Pre-Screening Tool for Opioid Misuse Risk Assessment in Adult Patients with Chronic, Non-Malignant Pain
Opioid Use Disorder (OUD) is a chronic disorder described as compulsive, repeated opioid drug use and prolonged opioid drug self-administration. There are two categories of patients who suffer from OUD; the first are those who get addicted to medical opioids. The second is patients who get addicted to non-medical opioids. A combination of environmental and genetic factors is known to influence OUD in patients.
Although there are available guidelines and oversight agencies that have requirements that ought to be met, the overall rates of death and overdose of the epidemic, most practitioners fail to utilize a standardized approach for assessment of risks as regards substance addiction and misuse either at the initial evaluation or during the follow-up visits. Stratification and risk assessment have both become the most important aspects of opioid prescribing to patients with chronic pain. The empirical data available is few on the specificity and sensitivity of the risk assessment tools that are commonly used (Jones et al., 2012). The concern for the risk of addiction is shared by patients, their families, and the physician. A critical patient subset of those with chronic pain syndrome may also suffer from SUD, while some may have a prior history of being addicted to opioids. On the other hand, there may be patients who may not have a history of substance abuse but could very well develop Aberrant Drug-Related Behaviors (ADRB) or become addicts. There are different literature variabilities on the risk of SUD or de-novo addiction in patients who commence opioid therapy where patients have chronic or acute pain; however, such a risk exists. Overall, the studies show that not all assessment tools for opioid abuse are equal in the way they predict future ADRB. It is probable that written risk assessment tools utilize subtle items that are better suited for specific patient populations (Jones et al., 2012).
Physicians are encouraged to utilize a rational approach with universal precautions for pain treatment. Physicians need to look into the emotional situation that surrounds addiction to opioids as this can be effective: physicians should assume that all patients who are under opioid prescription are also at a high risk of addiction; patients should be screened with an already established tool for a patient that is prescribed opioids as being at increased risk of addiction; screening every patient on an opioid prescription using a tool to show if there is an already existing addiction or the possibility of addiction. Capturing specific inappropriate use (that is, behaviors that indicate abuse, misuse, and other inappropriate use of medication) in RCTs helps in the evaluation of the drug property, that is, its potential abuse), as opposed to identifying the users’ clinical conditions, (that is SUD) (Smith et al., 2015). This study will seek to determine the best available tool for assessing opioid addiction in patients with chronic, non-malignant pain. In this section, the paper will discuss why this research is essential, the statement of the problem, the inclusion and exclusion criteria of literature, operational definitions, and the study’s purpose.
Why This Research Is Essential
Several studies have examined the prevalence of non-medicinal opioids and SUD in specific populations, including those with chronic pain. The critical risks which patients on prescription opioids include OUD development, overdose, and even death. Opioid addiction has caused an enormous burden on the healthcare system and countries’ economies; thus, chronic non-cancer guidelines on pain management suggest that patients are screened for risk of substance addiction, misuse, and abuse prior to prescribing opioids. It is a challenge to quantify this risk. Several risk assessment tools were developed to help identify and quantify patients at a high risk of suffering from SUD. These tools rely only on self-reporting and hence depend heavily on patients truthfully answering questions. When patients misrepresent their past behaviors or histories, it may impact the risk score that results from answering the questions posed in the assessment tools. At the same time, the possible dishonesty can make the answers questionable. Variability in the populations included in the studies and some measured outcomes can also weaken the tools’ generalizability. Hence, no single tool for assessing the risk can guarantee accuracy in risk determination for any one patient. It is not until DNA testing is included in the routine clinical testing can be accurate; otherwise, OUD development can be prevented by keeping patients opioid-naive, yet this is neither practical nor offering optimal care. The ongoing prescription of opioids should be made to understand the risk assessment tools limitations, proper and appropriate following of the patient, and regular screening of patients for ADRB. How these tools perform in a specific environment, such as pain clinics, hospital wards, and emergency departments, has not been studied sufficiently for a particular tool or tools to be recommended for use in a specific environment. Even with these limitations, it has been shown that utilizing standardized tools in risk assessment is worth it because it minimizes stress and offers useful information in a standardized manner. Therefore using a standardized tool for risk assessment for every patient considered for opioid prescription aligns with the ‘universal precautions’ mindset stated above.
