Opioid Risk Tool Research Articles

Attitudes Toward Opioids and Risk of Misuse/Abuse in Patients with Chronic Noncancer Pain Receiving Long-term Opioid Therapy.

To determine the attitudes of patients toward long-term opioid therapy (LtOT) and the potential risk of misuse/abuse in patients with chronic noncancer pain (CNCP). Prospective, descriptive epidemiological study. Multidisciplinary tertiary care pain center within the Montreal University Health Center. Patients who had had at least one visit at least one year prior to the invitation. We used four questionnaires: demographic questionnaire, the Drug Attitude Inventory Modified (DAI-M), the Opioid Risk Tool (ORT), and the Screening Tool for Addiction Risk (STAR). All questionnaires were administered in their validated French version. Three hundred seventy patients completed questionnaires. The response rate was 79.26%. Of those who responded, 61.62% women and 38.38% men, the mean age was 57 years. The patients had been treated with LtOT for an average of 6.31 years, and the median dose per day in morphine equivalents was 48.21 mg. The DAI-M showed that 32.16% had a positive attitude toward opioids, 39.73% had a negative attitude, and 22.16% had a neutral attitude. The ORT questionnaire demonstrated that 86.2% of the patients were at low risk of abuse/misuse, 13.2% were at moderate risk, and only 0.54% were at high risk. The STAR questionnaire showed that 4.2% had a low risk of abuse/misuse. Despite public opinion, patients treated with LtOT for CNCP and followed in a tertiary care pain center are at low risk for opioid misuse/abuse. We need to refine the way of prescribing opioids, should be selective with our patients, and should relive their pain adequately.

Opioid Safety Assessment Implementation in Palliative Care Clinic (S799)

•Implementation of Opioid Risk Tools in continuity patients in clinic is feasible and will assist in identifying at risk patients for abuse of narcotics.•Discuss cases with specific concerns in the ORT and what the next step would be in monitoring. The Center for Disease Control recently released guidelines for prescribing Opioids specifically excluding palliative care (PC) patients. This guideline and others specific to chronic non-malignant, non-PC (NM-NPC) chronic pain patients recommends routine screening for patients at risk of substance abuse. There are no existing guidelines that provide recommendations for safe opioid prescribing in PC despite recent reports of rates of opioid misuse similar to the NM-NPC chronic pain population. Here we report our experience with instituting a safety assessment for PC patients being considered for chronic opioid therapy (COT). All patients being considered for COT in an ambulatory PC clinic. Identified patients screened with a 7-point chronic opioid safety assessment: 1) medial co-morbidity review; 2) Opioid Risk Tool (ORT) screening; 3) UDT; 4) review of prescription monitoring program report; 5) Drug misuse history; 6) Informed Consent and Contract; 7) Safety and Education Counseling. Physician review of risk and subjective determination of appropriateness for COT is documented in medical record. 77 total patients in 12 weeks; 61.0% considered for COT. Mean age 52.5; 93.6% Caucasian; 61.7 Hispanic; 57.4% female. Primary PC diagnosis cancer in 76.5%; COT related to terminal illness in 51.1% and chronic NM-NPC in 48.9%. 46.8% compliance with complete safety assessment. 85.5% deemed appropriate for COT. 51.1% received long acting opioid; 27.7% received only immediate release. ORT results: min 0, 1st quartile 1, mean 3, quartile 7, max 14. UDT inappropriate 8.6%. Prescription monitoring report inappropriate 2.1%. Illicit drug history 3.6% (marijuana 10.6%). Implementation of routine, PC specific risk stratification is feasible for PC clinic and can help identify those at risk and engaging in opioid misuse.

