Chronic pain and prescription opioid abuse are extremely prevalent in the United States and
worldwide. The consequences of opioid misuse can be life-threatening with significant morbidity
and mortality, exacting a heavy toll on patients, physicians, and society. The risk for misuse of
prescribed opioids is much higher in patients with chronic pain, especially those with concurrent
substance use and /or mental health disorders. Several reasons can account for the occurrence
of opioid abuse and misuse, including self-medication, use for reward, compulsive use related to
addiction, and diversion for profit.
There is a need, therefore, for therapeutic approaches that balance treating chronic pain, while
minimizing risks for opioid abuse, misuse, and diversion. Chronic opioid therapy for chronic
non-cancer pain has seen a dramatic increase throughout the past 2 decades in conjunction
with associated increases in the abuse of prescribed opioids and accidental opioid overdoses.
Consequently, a validated screening instrument that provides an effective and rational method
for selecting patients for opioid therapy, predicting risk, and identifying problems once they have
arisen, could be of enormous benefit in clinical practice. An instrument as such has the potential
to attenuate the risk of iatrogenic addiction. Despite the recent introduction of various screening
strategies and instruments, no single test or instrument can reliably and accurately predict those
patients unsuitable for opioid therapy or pinpoint those requiring heightened degrees of surveillance
and monitoring throughout their therapy. Current opioid abuse screening tactics include assessing
premorbid and comorbid substance abuse; assessing aberrant drug-related behaviors; stratification
of risk factors; and utilizing opioid assessment screening tools. Several authors have contributed
numerous screening tools and instruments to aid the assessment of appropriate opioid therapy.
Additional essential measures include urine drug testing, prescription practice monitoring programs,
opioid treatment agreements, and implementing universal precautions. Presently accepted
recommendations consist of a combination of strategies designed to stratify risk, to identify and to
understand aberrant drug-related behaviors, and to tailor treatments accordingly.
This manuscript, Part 2 of a 2 part update, builds on the 2012 opioid guidelines published in Pain
Physician, and the 2016 guidelines released by the Centers for Disease Control and Prevention. It
reviews screening, monitoring, and addressing opioid abuse and misuse in patients with chronic
non-cancer pain.
Key words: Opioids, misuse, abuse, chronic pain, prevalence, risk assessment, risk management,
drug monitoring, aberrant drug-related behavior
