Data collected on a sample of chronic pain patients suggests that a new self-administered screening tool may be a reliable method for assessing the risk potential for aberrant medication-related behavior among those who are taking or being considered for long-term opioid therapy, according to results presented in the November issue of Pain.¹

Most physicians who prescribe pain medication have had no training in addiction issues and, lacking knowledge and experience with opioids, some clinicians may avoid prescribing them despite proven benefits.² The current study's investigators sought to develop and validate an assessment tool to help providers determine potential risk of abuse when prescribing opioids for chronic pain patients.

The Screener and Opioid Assessment for Patients with Pain (SOAPP) "provides clinicians with the ability to be more aware of those patients who may have greater difficulty modulating their own medical use of these drugs," the authors wrote. They added that, conversely, the questionnaire may also "help those clinicians who are uncomfortable prescribing opioids for pain management to realize that many patients are likely not to develop problems with these drugs."

"The use of long-term opioids for noncancer chronic pain is controversial," senior author Robert N. Jamison, PhD, associate professor of anesthesia and psychiatry at the Pain Management Center, Harvard Medical School and Brigham and Women's Hospital, in Boston, Massachusetts, told CIAOMed. "Therefore, we wanted to find a quick instrument that was reliable at predicting people who were at risk of problems for medication misuse."

The investigative team invited 26 specialists to identify predictors of problems and to rate the items. The 24 items identified as the most important predictors became the SOAPP questionnaire and was administered to 175 chronic pain patients who were taking or being considered for long-term opioid medication. Average age of participants was 47.7 years (SD = 11.2; range 23-88), 54.3% were female, and 43.2% had low back pain as their primary pain site. The questionnaire items were framed as "how often" questions, with 0 being "never or not often" and 4 being "often." The questions addressed areas of mood, car accident history, family history of substance abuse, others' perception of the patient's medication use, others' concern about the patient's drug and alcohol use, and legal problems.

At 6-months follow-up, the SOAPP was validated by identifying patients who exibited aberrant drug-related behavior in one or more of the following realms: a positive score on the Prescription Drug Use Questionnaire interview, a positive urine toxicology screen, or ratings by staff as to whether the patients were perceived to have a serious drug problem. Among the original participants, the data for 95 patients were evaluable; of these, 44 had positive Aberrant Drug Behavior Index scores and 51 had negative scores. "We had intentionally accepted a liberal index of substance misuse behavior in order to capture all subjects who may eventually demonstrate aberrant drug behavior," the study authors wrote.

"SOAPP is a very well developed and thoughtfully conceived screening instrument," Seddon Savage, MD, MS, associate professor of anesthesiology at Dartmouth Medical School and director of the Center on Addiction Recovery and Education, in Hanover, New Hampshire, told CIAOMed. "Early studies have suggested it is a reasonably valid and reliable tool, but time and clinical experience will give us an idea of its accuracy for predicting risks for addiction."

Of the original 24 questions, the investigators found that 14 seemed to be predictive of subsequent aberrant drug behaviors. The coefficient for these items, 0.74, was sufficient for a short questionnaire, investigators wrote in the published study. Study findings demonstrate that the receiver operating characteristics' curve analysis showed an area-under-the-curve of 0.881 (P <.001), a level that shows adequate sensitivity and specificity for a screening device.

According to study authors, the SOAPP can be easily understood by patients, is efficiently administered and scored, and provides clinicians with important information to determine which chronic pain patients may be at risk for misuse of long-term opioid medication.

"At this point, it's hard to improve on SOAPP as an initial screening tool," according to Dr. Savage, who additionally serves as a pain consultant at the Manchester Veterans Affairs Medical Center in Manchester, New Hampshire, and was not involved in the study. "I have not personally used this tool," she added, "but I look forward to doing so. I'm very enthusiastic about its potential."

The study was supported by an NIH grant and by a grant from Inflexxion, Inc, a subsidiary of Endo Pharmaceuticals.

References:

1. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112:65-75.

2. Jamison RN. Introduction to special edition. Clin J Pain. 2002;18:S1-S2.