How to Assess a Patient’s Risk for Long Term Opioid Therapy
A lot has changed in the past 10 years with our approach to opioid prescribing in the United States, in response to the opioid overdose and poisoning crisis that has taken too many lives. The situation continues to worsen, as non-medical fentanyl contaminates the drug supply, and more patients endure isolation and reduced access to health care and social services due to the COVID-19 pandemic. Many of us who care for patients with serious illness and serious pain, who prescribe opioids at times to treat their pain, have been re-examining our entire practices.
How do we assess our patients for risks from opioids and other substances? How do we talk with patients about sensitive topics (e.g., substance use, addiction) in ways that strengthen our relationships with them and build trust? How do we make clinical decisions with our patients about opioid therapy that maximize patient safety and minimize harm?
"Within our field of palliative care, there has been a growing awareness that we absolutely need to take incredibly seriously the issue of safe opioid prescribing for our patients."
Within our field of palliative care, there has been a growing awareness that we absolutely need to take incredibly seriously the issue of safe opioid prescribing for our patients. As palliative care specialists, we take care of patients with serious illnesses, some of whom live for years, often accompanied by pain that impairs function. Many of our patients have commonly accepted indications for opioid therapy, such as pain from active cancer, but many do not. Either way, we face the challenge of ensuring that when we prescribe opioid therapy, we do it in a way that maximizes the safety and well-being of our patients.
The question then becomes, “What can we do to keep our patients safe and to help them thrive?”
An Evolving Perspective on Pain Management
I’m on the record as admitting that my outlook on opioid therapy has changed substantially over the past 15 years. I’ve written and talked (and tweeted) about how I’m much less enthusiastic about opioids’ therapeutic potential than I was earlier in my medical career.
First, there was the growing awareness of the severe opioid overdose and poisoning epidemic that had taken root. Then I realized that I had many patients who were on long-term, high-dose opioid therapy who were not only still in severe pain, but were also significantly functionally impaired, depressed, and had a poor quality of life. Some had developed opioid use disorder, while others were ‘just’ living with long-term side effects, mood alterations, and all the risks of long-term opioid therapy (LTOT) without clear benefit. While those patients weren’t likely to fatally overdose themselves in my experience, putting them in a situation in which they were on high dose LTOT, but still in functionally impairing pain with low mood is a form of harm. It took me nearly a decade to realize how much harm this constituted. Too many of my patients were miserable on LTOT.
"... I had to come to grips with the fact that too many of my patients were not thriving."
As a palliative care physician, I want my patients to thrive, and have as good a quality of life as possible in light of their serious illness, and I had to come to grips with the fact that too many of my patients were not thriving. I realized I needed to do a better job of deliberately assessing risk of harms from chronic opioid therapy with my patients, so I could make better decisions as a clinician, and keep safety as a top priority as I cared for my patients day to day.
Making Fair Risk Assessments
So how do we, as palliative care specialists, make fair—truly fair—risk assessments?
We need to be mindful of own internalized biases as clinicians. Racism, classism, ageism, and other implicit biases and social prejudices influence how we approach patients. These can come out whether we’re aware of them or not, and can introduce error, resulting in harm to our patients. We have to approach all patients fairly, without assumptions, knowing that risky substance use and substance use disorders affect all corners of our society, while remembering that the substance use of poorer people and communities of color is far more stigmatized than the risky substance use that’s widespread amongst middle class and wealthy white communities. One strategy to minimize these biases is by employing universal opioid precautions, applied to all of our patients automatically.
"Using universal opioid precautions—an approach that’s essentially risk triage—is a must in 2022."
Using universal opioid precautions—an approach that’s essentially risk triage—is a must in 2022. This means triaging your patients into risk categories, and then using that information to help them manage their pain in the safest, most effective ways.
There’s broad professional agreement in the palliative care world about the top-level factors that should be in those universal precautions, and that includes:
- intentionally assessing the risk of harm from opioids in every single patient we are considering for chronic opioid therapy
- educating patients by having explicit discussions with them and their caregivers about opioid risk and safe use, including the risk of addiction and overdose; risks of combining opioids with other sedating medications or alcohol; and keeping the community safe from opioids being stolen or diverted
- using prescription drug monitoring programs (PDMPs), which are electronic databases that track controlled substance prescriptions so we know exactly what our patients are being prescribed.
