At AffirmHealth, our work focuses around working with clinicians to ensure that they are prescribing opioids in a reliable and compliant manner that gives administrators insight into what is happening across their organizations. From the clinician’s viewpoint, my job is to help ensure that the clinical information and the decision support we implement works in a way that actually improves care delivery to the patient—after all, if our work isn’t actually making care better, then we’re doing a disservice to the patient. While our blog has covered a wide range of critical issues around these topics, one thing we’ve never actually discussed is how clinicians should approach the topic of opioid abuse with their patients, strategies for successful risk screening, and what to do if one of your patients develops an opioid use disorder.
Approaching the Opioid Addiction
In prior posts we’ve discussed the mixed progress the country has made in countering the epidemic—while there are some signs of progress, there is ample evidence that suggests we have a long way to go. On a clinical level, this means that we absolutely need to continue aggressively screening our patients for opioid use disorder and assessing their risk for addiction development. But in a busy day filled with patient encounters, how do we decide who merits a closer examination? The simple answer, unfortunately, is that every patient that is prescribed opioids is at significant risk for addiction. Even when opioids are prescribed for legitimate, acute pain episodes, there is a risk for addiction when use continues beyond a few days. We know this based on a bevy of research studies released over the past few years. In our look at opioid prescribing limits, we discussed the 2017 U.S. CDC Morbidity and Mortality Weekly Report that showed a significant increase in addiction risk at days 3, 5, and 10. And among chronic pain patients, research has shown that up to one-third of patients taking chronic opioids misuse them and up to 10 percent become addicted over time. It has also been shown that a number of risk factors, outlined below, put certain groups at higher risk for continuing long term use as well as abuse of these medications.
It makes sense then, that every time we prescribe an opioid, we should give careful consideration to the risk for our patients. Our own clinical risk assessment should not only include the use of well validated research tools, but also discussion with our patients’ families when confidentiality and rights to privacy can be protected. Often times, the first hint we get that a patient is abusing opioids can come in the form of a concerned family member who notes that the patient’s mood has changed, or they have developed behaviors that seem off or unusual. We can and should use our clinical gestalt to develop an impression of the situation and use that impression to screen our patients for additional intervention. The short answer to our question about which opioid users to screen, then, is “every patient, every time.” But, a one size fits all approach is also not feasible and runs the risk of taking too much time without paying enough attention to high risk groups.
How to Screen Patients and Acknowledge Risk Factors
Research has shown that certain risk factors are associated with increasing rates of opioid abuse and can be used to help guide screening exams. They include:1
- Younger age, particularly teens and 20-30-year olds
- Stressful living circumstances such as poverty, homelessness, and unemployment
- Personal or family history of prior substance use
- Prior legal problems to include driving under the influence and other substance/drug related offenses
- Constant contact with other high-risk groups
- A history of severe depression or anxiety
- A history of tobacco use
Acknowledging the presence of these risk factors and discussing them at the time of prescription can be a helpful start for the astute clinician. Simply asking patients with a history of these risk factors whether they are misusing their medications may be a reasonable place to start. Unfortunately, however, many patients have a false incentive to mislead their prescribers and the clinician should consider applying a validated clinical assessment to help gather additional information.
It is critical when assessing risk that clinicians address these patients with a clear and non-confrontational approach. When patients perceive adverse judgement during their examination, the likelihood of inaccuracy increases. To that end, the National Institute on Drug Abuse Quick Screen which asks “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” is a possible first step. This question is also the first question of the Drug Abuse Screening Test (DAST) which includes 10 and 20 question versions and can be used if the patients answers the first question affirmatively.
In addition to the Quick Screen and DAST, the Opioid Risk Took (ORT) and Screener for Opioid Assessment for Patients with Pain-Revised (SOAPP-R) are two of the tools we frequently integrate into the AffirmHealth Shield platform. These tools differ from the DAST in that they are less direct in their line of questioning but still capture additional risk factors that put the patient at risk for opioid abuse. Each of these tools has been scientifically validated, but different providers have found differing value based on their clinical setting and patient population.
Finally, beyond the use of these screening tools, a good physical examination and lab testing to include urine drug testing can be used as critical sources of information to further assess patients at high risk.
What to Do If a Patient is Abusing Their Opioids
With the high incidence of opioid addiction, it is highly likely that providers who prescribe opiates will eventually encounter misuse or abuse within their patient panel. With that in mind, management of these patients should include the initiation of discussion around the need for treatment and the risk of continuing misuse. While some patients may immediately respond favorably to these discussions, many will not and may require additional interventions including referrals to ancillary health providers who may be able to provide another forum for patients and a care support team. This may include mental health and substance abuse counselors as well as family members if the patient is amenable to the involvement of these groups. As with tobacco and alcohol abuse, continuing discussion over time may be needed before patients are able to better understand the health hazards that these types of behaviors create.
Once the patient is willing to participate in treatment, managing opiate use disorder flows along three lines of care:
- Medication-assisted treatment
- Treatment of opiate overdose
Detoxification is often the first step and involves the use of medication and psychosocial support to assist with the actual weaning of the patient off of the opioids. Commonly used medications include buprenorphine, clonidine, and methadone in various doses that are tapered over the course of a week and has been shown to improve long term treatment adherence. Psychosocial support centers around addressing the underlying stressors and issues that may be contributing to the continuing opioid use behaviors.
Even after detoxification, however, many addicts will find that cravings for opioids can persist for years and decades after usage has stopped. To that end, medication-assisted therapy is recommended by SAMHSA as a critical part of continuing outpatient opioid cessation therapy. MAT includes the use of buprenorphine, naltrexone, and methadone in varying formulations on a longer-term basis as a means to mitigate the cravings that may be present. These drugs act with varying mechanisms on the mu-opioid receptor and all have been shown to improve long term adherence rates and the prevention of recidivism.
Finally, every patient that is prescribed any opiate is at risk for an overdose. We’ve previously discussed the role of naloxone and the national and state-level efforts to improve distribution and it is again worth stressing that naloxone is an absolutely critical tool in the prevention of fatal events. Naloxone is highly effective and can reverse the effects of an overdose within seconds to minutes. Naloxone is available over the counter in many states and clinicians should provide a prescription for naloxone any time an opiate is prescribed.
Fixing Opioid Use Disorder is Our Mission
Recognizing opiate use disorder and treating it appropriately is a key part of our mission at AffirmHealth. Our approach has always focused on keeping the patient provider relationship front and center to ensure that our platform improves the care we deliver to our patients. Subscribe to our blog and stay up to date on every topic in the opioid epidemic space.