Fast Fact #311 discussed the assessment and initiation of opioid therapy in patients with a history of a substance use disorder (SUD). This Fast Factwill highlight expert suggested strategies for opioid monitoring in this patient population. 

Patient Monitoring: Adherence checklists, electronic drug monitoring databases, and individual/group counseling can reduce opioid abuse in high-risk patients (1). Only one clinician and pharmacy should be utilized in providing opioids. Regular follow up visits should be scheduled to assess the “Four A’s of Pain” before and after every intervention (2,3): analgesia (pain relief);activities of daily living (functional status);adverse effects; aberrant drug-taking behaviors.

Aberrant Drug Behaviors are not all the same, each behavior should be evaluated based on the specific patient and situation.  Clinicians should assess the degree of risk involved with the aberrant drug behavior. Considerations include the extent of the aberrant behavior, including whether it has persisted despite attempts to correct it, if the patient is actively using, the type of substance (opioids, alcohol, methamphetamine, cocaine, cannabis), as well as level of abuse (daily intoxication, binge use).  

General Strategies

• Ask patients if they are using other substances or using their opioids to get high or emotionally cope with stressors.  Remind patients that these are routine questions asked to all patients.  
• Schedule more frequent visits, provide shorter-term prescriptions, and readdress opioid agreements.
• Intensify non-opiate pain strategies.

Patients who are using illegal drugs or alcohol.  

In addition to the general strategies, consider the type of substance:

• If cannabis or alcohol, perform a patient specific assessment: is there evidence of loss of control or adverse consequences?  Taper opioids or intensify monitoring depending on the scenario. 
• If cocaine, methamphetamine, or heroin, consider patient’s prognosis.  Either taper and discontinue opioids or negotiate use in a highly structured environment and/or ongoing addiction treatment. 

Active Substance Abuse: If the patient needs addiction treatment:

• Taper and then discontinue opioid therapy.
• Provide resources for treatment with an addiction specialist.
• Continue to treat pain via non-opioid and non-pharmacologic means — “fire the opioid, not the patient”. It is important to maintain a therapeutic relationship with the patient and assure non-abandonment. 

Opioid Diversion: Opioid diversion is a serious public health threat with legal ramifications. Patients actively using controlled substances have a higher risk for diversion.

Voluntary diversion occurs when a patient prescribed a controlled substance knowingly transfers it to another person.  This can range from “sharing” one or two pills with others to patients selling some or all of the prescribed medications.  Treatment teams should inform patients at the beginning of treatment that sharing medication is not permitted, and lost or stolen medications will not be replaced.

• Patients who share medications in small amounts (e.g. giving a pill to a spouse who has acute pain) should be re-educated on the dangers involved and be reminded of opioid agreements/clinic policies.
• Suspected diversion of large amounts of medication should be verified by calling the patient in for a pill count and UDS in the middle of the prescribing period.
• Clinicians should discontinue opioid therapy in patients with whom they have a reasonable degree of suspicion for diversion. Consideration should be given to notification of local police.  

Involuntary diversion occurs when a controlled substance is stolen from a patient without their knowledge. This happens more frequently in patients with unstable housing and/or family dynamics.

• Clinicians should discuss safety strategies with patients (e.g. lock boxes) and perform pill counts.
• Clinicians should utilize the help of social workers in determining if exploitation of a vulnerable adult is occurring which could necessitate the involvement of police or adult protective services.
• Consider weaning opioids if involuntary diversion continues given negative public health effects or placing the patient in a more supervised setting such as a nursing home or an inpatient hospice.
• Admission to the hospital to monitor pain management can be a useful management step in situations in which clinicians are suspicious for voluntary or involuntary diversion.

References:

1. Jamison RN, Ross EL, Michna E, et al. Substance misuse treatment for high risk chronic pain patients on opioid therapy: a randomized trial. Pain. 2010; 150(3): 390-400.
2. Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Adv Ther. 2000;17:70-83.
3. Peppin JF, Passik SD, Couto JE, et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Medicine. 2012; 13: 886-896.

Author’s Affiliations: University of Pittsburgh Medical Center

Version History: Originally edited by Sean Marks MD and electronically published in February 2016; updated in April 2019.

Conflicts of Interests: none reported