Clinicians who prescribe opioid drugs must acknowledge that some patients
engage in problematic, or aberrant, drug-related behaviors that may be
significant enough to be labeled abuse. Clinicians must further acknowledge
the possibility that opioids become the object of true addiction for a
small segment of the population predisposed to this disease. Finally,
clinicians must recognize that the potential for criminal activity exists
and that doctors are sometimes duped into providing drugs that are then
trafficked into an illicit market.
The safe and effective use of opioid therapy requires a clinical assessment
at the outset that is intended to judge the risk of these outcomes. This
assessment is complex because the likelihood of abuse, addiction or diversion
varies dramatically among the very diverse populations that are treated
with opioids for acute and chronic pain, and the factors that contribute
to this likelihood are undoubtedly numerous and, as yet, poorly characterized.
Nonetheless, an assessment is needed to inform the structuring of therapy,
the goal of which is to provide an appropriate level of monitoring and
control.
Several screening tools have been developed to identify patient characteristics
that can be useful in predicting aberrant drug-related behavior or addiction
during opioid therapy for chronic pain. Most of these tools have not yet
been adequately validated in large surveys and none have been incorporated
into clinical practice. They nonetheless provide useful clinical information
about the elements that may predict risk.
One study suggested that five factors may predict the occurrence of prescription
drug abuse:
- focus on opioids during clinic visits,
- pattern of early refills or dose escalation,
- multiple telephone calls or visits pertaining to opioid therapy,
- other prescription problems, and
- obtaining opioids from sources other than the clinic.
Another study identified three factors predictive of misuse and abuse:
- tendency to increase the dose,
- preference for a specific route of administration, and
- considering oneself addicted.
A third study, which provided validation data for a Screening Instrument
for Substance Abuse Potential (SISAP) linked the prediction of risk to
alcohol consumption, marijuana consumption, smoking and age. Another
validated questionnaire, the CAGE, was originally developed as a screening
tool for alcoholism and has been adapted into the CAGE-AID, a more
general instrument for screening drug abuse. According to this
instrument, two or more positive responses to the following
questions should lead to a detailed assessment:
In the past have you ever:
- Tried to Cut down or Change
your pattern of drinking or drug use?
- Been Annoyed or Angry
by others' concern about your drinking or drug use?
- Felt Guilty about the consequences
of your drinking or drug use?
- Had a drink or used a drug in the morning
(Eye-opener) to decrease hangover or withdrawal symptoms?
More recently, a large study provided initial validation for a new 26-item
Pain Medicine Questionnaire, which assesses a range of self-reported behaviors
and attitudes. These studies ultimately may generate an instrument that
is sufficiently brief, sensitive and specific to be used routinely in practice.
At the present time, however, none of these tools are in common clinical
use and the assessment of risk at the outset of therapy remains a clinical
judgment based on a comprehensive assessment of the medical and psychiatric
features of each case. In this assessment, experienced clinicians tend to
focus on several elements of the history to make a global judgment about
risk, including:
- prior and current history of drug abuse, and the associated details
(preferred drugs, ongoing or in the past, daily or intermittent use,
reflective of addiction or not, treatment needed or not, in established
recovery or not, ongoing involvement with a drug abuse subculture, etc.)
- family history of addiction
- major psychiatric comorbidity, particularly an untreated Axis I disorder
(such as major depression or an anxiety disorder) or a clinically significant
personality disorder.
This history, along with supporting documentation, is used to judge whether
the risk of abuse, addiction or diversion is likely to be low, moderate
or high. This impression, in turn, informs decisions concerning the structure
of therapy.
References
Adams LL, Gatchel RJ, Robinson RC, Polatin P, Gajraj N, Deschner M, Noe
C: Development of a self-report screening instrument for assessing potential
opioid medication misuse in chronic pain patients. J Pain Symptom Manage,
in press.
Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate
abuse in chronic pain patients: clinical criteria, incidence, and predictors.
Clin J Pain 1997;12:150-155.
Coambs RB, Jarry JL. The SISAP: a new screening instrument for identifying
potential opioid abusers in the management of chronic nonmalignant pain
in general medical practice. Pain Res Manage 1996;1:15-162.
Compton P, Darakjian J, Mitto K. Screening for addiction in patients with
chronic pain and “problematic” substance use: evaluation of
a pilot assessment tool. J Pain Symptom Manage 1998;16:355-363.
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