Opioid misuse in Canada and critical appraisal of aberrant behavior screening tools

Table 1 Definitions[8,10-13]

Tolerance	A state of adaptation where fixed doses of opioids over time results in the need for increasing doses to maintain the same effect
Physical dependence	A state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
Dependence (DSM-V criteria)[14]	A substance use disorder as a maladaptive pattern leading to clinically significant impairment or distress for at least 12 mo and meet ≥ 2 of the following:
	Recurring opioid use leading to a failure to fulfill role obligations
	Societal and interpersonal problems
	Using opioids in situations that are physically hazardous
	Tolerance
	Withdrawal
	Taking opioid in larger amounts and for longer periods than intended
	Unsuccessful at cutting down
	Spending time to obtain or use the opioid
	Giving up activities due to opioid use
	Continuing use despite physical or psychological problems
	Craving or strong urge to use the opioid
Aberrant behavior	Behaviours that may cause suspicion about addiction in opioid-treated pain patients or a behavior outside the boundaries of the agreed-on treatment plan which is established as early as possible in the doctor-patient relationship
Misuse	Use of a medication for non-medical use or for reasons other than prescribed. Wilful or unintentional use of a substance in a manner not consistent with legal or medical guidelines such as altering dosage forms, sharing medications with the potential for harmful consequences.
Abuse	Misuse with consequences. The use of a substance to modify/control mood or state of mind (to obtain a “high”) in a manner that is illegal or harmful to oneself or others. Examples of potential consequences include accident, injuries, blackouts, legal issues, and sexual behavior increasing the risk of sexually-transmitted diseases
Addiction	A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by compulsive use, continued use despite harm and craving
Diversion	The unintentional transfer of a controlled substance from legitimate distribution and dispensing channels into illegal channels or obtaining a substance by an illegal method

DSM-V: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Table 2 Consequences of opioid misuse[1,3,8,17,18,21]

Overdose-related death

Deteriorating social relationships

Reduced productivity/increased disability

Increased morbidity (opioid related side-effects/withdrawal symptoms, hyperalgesia)

Increased healthcare utilization/increased healthcare costs

Increased risk of blood-borne diseases (associated with injection drug use)

Malpractice claims

Increased drug diversion

Legal repercussions

Table 3 Risk factors associated with opioid misuse[8,23,24,26,27,37]

Non-modifiable risk factors	Age: Younger age (inverse risk relationship)
	Gender:
	Males (caucasian)
	Women misuse due to emotional issues versus men who misuse due to legal/behavioral issues
	Genetics:
	Family history of substance use disorder(s)
	Variations in OPRM1
	PENK gene polymorphisms
Reported pain severity/type of pain	Multiple pain complaints
	Chronic back pain
	Report greater degree of pain-related limitations
Comorbid psychological factors	History of substance use (cannabis, alcohol and other illicit drugs especially)
	Concomitant mood disorder, depression and/or anxiety
	Multiple psychosocial stressors
	Interpersonal problems with coworkers/family/friends
	History of risk-taking or thrill-seeking behavior
	Frequent contact with high-risk individuals or environments
Drug-related factors	Self-reported craving
	High daily doses (≥ 120 mg morphine equivalents per day)
	Use of short-acting opioids

OPRM1: μ-opioid receptor gene 1; PENK: Pre-proenkephalin.

Table 4 Aberrant drug-behaviors[5,9,38]

Indicator	Examples
Altering route of delivery1	Injecting, biting, crushing, separating oral formulations
Accessing opioids from other sources1	Obtaining the drug from friends/relatives
	Selling/purchasing from the “street”
	Double-doctoring
	Altering or creating fraudulent prescriptions
	Drug hoarding/trading
	Multiple emergency room visits
Unsanctioned use	Unauthorized dose escalations
	Binge use
Drug seeking behavior	Repeat prescription losses1
	Aggressive requesting of higher doses
	Harassing staff for faxed prescriptions or “emergency” fit-in appointments
	Manipulation of the prescribing physician
	Claiming nothing else “works”/requesting specific opioid1
Repeated withdrawal symptoms	Dysphoria, myalgias1, GI symptoms, cravings, nausea/vomiting etc.
Co-morbid conditions	Addicted to illicit drug, alcohol, cannabis and/or sedatives/hypnotics
	Underlying mood/anxiety disorders unresponsive to treatment
Social irregularity	Deteriorating/poor social function
	Concern expressed by family members
Views on opioid medication	Sometimes acknowledges being addicted
	Strong resistance to tapering or switching opioids
	Admits to mood-levelling effects
	Acknowledges distressing withdrawal symptoms

¹Associated with higher risk of addiction than others. GI: Gastrointestinal.

