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INTRODUCTION

Approximately 21% (50 million) of the U.S. adult population suffers from chronic pain.¹ Historically, chronic pain was defined as pain lasting or recurring longer than three months. Later that was modified to reflect pain that endured beyond that which is typical for an injury. Chronic pain does not resolve on its own and is now considered a disease unto itself.^2,3,4,5 It also is one of the most common reasons adults seek medical care.¹

Chronic noncancer pain (CNCP) is the most common cause of disability and reduced physical, psychological, and social well-being. It is also associated with higher utilization of health care services.⁶ The annual economic burden of treating chronic pain in working-age adults has been estimated at $635 billion (in 2010 dollars)—more than the annual combined cost to treat heart disease and cancer.⁷

Opioids can be an important component of a treatment regimen for chronic pain, including cancer-related pain.^4,6,8,9 A recent meta-analysis shows that, after being on opioids for more than three months, patients continue to have statistically significant but small improvements in pain reduction, physical functioning, and sleep quality.¹⁰ However, concerns about the opioid epidemic in the United States, the clear link between long-term opioid use/misuse, and questions about the benefits of long-term opioid usage for CNCP have prompted greater oversight on opioid prescribing.^{4,11,12,13,14}

Thus, prescribers face a daunting task as they strive to follow national guidelines and state regulations, balance the risks/benefits of prescribing opioids, and optimize patients’ functional outcomes in the face of chronic pain.^11,15,16

CDC recommendations for opioid prescribing

In 2016, the Centers for Disease Control and Prevention (CDC) issued twelve recommendations for how primary care physicians should use opioids when treating chronic noncancer pain in adults aged 18 and older:¹¹

While the CDC guidelines provide beneficial direction, they also have several limitations. They:

• Are not comprehensive
• Pertain only to adults
• Assume equal risk over all adult populations
• Offer no guidance for nonopioid alternatives

The CDC guidelines also have had some unintended consequences:¹⁷

• The lack of provider education on prescribing options and protocols makes some clinicians unwilling to prescribe opioids to patients who could clearly benefit from them.
• Nonopioid solutions (including nonpharmacological ones) are expensive and often not readily available. That has forced some patients to obtain opioids illicitly.
• Lower-risk Schedule III and IV opioids are not mentioned.
• In 2019, the Centers for Medicare & Medicaid Services (CMS) 2019 mandated safety edits for any prescription > 90 MMEs (morphine milligram equivalents) per day. That may unduly burden pharmacists with extensive consults to the many CMS beneficiaries with prescriptions that fall outside CMS guidance.
• The guidelines don’t account for patients on long-term opioid therapy who develop a tolerance to it.
  (Other patient variables that may warrant prescribing > 90 MMEs daily are discussed later in this monograph.)

Additionally, untreated chronic pain is a silent public health crisis that costs patients in terms of time, money, lost productivity, functional and psychological damage.¹⁷

This puts pharmacists in a unique position to be influencers in developing prescribing protocols, stratifying patients for risk of opioid misuse before pain medications are prescribed, performing medication reconciliation, and ensuring safe prescribing practices, especially for vulnerable populations.

This monograph offers pragmatic advice regarding safe opioid prescribing practices for four special populations. A special population is defined legally as a disadvantaged group. The precise definition varies among jurisdictions. Older people in nursing homes or children in vulnerable housing are typical examples of special populations.¹⁸ This paper expands upon the definition of special populations to discuss how all pediatric, geriatric, incarcerated people, and people who use drugs are disadvantaged in being able to obtain adequate relief from chronic pain. It also discusses how careful, customized opioid prescribing can minimize risks of adverse outcomes while delivering pain relief. Finally, it also offers pain assessments and opioid risk assessments that have been validated for each population discussed.

PEDIATRICS

The prevalence of chronic pain in children is 20% to 40%, depending on the condition.¹⁹ The long-term psychological consequences of untreated or undertreated pain in this population is well documented; however, a paucity of evidence exists regarding which drugs are most effective in treating chronic pain in children and adolescents.^20,21 Approximately 80% of the drugs given to children are prescribed off-label.¹⁹

A suite of recent Cochrane PaPaS (Pain, Palliative and Supportive Care) reviews of pain in children could not find enough evidence to recommend the use of antidepressants, antiepileptics, nonsteroidal anti-inflammatory drugs (NSAIDs), or paracetamol (acetaminophen) to treat chronic pain in children and adolescents. No studies met Cochrane Review requirements for the use of opioids use in this population.²²

Another Cochrane review in that suite concluded that cognitive behavioral therapy could significantly improve children’s chronic medical symptoms. A review for chronic headache noted that a variety of psychological therapies (relaxation, hypnosis, coping skills training, biofeedback, and cognitive behavioral therapy) had significant, lasting effects in reducing pain, disability, and anxiety.²²

Treatment recommendations for pediatric patients intensely reflect the desire to avert the risk of future opioid misuse, diversion, or dependency. It is a valid concern; prescription drug misuse rates are highest in adolescents and young adults.²³ In 2018, more than 10 million children aged 12 or younger misused opioids.²⁴ However, untreated or undertreated chronic pain in children and adolescents comes with its own risks: poor sleep hygiene, anxiety and depression; impairments in concentration, memory, and cognition; low cardiorespiratory fitness and poor quality of life; and a high chance of pain persisting throughout adulthood, including pain in new areas.²⁵

WHO guidelines

The 2020 World Health Organization offers the following broad guidelines for treating chronic pain in children:²⁶

• Use opioids sparingly and appropriately.
• Articulate a clear treatment plan (including an exit plan).
• Plan for disposal of unused opioids.
• Utilize modalities such as physical therapy and cognitive behavioral therapy (if available).

