Any treatment for pain should periodically be reviewed and evaluated by the clinician. New information about the patient’s state of health, condition or cause of pain, psychosocial and mental health, and nature of pain is noted. The clinician should look at the patient’s dosage, the medication schedule (to determine if the patient is indeed taking the prescription as directed and whether the current treatment should be continued or modified). This decision depends on evaluation of the progress toward the treatment objectives previously outlined in the plan of care. At such a review, it is critical to reinforce correct medication usage.
According to the Medical Society of Delaware,
The licensed practitioner shall periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Periodic review shall include, at a minimum, evaluation of the following:
2.5.1 continuation or modification of controlled substances for pain management therapy depending on the practitioner’s evaluation of the patient’s progress toward treatment goals and objectives.
2.5.2 satisfactory response to treatment as indicated by the patient’s decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function must be monitored and information from family members or other caregivers should be considered in determining the patient’s response to treatment.
2.5.3 if the patient’s progress is unsatisfactory, the practitioner shall assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (MSD, 2013)
Regular monitoring and ongoing assessment to determine if the treatment plan is on track and the patient is achieving results is essential. Providers should incorporate the following practices in their patient monitoring:
The purpose of risk assessment is to determine the likelihood that a patient will develop or display aberrant drug-related behaviors. Healthcare providers must be observant at all times for signs of nonadherance to treatment plans and dosage instructions. Aberrant drug-related behaviors include the following:
Spectrum of Aberrant Drug-Taking Behaviors
More suggestive of addiction*
*Documented in patient’s medical chart.
Less suggestive of addiction
As is evident above, not all aberrant drug-related behaviors by patients signify addiction. They may instead signify that the patient:
Clinicians need to look closely to determine the reason for the unexpected or aberrant behaviors. Such behaviors are important clinical signs.
It is important to consider all behaviors, and the multitude of reasons that patients may not take their medications as they are prescribed. Understanding the specific reason for each unexpected behavior can help the clinician to take the correct next step, and make decisions that help minimize risk, improve safety, and most of all benefit the patient. (Corsini & Zacharoff, 2011)
Healthcare professionals must be on the lookout for the following signs and symptoms of opioid abuse:
Prescribers have a number of tools at their disposal to help with ongoing assessment of chronic pain patients who are receiving opioid analgesic therapy. Here are a few of those tools.
This tool assesses patient progress on long-term opioid treatment for chronic pain, and is used throughout opioid treatment. It investigates various aspects of the patient’s pain, including level of physical pain, the effect of pain on the patient’s day-to-day living and functioning, adverse effects of pain, and noticeable drug-seeking behaviors. This tool is not predictive of drug-seeking behavior, nor does it predict positive and negative outcomes of opioid therapy. Research has shown that the PADT has strong validity and is useful to guide ongoing assessment and documentation (Chou, 2009; Passik, 2004).
Developed by Bruce D. Naliboff with support from VA Health Services Research and Development, this is a 20-item, yes/no assessment tool that can increase a provider’s confidence in determinations of appropriate vs. inappropriate opioid use (Wu et al., 2006).
This is a five-point questionnaire that assesses the risk of opioid abuse through evaluation of behaviors that are consistent with opioid abuse rather than answers to specific questions (Chabal et al., 2013).
This is a 26-item self-report assessment tool for ongoing monitoring of aberrant behaviors. It helps clinicians to identify whether a long-term chronic pain patient is exhibiting aberrant behaviors associated with opioid medication misuse (Dowling et al., 2007).
The PDUQ assesses problematic opioid misuse, abuse, and dependence in chronic pain patients. Evidence suggests the PDUQ’s key screening indicators are excellent predictors for the presence of addiction (Compton et al., 2008).
A self-administered questionnaire consisting of 28 items with binary (yes/no) answers created by Harvey A. Skinner in 1982. Scores of 6 or more indicate the presence of substance dependence or abuse with satisfactory measures of reliability and high levels of validity, sensitivity, and specificity (Yudko et al., 2007).
A 17-item patient self-assessment that helps clinicians identify whether a patient, currently on long-term opioid therapy, may be exhibiting aberrant behaviors associated with misuse of opioid medications. Since the COMM examines concurrent misuse, it is ideal for helping clinicians monitor patients’ aberrant medication-related behaviors over the course of treatment (Butler et al., 2007).
Regular urine drug screening (UDS) is appropriate for patients who are at higher risk for opioid abuse or addiction, and for any patient who is exhibiting signs of misuse or aberrant drug behavior. Urine screening can indicate drug diversion, misuse, or abuse, and the presence of an illegal drug might indicate addiction. Any nonprescribed opioid may signal drug abuse or doctor shopping. Of course, providers using routine urine drug screening must remember that all diagnosis and treatment must be based on a careful assessment of the patient. UDS tools can deliver false negatives or false positives.
Patients must provide a detailed history of their medication use over the previous days and hours. Also, providers must inform patients that urine will be used for a urine drug screening and get patient consent before performing the laboratory screening. Ideally, urine drug screening is part of the patient-prescriber agreement that is already in place.
Pill counting is one method of ensuring medication adherence and helps to prevent drug diversion. Counting pills is done to compare the number of doses remaining in a prescription container with the number of doses that should remain, if the patient adhered to the medication schedule perfectly. For this method to work, the prescriber must order the medication such that the patient has doses remaining at the time of the next visit, and then should ask the patient to bring remaining pills to the visit.
The limitation of this strategy is that one cannot be sure that absent pills were consumed; they may have been diverted instead. Healthcare professionals must keep careful records about the amount of medication dispensed, prescription date, date the prescription was filled, and how many doses remain before the refill.