Comparison of the Risk for Substance Abuse in Heart Failure and Cancer Patient Populations Using the Opioid Risk Tool and Urine Drug Screen (SA508D)

Comparison of the Risk for Substance Abuse in Heart Failure and Cancer Patient Populations Using the Opioid Risk Tool and Urine Drug Screen (SA508D)

Enhancing Risk Assessment in Patients Receiving Chronic Opioid Analgesic Therapy Using Natural Language Processing

Clinical guidelines for the use of opioids in chronic noncancer pain recommend assessing risk for aberrant drug-related behaviors prior to initiating opioid therapy. Despite recent dramatic increases in prescription opioid misuse and abuse, use of screening tools by clinicians continues to be underutilized. This research evaluated natural language processing (NLP) together with other data extraction techniques for risk assessment of patients considered for opioid therapy as a means of predicting opioid abuse. Using a retrospective cohort of 3,668 chronic noncancer pain patients with at least one opioid agreement between January 1, 2007, and December 31, 2012, we examined the availability of electronic health record structured and unstructured data to populate the Opioid Risk Tool (ORT) and other selected outcomes. Clinician-documented opioid agreement violations in the clinical notes were determined using NLP techniques followed by manual review of the notes. Confirmed through manual review, the NLP algorithm had 96.1% sensitivity, 92.8% specificity, and 92.6% positive predictive value in identifying opioid agreement violation. At the time of most recent opioid agreement, automated ORT identified 42.8% of patients as at low risk, 28.2% as at moderate risk, and 29.0% as at high risk for opioid abuse. During a year following the agreement, 22.5% of patients had opioid agreement violations. Patients classified as high risk were three times more likely to violate opioid agreements compared with those with low/moderate risk. Our findings suggest that NLP techniques have potential utility to support clinicians in screening chronic noncancer pain patients considered for long-term opioid therapy.

209 Assessing Risk of Opioid Abuse Among the Emergency Medicine Population

Prescription opioid abuse is a rapidly growing epidemic in the United States. The American College of Emergency Physicians recommends that prior to prescribing opioids to an individual the provider assess an individual's risk for opioid abuse. Few emergency medicine studies have assessed the use of validated opioid risk assessment tools to assess emergency department patients' risk of misusing opioids. In this study, we assess the feasibility of performing a self-administered validated opioid risk screening tool, the Opioid Risk Tool (ORT), in the waiting room of an emergency department and assessed the risk of opioid abuse among an emergency department (ED) population. The study was conducted over a 3-week period in the waiting room of an academic emergency department with an annual census of approximately 115,000 visits per year. All adults presenting to the emergency department were eligible. Individuals were approached while in the waiting room and chosen randomly based on their seat in the waiting room. The ORT was self-administered via an electronic tablet in the waiting room. The results of the survey were anonymous, and were not shared with clinician providers. A research coordinator was available while the individual completed the survey to assist with completion of the survey if necessary. Any difficulties completing the survey were recorded by the research coordinator. Descriptive statistics were used to analyze the data. A total of 212 individuals were enrolled out of 253 persons invited to participate yielding a response rate of 84%. All completed the survey without difficulty. Males represented 34% of the participants. Overall 40% of the total sample reported a family history of alcohol abuse, 36% reported a family history of illicit drug abuse, and 21% reported a family history of prescription drug misuse. There were no significant differences between the family history of alcohol abuse, illicit drug abuse, or prescription drug misuse between males and females. Males were significantly more likely to report a personal history of ethanol abuse (74% vs 51%) and illicit drug abuse (53% vs 34%). Females were significantly more likely to report a history of depression (44% vs 23%). Seventy-two percent of individuals had a moderate or high opioid risk score. Males had a significantly higher opioid risk score than females (8.9 vs 7.1) and the overall average opioid risk score was 7.69, which is considered moderate opioid risk. Forty-two percent of individuals had a high opioid risk score, which has been associated with a 91% risk of aberrant drug behavior. In our study greater than 70% of the emergency department population was at increased risk of abusing opioids. Future studies should be performed to assess the impact integrating opioid risk scoring tools into clinical practice has on provider prescribing patterns in the emergency department.