Table 5 Overview of Aberrant drug-related behaviors risk assessment tools

Name of assessment tool and type of study	Description	Who administers and time to administer	Interpretation of results	Validated	Sensitivity/specificity	Limitations	Intended use	Quality score[36]
Substance abuse assessment tools
Drug abuse screening test[39] Prospective/ multiple studies	28-item yes/no questionnaire to assess drug dependence or abuse (shorter versions of 10 or 20 items also available)	Patient; 5-10 min	A score of 6 or more indicates a drug abuse or dependence problem	Yes	0.81-0.96/0.71-0.94	Test and retest were only a few weeks apart (psychometrics may be falsely better), susceptible to patient deception. Also hasn’t been extensively tested in pain patients, therefore not specific to opioid use	For the initial assessment of drug abuse or dependence	N/A
Risk assessment tools
Opioid risk tool[40] Prospective	A 5-domain checklist (family history of substance abuse, personal history of substance abuse, age, history of sexual abuse and psychological disease) gender stratified and weighted	Patient; < 2 min	Low risk 0-3 points Moderate risk 4-7 points High risk ≥ 8 points	Yes	c statistic for male model = 0.82 and female = 0.85 (both excellent discrimination) Sensitivity to detect discontinuance of opioids due to ADRB = 0.45[35]	Has only been validated in a pain clinic, therefore applicability outside this population is limited	To be used as a risk assessment tool for aberrant behaviors prior to initial opioid prescription	4/9
Diagnosis, intractability, risk and efficacy inventory[41] Retrospective	7 item questionnaire-4 domains (diagnosis, intractability, risk and efficacy) with the domain of risk divided into 4 subcategories (psychological, chemical health, reliability and social support) to determine if a patient is suitable for maintenance opioid therapy	Physician; < 2 min	Each questions is scored from 1 (least compelling/favorable) to 3 (most compelling/favorable) A score of ≤ 13 indicates an unsuitable candidate for maintenance opioid therapy A score of ≥ 14 indicates a good candidate with higher scores with a greater likelihood of successful prescription	Yes	Sensitivity to detect discontinuance of opioids due to ADRB = 0.45[35] Sensitivity to detect discontinuance of opioids due to ADRB = 0.17[35] To predict patient compliance = 0.94/0.87	Used primary care vignettes versus real-time patients, small sample size (n = 61), drew upon patient cases in a referral centre (may not be generalizable), prospective validation needed	A decision tool to assess reliability of patients prescribed high risk therapy (opioids) in a primary care setting	N/A
Screener and opioid assessment for patients with pain1[36,42,43] Prospective	14-item questionnaire with answers scored on a likert 5-point scale of 0 (never) to 4 (very often) regarding drug history and other aberrant behaviors	Patient; < 5 min	A score of ≥ 8 indicates “high risk” of future aberrant drug related behaviors	Yes	Original Validation study 0.86/0.73 Sensitivity to detect likelihood of discontinuance of opioids due to ADRB = 0.72[35]	Predictive validity questionable as self-reported aberrant behaviors at baseline were compared to those at follow-up; also used PDUQ to identify/include higher-risk pain clinic participants (n = 175)	For the initial assessment of aberrant behaviors prior to initiating opioid therapy	5/9
Screener and opioid assessment for patients with pain– revised1[34] Prospective	24-item questionnaire with answers scored on a likert 5-point scale of 0 (never) to 4 (very often) regarding drug history and other aberrant behaviors	Patient; 2-5 min	Scores range from 0-96 Low risk < 18 points High risk ≥ 18 points	Yes	Original validation study 0.81/0.68 Ability to predict discharge from opioid treatment 0.39/0.69[33] Ability to predict presence of aberrant behaviors 0.41/0.71[33]	Has only been validated in a pain management clinic setting, less sensitive and specific than original SOAPP tool	For the initial assessment of aberrant behaviors prior to initiating opioid therapy	6/9
