Module 3 – Screening Procedures and Structured Follow-Up to Opioid Use Describe the importance of screening persons using opioids and persons with opioid use disorder for concurrent health conditions and identifying available resources to support resilience.

Learning Objectives

• Screening tools will be introduced that are appropriate for use in the assessment of common health conditions that persons who are using opioids or have an opioid use disorder may experience
• Examples of resources that support resilience among persons using opioids who have concurrent health conditions will be identified

Key Concepts

• Screening for concurrent health conditions such as mental health conditions, sleep disordered breathing, compromised liver and kidney function, infectious disease, tobacco, alcohol and other substances should be part of the comprehensive health assessment of persons who are using opioids and persons who have an opioid use disorder
• Resilience is the intrinsic ability to adjust to functioning following changes or disturbances so that actions are sustained even in the presence of continuous stress.
• Supporting resilience among persons that use opioids and persons that have an opioid use disorder may improve overall engagement and coping.

Screening

Persons using opioids/being considered for a trial of opioids for chronic pain and those who have an opioid use disorder (OUD) may also experience other health conditions that must be considered when developing a plan of care. The National Institute on Drug Abuse in the United States released the Common comorbidities with substance use disorders research report that identified mental health conditions, chronic pain, tobacco use and infectious disease specifically as warranting assessment in the context of OUD. Acknowledgement of the potential for increased risk for the development of physical health conditions such as cancer and heart disease underlines the importance of including a comprehensive history, including medication reconciliation and physical examination in the initial plan of care. (Reference Topic A). Screening for conditions that may impair absorption, metabolism and excretion of opioids must also be included at this stage as well.

The American Academy of Sleep Medicine (Rosen et al., 2019) has taken the position that providers must be aware that chronic opioid use can change sleep architecture as well as cause respiratory depression and increase risk for sleep-disordered breathing. Screening for sleep-related hypoventilation, central sleep apnea and obstructive sleep apnea should also be considered in the initial plan of care.

Screening in clients with selected concurrent health conditions

Mental health conditions

• History and screening for clients should include assessment for the presence of mental health conditions, particularly in the context of current or planned opioid use.
• Adequate mental health treatment and care may improve chronic pain and decrease the need for opioids.
• There is an acknowledged relationship between suicidality and depressed mood and anxiety that may be attenuated by the presence of chronic pain (Racine, 2018)
• There is an association between co-occurring Post Traumatic Stress Disorder and chronic musculoskeletal or nerve pain and opioid use disorders (Bilevicius et al., 2018)
• Clients with an active mental health condition should be stabilized before initiating opioids (Recommendation 4: 2017 Canadian Guidelines for Opioids for Chronic Non-Cancer Pain).
• Health and social service providers must ensure appropriate treatment for mental health conditions is in place when screening and assessment indicate there is a need.
• Referral to specialist mental health providers may be necessary for clients with complexity and/or when first-line treatment is not effective.

Some tools that can be used for mental health screening and assessment are included in the table that follows

Screening using laboratory testing for kidney and liver functions

• Providers should verify clients’ up to date serum creatinine to estimate GFR to establish baseline kidney function (Moyer, 2012).
• An up-to-date panel of serum liver function parameters should be considered for those at risk for hepatic diseases such as viral hepatitis, cirrhosis, fatty liver disease or hemochromatosis (Del Poggio & Mazzoleni, 2006).
• Providers may need to make opioid dosage adjustments if renal or hepatic dysfunction is evident (Gelot & Nakhla, 2014).

Screening for sleep disordered breathing

Screening for Obstructive Sleep Apnea and associated risk categories can be performed using questionnaires such as the STOP-Bang Questionnaire and the Berlin Questionnaire. Unfortunately, questionnaire based assessments are not consistently sensitive in identifying patients with sleep apnea (Satya, 2009). If sleep histories indicate there may be risk for sleep disordered breathing, consultation by a sleep specialist for assessment should be sought.

Infectious Diseases

Persons with opioid use disorders should be considered for screening for infectious disease (such as viral hepatitis, HIV) where comprehensive health history and examination and laboratory testing have provided an indication (Springer et al., 2018).

Additional screening and assessment

Tobacco, alcohol, and other non-opioid substance use screening should be part of the Comprehensive Health Assessment. Evidence-based screening and assessment tools can be found on a number of resource sites (e.g. National Institute on Drug Abuse).

Building Resilience in Individuals and Communities

Resilience is defined as “the process of adapting well in the face of adversity, trauma, tragedy or threats. It also includes coping with significant stress caused by problematic and toxic relationships in the family or at the workplace and the capacity to bounce back from difficult experiences”

Providers should work with persons using opioids and persons with an opioid use disorder to build resilience whenever possible. The American Psychological Association divides resilience in to four core components: connection, wellness, healthy thinking, and meaning. Focusing on these components can improve coping and encourage growth in times of adversity. In the context of chronic pain, psychological flexibility contributes to resilience and may contribute to improved pain and mood function (Gentil et al, 2019).

The Resilience Research Centre led by Dr. Michael Unger has tools and resources to promote individual and community resilience in addition to resilience measurement tools for children aged 5-9, youth aged 10-23 and adults (18+). Working with clients to establish a baseline measurement of resilience can begin the conversation toward developing a resilience plan. Additional resources such as the Mental Health Commission of Canada’s COVID 19 Self-care and Resilience Guide can be used by clients themselves or guided by a provider to put together a plan for self care and resilience in times of stress and adversity.

Both psychological and cognitive processes can be harnessed in working with individuals toward the development of personal resilience.

Stop and Think

Now that you have reviewed this content, consider the following:

Questions

Which of the following populations require special considerations for opioid therapy?

a. Persons with compromised renal function

b. Persons with a history of substance use disorder

c. Persons with comorbid psychiatric conditions

d. All of the above

Correct!

Incorrect. The correct answer is d.

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References