Using Risk Stratification to Determine Testing Frequency for Patients on Long-Term Opioid Rx

One question I’m frequently asked by other clinicians is, “How often should I be testing my chronic pain patients?”

When I ask how they currently determine testing in their practice, the answers range from “I don’t test because I know my patients” to “We roll dice when the patient registers.”

In my experience, physicians as a group have concerns regarding their ability to distinguish low risk patients from those who will likely require frequent monitoring. This concern can lead to a reluctance in prescribing long-term opioid medication.

A smart and frequently used strategy to establish testing frequency is based on stratifying patients based on risk. There are several risk assessment tools available for clinical use. While most clinicians are aware of these tools, there has been little information on how to implement the results (e.g., determine testing frequency). In February 2009, an article funded by the American Pain Society titled Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain recommends using a risk assessment tool along with a History, Physical Exam and other appropriate testing before initiating chronic opioid therapy (COT). According to these guidelines, “Tools that appear to have good content, face, and construct validity include the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1, the revised SOAPP (SOAPP-R), the Opioid Risk Tool (ORT), and the Diagnosis, Intractability, Risk, Efficacy (DIRE) instrument.” Monitoring recommendations for patients at low risk for adverse outcomes is at least once every 3 to 6 months, patients at very high risk could require monitoring on a weekly basis. Those patients falling in between these 2 categories would include those prescribed a change in opioid dosage, patients with an addicting disorder, older adults, those in an occupation demanding mental acuity, patients with an unstable or dysfunctional social environment and those with comorbid psychiatric or medical conditions.

I have personally used the SOAPP-R with good success and have recommended it to others. This 24 question self-report questionnaire is designed to aid in the process of determining which patients are at high risk for opioid misuse. Scores stratify patients into low, moderate and high risk categories. I have recommended UDM intervals as follows:

SOAPP-R Score	Risk Level	Monitoring Frequency
0-9	Low	1-2 times per year
10-21	Moderate	4-6 times per year
22+	High	weekly initially, then every visit

Keep in mind, the patient’s level of risk can change over time. It’s important to perform serial risk assessment surveys to restratify your patients. Also, there are differences between the available tools. You should choose the one that works for your practice.

Risk assessment tools like SOAPP-R are a simple, proven way to evaluate a patient’s potential for misuse. However, these tools should not be relied on exclusively as other monitoring techniques may also indicate high risk (e.g., illicit drugs detected in urine drug testing). For those patients who are high risk, combining UDM with pill counts, frequent follow-up visits, use of prescription monitoring programs (PMP) and family member interviews is an effective and reasonable monitoring strategy.