DE: Substance Abuse, Chemical Depence, and Drug DiversionPage 9 of 12

7. Periodic Review and Monitoring of Patients

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)

Monitoring Treatment

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:

  • Take a psychiatric history. Opioid therapy can cause depression and anxiety, which is especially common in patients taking high doses. Furthermore, addiction to opioids can cause depression due to negative impacts on social relationships, financial status, and other areas.
  • Assess patient functioning in multiple areas including work, family, activities of daily living, comparing before and after the medication.
  • Ask the patient if he or she feels any problems have resulted from the opioid use. Of particular concern are poor work function, interpersonal conflicts, and depression.
  • Assess whether the patient is experiencing an altered schedule of medication, including periods of excess use.
  • Determine of the present dosage is controlling pain and to what degree.
  • Ask the patient if she or he experiences any withdrawal symptoms such as discomfort if going without the opioid. Has the patient ever used the medication to avoid such discomfort or other withdrawal symptoms.
  • Determine whether the patient is experiencing withdrawal-mediated pain. Patients may report intense pain as the opioid wears off, pain all over, dysphoria, or severe pain and withdrawal symptoms in the morning, with quick relief after taking the opioid.
  • Be aware of and on the lookout for aberrant drug-related behaviors such as multiple prescribing doctors and purchasing opioids from family or friends, or from anywhere other than a pharmacy.
  • Perform a physical examination and be on the alert for physical signs and symptoms of drug abuse. (CAMH, 2011a)

Identifying Diversion and Drug-Seeking Behaviors

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:

  • Escalating the dose without a clinician’s order, especially rapidly escalating the dose. Psychoactive tolerance develops quickly, forcing a drug abuser to take more of the medication to achieve the same effect, often in doses significantly higher than a therapeutic dose for pain. In contrast, analgesic tolerance develops slowly. It would be expected that patients with stable pain would stay on the same dose for months or years.
  • Taking the drug in larger doses than prescribed and running out of medication early. Patients abusing opioids may aggressively request refills earlier than expected, or request additional doctor visits.
  • Acquiring opioids from sources other than by order of the clinician, such as an emergency department, acquiring additional doctors, or buy purchasing the drug on the street.
  • Altering or acquiring prescriptions by means of theft, fraud, or purchase.
  • Using the drug in any method other than that which was prescribed, such as by snorting, injecting, or chewing oral medications for quicker effect. (CAMH, 2011b)

Spectrum of Aberrant Drug-Taking Behaviors

More suggestive of addiction*

  • Concurrent abuse of alcohol or illicit drugs
  • Evidence of deterioration in the ability to function at work, in the family, or socially that appears to be related to drug use
  • Injecting oral formulations
  • Multiple dose escalations or other nonadherence with therapy despite warnings
  • Obtaining prescription drugs from nonmedical sources
  • Prescription forgery
  • Repeated resistance to changes in therapy despite clear evidence of drug-related diverse physical or psychological effects
  • Repeatedly seeking prescriptions from other clinicians or emergency departments without informing prescriber
  • Selling prescription drugs
  • Stealing or borrowing drugs from others (Passik, 2009)

*Documented in patient’s medical chart.

Less sugguestive of addiction

  • Aggressive complaining about the need for more drugs
  • Drug hoarding during periods of reduced symptoms
  • Openly acquiring similar drugs from other medical sources
  • Requesting specific drugs
  • Reporting psychic effects not intended by the clinician
  • Resistance to a change in therapy associated with tolerable adverse effects accompanied by expressions of anxiety related to the return of severe symptoms
  • Unapproved use of the drug to treat another symptom
  • Unsanctioned dose escalation or other nonadherence with therapy on 1 or 2 occasions (Passik, 2009).

As is evident above, not all aberrant drug-related behaviors by patients signify addiction. They may instead signify that the patient:

  • Is experiencing increased pain
  • Has accidentally been misusing the medication by taking more than intended
  • Is developing a physical tolerance to the opioid analgesic, which is not as effective as it once was
  • Is rationing doses to save money, for example, or selling doses for income
  • May have someone in his or her household or living situation who is stealing medication from the patient (Corsini & Zacharoff, 2011)

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)

General Symptoms of Narcotic Abuse

Healthcare professionals must be on the lookout for the following signs and symptoms of opioid abuse:

  • Analgesia (feeling no pain)
  • Sedation
  • Euphoria (feeling high)
  • Respiratory depression (shallow or slow breathing)
  • Small pupils
  • Nausea, vomiting
  • Itching or flushed skin
  • Constipation
  • Slurred speech
  • Confusion or poor judgment

Tools for Monitoring Ongoing Opioid Therapy

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.

Pain Assessment and Documentation Tool (PADT)

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).

Addiction Behaviors Checklist (ABC)

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).

Chabal 5-Point Prescription Opiate Abuse Checklist

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).

Pain Medication Questionnaire (PMQ)

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).

Prescription Drug Use Questionnaire (PDUQ)

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).

DAST Drug Abuse Screening Test

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).

Current Opioid Misuse Measure (COMM)

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).

Urine Screens

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

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.