The use of prescription drugs including opioid analgesics for other-than-legitimate medical purposes poses a significant health risk to individual patients and to society. Inappropriate prescribing can lead to drug diversion and abuse by individuals seeking to use opioids nonmedically. It falls to clinicians to use systematic precautions to minimize the possibility for abuse and diversion of controlled substances.

Risk Factors for Opioid Abuse and Drug Diversion

Research shows that there are several categories of risk factors for opioid abuse and addiction:

• Genetic predisposition
• Certain brain characteristics that can make someone more vulnerable to addictive substances than the average person
• Psychological factors (eg, stress, personality traits like high impulsivity or sensation seeking, depression, anxiety, eating disorders, personality and other psychiatric disorders)
• Environmental influences (eg, exposure to physical, sexual, or emotional abuse or trauma; substance use or addiction in the family or among peers; access to an addictive substance; exposure to popular culture references that encourage substance use)
• Starting alcohol, nicotine, or other drug use at an early age (CASA, 2017)

One factor that is strongly predictive of opioid abuse, misuse, or other aberrant drug-related behavior is a personal or family history of alcohol or drug abuse. However, the FDA (2014) wants clinicians to recognize that

. . . a history of substance abuse does not prohibit treatment with extended release/long-acting opioid analgesics but may require additional monitoring and expert consultation (FDA, 2014).

Assessment

SAMHSA’s Opioid Overdose Prevention Toolkit recommends that a thorough patient assessment and health history include specific questions. For example:

• “In the past 6 months, have you taken any medications to help you calm down, keep from getting nervous or upset, raise your spirits, make you feel better, and the like?”
• “Have you been taking any medications to help you sleep? Have you been using alcohol for this purpose?”
• “Have you ever taken a medication to help you with a drug or alcohol problem?”
• “Have you ever taken a medication for a nervous stomach?”
• “Have you taken a medication to give you more energy or to cut down on your appetite?
• “Have you ever been treated for a possible or suspected opioid overdose?”

Further, a patient history should include questions about the patient’s use of alcohol and over-the-counter medicines (SAMHSA, 2016a).

Physical Examination

During a physical examination, clinicians should also be on the lookout for the following signs in patients being seen for chronic pain:

• Needle marks in neck, hands, feet, and antecubital fossae
• Signs of opioid intoxication, including pinpoint pupils, sweating, drowsiness, nodding off, slurred speech, respiratory depression, stupor, and coma
• Signs of opioid withdrawal, including goose bumps, sweating, diarrhea, sniffles, dilated pupils, lacrimation, muscle tenderness, increased bowel sounds, shivering, nausea, emesis, rapid heartbeat, restlessness, and hypertension
• Signs of liver disease, including jaundice, enlarged liver and spleen, “stigmata” of chronic liver disease, and ascites (Dixon, 2018)