Issues in Long-term Opioid Therapy: Unmet Needs, Risks, and Solutions
2009; Elsevier BV; Volume: 84; Issue: 7 Linguagem: Inglês
10.4065/84.7.593
ISSN1942-5546
Autores Tópico(s)Pain Management and Placebo Effect
ResumoBoth chronic pain and prescription opioid abuse are prevalent and exact a high toll on patients, physicians, and society. Health care professionals must balance aggressive treatment of chronic pain with the need to minimize the risks of opioid abuse, misuse, and diversion. A thorough, ongoing assessment can help fashion a multimodal therapeutic plan, stratify patients by risk, and identify those who may exhibit aberrant behaviors after receiving opioid therapy. Appropriate safeguards (eg, urine drug screens, pill counts) may be used when necessary. Because not all aberrant behaviors have the same origins or implications, physicians must consider a differential diagnosis and tailor therapy accordingly. Opioid formulations designed to deter and resist abuse are currently in late-stage clinical development and address some but not all aspects of inappropriate opioid use. By incorporating physical and pharmacological barriers to obtaining the euphoric effects of opioids, these novel formulations may minimize problematic opioid use. The formulations use a variety of strategies, for example, combining opioids with naltrexone or niacin or incorporating the opioid in a high-viscosity matrix designed to resist physical and chemical extraction. Nonopioid medications as well as cognitive, behavioral, and interventional techniques should be considered for all patients with chronic pain, particularly for those who are unable to safely take their opioids in a structured fashion. The aim of this article was to help physicians prescribe opioid medications safely and successfully to patients who need them. A PubMed literature search was conducted using the keywords risk management, assessment, aberrant behavior, addiction, prescription abuse, and abuse-deterrent. Both chronic pain and prescription opioid abuse are prevalent and exact a high toll on patients, physicians, and society. Health care professionals must balance aggressive treatment of chronic pain with the need to minimize the risks of opioid abuse, misuse, and diversion. A thorough, ongoing assessment can help fashion a multimodal therapeutic plan, stratify patients by risk, and identify those who may exhibit aberrant behaviors after receiving opioid therapy. Appropriate safeguards (eg, urine drug screens, pill counts) may be used when necessary. Because not all aberrant behaviors have the same origins or implications, physicians must consider a differential diagnosis and tailor therapy accordingly. Opioid formulations designed to deter and resist abuse are currently in late-stage clinical development and address some but not all aspects of inappropriate opioid use. By incorporating physical and pharmacological barriers to obtaining the euphoric effects of opioids, these novel formulations may minimize problematic opioid use. The formulations use a variety of strategies, for example, combining opioids with naltrexone or niacin or incorporating the opioid in a high-viscosity matrix designed to resist physical and chemical extraction. Nonopioid medications as well as cognitive, behavioral, and interventional techniques should be considered for all patients with chronic pain, particularly for those who are unable to safely take their opioids in a structured fashion. The aim of this article was to help physicians prescribe opioid medications safely and successfully to patients who need them. A PubMed literature search was conducted using the keywords risk management, assessment, aberrant behavior, addiction, prescription abuse, and abuse-deterrent. Prescription opioid abuse is increasing and exacts a high toll on patients, physicians, and society. Nonmedical users of prescription pain relievers are perhaps the most troublesome population of individuals who abuse opioids; their number more than quadrupled from 1990 to 2000, with abuse of oxycodone and hydrocodone products particularly common.1National Institute on Drug Abuse (NIDA) NIDA Community Drug Alert Bulletin—Prescription Drugs. US Dept of Health and Human Services, Bethesda, MD2005http://www.nida.nih.gov/PrescripAlert/index.htmlGoogle Scholar, 2Passik SD Kirsh KL Donaghy KB Portenoy RK Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.Clin J Pain. 2006; 22: 173-181Crossref PubMed Scopus (130) Google Scholar Escalating prescription drug abuse is associated with higher rates of comorbidities and drug-related mortality.3White AG Birnbaum HG Mareva MN et al.Direct costs of opioid abuse in an insured population in the United States.J Manag Care Pharm. 