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CONTENTS
Managing Opioid EmergenciesOpioid Rescue & Disaster Preparedness
Managing An Opioid Overdose Crisis What to know. How to prevent overdose. What to do if it happens. By: Stewart B. Leavitt, MA, PhD; Addiction Treatment Forum, 2007(Summer).
Emergency Opioid Tapering During A Disaster What to do when medication access is interrupted by disaster. From: National Pain Foundation, undated.
Also see: From: Pain Treatment Topics - Lee A. Kral, PharmD, BCPS, March 2006.
Naloxone for Reversing Opioid Overdose or Overmedication
NOTE: Product information indicates that naloxone may be administered via intravenous (IV, which is preferred), intramuscular (IM), or subcutaneous (SC) routes. Dosing is typically specified for IV administration; however, dosing is the same for IM, or SC administration, although onset of action may be slightly slower and duration of effect may be longer with these other routes. Intranasal administration – via use of an atomizer device – also has been used successfully (“off-label”).
Naloxone – Drug Information (Labeling Info) From: Merck Manual / Lexi-Comp. August 2008. This authoritative document primarily offers information from the original labeling for Narcan®. Access checked 6/6/09.
Using Naloxone – Fast Facts (Palliative Care) By: von Gunten CF, Ferris F, and Weissman DE. Fast Fact and Concept #39: Using Naloxone, 2nd Ed. 2005(Jul). End-of-Life Palliative Education Resource Center. This document addresses special concerns regarding the management of suspected opioid overmedication and overdose in palliative care settings. Access checked 11/2/09.
Naloxone for the Reversal of Opioid Adverse Effects By: Marcia L. Buck, PharmD in Pediatr Pharm. 2002;8(8). Reproduced on Medscape, 2002. This brief article addresses the various applications of naloxone for countering adverse effects of opioids, including overmedication (intoxication), overdose, pruritus, constipation, and others. Access checked 6/6/09.
Intranasal Naloxone for Acute Opiate Overdose From: Source unspecified, undated. (For information purposes only.)
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Clinical Tools for Assessing Opioid RisksProperly validated and applied assessment tools can sometimes be useful for evaluating current or potential risks of drug abuse, misuse, addiction, or diversion associated with prescribed opioid analgesics for pain management. If properly interpreted, results may aid in determining appropriate opioid therapy, as well as in tailoring patient-specific monitoring regimens. However, use of the tools also requires added time for healthcare delivery and they are not intended to be used to denying any patients the most adequate treatment for pain relief. The 10 assessment tools listed below are available for free download and use in clinical practice.
SOAPP® – Screener and Opioid Assessment for Patients in Pain This questionnaire is available in 5, 14, and 24 question versions. It is intended to help facilitate assessment and planning of long-term opioid therapy for patients with chronic, and to help predict which patients might exhibit aberrant medication behaviors in the future. A tutorial on the use of SOAPP is provided, including an in-depth introduction, scoring instructions, and video case examples. COMM™ – Current Opioid Misuse Measure This 17-item, self-report questionnaire may help clinicians identify whether a patient, currently on long-term opioid therapy may be exhibiting aberrant behaviors associated with misuse of opioid analgesics. Since the COMM examines current behavior, it is ideal for helping clinicians to monitor patients during the course of therapy.
(Free registration required. Access checked 4/28/09)
ORT – Opioid Risk Tool This is a 5-item, yes/no self-report to help measure and predict a patient’s probability of displaying aberrant behaviors when prescribed opioid analgesia. DAST – Drug Abuse Screening Test A 28-item yes/no self-report for identifying patients with existing drug abuse or addiction problems. DIRE – Diagnosis, Intractability, Risk, Efficacy This is a clinician-rated, 7-item scale to screen for the appropriateness of long-term opioid therapy in patients with chronic noncancer pain, taking into account the likelihood of drug abuse, misuse, addiction, or drug diversion. CAGE-AID – Cut down, Annoyed, Guilt, Eye-opener - Adapted to Include Drugs A 4-item questionnaire developed for the quick screening of patients with possible alcohol or substance abuse problems. In many cases, a more specific and thorough tool should be used. SISAP – Screening Instrument for Substance Abuse Potential Five questions address concerns about alcohol, marijuana, and cigarette use in order to stratify patients with chronic noncancer pain according to potential risks of developing problematic behaviors during opioid therapy. 5-Point Prescription Opiate Abuse Checklist This brief checklist is based on DSM-III-R parameters and was developed by a committee of pain management specialists. It is proposed as gauging the patient’s level of adherence to a current opioid analgesia regimen. POSIT – Problem-Oriented Screening Instrument for Teenagers This 138-item screening questionnaire was designed to identify problems and potential healthcare needs in 10 areas, including substance use/abuse, mental health concerns, and others.
