Using Tools to Risk Stratify Patients for Long-term Opioid Therapy

Howard S. Smith, MD

Associate Professor
Academic Director—Pain Management
Department of Anesthesiology
Albany Medical College
Delmar, NY

Standard of care requires that patients being considered for long-term opioid therapy are assessed for the risk of medication misuse and abuse. During this process, clinicians may supplement the physical exam, comprehensive patient history, and ancillary testing with results from a risk assessment questionnaire, such as the revised Screener and Opioid Assessment for Patients with Pain and the Current Opioid Misuse Measure. These tools attempt to identify patients who may engage in problematic drug-taking behaviors based on various risk factors, most notably personal or family history of substance abuse and psychiatric profile. The decision to proceed with opioids and the structure of therapy are then based on the initial and ongoing risk stratification. Importantly, opioids are not necessarily contraindicated in higher risk patients, although a high degree of monitoring is likely required. Conversely, appropriate follow-up and oversight are still needed in patients perceived to be at low risk for aberrant behaviors.

References

Butler SF, Budman SH, Fernandez KC, Fanciullo GJ, Jamison RN. Cross-Validation of a Screener to Predict Opioid Misuse in Chronic Pain Patients (SOAPP-R). J Addict Med. 2009;3(2):66-73.
Wasan AD, Butler SF, Budman SH, et al. Does report of craving opioid medication predict aberrant drug behavior among chronic pain patients? Clin J Pain. 2009;25(3):193-198.
Chou R, Fanciullo GJ, Fine PG, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):131-146.
Passik SD, Kirsh KL, Whitcomb L, et al. Monitoring outcomes during long-term opioid therapy for noncancer pain: results with the Pain Assessment and Documentation Tool. J Opioid Manag. 2005;1(5):257-266.
Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the Current Opioid Misuse Measure. Pain. 2007;130(1-2):144-156.

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