2005; 11: 469-479PubMed Google Scholar, 4Paulozzi LJ Budnitz DS Xi Y Increasing deaths from opioid analgesics in the United States.Pharmacoepidemiol Drug Saf. 2006; 15: 618-627Crossref PubMed Scopus (559) Google Scholar The overall cost of prescription opioid abuse in the United States has been estimated at $9.5 billion (in 2005 US dollars), including health care, criminal justice, and workplace costs.5Birnbaum HG White AG Reynolds JL et al.Estimated costs of prescription opioid analgesic abuse in the United States in 2001: a societal perspective.Clin J Pain. 2006; 22: 667-676Crossref PubMed Scopus (120) Google Scholar Physicians who prescribe opioids must maintain extensive documentation and may be subject to investigation by the Drug Enforcement Administration.6Gourlay DL Heit HA Almahrezi A Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.Pain Med. 2005; 6: 107-112Crossref PubMed Scopus (440) Google Scholar, 7Trescot AM Boswell MV Atluri SL et al.Opioid guidelines in the management of chronic non-cancer pain.Pain Physician. 2006; 9: 1-39PubMed Google Scholar, 8Katz NP Adams EH Benneyan JC et al.Foundations of opioid risk management.Clin J Pain. 2007; 23: 103-118Crossref PubMed Scopus (132) Google Scholar This review article aims to help physicians prescribe opioid medications safely and successfully to patients who need them. A PubMed literature search was conducted using the keywords risk management, assessment, aberrant behavior, addiction, prescription abuse, and abuse-deterrent. Articles published between January 1, 1980, and December 31, 2008, were selected by relevance to the clinical use of prescription opioids in the treatment of chronic noncancer pain. Chronic pain and prescription opioid abuse are both highly prevalent. Chronic pain affects approximately 50 million Americans each year,9National Pharmaceutical Council I Joint Commision on Accreditation on Healthcare Organizations Scribd Web site. Pain: current understanding of assessment, management, and treatments. 2001.http://www.scribd.com/doc/7563477/National-pharmaceutical-council-NPC-npcnowGoogle Scholar whereas 48 million Americans 12 years or older have used prescription drugs for nonmedical reasons in their lifetimes.1National Institute on Drug Abuse (NIDA) NIDA Community Drug Alert Bulletin—Prescription Drugs. US Dept of Health and Human Services, Bethesda, MD2005http://www.nida.nih.gov/PrescripAlert/index.htmlGoogle Scholar Among the most potent analgesics available, opioids have a recognized role in the treatment of cancer- and noncancer-related chronic pain conditions.7Trescot AM Boswell MV Atluri SL et al.Opioid guidelines in the management of chronic non-cancer pain.Pain Physician. 2006; 9: 1-39PubMed Google Scholar, 10Carr DB Goudas LC Balk EM Bloch R Ioannidis JP Lau J Evidence report on the treatment of pain in cancer patients.J Natl Cancer Inst Monogr. 2004; : 23-31Crossref PubMed Scopus (88) Google Scholar Yet many physicians, concerned that their patients will become addicted, are reluctant to prescribe these agents, contributing to the widespread undertreatment of chronic pain.7Trescot AM Boswell MV Atluri SL et al.Opioid guidelines in the management of chronic non-cancer pain.Pain Physician. 2006; 9: 1-39PubMed Google Scholar Physicians must realize that patients exhibit a continuum of behaviors in response to opioid therapy11Kirsh KL Passik SD The interface between pain and drug abuse the evolution of strategies to optimize pain management while minimizing drug abuse.Exp Clin Psychopharmacol. 2008; 16: 400-404Crossref PubMed Scopus (59) Google Scholar (Figure 1). In practice, prescription opioid users are in heterogeneous categories that include extreme cases of medical and nonmedical abusers. However, most patients who take prescription opioids are somewhere in between, ranging from those with pain who adhere to their treatment regimen to those who purposefully abuse their medications or from nonmedical users who self-medicate by taking illicit opioids to those who abuse opioids recreationally. Family physicians likely see many patients with chronic pain in their practices. When evaluating and treating a patient with chronic pain, the family physician must balance the need for aggressive treatment with minimizing the risks of treatment. Numerous medical (opioid, nonopioid, interventional) and nonmedical (eg, physical therapy, acupuncture, cognitive-behavioral therapy) treatment options are available.12Argoff CE Pharmacologic management of chronic pain.J Am Osteopath Assoc. 2002; 102: S21-S27PubMed Google Scholar, 13Passik SD Kirsh KL Opioid therapy in patients with a history of substance abuse.CNS Drugs. 