Details are lacking regarding any specific drug except morphine, which the WHO deems appropriate to use in select circumstances for chronic pain, including palliative and end-of-life care. The guidelines acknowledge the lack of evidence-based data to support specific pharmacotherapies.²⁶

Consensus on best practices for pharmacological treatment of chronic pain in the pediatric population is often lacking. However, psychological interventions including Cognitive Behavioral Therapy and Acceptance and Commitment Therapy are validated for treating chronic pain in pediatric patients. Interventional procedures can facilitate physiotherapy, which also has been shown to ameliorate chronic pain. Evaluate pharmacotherapy on a case-by-case basis for its risks and benefits as part of a multimodal, interdisciplinary treatment program.²⁵ When available, follow disease-specific guidelines for pharmacological treatment, such as with sickle cell disease.²⁷

Suggested screening tools

In general, pain in children is underestimated and undertreated. Screening tools help a clinician assess the intensity of a patient’s pain and stratify patient risk if the clinician is considering an opioid for pain management. Sometimes a tool is available for a specific medical condition. As is true for all screening tools, use only validated ones specific to the patient population. Pain assessments need to be able to discern differences before and after treatment. Several that are recommended for the pediatric population follow.

Screening tools for pain

Self-assessment scales vary by age and the child’s cognitive and language skills for self-reporting pain. For younger children, a behavioral assessment is needed. Many tools have been validated for assessing only acute pain in alert or sedated pediatric patients. The ones listed in Table 2 have been tested on pediatric patients with chronic pain.²⁸

Screening tools for opioid misuse risk

Children and adolescents should be screened for past use of opioids (prescription or nonprescription). Two screening tools are helpful for this:²⁹

• APA Adapted NM ASSIST tools
• Brief Screener for Alcohol, Tobacco, and Other Drugs (BSTAD)

The adult version of APA Adapted NM ASSIST tools can be used to screen parents for opioid use/misuse.

NOTE: The National Institute for Drug Abuse (NIDA) website contains a comprehensive list of validated screening tools, organized by substance type (alcohol vs drugs), age (adolescents vs adults), and how the tool is administered (self-reported vs clinician-administered).²⁹

Pharmacists’ roles³⁰

Pharmacists have a unique opportunity to help develop a multidisciplinary team to manage and coordinate long-term opioid therapy. They can also:

• Spearhead safe prescribing guidelines that optimize chronic pain treatment in pediatric patients
• Create alerts in the electronic health record (EHR) to guide prescribers in treatment decisions
• Review PDMP data prior to dispensing an opioid prescription
• Ensure the amount prescribed aligns with timing of future appointments
• Suggest multimodal therapies that can enhance pharmacotherapy’s analgesic effects
• Educate families about opioid dosing and safe disposal of leftover medicine
• Ensure that a naloxone prescription is written for patients who: are taking > 50 MME per day of an opioid or a concurrent benzodiazepine or have a history of substance use disorder (SUD)

AGING POPULATION

At least 62% of people aged 65 and older suffer from chronic pain.¹ Assessing pain in this population can be difficult for many reasons:^31,32,33

• Comorbidities
• Cognitive decline
• Risk of drug-drug interactions from polypharmacy
• Prescription overlap from multiple transitions of care/fragmented care
• Patients’ reticence to talk about pain
• Patients’ or clinicians’ attitudes that pain is normal with aging
• Clinicians’ uncertainty regarding how to implement CDC guidelines in this population.

This puts older people at risk of being undertreated as well as overtreated.

Opioids have proven efficacy for noncancer pain in geriatric patients; however, prescribing requires close monitoring. Opioids can depress respiration, affect cognitive function, impair selective attention, decrease performance, suppress the immune system, and increase fall risks.^{34,35,36,37,38}

In the aging population, 50 morphine milligram equivalents (MME) per day is a commonly used threshold for opioid prescribing. Any higher dose is generally considered an increased risk for harm from opioids. More than a quarter of Medicare beneficiaries with new opioid use are prescribed higher doses than that.³² Is that an oversight or intentional? It depends on the patient.

Optimal dosages and common side effects are difficult to predict in this population.³⁹ Aging alters drugs’ pharmacokinetics and pharmacodynamics, key considerations when prescribing opioids to this population.

• Declining organ function and the potential for drug/drug interactions require starting these patients at lower initial doses and less frequent dosing intervals.
• Impaired renal and hepatic functions may prolong drug circulation, uptake, and distribution, and cause active metabolic byproducts to accumulate.
• Opioid prodrugs (codeine, hydrocodone, tramadol) may have limited efficacy in people who are poor CYP2D6 metabolizers.
• Aging’s shift in body fat vs total water volume may delay the onset of action and elimination of lipophilic drugs but increase the serum concentration of hydrophilic drugs (such as morphine and its derivatives).
• Some patients may need to transition from one opioid to another to enhance efficacy, address tolerance, or improve tolerability.

With the exception of buprenorphine, the half-life of opioids and their active metabolites are increased in older people. However, the mantra “start low, go slow” often isn’t followed.³¹ For example, in the hospital setting, default values for administering opioids are often higher than recommended for geriatric daily doses. The same is true for benzodiazepines, and both may be prescribed concurrently.^35,42 The American Geriatrics Society 2019 update to its Beers Criteria states to avoid use of opioids in concert with a benzodiazepine or gabapentinoid.⁴³

Nonadherence is another potential source of over- or underdosing. Nonadherence is common in older adults. Forty to 75% accidentally or intentionally misuse their prescriptions. They may take more medicine than prescribed, thinking it will help more. Conversely, they may underuse it or completely forget to take it. Adherence can be improved with pill boxes, text messages, and family support.³¹

The ideal treatment regimen for chronic pain in older people should be multimodal—incorporating pharmacotherapy, psychological support, physical rehabilitation, and interventional procedures if needed.³¹