Risk of Opioid Abuse and Biopsychosocial Characteristics Associated With This Risk Among Chronic Pain Patients Attending a Multidisciplinary Pain Treatment Facility

The objectives of this study were to (1) determine the proportion of patients referred to a multidisciplinary pain treatment facility at risk of opioid abuse, (2) examine biopsychosocial factors associated with this risk, and (3) compare patient outcomes 6 months later across risk of opioid abuse and type of treatment (opioids vs. no opioids). Participants were 3040 patients (mean age=53.3±14.7 y; female=56%) enrolled in the Quebec Pain Registry between July 2012 and May 2014. Patients answered self-report and nurse-administered questionnaires (pain and psychosocial constructs, Opioid Risk Tool, pain medication, etc.) before initiating treatment at the multidisciplinary pain treatment facility and 6 months later. Data were analyzed using the Pearson χ tests, multivariable binary logistic regression, and multivariate general linear model. Results showed that 81%, 13%, and 6% of patients were at low, moderate, and severe risk of opioid abuse, respectively. Civil status, pain duration, mental health-related quality of life, and cigarette smoking were significantly associated with risk of opioid abuse (P<0.001). There was a significant interaction between risk of opioid abuse and type of treatment in predicting 6-month pain outcomes and quality of life. Almost 20% of patients had a moderate/severe risk of opioid abuse; whether these patients were taking opioids or not for their pain, they had worse outcomes at follow-up. These results point to the importance of assessing risk of opioid abuse in chronic pain patients and to consider how this risk may impact on their clinical evolution.

Opioid risk assessment in palliative medicine.

Pain management with opioids is an integral part of palliative medicine. As the doses and durations of opioid therapy increase, the inherent risks of opioid therapy rise. Although opioids are effective analgesics, they bring with them complex medical and psychological side effects. Aberrant behavior is dangerous and can be difficult to identify as it results in a splitting in the goals of treatment between the patient and providers. One effective strategy in preventing that situation is through the early identification of at-risk patients. There are several tools that can help identify patients at higher risk of addiction and aberrant behaviors during opioid therapy. Structured use of these tools in conjunction with the clinic exam, regular follow-up visits, and lab testing can further reduce patient risk and improve success in opioid therapy. This article will review the background behind a structured strategy for opioid risk assessment using the Opioid Risk Tool, SOAPP-R, and DIRE tools. In addition, example aberrant behaviors and follow-up strategies will be reviewed. It will be demonstrated that careful screening and follow-up allow risk factors to be recognized and addressed early.

Validation of a new risk assessment tool: the Brief Risk Questionnaire.

Opioids remain a common method of treating chronic pain conditions despite some controversy. In an effort to address some of the risks of opioid medications, opioid risk assessment has become a standard of care when opioids are used to treat a chronic pain condition. Research to date has found that many currently available patient-completed written questionnaires are relatively poor at identifying which patients will engage in medication aberrant behavior in the future. Clinical interview techniques have been found to provide better prediction, but practitioners often prefer the convenience of patient-completed tools. In this study, a new brief patient-completed risk tool, the Brief Risk Questionnaire (BRQ), was created and compared with a structured clinical interview and two commonly used patient-completed risk assessment tools: the Opioid Risk Tool (ORT) and Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). The different risk assessment measures were administered to 454 patients at a pain clinic and their prediction of medication aberrant behavior at 6-month follow-up was compared. Results found that the BRQ was able to predict future medication aberrant behavior better than the other two patient-completed risk measures and almost as well overall as a structured clinical interview rating system. This study indicates that the BRQ could be a useful new tool for clinicians in conducting opioid risk assessment.

