Module 3 – Screening Procedures and Structured Follow-Up for Opioid prescribing Learning outcome: Demonstrate culturally safe/appropriate screening, assessment, intervention, structured follow-up, and support skills related to opioid use and opioid use disorder.

Learning Objectives

• Describe how person-centred practice can inform effective risk screening prior to the therapeutic use of opioids.
• Link informed consent for treatment initiation to elements in treatment agreements.
• Articulate the rationale for choosing general and/or population-specific screening tools.

Key concepts

• Opioid prescribing must only be initiated when the following are in place:
  • A person-centred dialogue between prescriber and the client
  • A comprehensive health history and physical and psychosocial assessment including a best possible medication history
  • Informed consent
  • An assessment for the risk of opioid misuse
  • A treatment agreement
• A number of screening tools exist to assess for the risk of opioid misuse
  • Choice of screening tools must be based on client assessment

Person-centred practice

Person centred practice is an approach that promotes putting people and families at the centre of their care and relating to them as partners and experts in their own experience: it is consistent with the philosophy of doing things with people rather than to them (Santana, Manalili, Jolley, Zelinsky, Quan & Lu, 2017).

Person-centred practice includes:

• respecting people’s values;
• taking into account people’s preferences and expressed needs;
• coordinating and integrating care;
• working together to make sure there is good communication, information and education;
• making sure people are physically comfortable and safe;
• providing emotional support;
• involving family and friends where able;
• making sure there is continuity between and within services; and,
• making sure people have access to appropriate care when they need it

Establishing a person-centred and trusting dialogue with the client is key to a successful and meaningful clinical relationship, especially in context of complex chronic care. This relationship must be established prior to risk screening, contracting and the initiation of a trial of opioid agonist therapy and will inform subsequent follow-up engagement.

Using a person-centred approach, a comprehensive health history and physical and psychosocial assessment including a best possible medication history and medication reconciliation (when possible) must be done and documented. Medication reconciliation is a structured process of comparison and resolution of discrepancies and has been shown to prevent errors at transition points. A clear rationale for the initiation of opioid therapy must be documented that is consistent with established guidelines relevant to the client’s context (e.g. NOUGG; PEER).

Initiating opioid agonist therapy

When considering the initiation of opioid therapy, informed consent must be established, risk screening performed and an opioid treatment agreement established.

Establishing informed consent  

• In establishing informed consent, the following topics need to be discussed with the client before initiating opioid agonist therapy (Cheatle & Savage, 2012):
  • Potential benefits with illustration (e.g. improved function; decreased craving)
  • Physical side effects and complications
  • Dependence and tolerance
  • Risks
    • Overdose
    • Diversion
    • Misuse
    • Addiction
    • Withdrawal
  • Treatment plan
    • goals of therapy
    • client expectations
    • follow-up and treatment evaluation
  • Safety considerations
    • Appropriate storage and disposal of opioids
    • Driving, childcare, lifestyle modifications etc.

Additional Resource: https://nationalpaincentre.mcmaster.ca/opioid/cgop_b01_r05.html

Clients must be able to examine the potential benefits and risks of opioid therapy alongside the treatment and monitoring plan in order the make an informed decision about consenting to proceed. Building on the person-centred practice approach, clients should have the opportunity to ask questions and discuss with family where needed. It may be necessary to provide additional time to support this process before proceeding.

Benefits of opioid risk screening

There is evidence that risk for opioid-related harm exists in the Canadian environment when actions that promote the appropriate use of opioids are not taken (Canadian Pain Task Force, 2019). Understanding that opioids are a legitimate and effective treatment choice in some circumstances, some clients prescribed an opioid may have risk factors for opioid-related harms, as well as risk for the development of an opioid use disorder. Knowledge of the presence of risk factors through opioid risk screening can inform the approach to using opioids, including the selection of type of medication and dosage form, prescription dispensing, frequency of follow-up, and the use of random urine drug screening. Additional information about risk of misuse and related behaviours can be found here (http://nperesource.casn.ca/modules/module-5/lesson-5-2-learning-outcome/)

Screening tools

Accurately predicting a client’s behaviour is difficult. Known risk factors can help to determine the probability of misuse or addiction. Multiple general screening tools are available that are for general use: a selection of these tools can be found in the following section.

General population screening tools

1. The Opioid Risk Tool (ORT) is a commonly used tool to assess the client’s risk for opioid misuse or use disorder. According to the client's response, they will be classified as being at low, moderate, or high risk for opioid addiction. A screening tool, such as the ORT, allows the clinician to monitor clients using opioids based on their risk profile. In addition, individuals at high risk for opioid addiction can be identified early and can be directed to counselling and therapy.
   • The ORT uses five categories of assessment (see Table 2):
     • Family history of substance abuse
     • Personal history of substance abuse
     • Age
     • History of preadolescent sexual abuse
     • Psychological disease
     • Each item that applies to the client is scored differently depending on the sex of the client.