Considerations for surgery

The aging population accounts for more than half of all patients that undergo surgery, yet little has been published regarding their post-operative use of opioids.³⁶ Surgery comes with a high risk of morbidity in this population, and one potential source can come from pre-existing polypharmacy when an opioid is added for postoperative pain.⁴¹

Many medications that older adults commonly take for conditions including chronic pain, depression, anxiety, and insomnia, act on the central nervous system. In 2015, the American Geriatrics Society Beers Criteria flagged administration of ≥ 3 central nervous system agents as a clinically important drug-drug interaction. Thus, adding an opioid for postoperative pain, even in opioid-naïve patients, can significantly increase older person’s risk of adverse events. Additionally, opioids with anticholinergic activity should be avoided, as they can accelerate cognitive decline.^31,44 A thorough preoperative medication review can avert such problems.⁴¹

Monitoring opioid usage after surgery is important as well. A large study of opioid-naïve older patients with preexisting chronic pain monitored their opioid usage postoperatively. Up to 25% of them were still taking opioids more than 90 days after minor surgery; 16% did the same more than 90 days after major surgery.³⁶

Dementia

Older patients with dementia may be the most challenging geriatric population to treat for pain because neuropathological changes alter their perception and expression of pain. However, untreated chronic pain can accelerate memory decline.⁴⁵

People with dementia typically cannot discriminate between low-pain vs high-pain events.⁴⁶ Vocalizations, facial expressions, and body movements may be this population’s only way to express pain. Unfortunately, healthcare providers may misinterpret those actions as neuropsychiatric symptoms of dementia.⁴⁷ That may lead to inappropriate treatment with an anxiolytic or antipsychotic.⁴⁸ Yet recognizing when the person is in pain and providing adequate pain control can relieve suffering, aggression, and agitation.⁴⁹

Symptoms that do not lessen with pain treatment are likely not pain-related but are instead dementia behavior.

Recommendations for pain treatment in people with dementia:^39,47

As with other populations, avoid certain drugs (analgesics that are anticholinergics, NSAIDs for their side effect profile). Additionally, for patients with dementia:

• Identify/treat obvious diseases (e.g., wounds/infections).
• Avoid cognitive behavioral therapy; it won’t work with this population.
• Start low; titrate up when using an opioid.
• Neuropathic pain may benefit from an anticonvulsant

Suggested screening tools

The prevalence of undertreating pain in the aging population underscores the need for an accurate pain assessment that can also detect changes after treatment.⁴⁷

Screening tool for pain

With cognitively intact geriatric patients:

Geriatric Pain Measure (GPM)
Geriatric Painful Events Inventory (GPEI)

Those are the only two designed specifically for older adults.³³

The Mini-Mental State Exam (MMSE) can be used as a screen for determining whether a person can reliably report pain. A score of 18 or higher is suggested as the cutoff for inability to self-report pain.⁴⁵

With geriatric dementia patients:

Mobilization-Observation-Behavior-Intensity-Dementia-2 pain scale (MOBID-2)⁴⁷
Pain Assessment in Advanced Dementia (PAINAD)⁵⁰

Screening tools for opioid misuse risk

None exist specifically for the aging population, but the American Geriatric Society recommends the Opioid Risk Tool (ORT) and the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R).³⁹ Both tools are discussed further at the end of this monograph.

Pharmacists’ roles

Pharmacists can

• Perform medication review/reconciliation to avert unnecessary or unsafe polypharmacy
• Detect inappropriate opioid prescribing
• Suggest safe pain medication combinations
• Provide patient and family education to improve adherence to treatment regimens and ensure safe medication storage/disposal
• Ensure naloxone is prescribed for patients as needed

INCARCERATED

Approximately 65% of the incarcerated population has an active substance use disorder (SUD). Another 20% percent was under the influence of drugs or alcohol at the time of their crime. This creates challenges for treating chronic pain in inmates because so many of them have a high tolerance to opioids.⁵¹

A 2019 report showed that only 5% of inmates received treatment for OUD.⁵² Naltrexone, methadone, and buprenorphine are effective for treating OUD and can reduce inpatient and outpatient mental health treatment utilization as well.⁵³ However, access to those treatments are often limited, and correctional facilities are not required to provide such rehabilitation.^54,55

Additionally, more than a third of inmates have a diagnosed mental illness—yet two-thirds of them report not receiving medications for it.⁵⁶ The combination of mental illness and SUD puts this population at especially high risk for poor clinical outcomes.⁵³

Inmates also have a disproportionate number of other comorbidities.⁵⁷ Collectively, this increases the probability that those inmates will suffer from chronic pain.⁵⁷ Additionally, the incarcerated population is increasing as well as aging—which underscores the increasing need for effective chronic pain management.⁵⁸

The Bureau of Prisons (BOP) provides detailed guidelines for treating chronic pain in inmates (Table 4).⁵¹

Suggested screening tools

Screening tools for pain

• The choice of pain scale will differ depending on whether mental illness, cancer, surgery, or a specific medical condition is a factor.
• If an inmate is an adolescent or is geriatric, a pain assessment specifically for that age group can better evaluate pain in that population.
• In all cases, multidimensional pain scales are preferred. The McGillPain Questionnaire (MPQ) is a good example. It measures pain intensity, distinguishes between types of pain, and discriminates between sensory and emotional aspects of pain. It can also detect changes after treatment. Many short and long versions of the MPQ exist.