http://www.emergingsolutionsinpain.com/index.php?option=com_content&task=view&id=346&Itemid=242 (Free registration and login required. Access checked 4/28/09)
From: Health.Utah.gov… Checklist for Adverse Effects, Function, and Opioid Dependence This 1-page checklist from the "Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain" provides a concise list of follow-up assessment considerations in patients taking opioid pain relievers. The checklist includes common adverse effects, potential areas of functional concern, and signs of opioid dependence. Access verified 5/04/09
http://health.utah.gov/prescription/pdf/guidelines/checklist%20for%20adverse%20effects.pdf
Monitoring Opioid Adherence in Chronic Pain Patients: Tools, Techniques, and Utility By: Laxmaiah Manchikanti, MD, et al. Pain Physician. 2008(March);11:S155-S180 (26pp).
The complex nature of drug misuse and abuse problems are discussed and, while no single monitoring technique can fully address these difficult issues, the authors describe how multiple approaches to adherence monitoring may be employed to sustain the prudent use of opioids for the treatment of chronic pain. Numerous charts and tables provide helpful summary information.
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Urine Drug Screening/Testing in Pain ManagementThe screening or testing of urine for both prescribed and unauthorized drugs can be an effective tool in clinical practice for the assessment and ongoing management of patients being considered for or currently managed with opioid analgesics for chronic pain. However, there are various approaches to such testing and it is not considered a substitute for good diagnostic skills. The several documents in this subsection provide helpful clinical guidance..
A Clinical Guide to Urine Drug Testing: Augmenting Pain Management & Enhancing Patient Care By: Catherine A.Hammett-Stabler, PhD, DABCC, FACB and Lynn R.Webster,MD, FACPM, FASAM. From: University of Medicine & Dentistry of New Jersey, Center for Continuing & Outreach Education. 2008(May); 28 pp.
Healthcare providers who order UDT should frequently consult with the laboratory to select appropriate tests and to keep informed of laboratory changes, such as adoption of new agents or assays. Practitioners should consider UDT results in the context of all the clinical information, and contact the laboratory to clarify test results when there is a discrepancy. This monograph provides necessary knowledge to interpret most UDT results within the context of pain management. Five case studies are included. Access verified 6/29/09.
Urine Drug Screening: Practical Guide for Clinicians By: Karen E. Moeller, PharmD, BCPP, et al. Mayo Clinic Proceedings. 2008;83(1):66-76.
Urine Drug Testing in Clinical Practice: Dispelling the Myths & Designing Strategies
As of April 2010, Edition 3 was no longer available and the 4th Edition was in preparation. Check the Academy's website for update information at: http://www.familydocs.org/professional-development/cme-monographs.php Urine drug testing (UDT) in clinical practice should be a consensual diagnostic test, which is done for the benefit of the patient with pain. This CME course helps healthcare providers (1) understand the purpose of UDT and identify a clear testing strategy, (2) distinguish between UDT for detecting illicit drug use and for monitoring adherence to an analgesic treatment regimen, (3) appreciate drug-testing methodology, instrumentation, and sensitivity/specificity of results, (4) identify strategies to improve analysis and interpretation of results, and (5) understand the limitations of UDT. Access checked 4/24/10.
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Commonsense Opioid-Risk Management in Chronic Noncancer Pain: A Clinician’s Perspective By: James D. Toombs, MD; from Pain Treatment Topics, August 2007.
Recognizing potential risks of opioids, treatment decisions regarding their use should be made only after a comprehensive evaluation of patients. Due consideration should be given to the complete medical history, including past or potential substance misuse. Taking all factors into account, opioid selection, doses, and treatment monitoring can be effectively tailored for patient needs and prudent clinical practice. Access checked 4/28/09.
