1. 2012;15;ES67-ES92Prescription Opioid Abuse in Chronic Pain: A Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse
   Narrative Review
   Nalini Sehgal, MD, Laxmaiah Manchikanti, MD, and Howard S. Smith, MD.

Both chronic pain and prescription opioid abuse are prevalent and continue to exact a heavy toll on patients, physicians, and society. Individuals with chronic pain and co-occurring substance use disorders and/or mental health disorders, are at a higher risk for misuse of prescribed opioids. Opioid abuse and misuse occurs for a variety of reasons, including self medication, use for reward, compulsive use because of addiction, and diversion for profit.

Treatment approaches that balance treating chronic pain while minimizing risks for opioid abuse, misuse, and diversion are much needed. The use of chronic opioid therapy for chronic noncancer pain has increased dramatically in the past 2 decades in conjunction with a marked increase in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they arise could be of enormous benefit. Such an instrument could potentially curb the risk of iatrogenic addiction. Although several screening instruments and strategies have been introduced in the past decade, there is no single test or instrument that can reliably and accurately predict patients who are not suitable for opioid therapy or identify those who need increased vigilance or monitoring during therapy.

At present screening for opioid abuse includes assessment of premorbid and comorbid substance abuse; assessment of aberrant drug-related behaviors; risk factor stratification; and utilization of opioid screening tools. Multiple opioid assessment screening tools and instruments have been developed by various authors. In addition, urine drug testing, monitoring of prescribing practices, prescription monitoring programs, opioid treatment agreements, and utilization of universal precautions are essential.

Presently, a combination of strategies is recommended to stratify risk, identify and understand aberrant drug related behaviors, and tailor treatments accordingly.

This manuscript will review the current state of knowledge regarding the growing problem of opioid abuse and misuse; known risk factors; and methods of predicting, assessing, monitoring, and addressing opioid abuse and misuse in patients with chronic noncancer pain.