Aberrant Drug-related Behaviors Research Articles

Chemical coping versus pseudoaddiction in patients with cancer pain

The purpose of this case series was to describe patients with aberrant drug-related behaviors and similar patterns of dose escalation in whom interdisciplinary assessment revealed different bases for their dose increases. During the period from December 26 to December 30, 2011, the medical records of two patients with opioid-related aberrant behaviors were reviewed. We described two patients with a significant cancer history and different comorbidities who presented with different aberrant drug-related behaviors and opioid requirements. Opioid-related aberrant behaviors can be interpreted in different ways, and two of the more common syndromes in cancer patients are chemical coping and pseudoaddiction. In advanced cancer patients, the boundaries between these conditions are not as clear, and diagnosis is often made retrospectively. Furthermore, there have been relatively limited studies describing these two syndromes. Thus, they continue to pose a diagnostic and treatment challenge that requires different approaches for effective management of symptoms. The key characteristic between the two syndromes is that the behaviors displayed in chemical coping are motivated by obtaining opioids to relieve psychosocial distress, while in pseudoaddiction these behaviors are motivated by uncontrolled nociceptive input. Close monitoring of the pain syndromes, aberrant behaviors, and opioid requirements over several visits is usually necessary to distinguish the two syndromes.

Addition of Objective Data to Identify Risk for Medication Misuse and Abuse: The Inconsistency Score

To identify and quantify the rate of aberrant drug-taking behaviors using objective data. Institutional Review Board-approved anonymous, voluntary, quality improvement project. University-based, multidisciplinary pain management center. Consecutive initial visit patients. Patients were interviewed, asked to provide a urine sample, and filled out a brief questionnaire about recent prescription, over-the-counter, and illicit drug use. Discrepancies between patient report (PQ), the Virginia State prescription monitoring program (PMP), referring physician records (MRs), and the point-of-care urine drug screen (POC UDS) results were scored from 0 (none) to a maximum of 2 points (2+ discrepancies) for each potential comparator between data sets. Maximum potential inconsistency score (IS) was 16 points. Two hundred nine patients were interviewed to yield 118 specimens. Mean age of participants was 48.2 years (22-83 year); 65.3% were female. IS scores ranged from 1 to 11, and 52.5% of the patients had an IS ≥ 3. Higher IS scores correlated with higher numbers of pharmacies, prescribing physicians, prescriptions on the PMP, and presence of illicit substances in the urine. Addition of either POC UDS or PMP to PQ and MR increased identification of inconsistencies by >400%, and PMP plus UDS by >900%. Patient report and the medical record are inadequate to screen for aberrant drug-related behaviors. Addition of PMP and POC UDS contribute significantly to identification of inconsistencies through higher IS scores and differentiate patients at higher risk of medication misuse, abuse, or diversion. Comparison of multiple sources of objective information provides better insight into inconsistencies of report and behavior, and may assist in more appropriate and safer prescribing decisions.

Shortening the Current Opioid Misuse Measure via computer-based testing: a retrospective proof-of-concept study

BackgroundThe Current Opioid Misuse Measure (COMM) is a self-report questionnaire designed to help identify aberrant drug-related behavior in respondents who have been prescribed opioids for chronic pain. The full-length form of the COMM consists of 17 items. Some individuals, especially compromised individuals, may be deterred from taking the full questionnaire due to its length. This study examined the use of curtailment and stochastic curtailment, two computer-based testing approaches that sequentially determine the test length for each individual, to reduce the respondent burden of the COMM without compromising sensitivity and specificity.MethodsExisting data from n = 415 participants, all of whom had taken the full-length COMM and had been classified via the Aberrant Drug Behavior Index (ADBI), were divided into training (n = 214) and test (n = 201) sets. Post-hoc analysis of the test set was performed to evaluate the screening results and test lengths that would have been obtained, if curtailment or stochastic curtailment had been used. Sensitivity, specificity, and average test length were calculated for each method and compared with the corresponding values of the full-length test.ResultsThe full-length COMM had a sensitivity of 0.703 and a specificity of 0.701 for predicting the ADBI. Curtailment reduced the average test length by 22% while maintaining the same sensitivity and specificity as the full-length COMM. Stochastic curtailment reduced the average test length by as much as 59% while always obtaining a sensitivity of at least 0.688 and a specificity of at least 0.701 for predicting the ADBI.ConclusionsCurtailment and stochastic curtailment have the potential to achieve substantial reductions in respondent burden without compromising sensitivity and specificity. The two sequential methods should be considered for future computer-based administrations of the COMM.