PICO: What pre-screening tool has the greatest value to Maryland prescribers when assessing opioid misuse risk when prescribing opioids for chronic, non-malignant pain in adults?
Statement of the Problem
Illicit use of opioids continues to increase globally and remains a threat to health, with misuse occurring in over 145 countries. In the US, while there is a continued rise in illicit opioids, it is increasingly driven by the use of synthetic opioids. For the effective treatment and management of an individual’s dependence on opioids, there needs to be a valid and reliable tool for identifying and diagnosing the affected population. Although several such tools are available, most are cumbersome or take up too much time when administering, require that healthcare staff undergo extensive training and certification for administration, lack rapid scoring, or are rated for clinical use only. Additionally, most of the screening instruments are sub-components of other assessments, while some are deficient in that they fail to acknowledge SUD as chronic and relapsing hence excluding persons who have not used opioids in the past one year (for example, those in recovery or detention) (Wickersham et al., 2015). Nonetheless, the measurement of inappropriate opioid use in clinical trials is important in helping assess its potential for medication abuse. Research done on opioid use shows a wide range of abuse and misuse, and thus, detecting the potential for abuse is critical. The efficacy of the assessment tools also plays a critical role in curtailing the epidemic. This research will seek to determine the most appropriate and effective tools for opioid use risk assessment.
Inclusion/Exclusion Criteria
The articles included in informing this research had to assess the sensitivity, specificity, and positive predictive value of the opioid screening tools among adults that estimate the risk of developing an OUD in patients with Chronic Non-malignant Pain (CNMP) whom opioids have been prescribed. A screening tool has to be included in the assessment or comparison of different tools. The study requirements needed to have been published between 2012 and today, preferably from 2016 onwards; be peer-reviewed in English; and have systematic reviews or original studies with print or online sources. Patients in the studies had to be above 18 years of age, from Maryland, of any gender or ethnicity, suffering from chronic pain lasting for more than three months, and receiving care from a primary care office. The prescribers had to be from Maryland, possessing a CDS and DEA# certificate.
Articles that were excluded were those that involved patients with chronic illnesses such as cancer, who were below 18 years and living outside of Maryland; opioid prescription that was less than three months; providers from specialty care or emergency department, which included risk tools that laced support from literature; and which failed to have followed up its subjects.
Operational Definitions
- Chronic, non-malignant pain: this is pain that goes on for more than three months and can be caused by a condition or disease because of areas in unknown but related to malignant etiology
- Non-medical use is ingesting drugs for purposes other than those prescribed or directed by a person not authorized to prescribe medications.
- Opioid misuse: describes the use of opioids outside of what is prescribed and includes taking the same in diverse forms such as injecting or snorting, in large quantities, without prescription, and over long periods.
- Opioid use disorder: this is the opioid use pattern that results in significant distress or impairment and is based on criteria such as the inability for one to control or curtail their use and causes home, work, or social challenges.
- Pre-screening risk assessment tool: this is a list of statements or questions that help stratify the future risk of opioid abuse or misuse.
- Primary care provider: a medical doctor, nurse practitioner, or physician assistant who provides an undifferentiated patient comprehensive care in internal or family medicine.
- Value: describes the best benefit to prescribing providers; literature efficacy and support; ease of use; and brevity balance.
Purpose of Study
Risk assessment tools originally aimed to screen for the risk of a patient or person developing ADRB following prescription opioids for pain management. ADRB can include a patient demanding access to opioids, rejecting any other alternative forms of care, demonstrating hostility and anger, or providing an inconsistent history. However, these behavior types can occur in equally diverse situations within an encounter between a patient and the clinician. The first risk assessment tool that challenges the current screening paradigm for ADRB is the Opioid Risk Tool for Opioid Use Disorder (ORT-OUD). The ORT-OUD shifted its focus to screening for OUD risk (Cheatle et al., 2019).
Opioid risk assessment tools have three purposes, and these are reassuring patients who are anxious over their risk and explaining to such patients that their history does not imply that their pain cannot be managed; informing patients that safety planning and effective pain management will be enhanced via utilization of opioid risk assessment tools; discussing with patients who have a prior history of SUD, that necessary safeguards will be taken in helping them in pain management well as treatment referral available, should the need arise.
