Screening for Risk of Non-Medical Opioid Use

  • Alexander D. Ginsburg MD
  • René Claxton MD MS
  • Julie W. Childers MD
  • Robert M Arnold MD

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Background: Opioids are frequently prescribed to treat pain and dyspnea. They also have high potential for non-medical opioid use (NMOU). To manage opioids safely, clinicians who care for patients with serious illness need to assess patients for NMOU and their risk of developing or exacerbating opioid use disorder (OUD).

Terminology: The language used to describe NMOU is often stigmatizing. Previously accepted terms such as abuse and addict have been demonstrated to negatively influence clinician perceptions of patients and should be avoided.  NMOU is a less stigmatizing way to refer to using a prescribed opioid in a way other than directed (e.g., taking more frequent doses than prescribed, administering via an unprescribed route), using it to achieve a particular feeling, or using non-prescribed opioids (1).

Benefits of screening: NMOU and OUD are relatively common among patients prescribed opioids. Among patients with chronic, non-malignant pain and no immediately identifiable terminal illness, approximately 25% engage in NMOU and 10% develop OUD (2). Although data in palliative care patients is limited, a systematic review of patients with cancer suggests a median NMOU prevalence of 18% (3,4). Identifying patients at risk of NMOU and OUD allows providers to tailor specific harm-reduction strategies (e.g., shorter prescriptions, rotating to buprenorphine, more frequent urine drug testing, deprescribing sedatives, utilizing scheduled rather than as need dosing) and attaining more tailored harm: benefit analyses of ongoing opioid prescribing (see Fast Facts #127, #311 and #312).

Published screening questionnaires for NMOU: There are multiple screening tools to assess risk of NMOU; however, none of these tools has been developed for – or validated in – patients with life-limiting illness. Among the most common screening tools are the Screener and Opioid Assessment for Pain Patients (SOAPP) and the Opioid Risk Tool (ORT). A scoping review demonstrates that the evidence for applying these tools in palliative care populations is sparse and psychometric testing in palliative care populations is lacking (5). Furthermore, systematic reviews suggest these screening tools are based on low-quality evidence (6) and have poor diagnostic accuracy (7).

  • SOAPP:  multiple variations (SOAPP-14, SOAPP-R, SOAP-SF) exist. It may have better sensitivity for assessing risk of NMOU than other questionnaires (8). It utilizes Likert scales for the domains of history of “legal problems or arrests”, personal and family substance use history, and medication-related behaviors [8]. There is concern that some SOAPP questions embed bias. For example, linking arrests with NMOU, may disproportionately patients groups affected by policing.
  • The ORT incorporates age, sex, personal or family history of drug or alcohol “abuse”, psychiatric conditions, and history of pre-pubescent sexual abuse in women. Although the ORT was initially validated for adults in primary care settings, subsequent studies suggest it may not be better than chance [9]. A revised ORT may outperform ORT (10). It eliminated the question of pre-pubescent sexual abuse and simplified the risk categorization (10).

Objective data: Objective methods of screening for NMOU risk include urine drug testing (UDT) and utilizing a state prescription drug monitoring program database (PDMP). Like the screening questionnaires, neither UDT nor PDMP use have robust evidence suggesting improved patient outcomes (11,12). Nevertheless, both tools are recommended by the CDC (13) and both are frequently utilized as part of a standardized screening approach in opioid prescribing for palliative care patients (14).

  • UDT provides information to help the clinician determine whether the patient is taking the prescribed medication or if there is evidence of use of unprescribed substances close to the time of the test. An unexpected negative or positive should trigger further inquiry into possible NMOU or substance use disorder (SUD). The value of UDT depends on a clinician’s understanding of the test characteristics (e.g., screening immunoassay, confirmatory chromatography), the substances/metabolites being screened for, and how recently these substances were used (see Fast Fact #110). Prior to obtaining UDT results, clinicians should ask patients about when they most recently took their medication or if there are other substances they think may be present in their urine (13). Additionally, clinicians should UDT in terms of opioids being higher-risk medications and a desire to keep the patient safe.
  • PDMP review allows providers to track whether the patient is receiving opioids from multiple prescribers, the date and quantity of previous prescriptions, and whether the patient is prescribed other high-risk medications such as benzodiazepines.

Routine substance use, symptom, psychiatric, and social histories are paramount. It can also be helpful to speak to previous or concurrent providers for their perspective on the patient’s risk of NMOU.