Compliance with Opioid Treatment Guidelines for Chronic Non-Cancer Pain (CNCP) in Primary Care at a Veterans Affairs Medical Center (VAMC)

The primary objective of this study was to measure prescribing compliance with the Veterans Affairs/Department of Defense treatment guidelines for chronic non-cancer pain (CNCP) in the primary care setting. We also determined the proportion of subjects who demonstrated aberrant drug-related behaviors (ADRBs) and the patient characteristics associated with them. This is a retrospective chart review. Primary care setting in Veterans Affairs Medical Center. All patients with CNCP between the ages of 18 and 87 years who received opioid prescriptions for 3 or more consecutive months during a 1-year period (July 2009 to August 2010) were eligible for inclusion. A random sample of 800 patients was selected using pharmacy prescription database. Chi-square test was utilized to analyze associations between ADRB and patient characteristics. About half the patients in our sample had a signed opioid pain care agreement (OPCA), and at least one urine drug test (UDT) was obtained. UDT was positive for an illicit drug/unreported opioid in 19.5% of the patients, and negative for the prescribed drug in 25.2% of the sample. About 10% of the sample population had morphine equivalent dose equal to or greater than 200 mg/day. ADRBs were identified in 22.9% of the patients. Younger age, psychiatric comorbidities, history of substance abuse, and high opioid dose were associated with high risk of ADRB, but the presence of OPCA lowered the risk of ADRB. This article studied the prescribing practices of opioids in a primary care setting and can be used to enhance provider education regarding chronic pain guidelines.

Aberrant behaviors in a primary care-based cohort of patients with chronic pain identified as misusing prescription opioids

To assess aberrant drug-related behaviors (ADRBs) in patients discharged from a community primary care practice for opioid misuse and treating physician's ability to identify predictive aberrant behaviors. Retrospective chart review of patients with chronic noncancer pain (CNCP) identified by their treating physician as misusing opioid analgesics, and patients with similar characteristics who had not been identified as misusing opioids. A survey of attending and resident physicians from these clinics on their knowledge of ADRBs was also collected. Community primary care clinic. Thirty-three patients with CNCP identified by their treating physician as misusing prescription opioid analgesics, and 33 patients randomly selected from the same clinic setting, with similar characteristics who had not been identified as misusing opioids. Twenty-four attending physicians and 42 resident physicians were surveyed on their training and knowledge of predictive aberrant behaviors. More identified misusers than nonmisusers reported positive history of substance abuse (p=0.001), tobacco use (p=0.011), taking multiple doses of prescribed opioids together (0.024), multiple complaints of pain requiring opioid treatment (p=0.006), and multiple phone calls to the clinic requesting opioid medications (p=0.027). Logistic regression on continuous variables revealed that only the number of phone calls to the clinic regarding opioids in the last 12 months achieved significance (p=0.028). Previously postulated and novel ADRBs suggestive of opioid misuse were identified in a community primary care setting. Differences in resident and attending physician's ability to identify key predictive ADRBs and lack of training in pain or addiction underscores the need for changes in medical school and residency programs.

Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use

The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system-depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.