2004; 18: 13-25Crossref PubMed Scopus (64) Google Scholar This article reviews the use of opioidpharmacotherapy in the management of chronic pain. Emphasis is on the risks of opioid abuse, misuse, and diversion when these agents are prescribed and identification of methods to assess the risk for such behaviors and reduce their likelihood. The primary care physician can strike the necessary balance by treating chronic pain appropriately, including the use of opioids when indicated, while using risk management strategies to minimize risk.6Gourlay DL Heit HA Almahrezi A Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.Pain Med. 2005; 6: 107-112Crossref PubMed Scopus (440) Google Scholar, 7Trescot AM Boswell MV Atluri SL et al.Opioid guidelines in the management of chronic non-cancer pain.Pain Physician. 2006; 9: 1-39PubMed Google Scholar Such strategies include risk assessment, risk stratification, and ongoing monitoring for aberrant drug-taking behaviors. Abuse-deterrent and abuse-resistant opioid formulations that incorporate physical or pharmacological barriers to common routes of abuse present an emerging set of tools to be used as part of a comprehensive risk management plan.14Woolf CJ Hashmi M Use and abuse of opioid analgesics: potential methods to prevent and deter non-medical consumption of prescription opioids.Curr Opin Investig Drugs. 2004; 5: 61-66PubMed Google Scholar, 15Webster LR PTI-821: sustained-release oxycodone using gel-cap technology.Expert Opin Investig Drugs. 2007; 16: 359-366Crossref PubMed Scopus (25) Google Scholar However, the potential public health benefits of these formulations will not be evident until they are approved and accessible to patients in need. Treatment options for chronic pain include nonpharmacological and pharmacological modalities. Choice of therapy should be guided by a comprehensive assessment, including history (eg, pain history, medical history, family history, psychosocial history, medications, past interventions), physical examination, and appropriate diagnostic studies. Underlying conditions, if present, such as a tumor or vertebral fracture causing spinal cord compression, should be treated as directly as possible while also treating the pain caused by these conditions. Successful treatment of the underlying condition does not guarantee complete pain relief, and pain relief does not guarantee elimination of the psychosocial issues that often accompany chronic pain conditions. The physician-patient relationship may be well served by a discussion of these matters at the onset of treatment so that expectations and goals can be managed. The therapeutic plan should be tailored to the individual and to the presenting problem, with analgesics properly selected to achieve the optimal balance between maximum analgesia and minimum adverse effects. Depending on the complexity of the patient's condition, such as in patients with active substance abuse disorder or those with a personal history of substance abuse, consultation with a pain specialist orpsychologist may be recommended, particularly if these issues are outside the physician's core expertise.9National Pharmaceutical Council I Joint Commision on Accreditation on Healthcare Organizations Scribd Web site. Pain: current understanding of assessment, management, and treatments. 2001.http://www.scribd.com/doc/7563477/National-pharmaceutical-council-NPC-npcnowGoogle Scholar, 13Passik SD Kirsh KL Opioid therapy in patients with a history of substance abuse.CNS Drugs. 2004; 18: 13-25Crossref PubMed Scopus (64) Google Scholar, 16American Academy of Pain Medicine American Pain Society The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain.Clin J Pain. 1997; 13: 6-8Crossref PubMed Scopus (340) Google Scholar Nonpharmacological approaches include physical, psychological, and interventional options (Table 1).9National Pharmaceutical Council I Joint Commision on Accreditation on Healthcare Organizations Scribd Web site. Pain: current understanding of assessment, management, and treatments. 2001.http://www.scribd.com/doc/7563477/National-pharmaceutical-council-NPC-npcnowGoogle Scholar Frequently, a combination of nonpharmacological and pharmacological therapies is effective in managing chronic pain and any related physical and psychosocial impairments.16American Academy of Pain Medicine American Pain Society The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain.Clin J Pain. 1997; 13: 6-8Crossref PubMed Scopus (340) Google Scholar If medications are used, pain severity is an important criterion for choosing a therapeutic option, but it is not the only consideration. Previously, the World Health Organization stepladder approach had been criticized for treating pain solely on its intensity. A more contemporary strategy now includes treatment based on the underlying mechanism of pain. A modification of the World Health Organization stepladder approach incorporates the role of additional pain management interventions when rational trials and upward titrations of various pharmacotherapies do not effectively control pain or when the benefits of treatment are offset by burdensome adverse events. In this recommendation, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant analgesics (eg, antidepressants and anticonvulsants) are suggested for the treatment of mild to moderate pain. For the treatment of moderate to severe pain or uncontrollable pain, opioids, NSAIDs, and adjuvant analgesics are recommended (Figure 2).17Fine PG The evolving and important role of anesthesiology in palliative care.Anesth Analg. 