Prescribers may be contributing to POUD. Roughly 76% of opioids used for nonmedical purposes were prescribed to someone else, 20% were prescribed to the user, and 4% came from other sources.1 Strategies to reduce POUD risk may be underused. In a retrospective cohort study of 1,612 patient electronic medical records from 8 primary care clinics that managed patients with long-term opioids for chronic noncancer pain (average prescribing duration of 2 years duration, ≥3 monthly prescriptions in 6 months), researchers evaluated how often prescribers used 3 risk reduction practices:
- urine drug tests
- regular office visits (≥1 every 6 months and within 30 days of changing opioid treatment)
- restricted early refills (≤1 opioid refill more than a week early).10
Risk factors for opioid misuse included age 1 early refill. Researchers found that even for high-risk patients, these strategies were used infrequently. Less than one-quarter of patients with ≥3 risk factors ever had a drug test, and those at increased risk were more likely to receive >1 early refill but no more likely to have more frequent visits. Issues such as patient entitlement, lack of physician education, and time constraints may explain why these strategies are not used more often.11
No one procedure or set of variables is sufficient to identify chronic pain patients who may be at risk for POUD. However, a history of drug or alcohol use disorders may be a significant risk factor.12,13
Few tools have been developed to help identify those at risk of AMTBs or POUD, and all have limitations.4,14 Recommended self-report measures include the Current Opioid Misuse Measure and the Opioid Risk Tool.15 A review of studies in which these kinds of tools were developed revealed limited evidence for their use; most studies had methodological shortcomings, did not use standardized AMTB criteria, and provided little assessment of whether these tools changed clinician behaviors or improved patient outcomes.16
Evaluating AMTBs
Although diagnosing POUD in pain patients receiving chronic opioids can be challenging, assessing for AMTBs typically is helpful. Once AMTBs are identified, they can be examined to determine what drives their expression (Table 14 and Table 217). However, often it is easier to identify AMTBs than to interpret their origins; as much as 30% to 50% of patients who complain of chronic pain may have primary substance dependence to sedatives, opioids, or both.11
Table 2
Aberrant medication-taking behaviors and POUD risk
| Behaviors more suggestive of POUD |
|---|
| Deterioration in function (work, social) |
| Illegal activities (selling medication, forging prescriptions, buying from non-medical sources) |
| Altering the route of administration (snorting, injecting) |
| Multiple episodes of ‘lost’ or ‘stolen’ prescriptions |
| Resistance to change therapy despite negative outcomes |
| Refusal to comply with toxicology testing |
| Concurrent, active abuse of alcohol, illegal drugs |
| Use of multiple physicians or pharmacies to obtain the prescription |
| Behaviors less suggestive of POUD |
| Complaints for more medication |
| Medication hoarding |
| Requesting specific pain medications |
| Openly acquiring similar medications from other providers |
| Occasional unsanctioned dose escalation |
| Nonadherence to other recommendations for pain therapy |
| POUD: prescription opioid use disorder Source: Reference 17 |
Although AMTBs are common among chronic nonmalignant pain patients,18,19 how often AMTBs reflect underlying POUD is uncertain.7 It is critical to interpret AMTBs with a balance of caution and care: “react therapeutically, not punitively.”20 Categorizing a patient’s AMTB as more or less likely to support a POUD diagnosis can be helpful, but is not conclusive (Table 2).17 Clinical correlation often is required. No single AMTB alone is indicative of POUD. When evaluating AMTBs, the treating provider should use a nonjudgmental stance, and consider obtaining collateral data from people who can provide differing perspectives of the patient’s behaviors, such as other clinicians, significant others, family, etc. (a release of information from the patient may be required). Another source of collateral data is prescription monitoring databases. These databases typically are state-based and provide electronic access to prescription information, allowing you to search for patterns—ie, use of multiple prescribers or pharmacies, undisclosed prescriptions, etc. Interest in establishing a single, federal database has been increasing, but striking a balance between carefully monitoring for AMTBs and protecting privacy remains unresolved.
DSM-IV-TR diagnostic criteria for opioid dependence21 can be challenging to interpret in patients who are prescribed opioids for pain (Table 3