Opioid Risk Tool (ORT) for Narcotic Abuse
The ORT may help identify patients at high risk for misuse, and who who might benefit more from other modalities of pain control besides narcotics (primarily applicable to patients with chronic pain).
Substance use, particularly of prescribed drugs, has been an increasing problem in the United States. It is reasonable to consider risk of future abuse/diversion/misuse, especially if considering prescribing narcotics to high risk patients.
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- Pain medications should not be withheld for painful conditions simply because a patient is deemed “high risk” by the ORT, but these patients should be considered for other modalities of pain control if appropriate.
- These high risk patients may be appropriate candidates for referral to pain management.
- Providers should exercise caution when starting any patient on chronic opiates.
Addition of the selected points. Complete scoring information can be found in the derivation study.
Facts & Figures
- Low risk: 0–3.
- Moderate risk: 4–7.
- High risk: ≥ 8.
- 185 patients were followed in chronic pain clinic.
- Tracked to determine who developed "aberrant behaviors".
- Developed a score based on this to calculate this risk.
- Of note, still 5% of "low-risk" patients still had aberrant behaviors..
Aberrant behaviors included a long list of behaviors indicating possible abuse, including but not limited to:
- Used additional opioids than those prescribed.
- Requested refills instead of clinic visit.
- Canceled clinic visit.
- Solicited opioids from other providers.
- Unauthorized ER visits.
From the Creator
Why did you develop the Opioid Risk Tool (ORT)? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
Every physician knows that opioids can be addictive. When it became acceptable to use opioid to control chronic non-cancer pain, I knew some patients would be at risk of developing an addiction, so I wanted to identify who was at most risk. I thought that if I knew who was at greatest risk of misusing/abusing their opioids I could mitigate harm. We have to understand that addiction to opioids is 50% genetic and 50% environmental. It is not resident in a drug. The ORT is based upon assessing the genetic and environmental factors that makes a person vulnerable. Of course anyone can develop an addiction.
How do you use the Opioid Risk Tool (ORT) in your own clinical practice? Can you give an example of a scenario in which you use it?
All patients are asked to complete the questionnaire on their first visit to the clinic even before I would make a decision whether an opioid should be prescribed. I then review the answers and sometimes I ask questions to be sure they have completed it correctly. The score is noted and documented in the chart with the initial exam.
What pearls, pitfalls and/or tips do you have for users of the Opioid Risk Tool (ORT)? Do you know of cases when it has been applied, interpreted, or used inappropriately?
It is meant to supplement other risk assessments or to diagnose a substance use disorder. It is not meant to predict abuse or addiction but to provide the clinician a sense of the probability the patient will display aberrant drug related behavior within a year if prescribed an opioid. Sometimes patients will not be honest and can provide incomplete or wrong answers. However, if they provide false information, it usually becomes apparent after a few visits and getting to know the patient.
What recommendations do you have for doctors once they have applied the Opioid Risk Tool (ORT)? Are there any adjustments or updates you would make to the score based on new data or practice changes?
If the doctor knows the patient, they may be able to help complete the tool on the first visit. This can improve its predictability. The score can also be updated if more accurate information is obtained during time the patients is being treated. Sometimes patients will provide false positive answers which overstates their risk, or not disclose important history which understates their risk. In time, the accurate picture usually develops.
Any other research in the pipeline that you're particularly excited about?
I only do clinical research now. Most of my work is on trying to find safer and more effective analgesics than opioids. Several companies are making progress in developing analgesics that could one day replace opioids as we know them today. I think this is necessary and exciting.
About the Creator
Lynn Webster, MD, is medical director at CRI Lifetree in Salt Lake City, Utah and is also the co-founder of LifeSource, a non-profit foundation providing education about pain-related issues. Dr. Webster has authored over 100 scientific abstracts and journal articles, and he recently published Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. He has also received honoraria related to formal advisory activities and as a consultant from the American Academy of Pain Management, American Board of Pain Medicine, Boston Scientific Corporation, and multiple pharmaceutical companies.
To view Dr. Lynn Webster's publications, visit PubMed