Opioids for Chronic Noncancer Pain: Prediction and Identification of Aberrant Drug-Related Behaviors: A Review of the Evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline

The Oregon Evidence-based Practice Center, Department of Medicine, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA.
The journal of pain: official journal of the American Pain Society (Impact Factor: 4.22). 03/2009; 10(2):131-46. DOI: 10.1016/j.jpain.2008.10.009
Source: PubMed

ABSTRACT Optimal methods to predict risk of aberrant drug-related behaviors before initiation of opioids for chronic noncancer pain and to identify aberrant behaviors after therapy is initiated are uncertain. We systematically reviewed published literature identified through searches of Ovid MEDLINE and the Cochrane databases through July 2008. Diagnostic test characteristics and accompanying confidence intervals were calculated with data extracted from the studies. Four prospective studies evaluated diagnostic accuracy of risk prediction instruments. Two higher-quality derivation studies found that high scores on the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1 and the Revised SOAPP (SOAPP-R) instruments weakly increased the likelihood for future aberrant drug-related behaviors (positive likelihood ratios [PLR], 2.90 [95% CI, 1.91 to 4.39] and 2.50 [95% CI, 1.93 to 3.24], respectively). Low scores on the SOAPP Version 1 moderately decreased the likelihood for aberrant drug-related behaviors (negative likelihood ratio [NLR], 0.13 [95% CI, 0.05 to 0.34]) and low scores on the SOAPP-R weakly decreased the likelihood (NLR, 0.29 [95% CI, 0.18 to 0.46]), but estimates are too imprecise to determine if there is a difference between these instruments. One lower-quality study found that categorization as high risk using the Opioid Risk Tool strongly increased the likelihood for future aberrant drug-related behaviors (PLR, 14.3 [95% CI, 5.35 to 38.4]) and classification as low risk strongly decreased the likelihood (PLR, 0.08 [95% CI, 0.01 to 0.62]). Nine studies evaluated monitoring instruments for identification of aberrant drug-related behaviors in patients on opioid therapy. One higher-quality derivation study found higher scores on the Current Opioid Misuse Measure (COMM) weakly increased the likelihood of current aberrant drug-related behaviors (PLR, 2.77 [95% CI, 2.06 to 3.72]) and lower scores weakly decreased the likelihood (NLR, 0.35 [95% CI, 0.24 to 0.52]). In 8 studies of other monitoring instruments, diagnostic accuracy was poor, results were difficult to interpret due to methodological shortcomings, or standard diagnostic test characteristics were not reported. Definitions for aberrant drug-related behaviors were not standardized across studies and did not account for seriousness of identified behaviors. No reliable evidence exists on accuracy of urine drug screening, pill counts, or prescription drug monitoring programs; or clinical outcomes associated with different assessment or monitoring strategies. PERSPECTIVE: Evidence on prediction and identification of aberrant drug-related behaviors is limited. Although several screening instruments may be useful, evidence is sparse and primarily based on derivation studies, and methodological shortcomings exist in all studies. Research that performs external validation, uses standardized definitions for clinically relevant aberrant drug-related behaviors, and evaluates clinical outcomes associated with different assessment and monitoring strategies is needed.


Available from: Perry G Fine, Jun 03, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from ,1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.
    Pain 04/2015; 156(4):569-576. DOI:10.1097/01.j.pain.0000460357.01998.f1 · 5.84 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Opioids are increasingly prescribed to provide effective therapy for chronic noncancer pain, but increased use also means an increased risk of abuse. Primary care physicians treating patients with chronic noncancer pain are concerned about adverse events and risk of abuse and dependence associated with opioids, yet many prescribers do not follow established guidelines for the use of these agents, either through unawareness or in the mistaken belief that urine toxicology testing is all that is needed to monitor compliance and thwart abuse. Although there is no foolproof way to identify an abuser and prevent abuse, the best way to minimize the risk of abuse is to follow established guidelines for the use of opioids. These guidelines entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors: history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations designed to deter tampering and abuse; initiation of treatment at a low dosage with titration in gradual increments as needed to achieve effective analgesia; regular reassessment to watch for signs of abuse, to perform drug monitoring, and to adjust medication as needed; and established protocols for actions to be taken in case of suspected abuse. By following these guidelines, physicians can prescribe opioids to provide effective analgesia while reducing the likelihood of abuse.
    Postgraduate Medicine 11/2014; 126(7):129-38. DOI:10.3810/pgm.2014.11.2841 · 1.54 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Dr. Belay is an anesthesiologist and board-certified pain management specialist in a thriving private practice. She has grown concerned over the past month since hearing that a well-respected colleague came under scrutiny for " troubling prescribing patterns " based on the percentage of his patients prescribed long-acting opioids. Dr. Belay receives a refill request for morphine from her patient Mr. Flora. He is a law professor at the local university who sustained a severe back injury six years earlier while replacing the catalytic converter in his award-winning antique car. Although he underwent spine surgery for the injury the same year, he has since suffered chronically worsening back pain that is frequently accompanied by a sharp pain that radiates along the leg. Before seeking the care of his pain specialist, he saw numerous orthopedic surgeons, chiropractors, physiatrists, neurologists, and physical therapists. Dr. Belay informs him he is due for an appointment before she can provide a refill. During his appointment, Dr. Belay discusses her long-term plans of reducing Mr. Flora's reliance on opioid therapy by supplementing it with adjuvants, injection therapy, and possibly a spinal cord stimulator. She offers him a trial of the spinal cord stimulator, explaining that, if successful, it would reduce the amount of oral medication needed, pose fewer side effects, and provide better long-term control of his chronic pain.
    03/2015; 17(3):202-208. DOI:10.1001/virtualmentor.2015.17.01.ecas1-1503