Physician. 2017; 20:S111-S133. 220 references.
Reprint: Alan D. Kaye, MD, PhD, Department of Anesthesiology, LSU Health, 1542 Tulane Ave. Rm # 656, New Orleans, LA 70112. E-mail: alankaye44@hotmail.com
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Psychological and Pain Scales; Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note: This article offers general rules but no specific scales to predict opioid misuse. Another abstract (Feingold) this month offers a review of scales for misuse of opioids and cannabis. Multiple scales are offered with a wide variation in rates predicted by them. The general guidelines in this abstract are quite useful.

Class: Pharmacology; addiction Opioid Abuse Predictors

The patient's risk of drug abuse must be assessed prior to the start of opioid therapy and the majority of risk-assessment tools revolve around previously discussed risk factors, as well as the presence of aberrant behaviors. While many screening tools have been developed, none has been fully validated across numerous populations and settings. There currently does not exist one single procedure or set of predictor variables capable of identifying patients with chronic pain who are "at-risk" for opioid misuse or abuse.

Patients with a history of alcohol or cocaine abuse and alcohol or drug-related convictions require more intense assessment and follow-up for signs of misuse if opioids are prescribed. Similarly, patients with comorbid psychiatric disorders and chronic non-cancer pain (CNCP) may benefit from a slower than normal titration of opioid doses, with the patient's mood and functioning closely monitored. Further recommended practices include prescribing less powerful medications such as non-controlled prescription adjuvants when possible, and establishing a controlled substance agreement (pain contract) signed by the patient, a witness, and the practitioner.

Opioid misuse in and of itself may present in diverse, aberrant drug-related behaviors such as requests for early renewals, reports of lost or stolen prescriptions, observable intoxication or withdrawal, demanding behaviors, or failure to respond to treatment.

Stratifying patients into risk categories is to determine the intensity and frequency of monitoring and clinical vigilance for all patients based on their risk of drug abuse. Low-risk patients do not exhibit past or present histories of personal or family substance use disorder (SUD). They also display no or a minimal co-occurring psychiatric disorder. The level of monitoring would be routine follow-up (every three months) unless there is a change in pain, function, or mood, or evidence of misuse.

Moderate risk patients display a past, personal, or family SUD, as well as a moderate co-occurring psychiatric disorder. Office visits should occur more frequently (monthly), and should consist of audits of their medical record (emergency department visits, doctor shopping), urine drug testing (UDT) and pill counts until improvements in their risk status are seen. High risk patients actively exhibit addiction or abuse disorders with either opioids or illicit drugs and/or display a co-occurring significant and unstable psychiatric disorder. These patients must be referred to interdisciplinary pain centers, an addictionologist, or a behavioral health center.

To help patients and providers navigate the challenges of COT and optimize therapy, a strategy of frequent re-assessment of safety, efficacy, and misuse is needed for patients on opioids to inform treatment decisions. To date, however, there is no widely accepted instrument or protocol to facilitate this monitoring strategy. Several opioid-specific screening tools are available for screening and monitoring of abuse. The clinician should remember that screening tools by themselves do not suffice to identify high risk patients, and a thorough personal and family history that includes substance abuse, psychiatric conditions, and sexual abuse should always be conducted irrespective of the use of screening instrument.

Urine screening, a noninvasive, inexpensive, and accurate monitoring strategy, is capable of detecting the majority of drugs for one to three days post-exposure. Treatment compliance is confirmed by objective analysis by possible exposure of misuse and abuse of drugs in patients receiving treatment with opioids.

An opioid treatment agreement (OTA) is intended to relay information to patients concerning the risks and benefits of treatment with opioids, as well as establish a jointly agreed upon regimen, develop a relationship between provider and patient, enhance opioid treatment adherence via a documented therapy framework, and organize procedures in the case of problems.

 "Universal precautions" (derived from the infectious disease approach) are a unified step process including establishing a diagnosis and treating improvable etiologies as well as comorbid psychiatric syndromes; evaluation of psychological status in conjunction with addiction risk; informed consent that includes anticipated benefits and foreseeable risks; a treatment agreement that describes the expectations and obligations of both provider and patient and sets boundary limits to enable early identification and intervention around aberrant behavior; pre- and post-intervention assessment of pain level and function; an appropriate trial of opioid therapy with or without adjunctive medications; reassessment of pain score and function; a periodic review of the pain diagnosis and comorbid conditions and careful and thorough documentation to reduce medicolegal exposure and risk of regulatory sanction.

Important Points:
Researchers and clinicians continue to investigate this complex issue of substance use disorders and chronic pain with the goal to create a more individualized, safer approach for patients with chronic pain. Society will require all stakeholders, patients, clinicians, scientists, governmental policy makers, pharmaceutical companies, and emerging technology manufacturers to play a role in the successful management of chronic non-cancer pain while minimizing opioid abuse.

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