Applying this to every patient minimizes the risk that we’ll miss important information about our patients because that little voice inside our heads said, “There’s no way a person like her could have a risky substance use history.”
When in Doubt, Ask
Another key to getting a good assessment of a patient’s risk is taking a very thorough history. And here’s the key to that: we have to ask a lot of questions.
This means asking our patients questions about their psychiatric history and past substance use. Without asking, they might not eagerly disclose the information to us, or even disclose it at all, which means that it’s our job. Why do we need that information? For a patient with a personal history of a substance use disorder—alcohol, stimulants, other opiates, etc.—their chances are of being harmed are significantly higher. These are widely accepted risk factors. We also need to ask them about any close family history of substance use disorders because that’s also clearly associated with elevated risk.
As for tools that can help us objectively assess risk, there are a couple of different options. No tools for assessing risks of harm of opioid therapy have been validated in palliative care clinic populations, so individual practices need to decide for themselves what makes the most sense. Some practices use the SOAPP, or Screener and Opioid Assessment for Patients with Pain. In my practice, we prefer to use the Opioid Risk Tool-Revised or ORT-R. What we like about the ORT-R is that it captures most of the widely accepted risk factors. It’s also short and so easy to administer that a clinician can get all the information they need for the ORT-R simply by taking a good medical history. It takes the patient’s medical history and assigns a number on it, giving our practice a way to talk about a patient’s risk in a simple, measured way.
"Doing nothing will cause much more harm than doing something. We can’t let the perfect be the enemy of the good here."
Unfortunately, we are in a position where ‘universal’ practices are not in fact happening everywhere, all the time. We have a long way to go. But even physicians in very small practices can do something. They may not use specialized tools like ORT-R, but they can take very good patient histories and talk to their patients about opioid use disorder (OUD). That’s definitely progress, and that matters. Doing nothing will cause much more harm than doing something. We can’t let the perfect be the enemy of the good here.
Making Choices for the Best Therapeutic Outcome
When we conduct these careful risk assessments, which we use to help us make decisions in conjunction with our patients, here’s what we need to keep in mind: “How can we best help our patients thrive?” and, “Will they thrive if we pursue this therapeutic option or that one?”
Risk assessments can help you identify the patients you need to worry about more—those who need extra safety practices. Then you can start figuring out what can help them. This may include shorter-term prescriptions, psychotherapy, and more frequent follow-ups. I will have a far longer and more extensive discussion with patients at elevated risk about the potential harms of chronic opioid therapy and realistic goals of opioid therapy for them than with those patients at ‘average risk’ (although I still discuss it with them at length, too!).
In other words, a high-risk designation doesn’t necessarily mean that I won’t prescribe an opiate to a person who needs one. Especially for my patients with serious illness and severe pain, I may decide with the patient that the potential benefits of chronic opioid therapy outweigh the risks, and that it is worth carefully trying. But the high-risk assessment will modify how I prescribe that opioid therapy to them. I might schedule more frequent follow-ups, give them fewer opiates at one time, or choose one particular opioid over another. For example, I’m more likely to use buprenorphine as my opioid of choice for my patients at higher risk.
"It’s not to say “yes” or “no” to opioids. It’s not black or white. It’s how to use opioid treatment effectively and appropriately in a way that meets our patient’s needs."
And that’s the lens I believe that we need on opioid risk assessment in the palliative care setting. It’s not to say “yes” or “no” to opioids. It’s not black or white. It’s how to use opioid treatment effectively and appropriately in a way that meets our patient’s needs. I trained in the 2000s in a climate of liberal opioid prescribing, in which I was willfully ignorant to some of the harms I was causing. Now, in 2022, it seems like we’re in a climate where some prescribers feel forced to taper all their patients off of chronic opioid therapy, regardless of the objective harm that may cause the patient. Neither approach is right. Neither approach centers individualized, shared decisions about pain care that prioritize patient safety and function and focus on carefully asking: “Is this person’s life better?”
So, ultimately, we should always remember to ask ourselves: “Are we safely making this person’s life better?” And if we’re not, we need to change course.
"Safe, effective, patient-centered care for complex chronic pain is one of the most challenging scenarios many clinicians face. CAPC’s Chronic Pain Strategies unit is designed to help practicing clinicians better care for these patients who so urgently need our help." - Drew Rosielle, MD, FAAHPM
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