Opioid risk assessment tools differ by the ease of administration, design, psychometrics used, as well as the risk variables that are predicted and monitored. There are more than 25 opioid risk assessment tools; however, Lawrence et al. (2017) do not recommend the use of ORT, Brief Risk Interview (BRI), and Brief Risk Questionnaire (BRQ) based on the assessed studies. Again, Jones et al. (2015) point out that the BRQ had the highest sensitivity, the ORT had the highest specificity, and the BRQ had the greatest AUC. A strong correlation was determined between SOAPP-R and COMM scores, though neither was strongly correlated with provider assessment (Varney et al., 2018). Of the 16 tools that were assessed, some were shown to be inappropriate for measuring the research parameters of the study (Smith et al., 2015). These variations in assessments form the basis of the current research. Hence, this research seeks to discuss the different opioid use risk assessment tools and determine their validity and reliability. The paper is a systematic review of literature extracted as described earlier in this paper. The information gathered from the literature will be assessed to determine which tool offers the highest benefits for evaluating the risk of opioid misuse, abuse, and disorder. Thus, the results will add to the knowledge gap in zeroing in the ideal tool and recommend the same for physicians in Maryland. Additionally, the research will also include a qualitative aspect where physicians will be requested to fill in questionnaires on different tools’ effectiveness. The participants signed consent forms agreeing to participate in the qualitative study.
References
Cheatle, M. D., Compton, P. A., Dhingra, L., Wasser, T. E., & O’Brien, C. P. (2019). Development of the revised opioid risk tool to predict opioid use disorder in patients with chronic nonmalignant pain. The Journal of Pain, 20(7), 842-851.
Jones, T., Moore, T., Levy, J. L., Daffron, S., Browder, J. H., Allen, L., & Passik, S. D. (2012). A comparison of various risk screening methods in predicting discharge from opioid treatment. The Clinical Journal of Pain, 28(2), 93–100. doi: 10.1097/AJP.0b013e318225da9e.
Jones, T., Schmidt, M.J., & Moore, T. (2015). Further validation of an opioid risk assessment tool: The Brief Risk Questionnaire. Annals of Psychiatry and Mental Health, 3(3), 1032 https://www.jscimedcentral.com/Psychiatry/psychiatry-3-1032.pdf
Lawrence, R., Mogford, D., & Colvin, L. (2017). Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain. BJA: British Journal of Anaesthesia, 119(6), 1092-1109.
Smith, S. M., Paillard, F., McKeown, A., Burke, L. B., Edwards, R. R., Katz, N. P., … & Wasan, A. D. (2015). Instruments to identify prescription medication misuse, abuse, and related events in clinical trials: an ACTTION systematic review. The Journal of Pain, 16(5), 389-411.
Varney, S. M., Perez, C. A., Araña, A. A., Carey, K. R., Ganem, V. J., Zarzabal, L. A., Ramos, R. G., & Bebarta, V. S. (2018). Detecting aberrant opioid behavior in the emergency department: a prospective study using the screener and Opioid Assessment for Patients with Pain-Revised (SOAPP®-R), Current Opioid Misuse Measure (COMM)™, and provider gestalt. Internal and emergency medicine, 13(8), 1239–1247. https://doi.org/10.1007/s11739-018-1804-3
Wickersham, J., Azar, M., Cannon, C., Altice, F., Springer, S. (2015). Validation of a brief measure of opioid dependence: The Rapid Opioid Dependence Screen (RODS). Journal of Correctional Health Care, 21(1), 12-26. https://doi.org/10.1177/1078345814557513
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Pre-Screening Tool for Opioid Misuse Risk Assessment in Adult Patients with Chronic, Non-Malignant Pain
Pre-Screening Tool for Opioid Misuse Risk Assessment in Adult Patients with Chronic, Non-Malignant Pain
It should be an Introduction which includes Background, Methods, inclusion and exclusion criteria of the articles listed in the Annotated Bibliography. I attached the file with Grading Criteria as well as my previous order which is good except of the used articles. PRISMA flow diagram has to show the process of selecting articles. We need to use just articles from the References/Annotated Bibliography. Thank you! I am apologize for the inconvenience.