The staggering rate of prescription opioid misuse, abuse, and overdose has placed a heavy burden on prescribing clinicians and their practices. Federal and state regulators have responded by enacting extensive opioid prescribing guidelines. Across the board, these guidelines prioritize the importance of properly assessing a patient’s risk of misuse or abuse.
When developing and implementing prescribing protocols across a healthcare organization, it is essential to make protocols risk-informed using evidence-based assessment tools. These tools assess a patient’s risk of misuse or abuse, but effective protocols also include mental health screenings to evaluate mood and anxiety disorders. Dr. Martin D. Cheattle effectively highlights safe opioid prescribing tools for risk assessment in a recent article.
The different instruments/assessments used for determining a patient’s risk vary by the patient’s stage and include:
- Risk assessments prior to initiating long term opioid therapy
- Risk monitoring assessments for patients currently undergoing long-term or chronic opioid therapy (consistent use for more than 90 days)
- Screening tools for non-opioid general substance abuse
Below is a breakdown of the different tools used to identify and quantify patient risk:
Risk Assessments Prior to Initiating Long-Term Opioid Therapy
- Opioid Risk Tool (ORT) – patient self-administered 5 item questionnaire designed to predict the risk of problematic drug-related behaviors; a score of 8+ is considered high risk for opioid misuse
- Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) – well validated 24 item instrument to predict the development of problematic drug-related behaviors; a score of 18+ indicates a patient is at risk for misusing prescribed opioids
- Screening Instrument for Substance Abuse Potential (SISAP) – 5 item questionnaire developed to predict the risk of opioid misuse; used less frequently than the ORT or the SOAPP-R
- Diagnosis, Intractability, Risk, and Efficacy (DIRE) – clinician-rated instrument used by primary care physicians to predict the efficacy of analgesia and adherence with long-term opioid therapy; scores range from 7-21; a score of 13 or below suggests that a patient is not suitable for long-term opioid therapy
- Drug Abuse Screening Test (DAST-10) – 5-minute self-reported tool to identify a wide range of potential drug abuse problems
Risk Monitoring Assessments in Patient’s Receiving Long-Term Opioid Therapy
- Prescription Drug Use Questionnaire-patient version (PDUQ-p) – patient self-administered 31 item tool intended to predict the potential for opioid abuse; cutoff value of 10+
- Current Opioid Misuse Measure (COMM) – patient self-administered 17 item questionnaire meant to identify patients who may be misusing opioids; a score of 9+ suggests problematic drug-related behaviors; one of the most commonly used tools for patients receiving long-term opioid therapy
- Patient Medication Questionnaire (PMQ) – patient self-administered 26 item instrument that identifies patients misusing opioids; higher scores suggest patient’s likely to misuse
- Pain Assessment and Documentation Tool (PADT) – clinician administered 41 item tool developed to identify patient misuse, no cutoff score
- Addiction Behavior Checklist (ABC) – clinician-completed 20 item questionnaire to determine problematic drug-related behaviors; a score of 3+ suggests problematic drug-related behaviors
Screening Tools for Non-Opioid Substance Abuse
When determining whether a patient is fit for long-term opioid therapy or to continue opioid therapy, it is important to screen for illicit or non-prescribed drug use, alcohol use, and tobacco use. The combination of these with prescribed opioids could have adverse consequences. There are a number of tools used to detect drug and alcohol abuse (see table above).
Evaluating A Patient’s Mental Health
As the Journal of Clinical Psychiatry reports that one in three adults who struggle with alcohol or drug abuse also suffers from depression, it is important to screen a patient for mood and anxiety disorders. If a disorder is undetected and/or not treated, it can lead to opioid misuse or abuse. Some commonly used tools include:
- Patient Health Questionnaire-9 (PHQ-9) – a multipurpose instrument for screening, diagnosing, and monitoring the severity of depression
- Generalized Anxiety Disorder (GAD) tool – a questionnaire designed to assess the severity of anxiety
SAMSHA's Center for Integrated Health Solutions provides additional resources related to screening tools focusing on mental health and substance abuse.
Assessing the 4 A's
In addition to screening patients, it is important for providers to include the "4 A's" in assessments:
- Analgesia (pain relief)
- Activities of Daily Living (psychosocial functioning)
- Adverse Effects (side effects)
- Aberrant Drug Taking (addiction related outcomes)
Taking Action at Your Practice
Patient risk identification and assessment is a critical aspect of developing effective opioid prescribing protocols. Here are a few general tips to get started:
- Review all applicable guidelines and regulations
- Select the risk assessment tools appropriate for your practice by collaborating with clinicians
- Run a pilot and collect feedback/suggestions from participating clinicians
For more, check out our recent posts on related topics:
- Opioid Prescribing in 2018: Protect Your Patients. Protect Your Practice.
- Pain in the Paperwork: Determine Risk and Document Medical Necessity
- A Platform to Facilitate Pain Management Compliance
- Does your Practice Have Effective Opioid Prescribing Protocols?
- Opioid Prescribing Guidelines: A State-by-State Overview
- SAMHSA Medication Assisted Treatment Protocols Are Out: Here's What You Need to Know
At AffirmHealth, we understand that developing prescribing protocols takes considerable time and effort. We partner with organizations to build and implement risk-informed protocols tailored to the practice. Our new product Shield is a software platform to help manage, facilitate and measure prescribing compliance using those protocols. We would welcome the opportunity to partner with your organization.
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