Sex life and the Oswestry Disability Index

Background contextDespite the option to not answer, there is widespread anecdotal belief that the Oswestry Disability Index (ODI) Section 8 (ODI-8/sex life) is answered inaccurately (ie, in relation to psychosocial factors, not pain) or that it repels ODI participation. Oswestry Disability Index versions have therefore been created that omit ODI-8; however, no evidence base justifies this. Interestingly, one recent study reported an ODI-8 response rate (RR) of 97%. PurposeThe aims of this study were to measure RR to sex life questions in patients with chronic low back pain (CLBP) and to validate that ODI-8 is answered appropriately and represents a specific measure of CLBP-mediated sexual inactivity. Study designOriginal. Patient sampleEighty-eight patients. Outcome measuresThe outcome measures used in this study were the ODI, the Sexual Quality of Life Scale–version 2 (SQOL-2), the Short Form-12 version 2 (mental and physical), the Depression Anxiety and Stress Scale, the Coping Strategies Questionnaire, the Short-Form McGill Pain Questionnaire–version 2, the Opioid Risk Tool, and the Fear-Avoidance Beliefs Questionnaire (work and physical). MethodChronic low back pain patients older than 18 years attending a multicultural Western spinal clinic were prospectively offered the aforementioned questionnaires. Sex life disability questions—pain dependent (ODI-8) and pain independent (SQOL-2)—appeared first and fifth in every sequence. ResultsResults were obtained in 65 patients (male 29, female 36). Despite expected response attrition with battery progression (RRs for the first and eighth questionnaires were 100% and 64.61%, respectively), RRs for ODI-8 (52.31%) and SQOL-2 (52.31%) were equal and significantly lower than others (p<.001). Nonresponders to ODI-8 (60.57±13.3 years) and SQOL-2 (59.68±13.34 years) were significantly older than responders (ODI-8: 47.82±12.17 years, p<.001; SQOL-2: 48.27±12.76 years, p=.001). Among ODI-8 or SQOL-2 responders, ODI-8 and SQOL-2 were not correlated (r=−0.340, p=.104). Although ODI-8 significantly correlated with prospectively identified pain-correlated questionnaires, ODI-8 did not correlate significantly with non–pain-correlated questionnaires. ConclusionContrary to previous findings, 47.69% of CLBP patients specifically ignored ODI-8; however, 100% completed the ODI remainder. Among “responders,” ODI-8 was validated as having measured CLBP-mediated sexual inactivity. The ODI-8 was therefore treated consistently, as directed: It was either answered appropriately (ie, in relation to pain) or it was ignored (respecting the clause “if applicable”). No ODI modification therefore appears required for adults older than 18 years attending a multicultural Western CLBP clinic: One standard form including ODI-8 appears to yield appropriate ODI-8 response-treatment, with unaffected ODI participation. Multiple ODIs circumventing ODI-8 appear unnecessary and redundant in this population.

Characteristics of chronic noncancer pain patients assessed with the opioid risk tool in a Canadian tertiary care pain clinic.

The Opioid Risk Tool (ORT) is a screening instrument for assessing the risk of opioid-related aberrant behavior in chronic noncancer pain (CNCP) patients. This study aims to compare patient characteristics documented in the original ORT study with those identified in CNCP patients assessed using a physician-administered ORT in a tertiary care pain clinic in Toronto, Canada. This was a descriptive cross-sectional study of 322 consecutive new patients referred over 12 months. Data extraction included ORT scores, demographics, pain ratings, opioid, and other medication use at point of entry, diagnosis, and other variables. Characteristics were compared with those described in the original ORT study. The total mean ORT scores of patients in this study were related to several demographic (gender, age, marital status, and country of birth) and nondemographic variables (employment status, cigarette smoking, and contribution of biomedical and/or psychological factors to presentation). Prevalence of characteristics noted in this patient sample differed substantially from that found in Webster and Webster as the basis for ORT scores. Significant differences existed between this study population and the patient sample from which the ORT was derived. Limitations of this study are discussed. We concur with the authors of the original study that the ORT may not be applicable in different pain populations and settings. Based on our findings, we encourage caution in interpreting the ORT in general CNCP settings until further studies are performed.

Further validation of an opioid risk assessment tool: the Brief Risk Interview.