Opioid Analgesics—Risky Drugs, Not Risky Patients

FROM 1999 TO 2010 THE NUMBER OF PEOPLE IN the United States dying annually from opioid analgesic–related overdoses quadrupled, from 4030 to 16 651. Patients’ predisposition to overdose could not have changed substantially in that time; what has changed substantially is their exposure to opioids. During this same time, the amount of opioids prescribed also quadrupled. The increase in prescribing occurred in the context of a greater emphasis on treating pain following efforts by the American Pain Society, the Veterans Health Administration, The Joint Commission, and others to increase recognition and management of pain, as well as advocacy by pain societies urging physicians to use opioids more readily for patients with chronic noncancer pain. Even though it is well known that prescription opioid use can lead to addiction or overdose, some opioid manufacturers and pain specialists suggest that few patients are susceptible to these risks. To distinguish low-risk from highrisk patients, use of screening tools, including the Screener and Opioid Assessment for Patients with Pain, has been advocated. Medication guides include statements such as “the chance [of abuse or addiction] is higher if you are, or have been, addicted to or abused other medicines, street drugs, or alcohol, or if you have a history of mental problems.” While there is likely to be a gradient of risk across patients, this statement may reassure clinicians that people with opioid addiction are different from most patients for whom they provide care. However, opioid dependence is much more common than previously believed and has been estimated to affect more than one-third of patients with chronic pain. No screening tool has sufficiently high sensitivity to rule out problems with opioids. Reported sensitivities of these tests for observed “aberrant drug-related behavior” (eg, dose escalation outside the treatment plan or forging prescriptions) among patients with chronic pain are generally within a range between 70% and 90%, which means that they miss 10% to 30% of patients at high risk of misuse or addiction. In addition, some industry-sponsored educational brochures suggest that physicians should ignore signs of opioid dependence in low-risk patients. For instance, some patients might not be considered at high risk of misuse even though they may use more opioids than prescribed (one definition of misuse). Some authors have stated that behaviors such as taking more opioids than prescribed may represent pseudoaddiction, a concept introduced in a case report in 1989 as “abnormal behavior developing as a direct consequence of inadequate pain management.” However, this concept remains untested, without scientific studies validating diagnostic criteria or describing long-term clinical outcomes. Nonetheless, some pain societies have promoted this concept and suggest that some patients demonstrating behaviors typical of opioid addiction may actually require higher doses. Rather than representing iatrogenic undertreatment of pain, however, behaviors described as pseudoaddiction may represent predictable responses to opioid exposure. Longterm opioid use typically results in tolerance. A standard clinical solution is to increase opioid dose. However, contrary to the view that there is no maximum safe dose if opioids are increased gradually over time, death from opioid overdose becomes more likely at higher doses. The most important risk factor for opioid analgesic– associated dependence or overdose is not a feature of any individual patient but instead simply involves receiving a prescription for opioids. For example, newly prescribed opioids after short-stay surgery are associated with a 44% increase in risk of becoming a long-term opioid user within 1 year. Another potential complication of screening for risk of opioid abuse is that identifying patients who should not receive opioids can stigmatize them, leading to consequences that do not help them. Patients who are questioned about substance use and then excluded from an expected treatment may feel embarrassed or abandoned. The decision to address a patient’s pain should not depend on

Usefulness of the opioid risk tool to predict aberrant drug-related behavior in patients receiving opioids for the treatment of chronic pain

The purpose of this study was to determine if the opioid risk tool (ORT) was clinically useful in guiding physician decision making during chronic opioid therapy and to determine whether there were differences between the patient-completed and physician-completed ORT. Retrospective review of prospectively collected data. A single-center tertiary care outpatient pain management center. One-hundred twenty-five patients who received chronic opioids as part of their pain therapy. Patients receiving care were asked to complete the ORT as part of their initial evaluation. In addition, as part of this study, a pain physician reviewed the information available at the time of the initial evaluation and completed the ORT. Medical records were reviewed for evidence of moderate-to-severe aberrant drug-related behavior (ADRB), according to specified criteria. Patient-completed and physician-completed ORT and presence or absence of moderate to severe ADRB. Of the 125 patients included in this study, physician-completed ORT was available for 125 patients, and a patient-completed ORT was available on 87 of these patients. There was good correlation between the patient-completed and physician-completed ORT (correlation coefficient = 0.61). There were 112 observations of ADRB in 53 of 125 patients (42.4 percent) during the observation period of an average of 7.8 months (range 2-17 months). Of these 53 patients, 32 (60.4 percent) were identified by urine drug screen (UDS) alone, 7 (13.2 percent) were identified by physician observation alone, and 14 (26.4 percent) were identified by both UDS and physician observation. Based on the physician-completed ORT, 41 of 106 (38.7 percent) low risk patients had ADRB, compared to 8 of 14 (57.1 percent) moderate risk, and 4 of 5 (80 percent) high risk patients. Neither the patient-completed nor the physician-completed ORT was strongly predictive of moderate-to-severe ADRB in patients receiving chronic opioid therapy for the treatment of noncancer pain in our pain center.

Management of Chronic Pancreatitis

Advances in our understanding of chronic pancreatitis have improved our care of patients with this disease. Although our therapies are imperfect and many patients remain symptomatic, appropriate medical care improves the quality of life in these patients. Proper management requires an accurate diagnosis, recognition of the modifiable causes of disease, assessment of symptoms and complications, treatment of these symptoms and complications utilizing a multidisciplinary team, and ongoing monitoring for the effect of therapy and the occurrence of complications.