       Table 2. Opioid Risk Tool

       Item		Mark Each Box That Applies	Item Score If Female	Item Score If Male
       1. Family history of substance abuse	Alcohol		1	3
       	Illegal drugs		2	3
       	Prescription drugs		4	4
       2. Personal history of substance abuse	Alcohol		3	3
       	Illegal drugs		4	4
       	Prescription drugs		5	5
       3. Age (mark box if 16–45)			1	1
       4. History of preadolescent sexual abuse			3	0
       5. Psychological disease	Attention deficit disorder, obsessive-compulsive disorder, bipolar, schizophrenia		2	2
       	Depression		1	1
       Total

       Total score risk category

       Low risk: 0–3

       Moderate risk: 4–7

       High risk: ≥ 8

       ---

       Adapted from Webster & Webster, 2005.

2. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is an eight-item measure that can be used in primary care settings to identify risk related to the use of 10 different substances across all levels of severity.
3. The CAGE-Adapted to Include Drugs (CAGE-AID) is a four-item measure to predict substance use disorders in a primary care context.
4. The Drug Abuse Screening Test (DAST) is a 28-item versions assess problematic drug use among multiple populations.
5. The Global Appraisal of Individual Needs—Short Screener (GAIN-SS) is a 20-item measure that examines internalizing and externalizing disorders, substance abuse, and criminal behaviour.
6. The Kreek-McHugh-Schluger-Kellogg Scale is a 28-item measure that considers the frequency, amount, and duration of use of opiates, cocaine, alcohol, and tobacco.
7. The Two-Item Conjoint Screen is a two-item measure that can be used in primary care to evaluate using substances more than intended to and feeling the need to cut down on substance use in the past year.

The practice toolkit provides a full list of additional tools available: http://nperesource.casn.ca/wp-content/uploads/2017/01/practicetoolkit.pdf

Urine drug testing

• Urine drug testing (UDT) is a component of a thorough client assessment and follow-up plan. UDT is used for two primary reasons: (1) to set a baseline measurement of substance use that can be used to assess the risk for opioid use disorder or addiction, and (2) to monitor and assess the client’s ongoing alliance with the opioid therapy and the therapeutic plan.
  • There are two types of UDT: point-of-care (POC) testing and laboratory testing.
    • POC testing: the urine sample is both collected and tested at the physician’s office or clinic. The results are immediate; however, the test tends to be less sensitive and specific than the laboratory urine drug testing.
    • Laboratory testing: there are two types of laboratory testing: immunoassay and laboratory-based specific drug identification, such as chromatography.

Additional information about UDT can be found within the National Guidelines for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (2017) https://nationalpaincentre.mcmaster.ca/opioid/cgop_b01_r03.html and http://nperesource.casn.ca/modules/module-1/lesson-4-urine-drug-testing-to-increase-prescription-safety/

Screening tools for specific populations

Adolescents

• The CRAFFT TOOL
  • The CRAFFT tool screens for both alcohol and other drug problems and is the only screening test that includes an item on drinking and driving (or riding with an intoxicated driver). Alcohol-associated motor vehicle accidents are a leading cause of death among adolescents, and a question regarding this risk should be a part of routine screening
  • It is comprised of six questions:  two or more positive responses indicates the need for further assessment.

• The Adolescent Alcohol and Drug Involvement Scale (AADIS) is an interview used to determine if assessment of alcohol or another drug use is needed.
• The GAIN-SS is a 20-item measure that examines internalizing and externalizing disorders, substance abuse, and criminal behaviour.
• The Drug Abuse Screen Test (DAST)—Adolescent is a 27-item scale that determines the presence and severity of problematic substance use among adolescents.

Pregnant and postpartum women

Screening for substance use is a part of complete obstetric care for all pregnant women.

• Originally developed to screen for alcohol misuse, T-ACE is also considered to be an acceptable method to screen for prenatal substance use. https://www.mirecc.va.gov/visn22/t-ace_alcohol_screen.pdf
• 4Ps and 4Ps Plus are recognized as the most validated universal tools for screening for substance use in pregnant women. https://www.nature.com/articles/7211266
  • 4Ps and 4Ps Plus have low to moderate specificity; some women could be falsely identified with drug or alcohol problems.
  • T-ACE
  • The 4 Ps
  • The 4 Ps Plus

  T-ACE

  A score of 2 or more is considered positive. Affirmative answers to questions A, C, or E = 1 point each. Reporting tolerance to more than two drinks (the t question) = 2 points.

  • 0-1 2+ Tolerance: How many drinks does it take to make you feel high?
  • No Yes Annoyance: Have people annoyed you by criticizing your drinking or drug use?
  • No Yes Cut Down: Have you ever felt you ought to cut down on your drinking or drug use?
  • No Yes Eye-opener: Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover?