Opioids remain a common method of treating chronic pain conditions despite some controversy. In an effort to address some of the risks of opioid medications, opioid risk assessment has become a standard of care when opioids are used to treat a chronic pain condition. Research to date has found that clinical interviews may be superior to currently available patient-completed written questionnaires in identifying patients likely to engage in medication aberrant behavior. The Brief Risk Interview (BRI) has been developed as a risk assessment tool that has the sensitivity of a clinical interview while eliminating the need for the lengthy process of an interview. The current study compared the predictive ability of the BRI with two commonly used patient-completed risk assessment tools: the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). After clinical staff at a pain practice underwent a 1-hour training program, 124 consecutive new patients were evaluated using the BRI, ORT, and SOAPP-R. Follow-up data found that the BRI was a good predictor of medication aberrant behavior and offered better sensitivity and better overall predictive accuracy than the ORT or the SOAPP-R. Overall, it appears that the BRI is a valid risk assessment tool that, after a brief training session, can be used effectively by pain clinicians. Further study is needed in other practice settings and with larger sample sizes.

The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain.

Chronic pain is common and use of long-term opioid therapy for chronic pain has increased dramatically. This report reviews the current evidence on effectiveness and harms of opioid therapy for chronic pain, focusing on long-term (≥1 year) outcomes. A prior systematic review (searches through October 2008), electronic databases (Ovid MEDLINE, Scopus, and the Cochrane Libraries January 2008 to August 2014), reference lists, and clinical trials registries. Using predefined criteria, we selected randomized trials and comparative observational studies of patients with cancer or noncancer chronic pain being considered for or prescribed long-term opioid therapy that addressed effectiveness or harms versus placebo, no opioid use, or nonopioid therapies; different opioid dosing methods; or risk mitigation strategies. We also included uncontrolled studies ≥1 year that reported rates of abuse, addiction, or misuse, and studies on the accuracy of risk prediction instruments for predicting subsequent opioid abuse or misuse. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively. Of the 4,209 citations identified at the title and abstract level, a total of 39 studies were included. For a number of Key Questions, we identified no studies meeting inclusion criteria. Where studies were available, the strength of evidence was rated no higher than low, due to imprecision and methodological shortcomings, with the exception of buccal or intranasal fentanyl for pain relief outcomes within 2 hours after dosing (strength of evidence: moderate). No study evaluated effects of long-term opioid therapy versus no opioid therapy. In 10 uncontrolled studies, rates of opioid abuse were 0.6 percent to 8 percent and rates of dependence were 3.1 percent to 26 percent in primary care settings, but studies varied in methods used to define and ascertain outcomes. Rates of aberrant drug-related behaviors ranged from 5.7 percent to 37.1 percent. Compared with nonuse, long-term opioid therapy was associated with increased risk of abuse (one cohort study), overdose (one cohort study), fracture (two observational studies), myocardial infarction (two observational studies), and markers of sexual dysfunction (one cross-sectional study), with several studies showing a dose-dependent association. One randomized trial found no difference between a more liberal opioid dose escalation strategy and maintenance of current dose in pain or function, but differences between groups in daily opioid doses at the end of the trial were small. One cohort study found methadone associated with lower risk of mortality than long-acting morphine in a Veterans Affairs population in a propensity adjusted analysis (adjusted HR 0.56, 95 percent CI 0.51 to 0.62). Estimates of diagnostic accuracy for the Opioid Risk Tool were extremely inconsistent and other risk assessment instruments were evaluated in only one or two studies. No study evaluated the effectiveness of risk mitigation strategies on outcomes related to overdose, addiction, abuse, or misuse. Evidence was insufficient to evaluate benefits and harms of long-term opioid therapy in high-risk patients or in other subgroups. Evidence on long-term opioid therapy for chronic pain is very limited but suggests an increased risk of serious harms that appears to be dose-dependent. More research is needed to understand long-term benefits, risk of abuse and related outcomes, and effectiveness of different opioid prescribing methods and risk mitigation strategies.

What question set is most effective to screen chronic pain patients for potential opioid abuse?

Evidence-Based Answer The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) appears to better predict potential opioid abuse than the Opioid Risk Tool (ORT), Pain Medication Questionnaire (PMQ), or Diagnosis Intractability Risk and Efficacy inventory (DIRE) score (SOR: B, multiple cohort studies).