Screening tools for opioid misuse risk⁸

• To predict prescription opioid misuse
  The Pain Medication Questionnaire (PMQ) and
  Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
• To screen for current misuse
  The Current Opioid Misuse Measure (COMM)

Pharmacists’ roles

Pharmacists can

• Ensure that correctional facilities comprehensively screen for undiagnosed infections, mental health issues, and other comorbidities
• Provide safe treatment for all those conditions as well as for chronic pain
• Ensure availability of buprenorphine-based medication for opioid use disorder (MOUD), a good long-term strategy for treating inmates with OUD
• Champion the availability of providing take-home naloxone upon release

That last item is a particularly urgent need. Individuals with OUD are at the greatest risk of opioid overdose and death the first two weeks after their release.⁶² Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons.⁶³

PEOPLE WHO USE DRUGS (PWUD)

Opioids are one of the most commonly used classes of illicit drugs.⁶⁴ Chronic noncancer pain and a history of substance abuse co-occur in approximately 43% of people who use drugs.⁶⁵ Similarly, the prevalence of CNCP in people on medication-assisted therapy ranges from 36% to 61.%.¹⁴

One of the biggest challenges for a prescriber is to distinguish between legitimate prescriptions of controlled substances vs those potentially used for illegitimate purposes.¹⁶ That challenge is heightened in the emergency department (ED) setting when patients present with severe pain.⁶⁶

PWUDs utilize the ED six times more often than patients who use the ED for any cause, and the prevalence has quadrupled in recent years.⁶⁷ Younger age and a prescription for a benzodiazepine or a heroin-related encounter increase the odds of subsequent encounters.⁶⁸

Injection of prescription opioids often portends broader polydrug use. Both greatly increase a person’s risk for

• All-cause and overdose-specific mortality
• Contracting hepatitis C (HCV)
• Contracting human immunodeficiency virus (HIV)

Many PWUDs also have undiagnosed or untreated co-occurring mental illnesses. All those conditions complicate treatment for CNCP.⁶⁸

This population’s high utilization of the ED presents unique interventional opportunities. However, the ED is not in a good position to screen for HCV, HIV, OUD, and mental illness while determining how to treat CNCP.⁶⁸

Anyone with a history of injection drug use should be routinely screened for HCV (hepatitis C).⁷¹ HCV infections are on the rise, particularly in younger people and women.⁷² Pregnant women may transfer the virus to the fetus.⁷³ A similarly urgent need exists to screen for HIV.⁶⁴ People who use opioids and have HIV are six times more likely to have a detectable viral load than non-opioid users.⁷⁴

Beyond ED visits, healthcare consumption in general is significantly higher in people who inject drugs than in people who do not.⁶⁵ Thirty percent of the former are re-admitted to the hospital within a year of their last encounter—most often for an infection, kidney failure, another drug-related incident, or psychiatric admission.⁷⁵ A serious complication such as an infection can be a teachable moment for the patient and can afford the time to perform screenings and interventions that are not always feasible in the ED setting.⁷⁶ Larger hospitals with an addictions team or other multidisciplinary team that understands SUD and OUD can be key in such interventions.⁷⁶

When people are hospitalized for infectious complications of IV opioid use, they are also at high risk for discharge-against-medical-advice and readmissions. Rates are lower if patients are discharged with any form of ongoing medication-assisted therapy.⁷⁷

The CDC recommends that prescribers avoid or exert extreme caution when prescribing opioids to people with histories of substance use. That leaves fewer therapeutic options for people who use drugs and suffer from CNCP. Nonpharmacological interventions may be not readily accessible or too expensive to afford. When pharmacological interventions produce unsatisfactory results, people turn to the streets to get illicit drugs for pain relief.⁷⁸

Miotto et al. agree that the safest pain treatment strategy for a person at risk of or recovering from OUD is a nonopioid and benzodiazepine-free approach. But with careful risk stratification, limited prescribing, and consistent monitoring, it is feasible.⁷⁹

Suggested screening tools

Screening tools for pain

The same guidelines apply as outlined in the Incarcerated section.

Screening tools for opioid misuse risk⁸

• To predict prescription opioid misuse
  The Pain Medication Questionnaire (PMQ) and
  Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R)
• To screen for current misuse
  The Current Opioid Misuse Measure (COMM)

Pharmacists’ roles

Pharmacists can:

• Lead in assembling an addictions team that can engage with people who need interventions when they come to the ED
• Help ensure that screenings for HCV, HIV, and mental health disorders are performed, especially when PWUDs are admitted to the hospital
• Spearhead the provision of MOUD (e.g., buprenorphine) to patients before discharge and refer patients to a local addictions agency for further help
• Educated ED staff on the benefits of prescribing buprenorphine
  Its shorter duration and structure as a partial mu-opioid agonist limit its potential for respiratory depression and accidental overdose.
  Buprenorphine and naloxone are recommended for people:
• At high risk of methadone toxicity, such as with older patients
• Taking high doses of benzodiazepines or other sedating drugs
• With a lower level of opioid tolerance
• At risk of having a prolonged QT interval

DRUGS PRESCRIBED WITH OPIOIDS: BENZODIAZEPINES AND GABAPENTINOIDS

Sometimes dangerous polypharmacy occurs through no fault of the user. An example is in treating patients with epilepsy. A four-year study (NHANES data) showed that 34% of patients with epilepsy took an opioid with either a benzodiazepine (BZD) or a gabapentinoid.⁸² Such combinations should be avoided whenever possible, as both types of drugs sedate users and suppress breathing.⁸³ Older patients are also often prescribed an opioid concurrently with a BZD—possibly written by different healthcare providers to address different complaints. People who take a prescription opioid with a BZD or with a non-BZD sedative/hypnotic are 60% more likely to overdose than if they had been exposed to an opioid alone.⁸⁴