  Total Score of 0-1, does not indicate potential prenatal risk.
  Total Score 2+, indicates potential prenatal risk.

  (Sokol et al., 1989); (Chang, 2001)

  The 4 Ps Tool

  This screening device is often used as a way to begin discussion about drug or alcohol use. Any woman who answers yes to one or more questions should be referred for further assessment.

  Version 1

  • No Yes Have you ever used drugs or alcohol during this pregnancy?
  • No Yes Have you had a problem with drugs or alcohol in the past?
  • No Yes Does your partner have a problem with drugs or alcohol?
  • No Yes Do you consider one of your parents to be an addict or alcoholic?

  NO to all of the above questions, does not require further assessment.
  YES to at least one of the above questions, should undergo further assessment.

  (Washington State Department of Health, 2012); (Yonkers et al., 2010)

  ---

  Version 2

  • No Yes Parents: Did any of your parents have a problem with alcohol or other drug use?
  • No Yes Partner: Does your partner have a problem with alcohol or drug use?
  • No Yes Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
  • No Yes Present: In the past month have you drunk any alcohol or used other drugs?

  NO to all of the above questions, does not require further assessment.
  YES to at least one of the above questions, should undergo further assessment.

  (ACOG Committee on Health Care for Underserved Women, & American Society of Addiction Medicine, 2012); (Ewing, 1990)

  The 4Ps Plus

  This is a modified version of 4Ps⁹

  • No Yes Parents: Did either of your parents ever have a problem with alcohol or drugs?
  • No Yes Partner: Does your partner have a problem with alcohol or drugs?
  • No Yes Past: Have you ever drunk beer, wine, or liquor?
  • No Yes Pregnancy: In the month before you knew you were pregnant did you smoke?
    • How many cigarettes did you smoke?
  • No Yes Pregnancy: In the month before you knew you were pregnant did you drink?
    • How many beers/how much wine/how much liquor did you drink?

  NO to all of the above questions, does not require further assessment.
  YES to at least one of the above questions, should undergo further assessment.

  (Chasnoff et al., 2005)

• CRAFFT is recommended by the American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women and the American Society of Addiction Medicine for use by women ages 26 years or younger.
• Additional Resource: Select Pregnant and Postpartum Women from the Table of Contents and scroll to the Case Study: Pregnant Patient https://opioidresource.ca/demo/m5-lesson.html

People living with chronic pain

The National Guidelines for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (2017) recommends opioid risk screening prior to the initiation of opioid therapy for chronic pain. (Link back to the ORT in the ‘General Population Screening Tools’ above). Specific screening tools for people living with chronic pain include the following:

• The Addiction Behaviors Checklist (ABC) https://www.vcuhealth.org/-/media/media/file/telehealth/addiction_behaviors_checklist.ashx
• The Brief Risk Interview (BRI) https://1luusk1s9bxol2tr7hdvs212-wpengine.netdna-ssl.com/wp-content/uploads/2019/04/MRC2.CORP_.X.03298-PsychU-BRI-Questions-Scoring-Mar2019-1.pdf
• The Current Opioid Misuse Measure (COMM) https://nationalpaincentre.mcmaster.ca/documents/comm_sample_watermarked.pdf
• The Diagnosis, Intractability, Risk, Efficacy (DIRE) https://www.mdcalc.com/dire-score-opioid-treatment
• The Prescription Drug Use Questionnaire (PDUQ)
• The Prescription Opioid Misuse Index (POMI)
• The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) http://nperesource.casn.ca/wp-content/uploads/2017/03/soapp_r_sample_watermark.pdf
• The Screening Instrument for Substance Abuse Potential (SISAP)
• The Screening Tool for Addiction Risk (STAR)

Opioid Treatment Agreements

A treatment agreement should be established that specifies the expectations of both the patient and prescriber. It is an excellent communication and accountability tool that documents the agreed-upon plan of care between the clinician and the client. Treatment agreements may include the following information:

• Goals of medication trial and benchmarks for treatment success;
• Terms of a medication trial: when it starts; what the medication and dose is; whether there will be titration; when to taper or discontinue;
• Restrictions relating to clinician prescribing responsibility;
• Dispensing pharmacy location;
• Storage of medications;
• Consequences relating to:
  • use of over-the-counter medications containing opioids and those not prescribed;
  • use of illicit substances;
  • opioid misuse
• Signature of the clinician and client, date and time.

A copy of the signed treatment agreement must be retained on the client record and revisited yearly and as needed with changes of prescribing clinician or dispensing pharmacy. A clean copy can be given to the client for their information. Some clinicians may wish to share the treatment agreement with other interdisciplinary team members as appropriate for communication purposes.