AB0462 Risk Factors Associated with Opioid Treatment of Patients with Rheumatoid Arthritis

BackgroundIn treat-to-target evaluation, approximately 80% of patients with RA request pain relief1. Opioid use was also approved in Japan for prevention of NSAID-related complications and elimination of pain (pregabalinin June...

Patient aberrant drug taking behaviors in a large family medicine residency program: a retrospective chart review of screening practices, incidence, and predictors.

Potentially aberrant drug-taking behaviors (pADTB) are described as any departure from strict adherence to prescribed use of medications for their intended indication. There are several validated instruments, processes, and databases available to assist the clinician in screening and stratifying risk for patients in which controlled substances are being prescribed or considered. Actual utilization of these tools in nonspecialist healthcare settings is largely unknown. The primary objective of this retrospective chart review was to describe utilization patterns of these common tools within a 56 physician family medicine training program. Secondary objectives included identification of site-specific predictors of pADTB and correlation of prescribing patterns with documented aberrant behaviors. A total of 202 chronic pain patients were identified for inclusion based on prior 12-month prescription and refill records within the electronic health record (EHR) from March 2008 through March 2009. Each patient included had at least one opioid for 30 days within the study period and had chronic pain symptoms for at least 90 days. Each chart was reviewed for predefined pADTB, controlled substance refill request, prescription drug monitoring profile, and post hoc investigator completion of the Opioid Risk Tool Clinician Form. Descriptive statistics and regression analysis was used to report results. Clinician documentation of risk-screening tool use of any type was limited to one patient of the 202 records reviewed. Within this sample, 203 unique pADTB were documented in the EHR records of 89 (44.1 percent) patients. Patients prescribed morphine or tramadol appeared to exhibit less use of multiple prescribers and multiple pharmacies while an association between this behavior and two or more concurrent opioid prescriptions became apparent. Those taking fentanyl or morphine exhibited unsanctioned dose escalations more frequently. These results suggest that routine evaluation of risk for abuse or misuse of opioid analgesics occurs infrequently in a large family medicine training program. pADTB exhibited by patients using opioids for chronic pain syndromes in this sample were consistent with those reported in other similar settings. Policies and procedures in primary care settings for improved risk evaluation and ongoing monitoring of chronic opioid therapy is needed.

Screening for substance abuse risk in cancer patients using the Opioid Risk Tool and urine drug screen

The use of opioids for management of cancer-related pain has increased significantly and has been associated with a substantial rise in rates of substance abuse and diversion. There is a paucity of data not only on the prevalence of substance abuse in cancer patients, but also for issues of drug use and diversion in family caregivers. This study aimed to evaluate the frequency of risk factors for substance abuse and diversion, and abnormal urine drug screens in cancer patients receiving palliative care. A retrospective chart review was performed for patients with cancer who were seen in the University of Virginia Palliative Care Clinic during the month of September 2012. We evaluated Opioid Risk Tool variables and total scores, insurance status, and urine drug screen results. Of the 114 cancer patients seen in September 2012, the mean Opioid Risk Tool score was 3.79, with 43% of patients defined as medium to high risk. Age (16-45 years old, 23%) and a personal history of alcohol (23%) or illicit drugs (21%) were the most common risk factors identified. We obtained a urine drug screen on 40% of patients, noting abnormal findings in 45.65%. Opioids are an effective treatment for cancer-related pain, yet substantial risk for substance abuse exits in the cancer population. Screening tools, such as the Opioid Risk Tool, should be used as part of a complete patient assessment to balance risk with appropriate relief of suffering.

