Opioid, Risk Tool

Brott NR, Peterson E, Cascella M.

Publication Details

Definition/Introduction

Opioids are a class of analgesics commonly employed in the treatment of acute and chronic pain conditions. [1] Apart from the analgesic effects, the opioids used in clinical practice may interfere with different physiological functions, including stress, temperature, respiration, endocrine activity, gastrointestinal activity, memory, mood, and motivation. These opioid-induced effects are produced by activating opioid receptors located in the central and peripheral nervous systems. These opioid receptors are an extensive family of receptors, including the Mu OPiate receptors (MOP, also indicated as MOR), the Delta OPiate receptors (DOPs or DORs), Kappa OPiate receptors (KOPs or KORs), and Nociceptin OPiate receptors (NOPs or NORs) also known as opioid-receptor-like receptor 1 (ORL1). Moreover, other opioid receptors such as the zeta, the epsilon, the lambda, and the iota opioid receptors have also been characterized.[1]

The use of opioids in treating chronic non-cancer pain is a current area of controversy due to the potential risk of patients' physical dependence on opioid medications.[2][3][4] However, the alarming data about the deleterious effects of the misuse or abuse of opioids (opioid crisis) seems to have a geographical contextualization, being especially evident in North America and Canada, while in Europe, the problem appears to be less apparent.[5][6]

Several tools have undergone development for assessing the risk of developing opioid use disorder. The Opioid Risk Tool (ORT) is a validated screening instrument commonly used in practice to evaluate the risk of future aberrant opioid use among chronic nonmalignant pain patients who receive prescribed opioids for pain relief.[7] In other words, the tool quantifies the risk of developing an opioid use disorder (OUD). The assumption is that there would be predisposing factors, including behavioral factors and factors strictly related to the patient's history and experiences. For instance, opioid-related aberrant behaviors include abuse, misuse, and diversion.[8] The matter is much more complicated as a previous history of addiction to opioids, or other substances is not the only predictive factor. In clinic practice, it is possible to note that many subjects with chronic pain syndromes that develop OUD do not have a prior history of addiction.

Webster et al. developed the ORT questionnaire., in 2005, as a self-performed screening tool designed for use by adult patients in primary care settings before beginning opioid treatment for pain management.[9] It consists of ten scorable components. For some items, a different score is assigned depending on gender. The questionnaire asks patients to report on:

  • Family history of substance abuse including alcohol (Female=1; Male=3), illegal drugs (2;3), and/or prescription drugs (4;4)
  • Personal history of substance abuse including alcohol (Female=3; Male=3), illegal drugs (4;4), and/or prescription drugs (5;5)
  • Whether the patient age range is between 16 to 45 years (1;1)
  • A history of preadolescent sexual abuse (3;0)
  • Psychological disease including attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), bipolar disorder, schizophrenia (2;2); and/or depression (1;1)

Scores are summed, and a score of 3 or below suggests a low risk for future opioid abuse, while a score of 4 to 7 indicates moderate risk. A score of 8 or greater suggests a high risk of future abusive drug-related behavior. According to the ORT, there are several interactive versions of the ORT available online, which allow for quick calculation of a patient's risk.

Cheatle et al. have recently developed and validated a weighted ORT eliminating the gender-specific history of preadolescent sexual abuse. Of note, they found that this revised ORT was able to better predict the development of OUD in individuals with chronic nonmalignant pain on long-term opioid therapy.[7]

Other opioid risk screening tools include the Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R), developed to predict aberrant drug-related behaviors before initiation of long-term opioid therapy;[10] the Diagnosis Intractability Risk Efficacy (DIRE) tool, the 17-item Current Opioid Misuse Measure (COMM) and its 9-item brief version, the 26-question Patient Medication Questionnaire (PMQ).[11][12][13][14]  

Issues of Concern

Over the past several decades, there has been a significant increase in opioid use, misuse, and abuse, although the phenomenon seems to be dramatic, especially in some geographical areas, while in others such as Europe, the consumption and misuse or abuse of opioids is less alarming. This upward trend in opioid use started in the 1990s, especially in the United States, which is the largest consumer of opioid drugs globally, accounting for close to 80% of the opioids produced worldwide. Prescription opioids are now the leading drug of abuse, and their use can produce both medical and psychological side effects. Opioid overdose, indeed, is the most common cause of accidental death among young adults. As of 2018, predictions suggest that there could be close to 500000 opioid-related deaths in the United States over the next decade. The effects of the misuse of opioids are manifold. In the surgical setting, for instance, opioid misuse is associated with an increased risk of postoperative complications, postoperative death, and falls and fractures in the elderly.[8][15][16][17][18]

Clinical Significance

Early identification of at-risk patients is an effective strategy in preventing aberrant opioid behavior. In the postsurgical setting, opioid abuse increases the risks of poor surgical outcomes, motor vehicle accidents, myocardial infarction, bone fractures, and death, among various other medical issues. Opioid-related adverse events have a direct positive correlation with the opioid dosages. Although the CDC has indicated there is insufficient evidence to determine the utility of opioid risk screening tools, some prescription guidelines suggest using these instruments. In this context, the ORT has been adopted in clinical practice to evaluate the risk of future aberrant opioid behavior.[8] Indeed, the ORT is better for low-risk screening, and it may be more useful in large-volume medical practices due to its relative ease of use.[15] Furthermore, the tool is easy to perform as administration and scoring take less than 1 minute. Concerning the clinical significance of ORT, although opioid use should not be stigmatized simply because a patient is considered "high risk" by the ORT, these patients should be treated with other modalities of pain control, such as non-invasive or minimally invasive treatments.