  • Substance use history: should include the frequency, duration, and route of each substance (including alcohol or tobacco); history of overdose or withdrawal; triggers for substance use; and prior SUD treatment (14-16). Clinicians should use open-ended questions that avoid stigmatizing language. For example, “Have you ever taken medications not prescribed to you?” or “Have you ever used heroin?” as recommended, non-judgmental ways of inquiring about NMOU and substance use (15).
  • Symptom history: beyond usual symptom assessment, clinicians should be able to estimate the patient’s morphine equivalent daily dose (MEDD). Higher MEDD has been associated with NMOU; however, varying cut-offs have been cited (e.g., 50 vs 120 MEDD) (18,19).  
  • Psychiatric history: personality disorders, psychosis, anxiety, and somatoform disorders have been associated with an increased NMOU risk (6). Absence of a mood disorder may be protective (6).
  • Social history: being single or divorced is associated with a higher risk for NMOU (18,20). Clinicians should inquire about their level of social support in their community (18,20).


  1. Saitz R, Miller SC, Fiellin DA, Rosenthal RN. Recommended use of terminology in addiction medicine. J Addict Med. 2021;15(1):3-7. doi:10.1097/ADM.0000000000000673
  2. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1
  3. Yusufov M, Braun IM, Pirl WF. A systematic review of substance use and substance use disorders in patients with cancer. Gen Hosp Psychiatry. 2019;60:128-136. doi:10.1016/j.genhosppsych.2019.04.016
  4. Preux C, Bertin M, Tarot A, et al. Prevalence of opioid use disorder among patients with cancer-related pain: a systematic review. J Clin Med. 2022;11(6):1594. Published 2022 Mar 14. doi:10.3390/jcm11061594
  5. Lau J, Mazzotta P, Fazelzad R, et al. Assessment tools for problematic opioid use in palliative care: A scoping review. Palliat Med. 2021;35(7):1295-1322. doi:10.1177/02692163211015567
  6. Klimas J, Gorfinkel L, Fairbairn N, et al. Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review. JAMA Netw Open. 2019;2(5):e193365. doi:10.1001/jamanetworkopen.2019.3365
  7. Chou R, Hartung D, Turner J, et al.. Opioid treatments for chronic pain. Comparative Effectiveness Review No. 229. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 20-EHC011. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. DOI: 10.23970/AHRQEPCCER229.
  8. Finkelman MD, Jamison RN, Kulich RJ, et al. Cross-validation of short forms of the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Drug Alcohol Depend. 2017;178:94-100. doi:10.1016/j.drugalcdep.2017.04.016
  9. Clark MR,  Hurley RW, Adams MCB. Re-assessing the validity of the Opioid Risk Tool in a tertiary academic pain management center population. Pain Med 2018;19(7):1382–1395, https://doi.org/10.1093/pm/pnx332
  10. Cheatle MD, Compton PA, Dhingra L, Wasser TE, O’Brien CP. Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain. J Pain. 2019;20(7):842-851. doi:10.1016/j.jpain.2019.01.011
  11. Rhodes E, Wilson M, Robinson A, et al. The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review. BMC Health Serv Res 19, 784 (2019). https://doi.org/10.1186/s12913-019-4642-8
  12. Wiseman LK, Lynch ME. The utility of universal urinary drug screening in chronic pain management. Can J Pain. 2018;2(1):37-47. Published 2018 Feb 8. doi:10.1080/24740527.2018.1425980
  13. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
  14. Bauer MR, Shamas T, Gillespie-Heyman S, Ruskin A. Feasibility of Safe Opioid Prescribing in Outpatient Palliative Care: A Quality Improvement Project. J Pain Symptom Manage. 2021;62(2):410-415. doi:10.1016/j.jpainsymman.2021.02.006
  15. Jahan AR, Burgess DM. Substance Use Disorder. [Updated 2022 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570642/
  16. Cragg A, Hau JP, Woo SA, et al. Risk Factors for Misuse of Prescribed Opioids: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2019;74(5):634-646. doi:10.1016/j.annemergmed.2019.04.019
  17. Sager Z, Childers J. Navigating Challenging Conversations About Nonmedical Opioid Use in the Context of Oncology. Oncologist. 2019;24(10):1299-1304. doi:10.1634/theoncologist.2019-0277
  18. Yennurajalingam S, Arthur J, Reddy S, et al. Frequency of and Factors Associated With Nonmedical Opioid Use Behavior Among Patients With Cancer Receiving Opioids for Cancer Pain. JAMA Oncol. 2021;7(3):404–411. doi:10.1001/jamaoncol.2020.6789
  19. Ulker E, Del Fabbro E. Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain. Oncologist. 2020;25(3):189-196. doi:10.1634/theoncologist.2019-0540
  20. Webster LR. Risk Factors for Opioid-Use Disorder and Overdose. Anesth Analg. 2017;125(5):1741-1748. doi:10.1213/ANE.0000000000002496

Author Affiliation:  University of Pittsburgh Medical Center, Pittsburgh, PA
Conflicts of Interest: None to report
Version History:  Originally published in August 2011; Copy-re-edited August 2015.  In January 2023 it underwent a major revision by Alexander D. Ginsburg MD.