Review of Opioid Risk Assessment Tools with the Growing Need for Telemedicine

Keywords::

• COVID-19
• opioid misuse
• opioid risk assessment
• patient safety
• telemedicine

Practice points

• Many routine practices of chronic pain management have had to be adjusted in the COVID-19 era.

• There are multiple validated risk assessment tools established to screen for patients at high risk for opioid misuse as well as maintain opioid therapy.

• The pain medication questionnaire and brief risk questionnaire are the best supported tools for initiating opioid therapy in the in-person outpatient setting, therefore either of them would make a good choice as part of a telehealth visit for starting patients on opioids.

• The Current Opioid Misuse Measure and the Screener and Opioid Assessment for Patients with Pain-Revised have performed well in the outpatient setting for maintaining patients on opioid therapy; together they would provide the best information at a telehealth visit.

• The Current Opioid Misuse Measure may help indicate who has developed aberrant behavior, while the Screener and Opioid Assessment for Patients with Pain-Revised can predict future misuse.

• As most studies performed on risk assessment tools were not tested in telemedicine settings, there is a need for direct studies to better evaluate their use in telemedicine.

The COVID-19 global pandemic has created a need to transition routine in-person or in-clinic care for patients to virtual-based assessment and care both during periods of social isolation and into ‘re-opening’ phases. Providers will continue to have to weigh the risks and benefits of viral transmissions against in-person visits for patients with severe chronic pain needs requiring opioid initiation or maintenance. For populations that may be vulnerable to viral transmission (immunocompromised patients, patients with cancer pain or palliative care needs), providers may deem it safer to continue providing care through telemedicine until improved transmission prophylaxis becomes readily available.

Telemedicine has been shown to improve management of chronic diseases and compliance with medications through many areas of medicine, including gastroenterology [1], primary care [2] and cardiology [3]. In fact, telehealth collaborative pain management can significantly increase the proportion of patients with improved pain [4]. While telemedicine strategies have been broadly proposed, there are a lack of studies demonstrating the efficacy of opioid screening tools through telemedicine [5]. However, there are multiple validated risk assessment tools established to screen for patients at high risk for opioid misuse [6]. These tools present scalable methods of screening for risk prior to initiating or maintaining chronic opioid therapy in conjunction with the standard patient history and physical examination and other validated pain measures such as Patient Reported Outcomes Measurement Information System (PROMIS). Here we review and evaluate opioid risk assessment tools for telemedicine and make recommendations for chronic pain patients who are either initiating or being maintained on an opioid regimen.

Which assessment tool should be used in initiation of therapy?

One of the most established surveys predicting opioid misuse is the pain medication questionnaire (PMQ) [6]. It is a validated 26-question survey that predicts future opioid abuse, by separating patients between low risk (L-PMQ), those who receive scores in the lowest third range, and high risk (H-PMQ), those who receive scores in the highest third range [7]. Studies that have looked at the association between low risk and high risk patients as determined by the PMQ have demonstrated significant more signs of aberrant behavior, such as being 2.3-times more likely to drop out of treatment, 3.2-times more likely to request more refills or require an opioid contract [8,9]. In validation studies, the sensitivities for predicting whether patients are in the H-PMQ or L-PMQ ranged from 74 to 82% while the specificities ranged from 58 to 93% [6].

The opioid risk tool (ORT), is a short survey that is used by physicians starting patients on opioid therapy [10]. It is an eleven part survey consisting of elements from the patient’s past medical, psychosocial and family history that have been associated with substance abuse. The resultant score separates patients into low risk (0–3), medium risk (4–7) and high risk (> = 8) for developing opioid-related aberrant behavior. In the original study, 5.6% of patients in the low risk category showed at least one aberrant behavior within the next year of treatment, compared with 28% in the medium risk category and 90.9% in the high risk category. Despite this trend, a study that utilized the ORT did not demonstrate good predictability of aberrant behavior [11]. Of note, this was a retrospective study done with physician’s completing the ORT based on the patient’s chart. Though the results were not significant, there was a trend for the more at risk patients to demonstrate aberrant behavior: 38.7% of low risk patients demonstrated aberrant behavior within an average of 7.8 months, compared with 57.1% of medium-risk and 80% of high-risk patients. While the ORT may not be statistically sound in determining those patients at most risk of misusing opioids, it can be another tool used along with initial screen by urine toxicology and clinical judgment.

A newer survey, the brief risk questionnaire (BRQ), is composed of 12 yes/no questions that have been evaluated against the ORT and was found to be superior in assessing for aberrant behavior 6 months after initiating therapy [12]. This survey was completed by more than 450 patients being considered for opioid therapy for chronic pain. It was compared with the ORT for predicting misuse at 6 months after initiation of opioid therapy. The BRQ ultimately proved to be a better predictor than the other two surveys and was found to be almost as good as a structured clinical interview. Though Jones et al.’s survey is the only study looking at the BRQ in comparison with other metrics, it does suggest the BRQ will be a promising initial survey for determining patients at risk of abusing opioids.

From the limited data on assessments that help predict future opioid misuse, the original PMQ appears to outrank the ORT and has more data supporting it compared with the BRQ. However, with additional future studies the BRQ could prove to be an easier telemedicine questionnaire due to its brevity. The length of the PMQ survey may prove helpful in a telemedicine visit as it makes a patient commit to a longer line of questioning. Though the PMQ was developed and validated with many quality studies in the outpatient setting, theoretically it could be predictive of aberrant drug behavior in a patient at the initial telemedicine visit regarding opioid use.

Which assessment tool should be used for maintenance of therapy?

