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Hawaii Anesthesiology Update 2008
August 4-8, 2008
The Fairmont Orchid, Hawaii (Big Island)
An Intensive Review of the Specialty of Pain Medicine: A Pain Board Oriented Review Course
Aug 23-28, 2008
Chicago City Centre Hotel, Chicago, IL
The Annual Fall Nurse Anesthetist Review and Update and Regional Anesthesia Hands-on Workshop
Dec 1-6, 2008
Westin Riverwalk, San Antonio, TX
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Home : Breakthrough Pain : Breakthrough Pain Resources : Expert Interview
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Interviews with pain specialists over a variety of breakthrough pain topics to enhanced your knowledge and understanding. Please note that the opinions expressed in these interviews are the personal opinions of the expert interviewee and do not necessarily reflect the opinions of the Dannemiller Foundation.
Opioid Risk Tool (ORT)
Interview with Lynn R. Webster, MD, FACPM, FASAM
 Lynn R. Webster, MD, FACPM, FASAM
Dr. Webster recently published in Pain Medicine journal preliminary results showing the Opioid Risk Tool (ORT) exhibited a high degree of sensitivity and specificity for determining which opioid-treated individuals are at risk for aberrant behavior.
Pain.com: Please explain what the ORT is and why it is needed.
Dr. Webster: The ORT is a five-question clinical interview or patient questionnaire to assess patients who may be at risk for opioid-related aberrant behaviors (Figure 1). It is administered to patients whose chronic pain is to be treated with opioids at the first clinical visit before treatment starts. Its aim is to predict the risk that behaviors will be exhibited once treatment is initiated.
The need is driven by the recent rise in prescription opioid abuse. According to the 2003 National Survey on Drug Use and Health, new nonmedical users of pain relievers more than quadrupled during the 10-year period of the 1990s. Many of these first-time users are young people. Substance abuse is a leading cause of preventable illness and death in the United States, and opioid analgesics are among the most frequently abused prescriptions. To keep opioids available to treat pain, as we must, doctors who treat pain are called on to help prevent abuse and addiction, too.
Pain.com: How is the ORT administered, and how does it work?
Dr. Webster: It is self administered by the patient in the office or waiting room and requires less than 5 minutes to complete. Patients are asked to identify their age; history of preadolescent sexual abuse; family and personal histories of alcohol, illegal drug or prescription drug abuse; and presence of certain mental diseases. These are the risk factors for abuse. The probability of opioid abuse increases with the number of positive responses.
Each risk factor is attributed a point value compared to other risk factors, and responses are weighted differently based on gender. Based on the total score, the patient is placed in one of three risk categories: Low risk with a score of 0 to 3 points total indicates individuals are unlikely to abuse; moderate risk with a total score of 4 to 7 points indicates individuals who are just as likely as not to abuse; and high risk with a total score of 8 or greater indicates individuals likely to abuse opioids.
Pain.com: Please talk a little about the risk factors contained in the questionnaire. Why are these considered the factors most predictive of abuse?
Dr. Webster: Many individual risk factors are linked to aberrant behaviors that might indicate abuse or addiction. These key factors were determined and substantiated through an investigation of the medical literature and my personal experience as a practicing pain and addiction specialist.
A family history of substance abuse can create both genetic and environmental risk factors for developing substance abuse or addiction. Numerous studies and clinical observation have shown that a personal history of substance abuse is a strong predictor of potential drug misuse.
Age is included as a risk factor because of the documented early onset of mental disorders and higher risk of drug abuse in young adults. Women who experience preadolescent sexual abuse have been shown to be at particular risk for mental disorders, (i.e., depression, anxiety and panic disorders and substance abuse disorders).
Mental disease is significantly correlated with substance abuse or addiction. One significant study showed that having a lifetime mental disorder can increase the risk of drug-abuse disorders by four times that of what is typically found in the general population. All of these studies are referenced in the Pain Medicine article.
Pain.com: Can you describe how the patient categories would be utilized and why this is necessary?
Dr. Webster: It is important to say, straight off, that in no way is this intended as a means to deny high-risk patients treatment for their pain. Rather, the purpose is to match the degree of clinical monitoring to the degree of risk based on the initial assessment. Monitoring measures include a number of interventions from routine to intense. All patients must understand and agree to certain treatment parameters: that all analgesics will be obtained from one physician and one pharmacy, that only enough drugs to last from visit to visit will be prescribed, and that the patient will be responsible if the drug supply is used before the next visit. The higher the risk, the more controls are put in place. For example, high-risk patients may need more urine drug screens, including some that are unannounced, shorter periods between visits and refills, counts of leftover medications and so forth.
Involving the patient's family is often essential and can help corroborate patient self report. Referral to an addiction specialist may be indicated if the patient has a history of addiction, and referrals to mental-health professionals can help manage psychiatric comorbidities. If violations of the opioid agreement persist, it may be necessary to discontinue opioid therapy. Documentation of every patient interaction is important to support the treatment plans recommended.
Pain.com: What statistical measures were used to judge the validity of the ORT?
Dr. Webster: To validate the ORT, the total score along with one or more observed aberrant behaviors, over the course of the study period, were used to compute the concordance index (c statistic) for each of the patients in the study sample. The c statistic is a measure of the predictive ability or diagnostic discrimination of the model and simultaneously assesses both sensitivity and specificity. The ORT displayed excellent discrimination for both the male (c = 0.82) and female (c = 0.85) prognostic models.
The paper published in Pain Medicine documents the results of a preliminary study showing the instrument was predictive in the setting in which it was administered. In the study, 185 new patients being treated with opioids for chronic pain took the ORT during their initial visits and then were monitored for 12 months. Of the low-risk patients, 17 out of 18 (94.4%) did not display an aberrant behavior. Of the high-risk patients, 40 out of 44 (90.9%) did display an aberrant behavior (Figure 2).
Pain.com: What are the strengths and weaknesses of the ORT, and how does it compare to other clinical measures of substance abuse?
Dr. Webster: In the sample tested, the ORT demonstrated validity and accuracy in predicting who is at high risk and low risk for opioid-related, aberrant behavior. It was less predictive for patients in the middle, moderate-risk category. This is the gray area. People in this category may abuse if they are exposed to enough stress with pain itself being a top stressor.
The advantages of a tool like the ORT lie in its opioid specificity and the fact that it is brief, easy to administer, nonconfrontational and predictive. The majority of now-available assessment tools diagnose current substance abuse rather than help predict it, are not specific to the use of opioids, tend to be long and cumbersome and are impractical for the average physician to use.
The ORT is part of new generation of tools that address the needs of opioid-treated pain patients. Other assessments having the same aim include the Screener and Opioid Assessment for Patients with Pain (SOAPP) and The Prescription Drug Use Questionnaire (PDUQ). All of these tools need further studies in a variety of pain settings to determine their wider applicability and to see if their results are consistent.
It would help the patient and the clinician to be able to tailor the monitoring of patients according to their risk profiles. Patients who are at high risk could be identified before opioid therapy starts and directed to appropriate treatment of the disorders that make them high risk. The goal is less abuse and better clinical outcomes.
References:
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.
Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain 2004; 112 (1-2):65-75.
Compton P, Darakjian J, Miotto K. Screening for Addiction in Patients with Chronic Pain and a "Problematic" Substance Use: Evaluation of a Pilot Assessment Tool. J Pain Symptom Manage 1998; 16(6): 355-363.
Figure 1:
Source: 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.
Figure 2:
Source: 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.
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