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Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners (Book)
This book presents a balanced perspective in advocating effective pain control via opioid analgesics, when appropriate, yet cautioning the reader about the many associated risks and pitfalls. The authors point out that primary care physicians, nurse practitioners, and other first-contact clinicians are uniquely positioned to make a difference at the beginning of medical treatment. Patients with chronic pain or a substance-use disorder are more likely to seek treatment from a general practitioner than from a specialist. So front-line healthcare providers can maximize the chances for success when patients begin opioid therapy. The authors include step-by-step protocols for assessing patients’ risks of opioid abuse as well as for legally protecting the opioid prescriber. An emphasis is on acknowledging and addressing drug-related behaviors that sometimes compromise effective pain treatment with opioids. Access checked 4/28/09.
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Patient Level Opioid Risk Management By: Nathaniel P. Katz, MD, MS; from PainEDU.org, Inflexxion, Inc., 2007.
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From: American Sleep Apnea Association. 2007.
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Opioids for Pain: Risk Management (Module 6)
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Rapid-Onset Opioids: Recognizing and Preventing Abuse, Addiction, and Diversion By: Lara K. Dhingra, PhD, and Steven D. Passik, PhD; from Medscape; 2006.
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Universal Precautions in Pain Medicine: By: Douglas L. Gourlay, MD and Howard A. Heit, MD, in Medscape Neurology & Neurosurgery, 7(1), 2005. Similarly published in Pain Medicine, 6(2), 2005.
By adopting a "universal precautions approach" to the management of all chronic pain patients, regardless of pharmacologic status, stigma is reduced, patient care is improved, and overall risk is contained. Careful application of this approach will greatly assist in the identification and interpretation of aberrant behaviors and, where they exist, the diagnosis of underlying addictive disorders. Treatment plans can then be adjusted on an individual basis, as described in this article. Access checked 4/28/09. < Back to Top >
Treating Pain and Preventing Abuse and Diversion
The aim of this continuing medical educational (CME) course is to minimize and prevent prescription drug diversion by helping physicians recognize the principles of good pain management and, at the same time, to recognize patients at risk of abuse, addiction, and diversion of opioid analgesics. Included discussions will help readers identify the “street” market for opioid analgesics, understand methods used by criminal drug diverters, and design strategies to minimize drug diversion without harming legitimate patients. Access checked 4/28/09. < Back to Top >
Opioid Risk Management - THCI Conference Presentations
It was recognized that abuse of Rx opioids has become a major problem in the U.S.-- ahead of cocaine, heroin, and stimulants -- and the pharmaceutical industry is subject to increasing pressures by the FDA, DEA, Congress, and the general public to minimize the risks associated with their opioid products. The one-day, invitation-only Opioid Risk Management conference featured 15 presentations of the latest information on these challenging issues, which are available for download and viewing at the Tufts Health Care Institute website. Access checked 4/28/09. < Back to Top >
Rights and Responsibilities of Healthcare Professionals in the Use of Opioids for the Treatment of Pain Consensus from: the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine; 2004.
Addiction to opioids may occur despite appropriate opioid therapy for pain. Persistent failure to recognize and provide appropriate medical treatment for the disease of addiction is poor medical practice and may become grounds for practice concern. Similarly, persistent failure to use opioids effectively when they are indicated as part of the treatment of pain, including in persons with active or recovering addiction, is poor medical practice and also may be a concern. This consensus document provides 8 recommendations for dealing with these and other vital issues. Access checked 4/28/09. < Back to Top >
Definitions Related to the Use of Opioids for the Treatment of Pain (Clarifications of "Addiction") Consensus from: The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. 2001.