For the remote outpatient management of patients already on opioid therapy, guidance from a large systematic review on surveys suggests the Current Opioid Misuse Measure (COMM) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) are helpful in the treatment of chronic pain patients on long-term opioid therapy [6]. These two self-reported surveys consist of psychometric parameters that correlate with findings from the Aberrant Drug Behavior Index, a more laborious rating system that incorporates self-reported data, prescribing physician reporting and urinary toxicology screening [13,14]. There are, however, some differences between the two questionnaires. The COMM is a verified 17 part questionnaire that takes into account patient behavior from the previous 30 days [15,16]. Each section can be ranked from never to very often (0–4) and a summation of greater than or equal to nine indicates the potential of opioid-related misuse. At this cut-off, the sensitivity for determining current misuse ranged from 71 to 77% and the specificity ranged from 68 to 71% [6].

The SOAPP-R is a 24 part questionnaire regarding behaviors with no specific time frame [14,17]. Sections are answered from never to always (0–4) and a score of greater than or equal to 18 indicates the risk of potential future misuse in the next 6 months. At this cutoff, the sensitivity for predicting future misuse ranged from 79 to 81% and the specificity ranged from 52 to 68% [6]. Considering these differences, the COMM is a good indicator of the patient’s behavior in the past month on treatment and the SOAPP-R is a good predictor of how the patient will be in the future. As has been suggested upon the revision of the SOAPP-R, these two surveys can synergistically help determine which patients are in trouble of abusing the prescription [14].

Therefore, our recommendation based on the data available would be to use the two assessments together in the maintenance of patients on opioid therapy. In the telemedicine follow-up meetings, the COMM can help deduce if someone is currently misusing and the SOAPP-R can help predict future misuse.

What are the problems with screening for opioid abuse remotely?

Opioid screening tools provide a unique compromise in remote monitoring of patients on chronic opioid therapy as they can be completed and self-reported by patients via an appropriate platform or completed along with a provider over the telephone. Moreover, the simple act of participation, or lack thereof, in the surveys can provide meaningful insight into the risk profile of each individual patient. Despite the ease of completing these screening tools and their general reliability, these modalities rely on honest self-reporting [6]. Consequently, therein lies the risk of a patient under-reporting abusive or concerning behavior due to the fear that they may no longer receive opioid prescriptions. With increased use of telemedicine, one should consider that access to providers across state lines may be easier to achieve as well, highlighting a potential need for monitoring prescriptions across state lines. Therefore, we would encourage providers to review the screening tools with patients to ensure appropriate participation.

Given the inherent pitfalls in these opioid screening tools, it is important to continue to broadly assess patients for aberrant behavior despite the results of the screening tool, including reviewing visits to other providers or emergency departments, monitoring prescriptions via state regulations (such as PMP in New York) to evaluate for multiple prescribers of opioids, understanding why a patient is running low on medication, obtaining input from the patient’s family and friends when appropriate and using urinary toxicology [14].

Can all assessment tools be performed remotely?

Fortunately, all opioid screening tools can be completed remotely, either by the patient independently or with a provider via telemedicine. This process can be streamlined by integrating the screening tool into an electronic patient portal, where patients have access to their medical information, so that both the tool can be completed and the results are readily available for review and to be tracked. Furthermore, patients may be tasked with completing the screening tools at predetermined intervals, and the results can be flagged to the provider’s inbox for further review and management. Though these processes would be particularly helpful during the COVID-19 pandemic, they may have a place in chronic opioid monitoring via telemedicine even as we move forward. Finally, there may be some value in using and comparing results from these screening tools in combination with other reported outcomes measures that look at the effectiveness of pain management treatment and that can also be administered remotely, such as PROMIS, Neck Disability Index or Oswestry Disability Index. If this infrastructure is not readily available, healthcare personnel can administer these tools to patients prior to their telemedicine visit with the primary pain management provider in order to efficiently risk stratify patients.

How can these assessment tools be utilized to delineate which patients require in-person visits?

Table 1 provides a summary of assessment tools, the appropriate settings for use and when the results necessitate in-person visits.

Table 1. Summary of risk assessment tools.

Assessment tool	When to use	Result necessitating in-person visits
PMQ	Initiation	Patient deemed in the H-PMQ category (scores of 25 or above)
BRQ	Initiation	High risk
ORT	Initiation (less supported)	High risk (>= 8)
SOAPP-R	Initiation/maintenance	Score >= 18
COMM	Maintenance	Score >= 9

BRQ: Brief risk questionnaire; COMM: Current Opioid Misuse Measure; H-PMQ: High risk from the PMQ; ORT: Opioid risk tool; PMQ: Pain medication questionnaire: SOAPP-R: Screener and opioid assessment for patients with pain-revised.

Conclusion

The PMQ and BRQ have the best performances on initiating opioid therapy in the in-person outpatient setting, therefore, either of them would make a good choice as part of a telehealth visit for starting patients on opioids. Similarly, the COMM and the SOAPP-R, have performed well in the outpatient setting for maintaining patients on opioid therapy, so together they would provide the best information at a telehealth visit. The COMM can help indicate who has developed aberrant behavior, while the SOAPP-R can predict future misuse. That being said, our recommendations are not based on studies that performed the assessments via telemedicine and clinical judgement and urinary toxicology should be used as needed.

Financial & competing interests disclosure

N Mehta is a consultant for Nevro, Biodelivery Sciences, Salix pharma Advisor and has research with Nevro and Abbott. A Gulati is a Medical advisor for AIS and a consultant for Medtronic, SPR therapeutics, Nalu Medical, Bausch Health and Flowonix. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.