Opioids, pain and addiction – practical strategies

Abstract

1. Addiction can occur with the repeated exposure of a biogenetically predisposed person to an addictive substance or behaviour. 2. In the patient with pain on opioid therapy, use the '4 Cs' to diagnose addiction. 3. Screening and risk stratification of all patients considered for opioid therapy is a key element of 'universal precautions' in pain management. 4. There are a number of established and new screening tools including the CAGE, Opioid Risk Tool and Screener and Opioid Assessment for Patients with Pain, which can be utilized in the office setting. 5. There are a number of potential ambiguous drug-related behaviours that should trigger a re-evaluation by the clinician. 6. Treating the higher-risk patient with opioids requires more assessment, more structure and more monitoring. Written opioid prescribing agreements and urine drug testing can be helpful strategies. 7. Essential documentation includes the '6As': Analgesia, Activity, Adverse effects, Ambiguous drug behaviours, Affect and Adequate prescription information.

Addressing Opioid-Related Chemical Coping in Long-Term Opioid Therapy for Chronic Noncancer Pain: A Multicenter, Observational, Cross-Sectional Study

“…After obtaining written, informed consent, the patients received a patient’s booklet and responded to the following questionnaires and forms: (1) Cut down, Annoyed, Guilty, Eye-opener Adapted to Include Drugs (CAGE-AID) [ 30 ]; (2) Brief Pain Inventory-Short Form (BPI-SF) [ 31 ]; (3) Pain Catastrophizing Scale (PCS) [ 32 ]; (4) Hospital Anxiety and Depression Scale (HADS) [ 33 ]; (5) Insomnia Severity Index (ISI) [ 34 ]; (6) Korean Instrumental Activities of Daily Living Scale (K-IADL) [ 35 ]; (7) Korean Connor-Davidson Resilience Scale (K-CD-RISC) [ 36 ]; and (8) Patient Global Impression of Change Scale (PGIC) [ 37 ]. Among the four questions in the CAGE-AID, one or more affirmative answers was considered “positive” for OUD [ 38 ]. BPI-SF measured pain intensity (Items 3–6) and pain interference (Item 9) [ 39 ], which had seven components scored from 0 (no interference) to 10 (interferes completely).…”

Hospital discharge opioid guidelines and policies: a Victorian survey

“…Identifying patients at high risk of opioid abuse or dependence can help reduce adverse outcomes. 23 Despite this, only four hospitals in the present study reported including this strategy in their guideline. Screening for key indicators in the patient's history, including family history and psychological makeup, can determine whether the patient has an increased risk of developing a dependence to opioids.…”

“…Identifying patients at high risk of opioid abuse or dependence can help reduce adverse outcomes . Despite this, only four hospitals in the present study reported including this strategy in their guideline.…”

“…Screening for key indicators in the patient's history, including family history and psychological makeup, can determine whether the patient has an increased risk of developing a dependence to opioids. 23,24 When identified as high risk, patients should not be denied opioids if they are clinically indicated, but treatment should be monitored and managed so the potential for misuse and harm is minimised. 18 Integrating this tool into a guideline may help reduce the risk of aberrant behaviour.…”

Navigating Challenging Conversations About Nonmedical Opioid Use in the Context of Oncology

“…In some situations, oncologists may continue to prescribe opioids but with more discussions of limits and aggressive treatment of nonpain symptoms . Signs of an opioid use disorder (OUD) include the four C's: loss of c ontrol over use, a c ompulsion to continue to use, c ravings for the substance, and use despite negative c onsequences . Many patients with cancer have a degree of difficulty controlling their opioid use and may have a mild OUD in addition to cancer‐related pain; other patients may have a more severe OUD, making it unsafe to prescribe opioids at all.…”