Risk Assessment Resources
The initial evaluation of the patient in pain should include a risk assessment to identify those patients who may be at risk to misuse, abuse, or divert opioid analgesics. These resources can be used in conjunction with the patient's personal and family history to individualize the level of patient monitoring required in the treatment plan. After the initial assessment, the clinician should continue to monitor the patient carefully for treatment efficacy and possible evidence of opioid misuse.66
- Four-question screener to be administered by healthcare provider
- Assesses for potential drug and alcohol problems
- Evaluates risk based on the following 4 behaviors associated with substance abuse: feelings that one should "Cut down on substance use," becoming Annoyed by criticism of substance use habits, feeling
- Guilty about one's use of substances, having an "Eye opener" in the morning to alleviate discomfort
- Affirmative answers to 2 out of 4 questions warrant further investigation68
- Provider-administered survey consisting of 5 questions66
- Analyzes patient and family history to determine a risk category for the patient
Initiating Opioid Therapy
An opioid agreement should be considered to document and clarify treatment goals and expectations. It should help facilitate compliance and educate patients on responsible participation in their pain care. Opioid agreements are best used practice-wide to avoid bias. See table 2 for important points of an opioid agreemtent.
Sample Opioid Agreement
A sample agreement includes risk/benefit information and a list of potential opioid side effects.
- Widely used, healthcare professional–administered questionnaire72
- Asks provider to rate 11 signs and symptoms of opioid withdrawal as observed on a numerical scale
References Used in the Section:
- 66Agency Medical Directors Group. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid therapy. http://www.agencymeddirectors.wa.gov/opioiddosing.asp. Accessed June 5, 2011.
- 67Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995; 94(3):135-140.
- 68National Institute on Drug Abuse. Diagnosis and treatment of drug abuse in family practice. http://archives.drugabuse.gov/diagnosis-treatment/diagnosis5.html. Accessed December 17, 2010.
- 69Community Anti-Drug Coalitions of America. Opioid Risk Tool (ORT). http://www.preventrxabuse.org. Accessed June 5, 2011.
- 70The Office of the Medical Director, Washington State Department of Labor and Industries. Opioid progress report. http://www.LNI.wa.gov/Forms/pdf/F245-359-000.pdf. Accessed June 5, 2011.
- 71California Society of Addiction Medicine. Guideline for Physicians Working in California Opioid Treatment Programs. Table 6. Clinical Opiate Withdrawal Scale (COWS). www.csam-asam.org/files/CSAMOTPGuideline21Apr09.pdf. Accessed June 5, 2011.
- 72Tompkins DA, Bigelow GE, Harrison JA, Johnson RE, Fudala PJ, Strain EC. Concurrent validation of the Clinical Opiate Withdrawal Scale (COWS) and single-item indices against the Clinical Institute Narcotic Assessment (CINA) Opioid Withdrawal Instrument. Drug Alcohol Depend. 2009;105(1-2):154-159.