The definitions offered in this brief document do not constitute formal diagnostic criteria, but it is hoped that they may serve as a basis for the future development of more specific, universally accepted diagnostic guidelines. The definitions and concepts presented were developed through a consensus process of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. Access checked 4/28/09. < Back to Top >
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Opioid Risk Management
Patients and their caregivers need to know how to distinguish opioid overmedication from overdose, and how to take appropriate emergency actions for each. Many tragic opioid overdose fatalities might be avoided by such education. In other cases, disruption of access to pain-relieving medications during disasters can cause distress and discomfort for patients maintained on opioids and other pain-relieving medications. This came to light during the U.S. Gulf Coast hurricanes in 2005, which caused many hardships for patients and healthcare providers alike. Knowing how to prepare in advance for such disasters and/or how to taper the medications in an emergency to curtail withdrawal can be extremely important. Documents in this section provide vital guidance for healthcare providers, which then can be passed along to patients and their caregivers.
PDF available at: 
This document was originally developed to address the management of overdose in patients maintained on methadone for addiction treatment. However, the useful principles apply to all opioids. Signs/symptoms distinguishing overmedication from overdose are described. There are special instructions for handling emergencies, including a list of "do’s and don’ts" and illustrations of basic CPR, rescue breathing, and the “recovery position.” Finally, recommendations for the application of naloxone, including in community settings, are provided. Access checked 6/15/09.
See HTML document: 
Following disasters — eg, hurricanes, floods, tornados, fires — persons with chronic pain who are physically dependent on opioids or other medications may not have access to their medications or refills. These instructions can help prepare patients and their caregivers in advance for such emergencies. There is an explanation of what patients may experience (eg, withdrawal signs/symptoms), and how they can minimize the discomfort until they can get help. Besides opioids, withdrawing from benzodiazepines and antidepressants — often included in a pain management regimen — is discussed. There also is a link to a section dealing with preparedness when there is advance warning of a potential disaster, such as a hurricane. Access verified 6/15/09.
There have been serious concerns about increases of overdose deaths associated with prescribed and illicit opioid agents. Naloxone is an effective and relatively safe antidote for the complete or partial reversal of opioid overmedication or overdose, including fatal respiratory depression, induced by natural and synthetic opioids. Because of the very short duration of action of naloxone (approx. 20-60 minutes) its reversal of opioid-induced respiratory depression may cease while the opioid action persists. Therefore, respiratory depression may recur and patients should continue to be very closely observed. Also note that, since naloxone reverses the effects of opioids, it may precipitate symptoms of withdrawal (eg, pain, hypertension, irritability) in patients maintained on or addicted to opioids. Naloxone (once sold as Narcan® and other brands) is available as a generic, and prefilled-syringe products are also available for home use.
From: A consortium in the UK; updated continuously.
This site appears to have valid and useful information, including links to legitimate published research articles of interest; however, identity of the site owners and authors cannot be verified. It is listed here for completeness of presentation and information purposes only, and the intranasal administration of naloxone is an “off-label” application. Access checked 6/6/09.
From: PainEdu.org…
From: Emerging Solutions in Pain (ESP)…
Also see... Tools for Assessing Pain & Pain-Related Disability 
Apart from opioid risks, a special section of this website has pain scales and checklists that are useful for clinically assessing how intensely patients are feeling pain and for monitoring the effectiveness of treatments at different points in time. These are variously designed for different age groups, as well as individuals who do not speak English and/or cannot verbalize responses.
The prevalence of opioid misuse, abuse, and addiction has fostered considerable concern among physicians, who may subsequently hesitate to prescribe these medications. This paper provides a comprehensive overview of the numerous monitoring approaches that have been described in the literature – including screening instruments and urine drug testing – and it addresses the benefits and limitations of these techniques and tools.
This CME monograph (credit now expired) focuses on patient-centered Urine Drug Testing, UDT, used to enhance the management of chronic pain patients. In this context, UDT can serve as a useful tool to help verify patient-reported compliance or to demonstrate unreported drug exposure. Three key elements of UDT must be appreciated for its best use: 1) the pharmacologic characteristics of the drugs tested, 2) their relationship to the urine sample, and 3) the type of analyses performed by the laboratory.