Nonsteroidal anti-inflammatory drugs should be avoided in patients with complex medical conditions including treatment-resistant hypertension, cardiovascular disease, and chronic kidney disease.⁸⁵ Thus, gabapentinoids (gabapentin and pregabalin) have become a point of focus for potential value in pain management.⁸⁶ Gabapentinoids alter calcium-dependent release of neurotransmitters that modulate pain.⁸⁷ They are FDA approved for very few indications, so much of their use is off-label. Gabapentinoids produce marginal analgesic effects in chronic pain conditions, including neuropathic pain.⁸⁶ In older patients, adding a gabapentinoid to a treatment regimen can contribute to unnecessary polypharmacy and potential side effects such as dizziness, somnolence, and gait disturbances—which can increase the risk of falls.⁸⁶

Gabapentinoid prescriptions have tripled over the past 15 years. That increase is most prominent in two populations: 1) patients for whom opioids and benzodiazepines are also prescribed and 2) patients with numerous comorbidities.⁸⁶

Diversion and illicit use of gabapentinoids is increasing, as the drugs reportedly augment opioid euphoria. In response, some states are mandating reporting of all gabapentinoids to prescription drug monitoring programs (PDMPs).⁸⁶

State laws vary on what drugs are considered Schedule II versus III drugs—as well as how they are allowed to be prescribed.⁸⁸ Troubling trends with drugs such as benzodiazepines and gabapentinoids are examples of why states are pushing for requiring prescribers to sign up for their PDMP as a prerequisite for state licensure.⁸⁸

ADDITIONAL GUIDANCE REGARDING SCREENING TOOLS

Despite all the therapies available for chronic pain, treatment remains challenging.⁸ Clinical guidelines call for risk assessment of aberrant drug-related behaviors prior to initiating opioid therapy for patients with CNCP.

Quantifying the risk of substance abuse, misuse, or addiction before prescribing opioids is challenging.⁸⁹ Screening tools continue to be underutilized, and clinicians face a dizzying array of assessments to choose from when stratifying patients for pain as well as risk of or current opioid use.⁶

Suggestions of validated screening tools have already been described for each special population in this monograph. However, a more comprehensive understanding of screening tools can help clinicians choose other or additional tools that are most useful for the patients they serve. To that end, this section offers six additional tips.

1. No single tool meets every need.

Select the screening tools that will best inform treatment decisions. Sometimes patient comorbidities and other factors may predicate using additional tools.

2. Pick the highest-ranked validated tools supported by the strongest body of evidence.

The three highest-ranking validated tools that appear repeatedly in this monograph are the PMQ, SOAPP-R, and COMM.⁸ The SOAPP-R is supported by the strongest clinical data from the most studies. All three of these tools have been validated for specific populations as noted. Additionally:

• A small number of other tools may accurately predict or identify opioid misuse.
• For example, the ORT was first validated in 2005 with new patients in a pain clinic. It is used widely with chronic pain patients; the American Geriatric Society recommends its use with the aging population, but it hasn’t been validated for the populations discussed in this monograph.
• Similarly, the Brief Pain Inventory (BPI) is widely used. It has been validated for patients with low back pain but not populations such as the incarcerated population as a whole.
• Validated assessments for nonopioid analgesics are lacking.

3. Some tools work better with some populations than others.

Match the tool with the population for which it has proven sensitivity and specificity. For example, Cheatle et al. developed a version of the Opioid Risk Tool (ORT) called the ORT-OUD, reportedly the first tool specific for predicting the risk of developing an opioid use disorder in patients with CNMP who were receiving opioid therapy. In that narrow population, the ORT-OUD showed high sensitivity and specificity.⁹² However, a cross-sectional study of diverse patient populations in an academic tertiary pain management center showed the ORT-OUD was no better than chance at predicting future opioid aberrant behavior.⁹³

4. Select a screening tool based on the population(s) you serve and what you need to accomplish.

As far as possible, tools should mirror your patient population. That may warrant using ancillary tools. For example, the STOP-Bang assessment is useful with the aging population. It can uncover that risk factor and potentially avert acute respiratory depression in patients taking one or more centrally acting medications. Questionable STOP-Bang results should be followed up with SpO₂ testing. For each one-unit increase in the STOP-Bang score, the odds of moderate-to-severe sleep apnea (AHI ≥ 15) increase by 70%. For each 1% SpO₂ decrease, the odds increase by 33%.⁹⁴

5. Consider the time and resources available to perform the screening.

Some tools take longer to administer and evaluate than others. Use validated, high sensitivity/specificity tools that fit with your practice’s resources and workflow.

6. Use screening tools as one component of a broader effort.

A complete opioid risk evaluation should include:⁸⁹

• Urine testing to confirm preliminary results from screening tools that predict opioid use or indicate current misuse
• Point-of-care testing
  (Be aware of its limitations, including false positives if testing for BZDs or non-heroin opioids.)
• Conversation with the patient
• Patient history/physical
• (if needed) Emergent initiation of treatment to counteract an overdose and referral to a treatment clinic within 48 hours

Final notes

Technology

Technology is playing a role in automating assessments by gleaning information from the patient’s electronic health record. Haller et al. created an algorithm to automatically populate the ORT from structured and unstructured data in patient EHRs. Testing to date shows 96% sensitivity, 92% specificity, and 93% positive predictive value (the odds of actually having an OUD based on positive results from the ORT).⁶

Overseas (tested in the UK, Germany, Italy, and Denmark), the Overdose Risk InfOrmation tool (ORION) appears to be good at translating a combination of risky and dysfunctional behaviors into the risk of suffering a drug overdose. It needs further validation, but the goal is to integrate it into a smartphone-based e-health app and test it on other populations.⁹⁵

National Institute of Drug Abuse (NIDA)

The NIDA website contains a comprehensive list of evidence-based (validated) screening tools, sorted by substance type (alcohol or drugs), age group (adults vs adolescents), and how the tool is administered (self-reporting vs clinician-administered).²⁹

CONCLUSION

Pharmacists are in a key position to suggest, test, and track safe prescribing practices for treating chronic pain. Additionally, they can champion the expansion of MOUD services and community referrals. Multimodal treatment strategies for chronic pain are needed, but resources for nonpharmacological adjunct therapy may not always be available. Careful patient selection, risk assessment, individualized treatment plans, routine patient monitoring, and ongoing assessments of response to therapy can help ensure successful and safe long-term treatment with opioids. Randomized clinical trials that rigorously measure the benefits of nonopioid treatment alternatives for chronic pain are sorely needed.

