In 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported approximately 2.3 million people 12 years of age and older had a prescription opioid use disorder. SAMHSA estimated that 8.7 million Americans aged 12 and older misused a prescription pain reliever in 2021. These staggering statistics highlight the need for responsible controlled substance and opioid prescribing. The reasonable evaluation of a patient’s pain management needs and medical conditions plays an integral part in prescribing controlled substances. Responsible prescribers must consider non-controlled alternatives and follow federal and state guidelines to ensure the safety of their patients.
Related: Evidence-Based Guidance on Prescribing Controlled Substances
DEA classification of controlled substances
The Drug Enforcement Administration (DEA) classifies controlled substances into 5 categories based on their medical use, potential for abuse, and potential for dependence. The following is a review of the 5 categories:
- Class I: High risk of abuse and no accepted medical use.
- Class II: High potential for abuse and psychological/physical dependence, accepted medical uses
- Class III: Low to moderate potential for psychological/physical dependence, lower risk of abuse than Class I and II
- Class IV: Low potential for abuse and low risk of psychological/physical dependence
- Class V: Lowest potential for abuse and contains limited quantities of certain narcotics
Risk factors for prescription drug misuse
The greatest predictor for prescription drug use disorders is the number of prescriptions issued for medically legitimate reasons. The greater the number of prescriptions for a particular drug correlates with an increased misuse of the medication. Other risk factors include:
- History of other substance use disorders
- Mental health disorders (especially PTSD and pain-related anxiety)
- Family history of substance use disorders
- Chronic pain
Assessing risk and screening tools
Every patient deserves access to effective and appropriate pain relief, provided to reduce adverse effects and minimize complications. Initial screening tests can help accurately identify pain and provide a basis for treatment. The visual analog scale (VAS) is one of the most widely used screening tools due to its simplicity of administration and accuracy. However, other screening tools like the Brief Pain Inventory and McGill Pain Questionnaire can be used.
After determining the treatment of pain is necessary, prescribers must perform a risk evaluation for substance use disorders (SUDs). This requires clinicians to gather and evaluate information through the history and physical, prescription monitoring programs, and screening tools to identify the risk of developing an untoward behavioral response to prescription opioids and other controlled substances.
Risk factors to consider
- Younger age (<30 years)
- Personal history of substance misuse
- Comorbid mental conditions, sleep disturbances, and mood disorders
- Exposure to parents or others with SUDs
- History of trauma or childhood adversity
- History of obtaining CS from multiple physicians
- Current or previous use of illicit street drugs
SUD screening tools
Several screening tools are available to assist clinicians in identifying patients at risk of controlled substance use disorders. These can consist of questionnaires with anywhere from one question to 80 questions. Fortunately, single-question questionnaires have proven to be 100% sensitive and 73.5% specific for detecting a drug use disorder and shown similar sensitivity and specificity for drug use compared to the 10-item Drug Abuse Screening Test (DAST).
The single-question questionnaire consists of asking patients, “How many times in the past year have you used an illegal drug or a prescription medication for nonmedical reasons?”
Screening for mental health disorders is important as they are often associated with chronic pain and present a risk for developing SUDs.
Considerations for when initiating pain medications
The Centers for Disease Control and Prevention (CDC) published a Clinical Practice Guideline for Prescribing Opioids in 2022. This resource can guide physicians and other prescribers in managing the use of opioids.
Acute pain
When addressing acute pain, controlled-release and long-acting opioids should not be considered. Immediate-release opioids should be used at the lowest dose necessary for the shortest period needed. In many cases this can be as short as 3 days; however, the patient’s unique needs must be considered when determining the duration of treatment.
Maximizing non-opioid treatment options can help reduce the overall need for opioids and minimize the treatment duration.
Chronic pain
The maximization of non-pharmacologic strategies and nonopioid medications should be the first-line treatment for subacute and chronic pain. This can include the use of home exercise programs, physical therapy, psychological treatment, and alternative measures such as manipulation, laser therapy, yoga, massage therapy, and acupuncture.
If non-pharmaceutical measures are insufficient in controlling pain, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered. Duloxetine is effective in managing chronic pain and should be considered before initiation of opioid medications. In patients with a neuropathic component of pain, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors (SNRIs), and anticonvulsants (such as pregabalin, gabapentin, and oxcarbazepine) can be effective management strategies.
If opioid therapy is indicated, starting at the lowest effective dose, utilizing immediate-release medications is preferred. Reassessment of opioid therapy should be performed within 1 to 4 weeks of initiation. Additional considerations should include the use of drug treatment plans, monitoring of prescription drug monitoring programs, and educating patients on the risks of withdrawal and overdose throughout the treatment periods.
Related: Effective Management of Acute and Chronic Pain with Opioid Analgesics
Recognizing Substance Use Disorders
The early recognition of SUDs is paramount in initiating proper treatment. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), defines SUDs as a problematic pattern of use leading to clinically significant impairment and two or more of the following within 12 months:
- The patient uses the substance in larger dosages or takes it a longer period than intended.
- Persistent desire or unsuccessful efforts to cut down or stop use.
- Patient spends substantial time obtaining, using, and recovering from the substance’s effects.
- Cravings and intense desires to use the substance are present.
- Failure to fulfill work, school, or home obligations due to persistent substance use.
- Social and interpersonal problems associated with continued use.
- Persistent use despite physically hazardous effects.
- Continued substance use despite knowing it is causing physical and psychological problems.
- The patient displays signs of tolerance.
- The patient displays signs of withdrawal.
The number of criteria present further divides the classification. Mild SUD is characterized by 2–3 criteria, moderate by 4–5 criteria, and severe by 6 or more of the above criteria.
Treating Substance Use Disorders
The recommended evidence-based treatment for OUD is the use of medications combined with behavioral counseling, case management, and peer support. Experts call this combination therapy MOUD. It can help relieve withdrawal symptoms and cravings and provide long-term options for patients. Currently, FDA-approved medications include methadone, buprenorphine, and extended-release naltrexone.
Benefits of treating substance use disorders with MOUD include:
- Lower risk of death secondary to overdose
- Improved social functioning
- Reduced risk of infectious diseases
Responsible prescribing of controlled substances
Taking precautions and selecting appropriate candidates when prescribing controlled substances can help reduce the risks of treatment. Following evidence-based protocols and frequent evaluation of the therapy can help identify dangerous patterns of use.
Staying current on all state and federal laws, as well as evidence protocols, is important for physicians to combat opioid and controlled substance epidemics.
