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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

Opioid Use Disorder (OUD) is a chronic disorder described as compulsive, repeated opioid drug use and prolonged opioid drug self-administration. Two categories of patients suffer from OUD; the first are those addicted to medical opioids. The second is patients who get addicted to non-medical opioids. A combination of environmental and genetic factors influences 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. Many physicians rely on their poorly validated signs of subjective impressions for judging whether a patient is at a high risk of Substance Use Disorder (SUD) (Ducharme & Moore, 2019).

Patients, their families, and the physician share the concern for the risk of addiction. 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. An evidence-based review by Fishbain (2008) showed that approximately 0.19 percent of patients with chronic pain and who are on opioid analgesics therapy would eventually develop SUD or ADRB when such patients have no history of opioid abuse or even a current addiction of the same at the time opioid treatment is commenced.

Patient assessment calls for the caregiver to use a systematic and standardized approach for all patients who will receive the opioids (Ducharme & Moore, 2019). 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. When a physician is unsure, a urine test can provide additional information (Ducharme & Moore, 2019). 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

OUD risks occur across the healthcare field continuum. Recent studies based on diverse populations have shown that prescribing opioids in the ED can increase the risk of repeated use of opioids (Hoppe et al., 2107; Barnett et al., 2017). One study showed that patients who take opioids before surgery remained on opioids past the average post-operative period of healing (Goesling et al., 2017). After a total knee replacement, 20 percent of the patients in the study pointed out that they still experienced prolonged pain at six months, extending the time that such patients were on opioids (Wylde et al., 2018). A retrospective analysis of administrative health claims has revealed that different chronic opioid use also occurs after surgery, such as cesarean section and total knee arthroplasty (Sun et al., 2016).

Additionally, two studies have shown that patients that have a history of use of antidepressants and benzodiazepine pre-surgery are depressive, have had drug or alcohol abuse, and over the age of 40 years have an increased risk of becoming chronic opioid users (Sun et l., 2016; Brummett et al., 2017). Pain continues to be prevalent in epidemic proportions; 25 million people have to endure pain daily, while 23 million people report experiencing pain of such intensity that they cannot care for or support themselves. While policies at the state and federal levels have addressed chronic non-malignant pain prescription opioids, opioids remain the choice for acute pain management, either as a neutral blockade adjunct or regimen for multimodal analgesia (St. Marie, 2019).

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 the present, 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 unknown but related to malignant etiology

Non-medical use is ingesting drugs for purposes other than those prescribed or directed by a person who is not prescribed 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

The original purpose of risk assessment tools was 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 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. Stratification of risk can be included in the patient’s medical records as this demonstrates complete accountability and assessment of the patient’s treatment plan (St.Marie, 2019).

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. A systematic review by Chou et al. (2015) revealed that opioid risk assessment tools’ diagnostic accuracy was very low or even insufficient in predicting the risk for overdose, abuse, and misuse of prescribed opioids. Further, before 2014, there lacked good reliability and validity for any of the opioid risk assessment tools used to predict the possibility of OUD development when prescribing opioids for pain management (Chou et al., 2015).

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. 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.


Barnett, M. L., Olenski, A. R., & Jena, A. B. (2017). Opioid-prescribing patterns of emergency physicians and risk of long-term use. New England Journal of Medicine376(7), 663-673.

Brummett, C. M., Waljee, J. F., Goesling, J., Moser, S., Lin, P., Englesbe, M. J., … & Nallamothu, B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA surgery152(6), e170504-e170504.

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 non-malignant pain. The Journal of Pain20(7), 842-851.

Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., … & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of internal medicine162(4), 276-286.

Ducharme, J., & Moore, S. (2019). Opioid Use Disorder Assessment Tools and Drug Screening. Missouri medicine116(4), 318–324.

Fishbain, D. A., Cole, B., Lewis, J., Rosomoff, H. L., & Rosomoff, R. S. (2008). What percentage of chronic non-malignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain medicine9(4), 444-459.

Goesling, J., Moser, S. E., Zaidi, B., Hassett, A. L., Hilliard, P., Hallstrom, B., … & Brummett, C. M. (2016). Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain157(6), 1259.

Hoppe, J. A., McStay, C., Sun, B. C., & Capp, R. (2017). Emergency department attending physician variation in opioid prescribing in low acuity back pain. Western Journal of Emergency Medicine18(6), 1135.

St Marie B. (2019). Assessing Patients’ Risk for Opioid Use Disorder. AACN advanced critical care30(4), 343–352.

Sun, E. C., Darnall, B. D., Baker, L. C., & Mackey, S. (2016). Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA internal medicine176(9), 1286-1293.

Wylde, V., Beswick, A., Bruce, J., Blom, A., Howells, N., & Gooberman-Hill, R. (2018). Chronic pain after total knee arthroplasty. EFORT open reviews3(8), 461-470.


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Pre-Screening Tool for Opioid Misuse Risk Assessment in Adult Patients with Chronic, Non-Malignant Pain


I request you to write the Introduction part (including Background and Methods) for my Capstone project. I attached my previous work that has to be consistent with this assignment. I will briefly explain what I do. The project will reveal which pre-screening tool is more efficient to predict opioid misuse disorders during long-term treatment of chronic pain. In this research, I included a 6-questions survey that I sent to the primary care and pain management center providers to assess which tool they found more useful in their practice. I put a consent form that they sign before the survey-taking. The Initial submission of protocol #1271, “Pilot Study: Survey on the Use of Opiate-Misuse-Screening-Tools by Maryland Prescribers,” was Exempt approved on Thursday, December 17th, 2020, by IRB Committee. I have already 65 respondents.

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

I attached my background assignment and article review that have been already graded, so please be CAREFUL with PLAGIARISM.

The current Introduction should mostly look like a systematic review in terms of posing a question, defining terms, and a search process, describing methods for locating literature, and determining if papers fit my criteria. I attached everything that I have done for it, including the databases for the literature searching. The Introduction has to have the clinical context, why this research is essential, a statement of the problem, PICO question, Inclusion/Exclusion criteria, operational definition, and purpose of the study. The teachers like PRISMA diagram that has to be in this part of the paper. Refer to all tables in the text.

PICO Question: 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?

Thank you!

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?

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