Lancaster Physician Spring 2020 - 15

SPRING 2020

Opioid medications continue to be prescribed (although now less
frequently) for the treatment of acute pain, chronic non-cancer pain,
and cancer pain. The four "As" of pain treatment outcomes are:

Another useful questionnaire to assess risk is the Opioid Risk
tool (ORT).

1) Analgesia (pain control)
2) Activities of daily living (psycho-social functioning)
3) Adverse effects
4) Aberrant drug taking (addiction-related outcomes)

This tool should be administered to patients
upon an initial visit prior to beginning opioid
therapy for pain management. A score of 3 or
lower indicates low risk for future opioid abuse, a
score of 4 to 7 indicates moderate risk for opioid
abuse, and a score of 8 or higher indicates a high
risk for opioid abuse. Mark each box that applies.

A formal diagnosis of OUD is important for ensuring patient
safety, planning pain therapy, weaning of opioid medication, and
making an appropriate referral. OUD should be suspected when
patients exhibit any aspect of the four "Cs" of opioid medications:

Female

Male

Alcohol

1

3

Illegal drugs

2

3

Rx drugs

4

4

Alcohol

3

3

Illegal drugs

4

4

Rx drugs

5

5

Age between 16 and 45 years

1

1

History of preadolescent sexual abuse

3

0

ADD, OCD, bipolar, schizophrenia

2

2

Depression

1

1

FAMILY HISTORY OF SUBSTANCE ABUSE

1) Compulsive use
2) Continued use
3) Cravings
4) Out-of-control use

PERSONAL HISTORY OF SUBSTANCE ABUSE

OUD is estimated to be present in up to 35 percent of chronic
opioid medication users. The diagnosis is particularly difficult
during pain treatment because many of the symptoms of OUD are
controlled by the presence of pain and/or the sheer consequences
of opioid exposure.

PSYCHOLOGICAL DISEASE

It is no wonder the medical profession has become increasingly "opioid-phobic" when considering the challenging nature of this patient
population and the increasing governmental and public scrutiny.
There are several opioid assessments that can be utilized to
categorize patients. The screening instrument for substance abuse
potential (SISAP) is often helpful.
QUESTION

CAUTION

How many alcoholic drinks per day/
per week

Men - greater than 5 per day or 17 per week
Women - greater than 4 per day or 13 per week

Use of marijuana/hashish in last year

Admission of recent use

Smoke cigarettes

Admission of recent use

Age

Less than 40

FOR GUIDANCE WITH PATIENTS WITH POTENTIAL OPIOID
ADDICTION ISSUES, CONNECT WITH THE PA MEDICAL SOCIETY
FOR RESOURCE INFORMATION.

PAMEDSOC.ORG
OR CALL 855.726.3348

LANCASTER

SCORING TOTALS

A third tool is the Screener and Opioid Assessment for Patients
in Pain (SOAPP). It is a 14-item, self-administered form capturing
the primary determinants of aberrant drug-related behavior.
Clinicians need to assess patients prior to the initiation of opioid
therapy. The key to reducing the risk of aberrant behavior in the
high-risk patient population is frequent monitoring and a structured
intervention with psychotherapy. Studies have demonstrated that
high-risk patients in structured settings with frequent follow-up and
support reduce the probability of aberrant behaviors to the same rate
as the low-risk group. None of the groups demonstrated an absence
of aberrant behaviors.
The opioid epidemic has now made it difficult for patients in pain
to access controlled substances. Physicians are understandably anxious
about the ramifications of being scrutinized by the agencies monitoring
opioid prescriptions. Educating your pain patients on all of the available
non-opioid treatment options and identifying patients who are at high
risk for aberrant behaviors is of the utmost importance. Careful initial
assessment, monitoring, and establishing a highly structured approach
to the management of patients requiring opioid medications for the
treatment of their pain is critical to maintaining safe patient care.

15

PHYSICIAN


http://www.PAMEDSOC.ORG

Lancaster Physician Spring 2020

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