2005; 100: 183-188Crossref PubMed Scopus (50) Google ScholarTABLE 1Nonpharmacological Options for Treating Chronic PainData from reference 9.Option typeExamplePhysical Self-administered therapies Bandage wrapsCorsetsCounterirritant creamsExerciseHeat or cold applicationLimitation of activitiesPostural changesPhysical medicine DeconditioningHydrotherapyMassage therapyMechanical devices (eg, splints)Physical and occupational therapyRange-of-motion programsPsychological Attention control exercisesBiofeedbackCognitive-behavioral therapyDesensitizationDistractionGoal-setting and pacing strategiesGuided imageryHypnosisPatient educationPsychotherapy for comorbid conditions, such as depression and anxietyRelaxation trainingInterventional BracingInjection and radiation therapyNerve blocksNeurodestructive surgical techniquesTranscutaneous electrical nerve stimulationVertebroplasty Open table in a new tab The general thought among pain specialists is that some medications are more effective for one type of pain than another (eg, NSAIDs for nociceptive pain and anticonvulsants or antidepressants for neuropathic pain). However, few blinded comparative clinical studies have been published to support such beliefs.18Harke H Gretenkort P Ladleif HU Rahman S Harke O The response of neuropathic pain and pain in complex regional pain syndrome I to carbamazepine and sustained-release morphine in patients pretreated with spinal cord stimulation: a double-blinded randomized study.Anesth Analg. 2001; 92: 488-495Crossref PubMed Scopus (133) Google Scholar, 19Dworkin RH Backonja M Rowbotham MC et al.Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations.Arch Neurol. 2003; 60: 1524-1534Crossref PubMed Scopus (1055) Google Scholar Opioids are currently regarded as effective in the treatment of nociceptive pain, and there is increasing evidence from several controlled clinical studies on longer-acting opioid formulations (eg, methadone, oxycodone, levorphanol) for their utility in treating neuropathic pain as well.7Trescot AM Boswell MV Atluri SL et al.Opioid guidelines in the management of chronic non-cancer pain.Pain Physician. 2006; 9: 1-39PubMed Google Scholar, 19Dworkin RH Backonja M Rowbotham MC et al.Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations.Arch Neurol. 2003; 60: 1524-1534Crossref PubMed Scopus (1055) Google Scholar, 20Gimbel JS Richards P Portenoy RK Controlled-release oxycodone for pain in diabetic neuropathy: a randomized controlled trial.Neurology. 2003; 60: 927-934Crossref PubMed Scopus (466) Google Scholar, 21Morley-Forster PK Clark AJ Speechley M Moulin DE Attitudes toward opioid use for chronic pain: a Canadian physician survey.Pain Res Manag. 2003; 8: 189-194PubMed Google Scholar Guidelines suggest that long-acting (controlled-release or sustained-release) opioids are useful for patients with continuous pain, whereas short-acting (immediate-release) opioids are used to manage intermittent and breakthrough pain.9National Pharmaceutical Council I Joint Commision on Accreditation on Healthcare Organizations Scribd Web site. Pain: current understanding of assessment, management, and treatments. 2001.http://www.scribd.com/doc/7563477/National-pharmaceutical-council-NPC-npcnowGoogle Scholar Attentive care by a physician can often manage or even prevent the occurrence of common adverse effects caused by opioid therapy (eg, constipation, nausea, vomiting, endocrine dysfunction).7Trescot AM Boswell MV Atluri SL et al.Opioid guidelines in the management of chronic non-cancer pain.Pain Physician. 2006; 9: 1-39PubMed Google Scholar Often, patients develop tolerance to many of these adverse effects, although careful monitoring is always important. Despite additional treatment, some patients experience intolerable adverse effects that may be remediated by opioid rotation or multimodal treatment. Combining drugs with different mechanisms of action (eg, an NSAID and an opioid for chronic pain associated with arthritis) can often enhance analgesia while lowering the necessary doses of drugs and reducing adverse effects. Although multidrug therapy appears to be a common practice, few formal clinical studies of this treatment concept have been published. In the only randomized controlled study of the use of such multidrug therapy, an opioid and an antiepileptic drug were administered either in combination