Drug testing, commonly used in health care, workplace, and criminal settings, has become widespread during the past decade. Urine drug screens have been the most common method for analysis because of ease of sampling. The simplicity of use and access to rapid results have increased demand for and use of immunoassays; however, these assays are not perfect. False-positive results of immunoassays can lead to serious medical or social consequences if results are not confirmed by secondary analysis, such as gas chromatography–mass spectrometry (GCMS). The Department of Health and Human Services’ guidelines for the workplace require testing for the following 5 substances: amphetamines, cannabinoids, cocaine, opiates, and phencyclidine. This article discusses potential false-positive results and false-negative results that occur with immunoassays of these substances and with alcohol, benzodiazepines, and tricyclic antidepressants. Other pitfalls, such as adulteration, substitution, and dilution of urine samples, are discussed. The practical concepts summarized in this article should minimize the potential risks of misinterpreting urine drug screens. Access checked 4/28/09.
By: Douglas L. Gourlay, MD, FRCPC, FASAM; Howard A. Heit, MD, FACP, FASAM; Yale H. Caplan, PhD, D-ABFT; from California Academy of Family Physicians. 2006 (Edition 3).
Opioids have a legitimate and important role in treating chronic noncancer pain (CNP). Although there are risks, these medications should be available to patients who gain benefit from them and can use them safely. In this guidance paper, James Toombs, MD, applies the Model Policy for the Use of Controlled Substances for the Treatment of Pain from the Federation of State Medical Boards to provide a practical clinical framework helping to minimize risks when prescribing opioids. This allows standardizing the process of opioid management but does not dictate or constrain individualized approaches to therapy.
By: Lynn R. Webster, MD, FACPM, FASAM, and Beth Dove; June 2007.
Patients with untreated obstructive sleep apnea (OSA) stop breathing repeatedly during sleep, sometimes hundreds of times during the night and often for a minute or longer. Besides other concerns with this disorder, persons with OSA who are prescribed opioid analgesics may be at particular risk of respiratory depression and fatal asphyxia. This quick, 6-item questionnaire – the Snore Score -- can help detect patients who have or are at risk for OSA, and thereby help guide better informed opioid-prescribing decisions. Accessed 4/28/09. 
Pain management has become a medical-legal minefield. This brief CME program presents 8 preventative measures that can help reduce healthcare providers' risks of incurring a medical-legal action while providing effective pain relief for patients in need: 1) prescribe only to your patients; 2) assess pain thoroughly; 3) educate and provide informed consent; 4) document; 5) don’t hesitate to get help; 6) know how to manage addiction risk in patients with pain; 7) have a reliable emergency call system; and 8) don’t fail to treat pain. Access checked 4/28/09.
Pain management requires a multidimensional approach to ensure safety as well as efficacy. Considering the potential growth of rapid-onset opioids in pain management, this brief CME course offers techniques for the recognition of addiction as well as aberrant drug-taking behavior. Various strategies and guidance are presented regarding therapeutic dosing and the use of rapid-onset opioids for breakthrough pain. Two important practices are discussed: 1) thorough prescreening of patients, and 2) the clinician’s responsibility to monitor treatment compliance. Access checked 4/28/09.
Both the under-treatment of pain and opioid drug abuse are serious problems in our society. The Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA) have recommended that the makers of scheduled opioid analgesics develop Risk Management Programs (RMPs) that address abuse and diversion. One of the key parts of the RMP is an educational program "assuring the safe prescribing of the product by physicians."
In March 2005, leading experts from industry, academia, and regulatory agencies gathered in Boston to discuss current thinking and future directions in opioid risk management. The conference, chaired by Nathaniel Katz, MD, MS, of Tufts University School of Medicine, addressed issues surrounding the abuse of prescription opioid analgesics.
Healthcare professional concerns regarding the potential for harm to patients -- as well as possible legal, regulatory, licensing, or other third party sanctions related to the prescription of opioids -- contribute significantly to the mistreatment of pain. Though many types of pain are best addressed by non-opioid interventions, opioids are often indicated as a component of effective pain treatment.
Scientists, clinicians, regulators, and the lay public use disparate definitions of terms related to pain and addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals.
This special section focuses on the clarification, identification, prevention, and treatment of addictive disorders within the context of pain and, conversely, on pain management in persons with a history of addiction. Patients in pain may misuse a variety of substances to palliate their conditions, including prescribed and illicit opioids. Continued misuse can become harmful abuse, which may lead to physiological and psychological dependence (addiction). The interface of pain and addiction is a common and vexing problem in clinical practice.