Self‐Reported Practices in Opioid Management of Chronic Noncancer Pain: A Survey of Canadian Family Physicians

In May 2010, a new Canadian guideline on prescribing opioids for chronic noncancer pain (CNCP) was released. To assess changes in family physicians' (FPs) prescribing of opioids following the release of the guideline, it is necessary to know their practices before the guideline was widely disseminated. To determine FPs' practices and knowledge in prescribing opioids for CNCP in relation to the Canadian guideline, and to determine factors that hinder or enable FPs in prescribing opioids for CNCP. An online survey was developed and FPs who manage CNCP were electronically contacted through the College of Family Physicians of Canada, university continuing medical education offices and provincial regulatory colleges. A total of 710 responses were received. FPs followed a precautionary approach to prescribing opioids and already practiced in accordance with Canadian guideline recommendations by discussing adverse effects, monitoring for aberrant drug-related behaviour and advising caution when driving. However, FPs seldom discontinued opioids even if they were ineffective and were unaware of the 'watchful dose' of opioids, the daily dose at which patients may need reassessment or closer monitoring. Only two of nine knowledge questions were answered correctly by more than 40% of FPs. The main enabler to optimal opioid prescribing was having access to a patient's opioid history from a provincial prescription monitoring program. The main barriers to optimal prescribing were concerns about addiction and misuse. While FPs follow a precautionary approach to prescribing opioids for CNCP, there are substantial practice and knowledge gaps, with implications for patient safety and costs.

Toxicology Fellow’s Perspective: Filling a Void in Medical Education Regarding Opioids

Toxicology Fellow’s Perspective: Filling a Void in Medical Education Regarding Opioids

Aberrant Drug-Related Behaviors: Unsystematic Documentation Does Not Identify Prescription Drug Use Disorder

No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD. A cross-sectional study of PC patients at an urban, academic medical center. Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits. Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD. Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6). EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.

Sublingual buprenorphine/naloxone for chronic pain in at-risk patients: Development and pilot test of a clinical protocol

Objective: Sublingual buprenorphine/naloxone (Bup/Nx) is approved for addiction treatment and may be useful for pain management, particularly in opioid-treated patients with pain with nonadherence behaviors. The transition of opioid-treated patients with pain to buprenorphine carries the risk of precipitated withdrawal and increased pain. This study convened pain and addiction specialists to develop and pilot a clinical protocol for safe transitioning to Bup/Nx. Design: The protocol was revised three times based on outside expert review and pilot study observations. The pilot was conducted with a prospective cohort of 12 patients with moderate to severe chronic pain, who were receiving long-term opioid therapy with any full µ-agonist drug, and had exhibited one or more aberrant drugrelated behaviors. Patients were followed up for 3-6 months with the expectation that they would experience few adverse events (AEs) and report lower pain severity. Results: The three patients on the highest baseline opioid dose (equivalent to 303-450 mg of oral morphine) and the three on the lowest doses (=20 mg) had early AEs when switched to Bup/Nx and did not complete the trial. Of the remaining six, one withdrew due to AEs; one responded well, then withdrew; and four completed a 3-month trial. A mixed-effects model controlling for dropouts found that average and worst pain significantly decreased after the switch to Bup/Nx (both p < 0.01). Conclusion: Based on this experience, the protocol recommends Bup/Nx for pain only when baseline opioid doses are within bounds that reduce AEs at transition and incorporates dose flexibility to further reduce risks. This protocol warrants further testing. Keywords: buprenorphine, chronic pain, treatment guidelines, opioid therapy, withdrawal DOI:10.5055/jom.2012.0137

Sublingual buprenorphine/naloxone for chronic pain in at-risk patients: Development and pilot test of a clinical protocol