REFERENCES

1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults — United States, 2016. Morb Mortal Wkly Rep. 2018;67(36):1001-1006.
2. Treede R-D, Riefb W, Barkeb A, et al. Chronic pain as a symptom or a disease: the IASP classification of chronic pain for the International Classification of Diseases (ICD-11). Pain. 2019;160(1):19-27.
3. Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health Syst Pharm. 2015;72(18):1531-43.
4. Hagemeier NE. Introduction to the opioid epidemic: the economic burden on the healthcare system and impact on quality of life. Am J Manag Care. 2018;24(10 Suppl):S200-S206.
5. Greenberg EN. The consequences of chronic pain. J Pain Palliat Care Pharmacother. 2012;26(1):64-7.
6. Haller IV, Renier CM, Juusola M, et al. Enhancing risk assessment in patients receiving chronic opioid analgesic therapy using natural language processing. Pain Med. 2017;18(10):1952-1960.
7. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715-724.
8. Lawrence R, Mogford D, Colvin L. Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain. Br J Anaesth. 2017;119(6):1092-1109.
9. Paice JA. Pain in cancer survivors: How to manage. Curr Treat Options Oncol. 2019;20(6):48.
10. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: A systematic review and meta-analysis. JAMA. 2018;320(23):2448-2460.
11. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65.
12. Economic burden of illness in opioid use disorder (OUD) and medication-assisted treatments. Am J Managed Care. October 2020 Suppl. Accessed October 10, 2021.
13.  https://www.ajmc.com/view/economic-burden-of-illness-in-opioid-use-disorder-oud-and-medication-assisted-treatments
14. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain. 2015;156(4):569-576.
15. Vadiveliu N, Kai AM, Kodumudi G, et al. Recommendations for substance abuse and pain control in patients with chronic pain. Curr Pain Headache Rep. 2018;22(4):25.
16. Edwards FJ, Wicelinski R, Gallagher N, et al. Treating opioid withdrawal with buprenorphine in a community hospital emergency department: An outreach program. Ann Emerg Med. 2020;75(1):49-56.
17. Preuss CV, Kalava A, King KC. Prescription of Controlled Substances: Benefits and Risks. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.
18. Pergolizzi Jr JV, Rosenblatt M, LeQuang JA. Three years down the road: The aftermath of the CDC guideline for prescribing opioids for chronic pain. Adv Ther. 2019;36:1235-1240.
19. USLegal Inc. Special population law and legal definition. Accessed September 23, 2021. https://definitions.uslegal.com/s/special-population/
20. Ferland CE, Vega E, Ingelmo PM. Acute pain management in children: challenges and recent improvements. Curr Opin Anaesthesiol. 2018;31(3):327-332.
21. Pardesi O, Fuzaylov G. Pain management in pediatric burn patients: Review of recent literature and future directions. J Burn Care Res. 2017;38(6):335-347.
22. Senger A, Bryce R, McMahon C, Baerg K. Cross-sectional study of pediatric pain prevalence, assessment, and treatment at a Canadian tertiary hospital. Can J Pain. 2021;5(1):172-182.
23. Cochrane PaPaS (Pain, palliative and Supportive Care) reviews. Pain in children. Accessed October 14, 2021. https://papas.cochrane.org/our-reviews/reviews-topic/pain-children
24. Schepis TS, Teter CJ, McCabe SE. Prescription drug use, misuse and related substance use disorder symptoms vary by educational status and attainment in U.S. adolescents and young adults. Drug Alcohol Depend. 2018;189:172-177.
25. Neeki MM, Dong F, Archambeau B, et al. San Bernardino County Youth Opioid Response: Improving access to evidence-based medical treatment for opioid use disorder Cureus. 2020;12(8):e9781.
26. Vega E, Bealieu Y, Gauvin R, et al. Chronic non-cancer pain in children: we have a problem, but also solutions. Minerva Anestesiol. 2018;84(9):1081-1092.
27. World Health Organization. Guidelines on the management of chronic pain in children. 2020. Accessed October 12, 2021. https://www.who.int/publications/i/item/9789240017870
28. Pham CD, Hua DT. Clinical guideline highlights for the hospitalist: Management of acute and chronic pain in sickle cell disease. J Hosp Med. 2021;16(4):228-229.
29. Beltramini A, Milojevic K, Pateron D. Pain assessment in newborns, infants, and children.
30. Pediatr Ann. 2017;46(10):e387-e395.
31. National Institute on Drug Abuse. Screening and assessment tools chart. Updated May 6, 2021. Accessed September 23, 2021. https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools 
32. Matson KL, Johnson PN, et al; for the Advocacy Committee on behalf of Pediatric Pharmacy Advocacy Group. Opioid use in children. J Pediatr Pharmacol Ther. 2019;24(1):72-75.
33. Kress H-G, Ahlbeck K, Aldington D, et al. Managing chronic pain in elderly patients requires a CHANGE of approach. Curr Med Res Opin. 2014;30(6):1153-64.
34. Raman SR, Bush C, Karmali RN, et al. Characteristics of new opioid use among Medicare beneficiaries: Identifying high-risk patterns. J Manag Care Spec Pharm. 2019;25(9): 966–972.
35. Kang Y, Demiris G. Self-report pain assessment tools for cognitively intact older adults: Integrative review. Int J Older People Nurs. 2018;13(2):e12170.
