Choosing the Right Risk Assessment Tools to Identify Aberrant Behavior

LAS VEGAS — Most state medical boards and the US Drug Enforcement Administration require pain management specialists to screen patients for the potential to misuse, abuse, and divert opioids.

Besides being mandated, risk assessment is good clinical practice, according to Ted Jones, PhD, a psychologist who specializes in pain management and the evaluation of addiction risk. 

“When an opioid prescription is written, a good provider needs to do some sort of assessment of the person who will obtain, store, and administer the opioid. The provider is then responsible for creating a treatment plan that increases the chances that opioids are ingested by the patient exactly as directed,” said Dr. Jones, who works at Pain Consultants of East Tennessee, named an American Pain Society 2014 Center of Excellence. “Our recent national experience shows the potential disastrous results if this is not done.”

He advised audience members to avoid using “gut impressions” to assess patient propensity for medication aberrant behaviors (MABs), as studies show clinicians perform poorly at predicting MABs using intuition alone. 

“Using a validated assessment tool conforms to the current standard of care in opioid prescribing and offers more accurate information for the prescribing clinician,” said Dr. Jones. 

During his session he reviewed the 9 currently validated screening tools to predict MAB in patients prescribed opioids for chronic pain conditions: 

  • Screener and Opioid Assessment for Patients With Pain (SOAPP; Butler, 2004)
  • Pain Medication Questionnaire (PMQ; Adams, 2004)
  • Opioid Risk Tool (ORT; Webster, 2005)
  • Diagnosis, Intractability, Risk, Efficacy (DIRE; Belgrade, 2006)
  • Screener and Opioid Assessment for Patients With Pain - Revised (SOAPP-R; Butler, 2008)
  • Prescription Drug Use Questionnaire Self-report (PDUQp; Compton, 2008)
  • Brief Risk Interview (BRI; Jones, 2013)
  • Narcotic Risk Manager (NRM; Gostine, 2014)
  • Brief Risk Questionnaire (BRQ; Jones, 2015)

“No one tool is right for every practice. Tools vary in how they are administered, the ease of scoring, and the detail of information provided,” emphasized Dr. Jones. 

Each has advantages and disadvantages, with some appearing to overrate or underrate risk depending on how they are used or the clinical setting.  

“A patient's treatment plan should be adjusted based on the results of the risk assessment. Specifically, the frequency of monitoring and the variety of opioid medications should be chosen based on the level of risk of the patient,” said Dr. Jones. 

He encouraged practices to create a specific protocol for monitoring and prescribing medications for patients at various risk levels, so that when MABs arise clinicians are unified in their approach for handling these situations.

“The field of risk assessment also needs to begin to formally define overdose risk for patients,” added Dr. Jones.

He pointed out that predicting medication overdose risk requires assessing a different set of variables than those available in current risk assessment tools and recommended that clinicians conduct both a behavioral risk assessment for opioid misuse and a separate medical risk assessment for overdose.

“Unfortunately there is no current scale or algorithm for assessing medical risk, but it is on the legal/regulatory radar and you should be very aware of it if you prescribe opioids,” he cautioned.

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