Questions

For clients starting opioid therapy, four types of major risks should be discussed. Which of the following is not one of the four major types of risk?

a. Overdose

b. Diversion

c. Addiction

d. Tolerance

e. Withdrawal

Correct! Although tolerance should be discussed with clients, on its own it is not a major risk of opioid use.

Incorrect. The correct answer is d. Although tolerance should be discussed with clients, on its own it is not a major risk of opioid use.

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Overall, what percentage of opioid clients might benefit from strong boundary-setting around opioid use?

a. Less than 1 percent

b. 10 percent

c. 25 percent

d. Over 50 percent

Correct! According to L. Hatcher (personal communication, Feb.5, 2016), about 10 percent of clients benefit significantly from strong boundaries around opioid use.

Incorrect. The correct answer is b. According to L. Hatcher (personal communication, Feb.5, 2016), about 10 percent of clients benefit significantly from strong boundaries around opioid use.

References

ACOG Committee on Health Care for Underserved Women, & American Society of Addiction Medicine (2012). Opioid abuse, dependence, and addiction in pregnancy (Committee Opinion No. 524). Obstetrics and Gynecology, 119(5), 1070–1076. http://m.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy

Canadian Institute for Health Information. (2019). Opioid prescribing in Canada: How are practices changing?. Ottawa, ON: CIHI. Retrieved from https://www.cihi.ca/sites/default/files/document/opioid-prescribing-canada-trends-en-web.pdf

Canadian Pain Task Force. (2019). Chronic pain in Canada: Laying a foundation for action. https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019.html

Center for Adolescent Substance Abuse Research, Children’s Hospital Boston. (2009). The CRAFFT screening interview. http://www.ceasar.org/CRAFFT/pdf/CRAFFT_English.pdf

Chasnoff, I. J., McGourty, R. F., Bailey, G. W., Hutchins, E., Lightfoot, S. O., Pawson, L. L., Fahey, C., May, B., Brodie, P., McCulley, L., & Campbell, J. (2005). The 4P's Plus screen for substance use in pregnancy: Clinical application and outcomes. Journal of Perinatology, 25(6), 368–374.

Cheatle, M.D., Savage, S.R., 2012. Informed Consent in Opioid Therapy: A Potential Obligation and Opportunity. Journal of Pain and Symptom Management 44, 105–116. doi:10.1016/j.jpainsymman.2011.06.015

Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P., Donovan, M. I., Fishbain, D. A., Foley, K. M., Fudin, J., Gilson, A. M., Kelter, A., Mauskop, A., O'Connor, P. G., Passik, S. D., Pasternak, G. W., Portenoy, R. K., Rich, B. A., Roberts, R. G., Todd, K. H., Miaskowski, C., & American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113–130.

Guideline Group. (2010). Canadian guideline for safe and effective use of opioids for chronic non-cancer pain: Part B: Recommendations for practice. (2010). http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf

Hansen, M. D., Solanki, D. R., Jordan, A. E., & Colson, J. (2011). Urine drug testing in chronic pain. Pain Physician, 14, 123–143.

Institute for Safe Medication Practices Canada. (2011). Optimizing medication safety at care transitions: Creating a national challenge. https://www.ismp-canada.org/download/MedRec/MedRec_National_summitreport_Feb_2011_EN.pdf

Kahan, M., Mailis-Gagnon, A., Wilson, L., & Srivastava, A., & National Opioid Use Guideline Group. (2011). Canadian guideline for safe and effective use of opioids for chronic noncancer pain: Clinical summary for family physicians. Part 1: General population. Canadian Family Physician, 57(11), 1257–1266.

Reisfield, G. M., Salazar, E., & Bertholf, R. L. (2007). Rational use and interpretation of urine drug testing in chronic opioid therapy. Annals of Clinical & Laboratory Science, 37(4), 301–314.

Taha, S. (2018). Best practices across the continuum of care for treatment of opioid use disorder. Canadian Centre on Substance Use and Addiction.

Taha, S., Maloney-Hall, B., & Buxton, J. (2019). Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy. Substance Abuse Treatment, Prevention, and Policy, 14(1), 1–10.

Tordoff, S. G., & Ganty, P. (2010). Chronic pain and prescription opioid misuse. Continuing Education in Anaesthesia, Critical Care & Pain, 10(5), 158–161.

Washington State Department of Health. (2012). Substance abuse during pregnancy: Guidelines for screening. http://aia.berkeley.edu/media/pdf/WA_15_PregSubs_E12L.pdf

Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Medicine, 6(6), 432–442.

Yonkers, K. A., Gotman, N., Kershaw, T., Forray, A., Howell, H. B., & Rounsaville, B. J. (2010). Screening for prenatal substance use: development of the Substance Use Risk Profile-Pregnancy scale. Obstetrics and Gynecology, 116(4), 827.