36. Pergolizzi J, Böger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;8(4):287-313.
37. Blachman NL, Leipzig RM, Mazumdar M, Poeran J. High-risk medications in hospitalized elderly adults: Are we making it easy to do the wrong thing? J Am Geriatr Soc. 2017;65(3):603-607.
38. Santosa KB Hu HM Brummett CM, Olsen MA, et al. New persistent opioid use among older patients following surgery: A Medicare claims analysis. Surgery. 2020;167(4):732-742.
39. van der Leeuw G, Leveille SG, Dong Z. Chronic pain and attention in older community-dwelling adults. J Am Geriatr Soc. 2018;66(7):1318-1324.
40. Lazzari M, Marcassa C, Natoli S, et al. Switching to low-dose oral prolonged-release oxycodone/naloxone from WHO-Step I drugs in elderly patients with chronic pain at high risk of early opioid discontinuation. Clin Interv Aging. 2016;11:641-9.
41. American Geriatrics Society. Pharmacological management of persistent pain in older persons. Am
42. Geriatr Soc. 2009;57:1331–1346.
43. Pergolizzi JV, Gharibo C, Ho Y-K. Treatment considerations for cancer pain: A global perspective. Pain Pract. 2015;15(8):778-92.
44. Naples JG, Geliad WF, Hanlon JT. Managing pain in older adults: The role of opioid analgesics. Clin Geriatr Med. 2016;32(4):725-735.
45. Kim M, Mitchell SH, Gatewood M, et al. Older adults and high-risk medication administration in the emergency department. Drug Healthc Patient Saf. 2017;9:105-112.
46. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694.
47. Aubrun F, Gazon M, Schoeffler M, Benyoub K. Evaluation of perioperative risk in elderly patients. Minerva Anestesiol. 2012;78(5):605-18.
48. Achterberg W, Lautenbacher S, Husebo B, Erdal A, Herr K. Pain in dementia. Pain Rep. 2019;5(1):e803.
49. Borg C, Sala E, Chainay H, et al. How do patients with Alzheimer's disease imagine their pain? Eur J Pain. 2021;25(2):466-472.
50. Flo E, Gulla C, Husebo BS. Effective pain management in patients with dementia: benefits beyond pain? Drugs Aging. 2014;31(12):863-71.
51. Mitchell G, Rooney S, Sheeran C, Strain J. Medicines management for people with dementia
52. Nurs Stand. 2019;34(3):37-43.
53. Bauer U, Pitzer S, Schreier MM, et al. Pain treatment for nursing home residents differs according to cognitive state — a cross-sectional study. BMC Geriatr. 2016;16:124.
54. Inelmen EM, Mosele M, Sergi G, et al. Chronic pain in the elderly with advanced dementia. Are we doing our best for their suffering? Aging Clin Exp Res. 2012;24(3):207-12.
55. Federal Bureau of Prisons. Pain management of inmates: Clinical guidance. June 2018. Accessed October 14, 2021. https://www.bop.gov/resources/pdfs/pain_mgmt_inmates_cpg.pdf
56. National Institute on Drug Abuse. Criminal Justice DrugFacts. Updated June 2020. Accessed October 10, 2021. https://www.drugabuse.gov/publications/drugfacts/criminal-justice.
57. Robertson AG, Easter MM, Lin H-J et al. Associations between pharmacotherapy for opioid dependence and clinical and criminal justice outcomes among adults with co-occurring serious mental illness. J Subst Abuse Treat. 2018;86:17-25.
58. Macmadu A, Goedel WC, Adams JW, et al. Estimating the impact of wide scale uptake of screening and medications for opioid use disorder in US prisons and jails. Drug Alcohol Depend. 2020;208:107858.
59. Anno BJ. Correctional health care guidelines for the management of an adequate delivery system. National Commission on Correctional Health Care. U.S. Department of Justice. December 2001. Accessed October 12, 2021. https://nicic.gov/correctional-health-care-guidelines-management-adequate-delivery-system
60. Prison Policy Initiative. Mental health. Updated October 14, 2021. Accessed October 10, 2021. https://www.prisonpolicy.org/research/mental_health/
61. Stephens SL, Cassel JB, Noreika D, Del Fabbro E. Palliative care for inmates in the hospital setting. Am J Hosp Palliat Care. 2019;36(4):321-325.
62. Williams BA, Ahalt C, Stijacic-Cenzer, I, et al. Pain behind bars: The epidemiology of pain in older jail inmates in a county jail. J Palliat Med. 2014;17(12):1336-43.
63. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S240-52.
64. Mitchell M. Medicolegal Considerations in the management of opioid use disorder with buprenorphine in the correctional setting. J Correct Health Care. 2021;27(3):210-214.
65. Horton M, McDonald R, Green TC, et al. A mapping review of take-home naloxone for people released from correctional settings. Int J Drug Policy. 2017;46:7-16.
66. Pearl B. Ending the war on drugs: By the numbers. June 27, 2018. Accessed October 9, 2021. https://www.americanprogress.org/issues/criminal-justice/reports/2018/06/27/452819/ending-war-drugs-numbers/
67. Joudrey PJ, Khan MR, Wang EA et al. A conceptual model for understanding post-release opioid-related overdose risk. Addict Sci Clin Pract. 2019;14(1):17.
68. Bahji A, Cheng B, Gray S, Stuart H. Mortality among people with opioid use disorder: A systematic review and meta-analysis. J Addict Med. 2020;14(4):e118-e132.
69. Chang JS, Kushel M, Miaskowski C, et al. Provider experiences with the identification, management, and treatment of co-occurring chronic noncancer pain and substance use in the safety net. Subst Use Misuse. 2017;52(2):251-255.