Ongoing assessment tools (monitoring)
Addiction behaviors checklist1[44] Prospective cohort	20-item yes/no questionnaire evaluating aberrant behaviors since last clinic visit and within current clinic visit	Physician; 5-10 min	A score of ≥ 3 “yes” answers indicates possible inappropriate opioid use and should alert physician to investigate further	Yes	0.88/0.86	Validation study conducted in predominantly male veterans and some high risk patients were excluded	A tool to assess previous and current/ongoing aberrant behaviors of patients on opioids	4/9
Current opioid misuse measure1[45] Cross-sectional	17-item questionnaire with answers scored on a Likert scale from 0 (never) to 4 (very often) assessing the frequency of aberrant behaviors in the previous 30 d	Patient; < 10 min	A cut-off score of ≥ 10 weakly increases the risk for ADRB	Yes	0.74/0.73	Has only been validated in a pain management centre, small follow-up sample size (n = 87), cross-validation studies are pending, limited evidence	To be used as a monitoring tool for aberrant behaviors in chronic pain patients	5/9
Pain medication questionnaire[46,47] Cross-sectional Prospective cohort (long-term evaluation)	26-item self-assessment questionnaire with answers scored on a Likert 5-point scale of 0 (disagree) to 4 (agree)	Patient; 5-10 min	Low risk 0-34 points High risk: 70-104 points High risk patients are associated with history of substance abuse, higher psychosocial distress and poorer functioning	Yes	None available	Has only been validated in a pain management clinic setting	An assessment tool for ongoing aberrant behaviors	6/9 4/9 (long-term)
Prescription drug use questionnaire1[31,48] Cross-sectional	42-item yes/no questionnaire evaluating 6 domains: evaluation of pain condition, opioid use patterns, social/family factors, family history, history of substance abuse and psychiatric history	Physician; 15 min	Each “yes” answer counts as one point. A score of 15 or greater indicates a substance use disorder	Yes, but poor results	Cronbach’s coefficient for reliability α = 0.81 in original study with pain clinic patients but decreased to α = 0.56 in a general medical setting	Evaluates risk at a single time point, very lengthy/time consuming. Pain clinic patients only; designed to be administered by a mental health care practitioner. Performed poorly in a general medical population	A tool for addictive behaviors to be used in conjunction with other clinical criteria (DSM) to assess for the presence of addictive disease	6-7/9
Prescription opioid therapy questionnaire1[49] Retrospective	Substance Abuse History Interview (3 questions) plus checklist of 6 aberrant behaviors	Physician; 2-5 min	Each item checked on substance abuse history equals one point 0-1 low risk 2-3 high risk	Yes	Sensitivity and specificity for each of the 6 aberrant behaviors determined[36] but some inconsistencies with original study	Limited to a pain clinic population, developed using retrospective chart review	A screening tool to identify substance abuse history and ongoing aberrant behaviors	7/92
Documentation tools
Patient assessment and documentation tool1[50] Cross-sectional (field tested)	A 41-item clinician-directed interview chart note tool divided into 4 domains (4 A's): analgesia, activities of daily living, adverse events and aberrant drug-related behaviors	Physician; 10-15 min	A descriptive tool to aid in documentation (chart note)	Field-tested, but not validated	N/A	Descriptive tool; validation needed (no sensitivity or specificity data available)	A documentation tool to organize chart note information related to opioid use	N/A

¹Recommended for use in the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain Practice Toolkit[9];

²method of quality determination not consistent with original study design therefore questionable interpretation. ADRB: Aberrant drug-related behaviors; N: Sample size; N/A: Not assessed; PDUQ: Prescription drug use questionnaire; SOAPP: Screener and opioid assessment for patients with pain; DSM: Diagnostic and statistical manual of mental disorders.