Performing Risk Assessment in Opioid Therapy
Screening patients for a predisposition to opioid abuse prior to treatment can help prevent abuse and develop better treatment plans.
The number of opioid prescriptions has risen dramatically in the United States in the past 20 years, in spite of weak evidence to support their long-term safety and efficacy.1 The Centers for Disease Control and Prevention have termed the overuse of opioids an ‘epidemic’ in the United States. While much focus is being given in workers’ compensation to controlling the utilization of opioids to treat chronic pain resulting from workplace injuries, more attention must be given to ensure that only the right patients are chosen to receive opioid therapy in the first place.
Risks of opioid therapy such as psychological dependence, misuse and abuse, are well known, and persist among all users. But, for patients with current or previous substance use disorders (SUD), these risks can not only be much higher, but also limit the benefit of opioids in treating pain related to the injury.2
Other risks for opioid abuse include:
- Age (older than 40 years)
- Sex (male)
- Family history of substance abuse
- Presence of a psychological disorder (e.g., ADHD, obsessive-compulsive disorder, depression)
These issues may limit the effectiveness of opioid therapy and/or be predictive of future complications with use.3
Risk Assessment Can Help Predict Abuse
A recent study found that chronic pain patients who also had a psychiatric disorder were more likely to receive opioids than other pain patients. It further showed a correlation with higher doses of opioids and higher rates of psychiatric illness.4 It is therefore imperative that underlying issues which may be predictive of greater opioid utilization and abuse potential be uncovered before the first prescription is written. There are several clinical tools – among them the DIRE, ORT, and SOAPP-R – that can be used by prescribers to help uncover pre-existing issues and predict future abuse potential. The accompanying table illustrates comparisons between these valuable assessment tools.
None of these tools, however, are lie detectors; they cannot prevent a patient’s deception if that is their intent. These tools should be used to complement the prescriber’s clinical assessment along with the use of other data, and should be part of obtaining a comprehensive patient history prior to opioid prescribing.
Assessing risk in opioid use is not limited to pre-screening, of course. All opioid patients, even those compliant with prescribed therapy, should undergo additional routine screening for behavioral issues that may complicate treatment.
Behavioral risks include screening for:
- Early refill requests
- Claims of lost/stolen prescriptions
- Unauthorized dose escalations
- Abnormal urine drug screening
These behaviors may raise a 'yellow flag' of caution, and patients who demonstrate these risks should warrant closer monitoring.
Obtaining a comprehensive patient history is also a critical initial step when prescribers consider long-term opioid use. Pre-existing substance use disorders, as well as other psychiatric conditions can, if improperly accounted for and addressed, significantly impair attaining functional goals and lead to aberrant opioid use behavior. It is important that prescribers identify patient specific risks and accommodate this risk into a patient-specific opioid treatment and monitoring plan.
Payers and claims professionals managing injured workers’ care should request documentation from prescribers that these forms of screening are performed as part of the overall treatment plan in every case. Prescribers should also be able to describe how opioid prescribing and/or monitoring would be altered if the injured worker’s risk level changes. The information gained through screenings helps to develop better treatment plans and allows for informed decisions, which assist in producing better patient outcomes. Educating all prescribers on the importance of pre-screening and monitoring patients for these risks before an opioid is prescribed is a critical challenge in addressing our nation’s opioid epidemic.