70. Reyes-Gibby CC, Anderson KO, Todd KH. Risk for opioid misuse among emergency department cancer patients. Acad Emerg Med. 2016;23(2):151-8.
71. Krawczyk N, Eisenberg M, Schneider KE, et al. Predictors of overdose death among high-risk emergency department patients with substance-related encounters: A data linkage cohort study. Ann Emerg Med. 2020;75(1):1-12.
72. Balio CP, Wiley Jr KK, Greene MS, Vest JR. Opioid-related emergency department encounters: Patient, encounter, and community characteristics associated with repeated encounters. Ann Emerg Med. 2020;75(5):568-575.
73. Puzhko S, Roy E, Jutras-Aswad D, et al. High hepatitis C incidence in relation to prescription opioid injection and poly-drug use: Assessing barriers to hepatitis C prevention. Int J Drug Policy. 2017;47:61-68.
74. Chilunda V, Calderon TM, Martinez-Aguado P, Berman JW. The impact of substance abuse on HIV-mediated neuropathogenesis in the current ART era. Brain Res. 2019;1724:146426.
75. Brown JL, Gause NK, Lewis D, Winhusen T. Examination of the hepatitis C virus care continuum among individuals with an opioid use disorder in substance use treatment. J Subst Abuse Treat. 2017;76:77-80.
76. Verna EC, Schluger A, Brown RS Jr. Opioid epidemic and liver disease. JHEP Rep. 2019;1(3):240-255.
77. Bell R, Wolfe I, Cox D, et al. Hepatitis C screening in mothers and infants exposed to opioids. Hosp Pediatr. 2019;9(8):639-642.
78. Coviello DM, Lovato R, Apostol K, et al. Prevalence of HIV viral load suppression among psychiatric inpatients with comorbid substance use disorders. Community Ment Health J. 2018;54(8):1146-1153.
79. Grzebinski S, Stein L, Dhamoon MS. Characteristics and outcomes of hospitalizations and readmissions for opioid dependence and overdose: nationally representative data. Subst Abus. 2020:1-8.
80. Velez CM, Nicolaidis C, Korthuis PT, Englander H. “It’s been an experience, a life learning experience”: A qualitative study of hospitalized patients with substance use disorders. J Gen Intern Med. 2017;32(3):296-303.
81. Wang SJ, Wade E, Towle J, et al. Effect of inpatient medication-assisted therapy on against-medical-advice discharge and readmission rates. Am J Med. 2020;133(11):1343-1349.
82. Dassieu L, Kaboré J-L, Choinière M, Arruda N, Roy E. Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis. Int J Drug Policy. 2019;71:150-156.
83. Miotto K, Kaufman A, Kong A, Jun G, Schwartz J. Managing co-occurring substance use and pain disorders Psychiatr Clin North Am. 2012;35(2):393-409.
84. Hickman M, Steer C, Tilling K, et al. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. Addiction. 2018;113(8):1461-1476.
85. Srivastava A, Kahan M, Nader M. Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone? Can Fam Physician. 2017;63(3):200-205.
86. Terman SW, Aubert CE, Hill CE, et al. Polypharmacy in patients with epilepsy: A nationally representative cross-sectional study. Epilepsy Behav. 2020;111:107261.
87. National Institute on Drug Abuse. Opioids and benzodiazepines. Updated February 3, 2021. Accessed September 29, 2021. https://www.drugabuse.gov/drug-topics/opioids/benzodiazepines-opioids
88. Cho J, Spence MM, Niu F, et al. Risk of overdose with exposure to prescription opioids, benzodiazepines, and non-benzodiazepine sedative-hypnotics in adults: A retrospective cohort study. J Gen Intern Med. 2020;35(3):696-703.
89. Szeto C-C, Sugano K, Wang J-G, et al. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut. 2020;69(4):617-629.
90. Goodman CW, Brett AS. A clinical overview of off-label use of gabapentinoid drugs. JAMA Intern Med. 2019;179(5):695-701.
91. Lancia M, Gambelunghe A, Gili A, et al. Pregabalin abuse in combination with other drugs: Monitoring among methadone patients. Front Psychiatry. 202011;10:1022.
92. Soelberg CD, Brown Jr RE, Du Vivier D, Meyer JE, Ramachandran BK. The US opioid crisis: Current federal and state legal issues. Anesth Analg. 2017;125(5):1675-1681.
93. Ducharme J, Moore S. Opioid use disorder assessment tools and drug screening. Mo Med. 2019;116(4):318-324.
94. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-442.
95. Garg A, Pathak H, Churyukanov MV, Uppin RB, Slobodin TM. Low back pain: critical assessment of various scales. Eur Spine J. 2020;29(3):503-518.
96. Cheatle MD, Compton PA, Dhingra L, Wasser TE, O’Brien CP. Development of the Revised Opioid Risk Tool to predict opioid use disorder in patients with chronic nonmalignant pian. J Pain. 2019;20(7):842-851.
97. Clark MR, Hurley RW, Adams MCB. Re-assessing the validity of the Opioid Risk Tool in a tertiary academic pain management center population. Pain Med. 2918;19(7):1382-1395.
98. Chung F, Wong J, Bellingham G, et al. Predictive factors for sleep apnoea in patients on opioids for chronic pain. BMJ Open Respir Res. 2019;6(1):e00523.
99. Carrà G, Crocamo C, Humphris G, et al. Engagement in the Overdose Risk InfOrmatioN (ORION) e-Health tool for opioid overdose prevention and self-efficacy: A preliminary study. Cyberpsychol Behav Soc Netw. 2017;20(12):762-768.

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