or alone in patients with neuropathic pain. In that study, Gilron et al22Gilron I Bailey JM Tu D Holden RR Weaver DF Houlden RL Morphine, gabapentin, or their combination for neuropathic pain.N Engl J Med. 2005; 352: 1324-1334Crossref PubMed Scopus (943) Google Scholar found that a combination of morphine and gabapentin provided superior analgesia in patients with neuropathic pain at lower doses than placebo or each drug taken as monotherapy. If opioid therapy is considered for a patient, the risks of opioid abuse, misuse, and diversion should be carefully assessed. The object of risk assessment is to identify the likelihood that a patient will exhibit aberrant behaviors (eg, abuse, misuse, diversion, addiction; Table 223Passik S Portenoy RK Ricketts PL Substance abuse among cancer patients, part 1: prevalence and diagnosis.Oncology (Williston Park). 1998; 12 (524.): 517-521PubMed Google Scholar) once opioid therapy has been prescribed so that appropriate safeguards can be placed in his or her pain management plan.3White AG Birnbaum HG Mareva MN et al.Direct costs of opioid abuse in an insured population in the United States.J Manag Care Pharm. 2005; 11: 469-479PubMed Google Scholar, 24Webster LR Webster RM Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.Pain Med. 2005; 6: 432-442Crossref PubMed Scopus (741) Google Scholar Some patients are at greater risk for abuse, misuse, diversion, and addiction than others, but identifying these patients can be a complex task because there is no clear consensus on their respective definitions. On the assumption that every patient has a degree of risk, a universal precautions approach is advised, beginning with a thorough risk assessment for every patient who is to be prescribed opioid therapy for chronic pain.6Gourlay DL Heit HA Almahrezi A Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.Pain Med. 2005; 6: 107-112Crossref PubMed Scopus (440) Google Scholar Risk management comprises a suite of assessment, monitoring, and treatment tools that need to be considered for each patient and individualized as clinically indicated11Kirsh KL Passik SD The interface between pain and drug abuse the evolution of strategies to optimize pain management while minimizing drug abuse.Exp Clin Psychopharmacol. 2008; 16: 400-404Crossref PubMed Scopus (59) Google Scholar (Table 3).TABLE 2Spectrum of Aberrant Drug-Taking BehaviorsData from reference 23.More suggestive of addictionaDocumented in patient's medical chart.Less suggestive of addiction Concurrent abuse of alcohol or illicit drugsEvidence of a deterioration in the ability to function at work, in the family, or socially that appears to be related to drug useInjecting oral formulationsMultiple dose escalations or other nonadherence with therapy despite warningsObtaining prescription drugs from nonmedical sourcesPrescription forgeryRepeated resistance to changes in therapy despite clear evidence of drug-related diverse physical or psychological effectsRepeatedly seeking prescriptions from other physicians or emergency departments without informing prescriberSelling prescription drugsStealing or borrowing drugs from others Aggressive complaining about the need for more drugsDrug hoarding during periods of reduced symptomsOpenly acquiring similar drugs from other medical sourcesRequesting specific drugsReporting psychic effects not intended by the physicianResistance to a change in therapy associated with tolerable adverse effects accompanied by expressions of anxiety related to the return of severe symptomsUnapproved use of the drug to treat another symptomUnsanctioned dose escalation or other nonadherence with therapy on 1 or 2 occasionsa Documented in patient's medical chart. Open table in a new tab TABLE 3Risk Management Package for Patients Undergoing Opioid TherapyData from reference 11. Screening and risk stratificationUse of prescription monitoring program dataCompliance monitoring Urine drug testingPill or patch countsEducation about drug storage and sharingPsychotherapy and highly structured approachesAbuse-deterrent or abuse-resistant strategies in opioid formulation Open table in a new tab Patients should be assessed for known risk factors for opioid abuse, including smoking,25Akbik H Butler SF Budman SH Fernandez K Katz NP Jamison RN Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP).J Pain Symptom Manage. 2006; 32: 287-293Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar psychiatric disorders, and personal or family history of substance abuse.24Webster LR Webster RM Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.Pain Med. 2005; 6: 432-442Crossref PubMed Scopus (741) Google Scholar For example, smoking is a risk factor for substance abuse because approximately 75% to 95% of patients beingtreated for a substance abuse disorder smoke,26Rohsenow DJ Colby SM Martin RA Monti PM Nicotine and other substance interaction expectancies questionnaire: relationship of expectancies to substance use.Addict Behav. 