Nursing, Allied Health, and Interprofessional Team Interventions

For patients with an established treatment plan involving opioid therapy, frequent follow-up is essential for all patients, no matter their risk stratification. Higher risk patients require more frequent monitoring than lower-risk patients. Follow-ups may include re-screening of risk, urine drug screening, and observation for other clues of drug abuse. These clues may consist of requests for dose escalation, doctor shopping, forging prescriptions, requesting early prescriptions, unscheduled clinic visits, or emergency room visits with complaints of pain. Urine drug screening may identify illicit substances or non-use of prescribed medication. It is strongly recommended to collect a baseline urine drug screen to identify pre-existent drug abuse when present. These recommendations should involve interdisciplinary cooperation of physicians, nurses, technicians to improve patient outcomes.[15] [Level 2]

Review Questions

References

1.
Herman TF, Cascella M, Muzio MR. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 30, 2023. Mu Receptors. [PubMed: 31855381]
2.
Pathan H, Williams J. Basic opioid pharmacology: an update. Br J Pain. 2012 Feb;6(1):11-6. [PMC free article: PMC4590096] [PubMed: 26516461]
3.
Salsitz EA. Chronic Pain, Chronic Opioid Addiction: a Complex Nexus. J Med Toxicol. 2016 Mar;12(1):54-7. [PMC free article: PMC4781803] [PubMed: 26602212]
4.
Rhodes E, Wilson M, Robinson A, Hayden JA, Asbridge M. The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review. BMC Health Serv Res. 2019 Nov 01;19(1):784. [PMC free article: PMC6825333] [PubMed: 31675963]
5.
Bigal LM, Bibeau K, Dumbar S. Patterns in opioid prescription in the United States by region and prescribers over a 4-year period. J Opioid Manag. 2019 Nov/Dec;15(6):499-506. [PubMed: 31850512]
6.
Miceli L, Bednarova R, Rizzardo A, Cuomo A, Riccardi I, Vetrugno L, Bove T, Cascella M. Opioids prescriptions in pain therapy and risk of addiction: a one-year survey in Italy. Analysis of national opioids database. Ann Ist Super Sanita. 2018 Oct-Dec;54(4):370-374. [PubMed: 30575575]
7.
Cheatle MD, Compton PA, Dhingra L, Wasser TE, O'Brien CP. Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain. J Pain. 2019 Jul;20(7):842-851. [PMC free article: PMC6768552] [PubMed: 30690168]
8.
Clark MR, Hurley RW, Adams MCB. Re-assessing the Validity of the Opioid Risk Tool in a Tertiary Academic Pain Management Center Population. Pain Med. 2018 Jul 01;19(7):1382-1395. [PMC free article: PMC7191882] [PubMed: 29408996]
9.
Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005 Nov-Dec;6(6):432-42. [PubMed: 16336480]
10.
Black RA, McCaffrey SA, Villapiano AJ, Jamison RN, Butler SF. Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8). Pain Med. 2018 Oct 01;19(10):1982-1987. [PubMed: 29024987]
11.
Salmond S, Allread V. A Population Health Approach to America's Opioid Epidemic. Orthop Nurs. 2019 Mar/Apr;38(2):95-108. [PMC free article: PMC6519712] [PubMed: 30768537]
12.
Butler SF, Budman SH, Fernandez KC, Houle B, Benoit C, Katz N, Jamison RN. Development and validation of the Current Opioid Misuse Measure. Pain. 2007 Jul;130(1-2):144-56. [PMC free article: PMC1950245] [PubMed: 17493754]
13.
McCaffrey SA, Black RA, Villapiano AJ, Jamison RN, Butler SF. Development of a Brief Version of the Current Opioid Misuse Measure (COMM): The COMM-9. Pain Med. 2019 Jan 01;20(1):113-118. [PubMed: 29237039]
14.
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. 2004 May;27(5):440-59. [PubMed: 15120773]
15.
Dale R, Edwards J, Ballantyne J. Opioid risk assessment in palliative medicine. J Community Support Oncol. 2016 Mar;14(3):94-100. [PubMed: 27058865]
16.
Combs B, Hughes MM, Ariagno J, Turcotte E. Opioid Epidemic. Orthop Nurs. 2019 Mar/Apr;38(2):92-94. [PubMed: 30882550]
17.
Manchikanti L, Helm S, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician. 2012 Jul;15(3 Suppl):ES9-38. [PubMed: 22786464]
18.
Clark DJ, Schumacher MA. America's Opioid Epidemic: Supply and Demand Considerations. Anesth Analg. 2017 Nov;125(5):1667-1674. [PubMed: 29049112]

Disclosure: Nathan Brott declares no relevant financial relationships with ineligible companies.

Disclosure: Elisha Peterson declares no relevant financial relationships with ineligible companies.

Disclosure: Marco Cascella declares no relevant financial relationships with ineligible companies.