Sublingual buprenorphine/naloxone (Bup/Nx) is approved for addiction treatment and may be useful for pain management, particularly in opioid-treated patients with pain with nonadherence behaviors. The transition of opioid-treated patients with pain to buprenorphine carries the risk of precipitated withdrawal and increased pain. This study convened pain and addiction specialists to develop and pilot a clinical protocol for safe transitioning to Bup/Nx. The protocol was revised three times based on outside expert review and pilot study observations. The pilot was conducted with a prospective cohort of 12 patients with moderate to severe chronic pain, who were receiving long-term opioid therapy with any full m-agonist drug, and had exhibited one or more aberrant drug-related behaviors. Patients were followed up for 3-6 months with the expectation that they would experience few adverse events (AEs) and report lower pain severity. The three patients on the highest baseline opioid dose (equivalent to 303-450 mg of oral morphine) and the three on the lowest doses (≤20 mg) had early AEs when switched to Bup/Nx and did not complete the trial. Of the remaining six, one withdrew due to AEs; one responded well, then withdrew; and four completed a 3-month trial. A mixed-effects model controlling for dropouts found that average and worst pain significantly decreased after the switch to Bup/Nx (both p < 0.01). Based on this experience, the protocol recommends Bup/Nx for pain only when baseline opioid doses are within bounds that reduce AEs at transition and incorporates dose flexibility to further reduce risks. This protocol warrants further testing.

Risk Factor Assessment for Problematic Use of Opioids for Chronic Pain

Opioid analgesics provide effective treatment for noncancer pain, but many health providers have concerns about cognitive effects, tolerance, dependence, and addiction. Misuse of opioids is prominent in patients with chronic pain and early recognition of misuse risk could help providers offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. Many persons with chronic pain also have significant medical and psychiatric comorbidities that affect treatment decisions. Neuropsychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management. The assessment of different domains using semi-structured interviews, sensory and neuropsychological testing, and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral, and social issues in order to facilitate treatment planning. In this review we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic pain, and present an overview of assessment and treatment strategies that can be effective in improving outcomes associated with the use of prescription opioids for pain. Finally we briefly discuss the effect of opiate analgesics on cognition and review some intervention strategies for chronic pain patients.

PS1-01: Alcohol and Drug Use Among Chronic Opioid Therapy Patients

Background/AimsOpioid misuse and abuse is a significant public health problem, and there is a need to better identify at-risk individuals. Study aims were to examine patient characteristics associated with alcohol and other drug (AOD) use and aberrant drug related behaviors in chronic opioid therapy (COT) patients.MethodsWe conducted a telephone survey of a random sample of 972 COT patients in an integrated health care delivery system in 2009. Measures included weekly alcohol use and any illicit drug use in the last three months, and a composite measure of alcohol-only use, drug-only use, both alcohol and drug use, and tobacco only use. We conducted weighted multivariate logistic regressions models of AOD use and of aberrant drug-related behavior.ResultsFourteen percent were weekly alcohol users (134/972), 16% used illicit drugs (157/972), 9% (83/972) used both alcohol and drugs, 8% used only drugs (74/972), 34% (334/491) used only alcohol, and 50% (481/972) did not use any substances. Multivariate models indicated illicit drug use was associated with a higher likelihood for weekly alcohol use, while being female, a higher daily opioid dose, and greater pain severity was associate with a lower likelihood of weekly alcohol use. Tobacco use, weekly alcohol use, depression symptoms, being male, and middle age was associated with a higher likelihood of illicit drug use. For aberrant drug related behaviors, drug-only use and both alcohol and drug use (compared to no AOD use) were associated with a higher likelihood of receiving opioids from friends or family in the last year, as were postive depressive symptoms and younger age. Both AOD use and depression symptoms were associated with a higher likelihood of giving opioids to others, while a high daily dose was associated with a lower likelihood of giving opioids to others, compared to the lowest dosage. Polysubstance use gender, and depression were risk factors in this sample. Post hoc analyses of primary care utilization indicated that those with high dosage opioids were more likely to have a certain threshold of primary care visits in the last year, suggesting there is an opportunity to manage these high risk patients.

Prescription Opioid Abuse in Chronic Pain: A Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse

Both chronic pain and prescription opioid abuse are prevalent and continue to exact a heavy toll on patients, physicians, and society. Individuals with chronic pain and co-occurring substance use disorders and/or mental health disorders, are at a higher risk for misuse of prescribed opioids. Opioid abuse and misuse occurs for a variety of reasons, including self medication, use for reward, compulsive use because of addiction, and diversion for profit. Treatment approaches that balance treating chronic pain while minimizing risks for opioid abuse, misuse, and diversion are much needed. The use of chronic opioid therapy for chronic noncancer pain has increased dramatically in the past 2 decades in conjunction with a marked increase in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they arise could be of enormous benefit. Such an instrument could potentially curb the risk of iatrogenic addiction. Although several screening instruments and strategies have been introduced in the past decade, there is no single test or instrument that can reliably and accurately predict patients who are not suitable for opioid therapy or identify those who need increased vigilance or monitoring during therapy. At present, screening for opioid abuse includes assessment of premorbid and comorbid substance abuse; assessment of aberrant drug-related behaviors; risk factor stratification; and utilization of opioid assessment screening tools. Multiple opioid assessment screening tools and instruments have been developed by various authors. In addition, urine drug testing, monitoring of prescribing practices, prescription monitoring programs, opioid treatment agreements, and utilization of universal precautions are essential. Presently, a combination of strategies is recommended to stratify risk, identify and understand aberrant drug related behaviors, and tailor treatments accordingly. This manuscript will review the current state of knowledge regarding the growing problem of opioid abuse and misuse; known risk factors; and methods of predicting, assessing, monitoring, and addressing opioid abuse and misuse in patients with chronic noncancer pain. Key words: Opioids, misuse, abuse, chronic pain, prevalence, risk assessment, risk management, drug monitoring, aberrant drug-related behavior

A Comparison of Various Risk Screening Methods in Predicting Discharge From Opioid Treatment

Risk assessment and stratification has become an important aspect of the prescribing of opioids to patients with chronic pain. There is little empirical data available on the sensitivity and specificity of commonly used risk assessment tools. This paper describes 2 studies that compare the prediction capabilities of various risk assessment tools. The first study presents data on patients at a pain practice whose treatment with opioids was stopped due to their engaging in aberrant drug-related behavior. Patients were assessed with the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), the Pain Medication Questionnaire, the Opioid Risk Tool, and a clinical interview. A second study compared the risk assessment measures, SOAPP-R, Pain Medication Questionnaire, Opioid Risk Tool, and a clinical interview. Data were gathered on whether patients had engaged in aberrant drug-related behavior at 6-month follow-up. Significant differences in the measures were found. Accuracy did not appear to be a function of the type of aberrant drug-related behavior that the patient engaged in for any of the measures. The clinical interview showed the best sensitivity of the 4 risk measures in predicting risk. The SOAPP-R showed the best sensitivity of the self-report measures. However, the SOAPP-R appears to overrate risk. Overall, these studies indicate that not all risk assessment tools are equal in their ability to accurately predict future aberrant drug-related behavior. It may be that written risk assessment tools that use more subtle items are better suited to certain patient populations.

Chronic Pain: Reducing Costs Through Early Implementation of Adherence Testing and Recognition of Opioid Misuse

Objective: To review the literature on costs associated with chronic pain therapy and to identify key contributing factors. Also, to assess the potential cost-saving benefits of monitoring pain treatment adherence using urine drug tests (UDTs), emphasizing their use in opioid therapy. Results: Reduced productivity, compensation costs, and treatment of comorbid conditions related to chronic pain contribute to the substantial financial burden of chronic pain management in the United States. The growing use of opioids for chronic pain increases the risk for drug nonadherence and associated drug abuse, potential addiction, and aberrant drug-related behaviors (ADRBs). Treatment of drug abuse increases health care costs; opioid abusers are 25 times more likely to require hospitalization than nonopioid abusers. Early detection of patient nonadherence using UDTs could significantly reduce costs of chronic pain therapy by allowing the physician to identify and treat patients' ADRBs related to controlled substances and drug addiction and abuse problems. Adherence in chronic pain may be determined by point-of-care (POC) tests, and more sensitive laboratory urine tests employing gas chromatography/mass spectrometry with high-performance liquid chromatography tests (LUTs). Cost-benefit studies suggest that the cost of LUTs to optimize adherence may reduce costs associated with nonadherence, such as inpatient clinical care and patient self-release. Current estimates indicate that appropriate use of LUTs could produce decreases up to 14.8-fold in the cost of chronic pain therapy. Conclusions: The cost benefits of UDTs can only be fully realized if physicians know how to define and detect various types of drug abuse, addiction, and diversion. Physicians should be educated on the proper implementation of POC tests and LUTs, and interpretation of adherence data. Early monitoring of drug adherence using POC tests and follow-up LUTs may provide substantial cost savings associated with health care issues incurred in nonadherent chronic pain patients, especially those taking opioid therapy.

Assessment and treatment of abuse risk in opioid prescribing for chronic pain.

Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no “gold standard” for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.