2005; 30: 629-641Crossref PubMed Scopus (40) Google Scholar and 2 leading screening tools have linked smoking to aberrant behaviors in patients with pain.25Akbik H Butler SF Budman SH Fernandez K Katz NP Jamison RN Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP).J Pain Symptom Manage. 2006; 32: 287-293Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 27Coambs RB Jarry JL The SISAP: a new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain within general medical practice.Pain Res Manag. 1996; 1: 155-162Google Scholar Patients who have risk factors or are determined through the clinical screening tools to be at high risk should not necessarily be excluded from opioid pharmacotherapy if such treatment has been determined to be the best course of action. However, these patients should begin taking an opioid medication only after a highly structured treatment plan has been created to encompass all aspects of the risk management package discussed herein, particularly strict and frequent monitoring. Effective screening tests are available to aid in risk assessment, including the Opioid Risk Tool (ORT), the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), and the Screening Instrument for Substance Abuse Potential (SISAP). ORT is a self-administered, 5-question test that measures risk factors associated with substance abuse, including personal and family history of substance abuse, age, history of preadolescent sexual abuse, and psychological diseases. ORT has a high degree of sensitivity and specificity for determining which patients are at risk for opioid abuse, misuse, and diversion.24Webster LR Webster RM Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool.Pain Med. 2005; 6: 432-442Crossref PubMed Scopus (741) Google Scholar SOAPP-R, a 24-item, self-administered questionnaire, also has shown validity and reliability as a measure for stratifying risk of aberrant opioid-related behavior among patients with chronic pain.28Butler SF Fernandez K Benoit C Budman SH Jamison RN Validation of the Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R).J Pain. 2008 Apr; 9 (Epub 2008 Jan 22.): 360-372Abstract Full Text Full Text PDF PubMed Scopus (355) Google Scholar Patients rate questions about the frequency of behaviors such as substance abuse, the patient-physician relationship, antisocial behaviors, behaviors associated with medication, issues involving personal care and lifestyle, neurobiological need for medicine, psychiatric disorders, and psychosocial difficulties on a scale of 0 (never) to 4 (very often).29Butler SF Budman SH Fernandez K Jamison RN Validation of a screener and opioid assessment measure for patients with chronic pain.Pain. 2004; 112: 65-75Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar Of the 24 SOAPP items, 14 are apparent predictors of aberrant drug use29Butler SF Budman SH Fernandez K Jamison RN Validation of a screener and opioid assessment measure for patients with chronic pain.Pain. 2004; 112: 65-75Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar; an abbreviated version of SOAPP using the 14 items has recently been validated and published.25Akbik H Butler SF Budman SH Fernandez K Katz NP Jamison RN Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP).J Pain Symptom Manage. 2006; 32: 287-293Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar SISAP, a 5-item, physician-administered instrument, also demonstrates good sensitivity and specificity. It identifies at-risk patients through inquiries about age and drug, alcohol, and cigarette use; however, SISAP lacks questions about psychiatric comorbidities.27Coambs RB Jarry JL The SISAP: a new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain within general medical practice.Pain Res Manag. 1996; 1: 155-162Google Scholar Although many validated tools are available, the choice of the appropriate tool often depends on the needs of each practice. For example, ORT is a short, self-administered test that can be used quickly and easily in a busy primary care practice, whereas SOAPP is a slightly longer test, factoring in more complex variables that may be better suited to a specialty practice. When available, prescription monitoring programs, which exist in 35 states and monitor when and where prescriptions are filled, can provide physicians with valuable information about prescription compliance. Urine drug tests (UDTs) can be particularly useful among patients with inadequate response to opioid therapy and patients treated with opioid analgesics on a long-term basis.6Gourlay DL Heit HA Almahrezi A Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.Pain Med. 2005; 6: 107-112Crossref PubMed Scopus (4
Referência(s)