Opioid addiction has become one of the leading drug problems today in the United States. There are many risk factors associated with opioid addiction, including a history of substance abuse, psychiatric disorders that are untreated, a younger age, or environments which encourage substance abuse. There are many tools used to find attributes that are associated with opioid overdose prevention. These tools can be split up into two categories; assessments made before opioid use begins-the opioid risk tool, opioid conversion kit, and STOP-Bang- and those made after-opioid agreement, urine toxicology screening, and prescription drug monitoring program. The attributes associated with opioid addiction prevention can be identified and the efficiency and helpfulness of these different tools will be analyzed to determine how to best reduce opioid addiction and overdose.
The opioid epidemic is a serious national crisis seriously affecting public health and social welfare. In fact, as of 2018, more than 115 people in the United States die every day from an opioid overdose. And in 2016, about two thirds of the fatal overdoses involved opioids. The opioid epidemic happened because pharmaceutical companies claimed that patients would not become addicted to the prescription opioid pain relievers in the late 1990s, and prescriptions began to rise. Opioids then became widespread and misused before the addiction of this drug became clear. Then, in 2014, between 26.4 million and 36 million people worldwide abused opioids. And as of 2018, about 21-29 percent of prescribed opioids for chronic pain are misused and 8-12 percent of patients develop an opioid use disorder. Declared a national public health emergency by President Trump, the opioid epidemic is “the worst drug crisis in American history”.
Prescription opioids are usually used to treat patients with chronic pain. Opioids are effective in managing chronic pain because they are able to impersonate the brain chemical endorphins, which serves as a messenger between nerve cells, also known as a neurotransmitter. Endorphins are produced as a response to stimuli; specifically, stress, fear, or pain. Brain cells release endorphin molecules, which then float across a gap to another cell, where they bind to receptor molecules. These receptors are found in the parts of the brain responsible for blocking pain and controlling emotion. So, when opioids enter these receptors, they block the cells’ transmission of pain signals, effectively fighting pain. And while prescription opioids can be safe when correctly prescribed and taken for a controlled time, they also produce a type of high that can easily lead to opioid misuse and addiction that then quickly lead to overdoses and deaths. Unfortunately, ways of monitoring and controlling opioid use have become necessary. 705 patients who were receiving opioid therapy for non-cancer pain from four or more physician orders within the United States healthcare system were interviewed to identify risk factors. This study found that current dependence was associated with age, opioid abuse history, high dependence severity, depression, and psychotropic medication usage. Those who were at the highest predicted risk for dependence on opioids were those with an age younger than 65, depression, use of psychotropic medication, and pain impairment along with a history of severe dependence and abuse of opioids. Patients with the first four variables were also at a high predicted risk for current dependence, but significantly less than those with all six. With the knowledge of risk factors associated with opioid addiction and overdose, it is important that tools are indicated and researched to prevent opioid-related deaths. We found six tools that can be utilized to prevent opioid misuse and overdoses: the opioid risk tool, opioid conversion kit, STOP-bang, opioid agreement, urine toxicology screening, and prescription drug monitoring program. And while these tools are individually used by clinicians and health physicians to look for signs of opioid misuse, an analysis and comparison of the efficiency of each tool is necessary to determine the most beneficial tool, or combination of tools, that can be implemented to help control the opioid epidemic.
Methodology and Approach
Opioid Risk Tool (ORT)
The Opioid Risk Tool was designed to assess the risk of opioid abuse in chronic non-cancer patients and is presented to patients as a simple screening questionnaire. The ORT records the patient’s age, psychological/psychiatric comorbidities, history of preadolescent sexual abuse, and family and personal history of substance abuse.
Strengths: : This tool is often used because it is concise. The patients can also easily complete the questionnaire themselves. The ORT assesses many variables that are appropriate to use to evaluate the possible risk of opioid addiction and misuse. Many variables have been found significant between the ORT score and the original data obtained by Webster and Webster when they initially developed the opioid risk tool.
Weaknesses: When clinicians administer this test to patients, it is not certain that certain issues will be truthfully revealed. For example, questions regarding marijuana use or sexual abuse may not be answered truthfully by patients. Certain variables on the tool are also subject to interpretation. When the tool is used in the United States, questions asking about “illegal drug use” will vary by state. It is also unclear how much of the drug or how often the drug must be used before considered “illegal”. This test also does not include other variables such as presence of psychological factors that may increase the efficiency of the opioid risk tool.
Opioid Conversion Kit
The opioid conversion kit is an equianalgesic opioid dosing calculator created to convert between opioids and other medications. This way, those prescribing opioids are able to rotate between different opioids and medications in order to create the least harmful combination of drugs possible.
