First published on June 1, 2014
It is important to clearly address these responsibilities and expectations at the onset of establishing a treating relationship, particularly when the increasingly controversial subject of opiate medications is involved.
Risk Identification and Stratification
Patients should be notified prior to their visit that medications will not be prescribed during their first appointment. The purpose of the initial evaluation is to obtain a thorough history and physical examination to ascertain the most appropriate treatment course. The history should include information relevant to the pain condition, past medical history, and psychiatric functioning. A risk assessment tool for substance abuse should be administered in the event that opioid prescribing will be a part of the treatment plan…
Patients who are categorized as “Low Risk” on the ORT, present a medication history that corresponds with the CURES [PDMP] report, have a UDS result that is consistent with their prescribed medications, and do not have untreated or undertreated mental health issues are considered at low risk for opioid abuse. Prescribing of opioids may be initiated if it is clinically indicated. Before opioids are prescribed, the patient should sign written documents that explain the risks of opioid therapy and the parameters of treatment…
Consistent UDS results, CURES reports, and appropriate responses in the above areas suggest a lack of contraindications for continued opioid use. However, any deviations in the above parameters would result in the patient being recategorized as being “At Risk” and would prompt a switch to the pathway described in the next section.
Patients are considered “At Risk” for opioid abuse due to any combination of the following:
-Moderate- or high-risk result on the ORT
-Medication history that does not correspond to the CURES report
-UDS result that is inconsistent with prescribed medications
-Untreated or undertreated mental health issues
An evaluation by a pain psychologist should be obtained for all at-risk patients to identify the nature and extent to which psychological factors may be influencing the patient’s predicament. An additional consultation with an addiction medicine specialist should be obtained for patients at moderate or high risk based on the ORT, incongruent CURES, or inconsistent UDS results.
Upon completion of the additional evaluations, the information should be integrated to identify whether the patient should be recategorized as low risk or if an active substance abuse disorder is present that necessitates formal addiction treatment…
Reasons to Consider Opioid Cessation
It is critical for prescribing providers to actively monitor patients to ensure that use of opioid therapy remains appropriate. The parameters surrounding the number and type(s) of infractions that would result in medication discontinuation should be specified clearly in the agreement. Once the threshold for discontinuation has been reached, providers should initiate a taper. Contraindications for continued prescribing include (but are not limited to) aberrant behavior, lack of functional improvement, and medical complications…
Lack of Functional Improvement
One of the hallmark differences between acute and chronic pain is the fact that the latter lacks a definitive cure; thus, treatment approaches focus on management of the condition. It can be tempting to focus solely on pain palliation when prescribing medication, but optimal pain management treatment should encompass a wider range of factors, including functional status and emotional well-being. Use of activity diaries (documents in which patients track daily activity), monitoring of work absenteeism due to pain, and obtaining corroborating information from family members may facilitate assessment of functioning…
Opioid Risk Tool (ORT) Assessment Instrument
Reprinted With Permission from Lynn Webster, MD
I took the test and scored in the “high risk” category. In fact, I can’t imagine that too many pain patients would score in the low or moderate risk categories, as you (and your family) would have to be saints (or devout Mormons) to do so. And if you have a large family, then you’ll have a higher risk for family members who have abused drugs or alcohol.
For instance, who doesn’t have a family member that has abused alcohol? And if you’re an older pain patient, who hasn’t abused alcohol in their youth? I know I did — not to the point of addiction, but I did some wild partying in my younger days. Of course, I quit drinking (and partying) a very long time ago. I can’t remember the last time I had any alcohol, including wine. Still, I’d be penalized for stuff that happened over 25 years ago.
And the test appears to discriminate against men, who get a higher score than women if they’ve ever abused alcohol and/or illegal drugs. And if you’re a woman who’s been a victim of preadolescent sexual abuse, you get high marks used against you — but if you’re a man, you get no marks at all.
My high risk score just confirms that if I were to see a pain doctor, I would be denied any kind of treatment that included pain medication. Of course, this test is self-reported by patients, so I could always lie on the questionnaire, as I’m sure many patients do.