Improve and Expand Screening and Testing for Misuse and Dependency

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Introductory Paragraph

Screening is one of the key approaches to prevent opioid misuse. Improving and expanding screening is an important part of a comprehensive strategy. The approach is to detect risks, so people who are more likely to misuse are not prescribed opioids at all -- or if they are, with added precautions. Some types of screening can help identify interventions for people who are in the early stages of misusing opioids before they develop an addiction.

Key Information

Screening for Risk Factors Can Minimize People Misusing Opioids

Prescribing physicians and medical professionals should evaluate mental health issues which make patients vulnerable to addiction. Hilary Connery, M.D., Ph.D., assistant professor of psychiatry at Harvard Medical School says “If you ignore screening for trauma, self-harm, and suicide, you’re missing a crucial opportunity for prevention.” [1]

Carol Falkowski, CEO of Drug Abuse Dialogs, emphasizes the need to expand testing and screening in doctors’ offices. In citing the opportunity to increase referrals, Falkowski said that less than 5% of the referrals to treatment come from doctors’ offices. [2]

Screening and Testing Types

There are a variety of screening tools that are appropriate for different scenarios. The two main categories are informational and toxicological. Informational screening tools provide risk stratification and can aid decisions on when additional toxicology testing is appropriate.

  • SBIRT (Screening, Brief Intervention, and Referral to Treatment). Screening is the first step to recognizing whether a person may have a substance use disorder. [3] See the SBIRT Program wiki page for more information. [4]
  • Urine Drug Testing. There are two categories of urine drug testing: screening and confirmatory.
  • Saliva Drug Screening. For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system. Unlike urine tests, a saliva test cannot be adulterated, it can be administered rapidly, has the ability to test for many things, shows the metabolite drug, and is cost-effective. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code.

Key Benefits of Toxicology Testing for Misuse

When done well, toxicology testing for misuse can contribute to addressing the opioid crisis in several ways:

  • It provides prescribing physicians with insights to reduce or eliminate prescriptions of opioids in situations where the risk of misuse is high.
  • It quickly detects if opioids are being overused so steps to stop misuse can begin earlier.
  • It detects if opioids are being underused and potentially diverted to illegal use (being sold or given away) or left around for possible theft.
  • It enhances accountability and discourages people from misusing or diverting opioids because such behavior will be detected

Recommended Testing for People on Chronic Opioid Therapy

Researchers estimate that 5 to 8 million American adults are prescribed long-term opioid therapy. [5] People on chronic opioid therapy are at significant risk for developing Opioid Use Disorder, with one review of studies showing that an average of between 3% and 19% of people on chronic opioid therapy develop an addiction.[6] The following are recommended practices when people are on chronic opioid therapy:

  • All patients should be assessed for risk factors, and then classified and stratified to optimize the testing protocols used.
  • All patients on chronic opioid therapy should have a detailed treatment agreement in the form of a contract signed by both the patient and physician that clearly identifies risks and the terms under which opioids may be prescribed.
  • Physicians must review PDMP data before prescribing opioids to identify possible risks or evidence of misuse or redirection.
  • Drug screening (or preferably, toxicology testing) prior to the initiation of opioid therapy.
  • Pill counts
  • Screening to potentially make referrals to mental health providers or social service providers.

Relevant Research

This literature review provides an overview of research which assessed substance use screening in outpatient adult and pediatric behavioral health settings. [7]

This article documents the correlation between comprehensive screening and risk stratification with decreased costs for patients, providers, and insurers. It concludes that prescribers are able to make increasingly well-informed decisions in treatment-planning regarding what to prescribe and how to best monitor patients for safety based on individual risk profiles. [8]

Impactful Federal, State, and Local Policies

Only 11 states make it mandatory for physicians to randomly test patients if they are writing multiple controlled substances prescriptions.

Available Tools and Resources

Opioid Abuse Risk Screener (OARS) was developed as a comprehensive self-administered measure of potential risk that includes a wide range of critical elements noted in the literature to be relevant to opioid risk. [9] InteraSolutions, the company that developed OARS, received a 2018 recipient of the State of Ohio's Opioid Science Challenge that seeks to identify and support scientific breakthroughs which help to address the opioid crisis. The OARS screening tool was recognized as one of those important breakthroughs. [10] OARS is 43-question assessment is administered using an iPad (tablet) and takes about 10 - 12 minutes to complete. It is HIPAA compliant, EMR supported, and has high reliability, validity and predictability scores. The assessment is instantly scored, and a report is available to the prescribing physician that provides a summary opioid risk profile and a multidimensional assessment of risk factors. The OARS also provides depression and anxiety scores that can be used for SBIRT assessments and wellness visits, including scores for the PHQ-9 and the GAD-7. All information is provided in a compressive easy-to-read report which clearly identifies aberrant behavior and risk factors for follow-up by the provider with the patient. The OARS is reimbursable with an average rate of $40 per screening. Providers can get reimbursed in most cases with the CPT Code 96103 or the SBIRT codes.

Promising Practices

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