Strengths: Studies have found that using conversion kits can help decrease pain and improve quality of life for patients with chronic non-cancer pain. Using ratios correctly limits the possibility of opioid addiction and misuse.
Weaknesses: The conversion ratios are often found to be arguable. While every person’s body is different and may react to drugs differently, it can also be extremely dangerous to alter conversion rates. Physician errors in calculating doses of medication can create such a harmful ending. Different drugs can also create more health issues. For example, the conversion to methadone can lead to respiratory depression and respiratory failure. Clinicians have also been found to be very unable to correctly convert the necessary doses.
The STOP-Bang is a questionnaire made up of 8-items testing for obstructive sleep apnea, which is a common sleep disorder where there is irregular stoppage or reduction of airflow during sleep. This tool asks about snoring, tiredness during the day, observed stop breathing, blood pressure, body mass index, age, neck size, and gender. The risk of having obstructive sleep apnea is determined by how many questions were affirmatively answered. The use of opioids for longer than 6 months puts patients at the risk of developing obstructive sleep apnea.
Strengths: This tool can be more easily scored in environments where there is no access to computer scoring programs. STOP-Bang is also more sensitive and can better identify more patients at the risk of sleep disordered breathing. It was also found that this tool was the best way to measure moderate to severe or severe cases of disordered breathing. There is also a direct link between sleep apnea and opioid use, so the use of the STOP-Bang can help prescribers determine the effect of opioids on patients.
Weaknesses: The STOP-Bang was not the best overall at determined patients at risk of developing sleep disordered breathing. The 4 variable screening tool had higher specificity at predicting moderate to severe and severe sleep disordered breathing. There is also not a 100% causation relationship between opioid use and sleep apnea.
The opioid agreement is a document that contains statements designed to help patients understand their responsibilities with the use of opioids. This document is signed before beginning long-term treatment with opioids and the conditions under which opioid treatment may be discontinued and the responsibilities of the pain treatment provider are identified.
Strengths: This document is able to facilitate communication between the patients and the prescribers of opioids. The opioid agreement is also able to settle out any questions or concerns before the use of long-term opioid treatment begins. The form emphasizes doctor-patient communication and is more open about the risks and benefits of opioid treatment.
Weaknesses: The opioid agreement may stigmatize pain patients and creates barriers to prescribing opioids. There is also a sense of undermining physician and patient trust. When used alone, there is almost no evidence that they minimize risk of opioid misuse. This document can also create a sense of mistrust and shame in patients.
Urine Toxicology Screening
A routine urine toxicology screening is a very common tool used to reduce prescription opioid misuse. This tool tests for inappropriate use of opioids along with the use of illicit drugs. The use of random urine toxicology screening is expected to reduce misuse of drugs.
Strengths: There is a general agreement among those that use urine toxicology screenings about which of the opioid-users to monitor, how often to monitor them, and what drugs should be tested using the tool. The urine toxicology screening also has less reliance on intuition when assessing for misuse. There is also the benefit that while clinicians fear of wrongly accusing patients and thus find it challenging to talk about potential misuse, the patient’s urine toxicology test creates a more comprehensive assessment and is framed around clinic policies. There may also be discrimination of testing for opioid misuse because of certain risk factors, but the routine use of this tool is an equalizing tool. The urine toxicology screening also provides more information about the patients’ current medical treatment and conditions. There have been significant reductions in drug misuse with monitoring combined with random urine drug testing.
Weaknesses: There is insufficient education and training about how to interpret and implement test findings throughout clinicians. Individual clinicians are left to manage interpretation of the urine toxicology tests. There may also be a lack of clarity on how and when to act on tests that indicate drug misuse. Strictly following clinic guidelines for urine toxicology tests can conflict with clinician’s own decisions about best practices for pain management. There is also a lack of definite course of action, making this tool limiting in scope and lacking context.
Prescription Drug Monitoring Program (PDMP)
The prescription drug monitoring program is consisted of statewide databases that collect data about the prescription of controlled substances. Created as a policy intervention, the PDMPs are used to reinforce the appropriate use of opioids, detect and discourage misuse, and advise public health officials.
Strengths: The use of mandatory PDMP was effective in reducing prescriptions for opioid analgesics. The tool found that a moderate increase in non-opioid analgesics led to a significant decrease in the frequencies and quantities of prescriptions for opioid analgesics. The overall effectiveness tool also rises when health-care providers can access the data from the PDMP.
Weaknesses: This tool can jeopardize pain treatments for urgent care patients. Because of the mandatory PDMP, there is a risk of underprescribing pain medications. The effectiveness of state PDMPs is lowered when there is little interstate data sharing. Prescription drug-dispensing information is not often available to state PDMPs in real time. There is also a lack of awareness of PDMP data, data restrictions on access to the PDMP, and a lack of tech interoperability and standardization. The impact of PDMP programs is affected by the wide variability in the design and functioning.