A Single-Center, Retrospective Analysis Evaluating the Utilization of the Opioid Risk Tool in Opioid-Treated Cancer Patients

ABSTRACTThe Opioid Risk Tool (ORT) is a screening tool used to assess risk of opioid misuse by stratifying aberrant drug-seeking behaviors and/or identifying known risk factors for drug abuse. The objectives of this study were to risk stratify opioid misuse in a cancer pain population and determine the most common patient risk factors associated with misuse utilizing the ORT. This was a retrospective analysis conducted at an academic comprehensive cancer center. Patients were referred by an oncologist or hematologist to an outpatient palliative care clinic. One-hundred and fourteen patients with cancer (n = 107) or sickle cell disease (n = 7) were evaluated from July 2012 to July 2013. During the clinical interview, patients responded to a clinician administered ORT. Based on the ORT score, patients were stratified into low, moderate, or high risk for opioid misuse. Sample size included 57 men and 57 women. Sixty-five, 21, and 28 patients were deemed low, moderate, and high risk based on the ORT, respectively. The most common risk factors for opioid misuse were a history of depression (women = 32; men = 22) and family history of alcohol abuse (women = 26; men = 22). There was no difference between men and women in the prevalence of depression (P = .17) or family history of alcohol abuse (P = .57). The least common risk factor was a personal history of prescription drug abuse (n = 1) in women and history of preadolescent sexual abuse in men (n = 0). Twenty-five percent (n = 28) of the sample population were deemed high risk based on the ORT. Screening of cancer patients in the palliative care setting suggests that risk factors for opioid misuse exist. Stratifying patients based on a routine screening tool may help identify cancer patients at risk for aberrant drug behaviors.

A single center, retrospective analysis evaluating aberrant drug behavior stratification utilizing the opioid risk tool in patients with cancer.

167 Background: Historically, it was believed that cancer patients could not have aberrant drug behaviors. However, clinical experience suggests otherwise. The prevalence of aberrant drug behaviors of cancer patients is unknown as screening is uncommon. Consequently, the UCSD Moores Cancer Center outpatient palliative care clinic initiated screening of aberrant drug behaviors utilizing the opioid risk tool (ORT) on new consultations. The purpose of this retrospective analysis was to identify key risk factors of aberrant behaviors of cancer patients and formulate a routine approach to follow-up and medications quantities. Methods: The treating oncologist referred new consultations to the outpatient palliative care clinic. A cohort of 93 cancer patients was evaluated from July 2012 to February 2013. Patients completed a 10-item, provider-administered, ORT during the consultation visit. Based on the ORT, patients were stratified into high-, moderate-, or low-risk for abarrent drug behavior and follow-up appointments and opioid quantities were adjusted accordingly. Results: Of the 93 patients, 48% were men and 52% women. Most patients had metastatic cancer (n=50; 54%) of gastrointestinal primary (n=27; 29%). Fifty-six (60%) patients were stratified as low-, 15 (16%) moderate-, and 22 (24%) high-risk based on ORT score. The most common risk factors for aberrant behaviors were a history of depression (women=25; men=17) and family history of alcohol abuse (women=22; men=18). There was no difference in the prevalence of depression (p=0.17) or family history of alcohol abuse (p=0.57). The least common risk factor was a personal history of prescription drug abuse (n=1) in women and history of preadolescent sexual abuse in men (n=0). Conclusions: Screening of cancer patients suggests risk factors for aberrant drug behavior exist. Stratifying patients based on a standard, routine tool can help identify cancer patients at risk for aberrant drug behaviors. Moderate and high-risk patients can then be followed closely with limited quantities of opioids until trust is established.

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.

Preliminary data on a new opioid risk assessment measure: The Brief Risk Interview

Risk assessment and stratification have become a central issue in prescribing opioids to patients with chronic pain. Research to date on various risk screening measures has shown that a clinical interview by an experienced clinician offers superior predictive ability in identifying patients who are more likely to engage in future medication aberrant behavior. The current study represents a pilot study of an interview rating scale that is designed to replicate this clinical assessment. This study compares the predictions of medication aberrant behavior made by the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the new interview rating scale, the Brief Risk Interview (BRI). A sample of 196 patients was assessed by each of the three risk measures and then follow-up data were gathered at 6 months post interview to determine which patients had engaged in medication aberrant behavior and had been discharged from the practice. The BRI shows superior predictive ability in identifying patients who later engage in medication aberrant behavior. Although more study in other settings is needed, these preliminary data suggest that the Brief Risk Interview could be a useful tool for any pain clinician in assessing risk through the use of information gathered in a brief interview.