Analysis and Comparison of Approach
In order to compare the six tools to determine the best approach to reduce opioid misuse, we will employ three different metrics. In the chart below, the tools that are considered good for the metric will be colored green; those that are considered both positive and negative will be colored yellow; and those that are considered bad will be colored red. The metrics that will be used to compare the tools will be efficiency, scalability, and usability. For efficiency and usability, we assigned a value of 5, 3, and 1 for green, yellow, and red, respectively. For scalability, we assigned a value of 3, 2, and 1 for green, yellow, and red, respectively. Efficiency is defined in this study as how well the tool is able to reduce opioid misuse. Scalability is defined in this study as the sample size of the study done on the tool. Usability is defined in this study as how easy the tool is to use.
The level of efficiency will be determined by how well the tool is able to prevent opioid misuse. These calculations have been done in separate studies evaluation the individual tool. The opioid risk tool is more or less efficient because it is able to identify at-risk patients using variables, but the complete truth may not be revealed. The opioid conversion kit is also more or less efficient because used correctly, it is able to prevent opioid misuse, but it is very hard to be matched precisely to a specific person. The STOP-Bang is effective because it is sensitive and can identify patients at risk of opioid misuse. The opioid agreement is not effective because used alone, there is no evidence to minimize risk of opioid misuse. The urine toxicology screening is effective because it is able to accurately determine drug abuse. The prescription drug monitoring program is effective because it decreases the prescriptions of opioids and thus leads to a decrease in opioid misuse. For scalability, we have decided to use a threshold of 100/1000 for several reasons. First, the data used in each study fall within this threshold, making it a logical choice. This threshold is also easy to understand. The opioid risk tool had a sample size of 332, making it more or less reliable; the opioid conversion kit had a sample size of 29, making it unreliable; the STOP-Bang had a sample size of 60, making it unreliable; the opioid agreement had a sample size of 1285, making it reliable; the urine toxicology screening had a sample size of 500, making it more or less reliable; and the prescription drug monitoring program had a sample size of 6204, making it reliable. Usability will be determined by whether clear directions are included and there is uniformity between doctors who use the tool. The tools that have both clear directions and uniformity will be green, those with only one will be yellow, and those with none will be red. The opioid risk tool can be subject to interpretation but has clear directions making it more or less usable. The opioid conversion kit does not have clear directions and is not uniform between doctors making this tool unusable. The STOP-Bang and the opioid agreement have clear directions and is uniform between doctors, making these tools usable. The urine toxicology screening has clear directions but leaves individual clinicians to manage the interpretations of the test, making this tool more or less usable. The PDMP has clear directions and uniformity making this tool usable.
In this study, we found that overall, the prescription drug monitoring program was the most efficient at reducing opioid abuse. The PDMP was evaluated on a group of more than 1000 people, making the tool’s study credible; it was also efficient at reducing drug abuse, was easy for the tool administrators to use, and had clear instructions. The STOP-Bang was the next best tool to reduce opioid misuse. With a good efficiency and usability, but because the study was done on a group of less than 100, it was unreliable. While sleep apnea is not 100% related to opioid abuse, a correlation has been found, so this tool should be used with another tool.
After the STOP-Bang, the urine toxicology screening was best at reducing drug abuse because of a high efficiency, but a more or less scalability and usability. This test should always be used, no matter which other tool is being utilized because of its extremely high efficiency at determining opioid abuse.
The opioid agreement was deemed the fourth best tool because while it was inefficient at reducing opioid abuse alone, it had a strong credibility with a sample size of over 1000 and was very usable for the tool administers. This tool would be best used with another tool, preferably with the PDMP, in order to have the best results. The opioid risk tool was deemed the second worst tool in determining opioid misuse because the efficiency, usability, and scalability were just more or less positive. If used, this tool should be used in conjunction with a better scoring tool because the results of this test can be misleading. The opioid conversion kit was the worst tool out of the six tools evaluated because while it was more or less efficient, the tool was tested on a small sample size, and was very confusing for the administer of the test to use. We recommend that this tool only be used with one of the better scoring tools because using the opioid conversion kit alone can often lead to different types of drug abuse and complications. In the future, we would like to further research these tools with more metrics and a wider database of studies. Some limitations in this study was a lack of studies evaluated and any possible errors in the original studies. We recommend that the prescription drug monitoring program be studied further and implemented across states with a national database because of its promising reduction in opioid abuse. The urine toxicology screening should always be used in order to check for any signs of drug abuse in case an error by the opioid administer was made. The opioid agreement should also be used, but only with another tool because of its inefficiency alone.