Principles of risk management during opioid treatment for pain

	Goals	Strategies	Comments
Stratification of risk	To clarify the likelihood of future aberrant drug-related behavior	Regard as high risk if: History of alcohol or drug misuse Family history of alcohol or drug misuse Major psychiatric disorder Other factors that suggest risk: Cancer associated with heavy alcohol use or smoking Current heavy smoking Young age History of automobile accidents, chronic unemployment, poor support system Factors that can mitigate risk: Poor performance status Restricted prognosis Active recovery program	All patients should undergo risk assessment and stratification; although many questionnaires have been developed to predict aberrant behavior or addiction, the clinical assessment is generally used in practice.
Structuring of treatment commensurate with risk	Practices to match monitoring with risk, and when needed to help patients maintain control	Strategies include: Use of drug monitoring (eg, urine drug testing) Small amounts prescribed No use of short-acting drugs Use of one pharmacy Pill counts at time of visit Compulsory consultations	The decision to implement one or more of these strategies is a matter of clinical judgment.
Assessment of drug-related behaviors over time	Track drug use in tandem with all relevant outcomes	Monitor: Drug-related behavior - eg, need for early refills, obtaining several prescriptions, etc Pain relief Adverse drug effects Effect of drug on other outcomes	Broad monitoring of outcomes is consistent with integration of pain management into a palliative care model.
Response to aberrant drug-related behaviors	Clinician compliance with laws and regulations; identification of patients needing additional management	If the patient engages in aberrant drug-related behavior: Reassess and diagnose (addiction, other psychiatric disorder, pseudoaddiction, family issues, criminal intent) If diversion into the illicit marketplace is discovered, stop prescribing Otherwise, restructure treatment to improve control and obtain consultative help as needed	Even advanced illness does not free the clinician from the requirement of compliance with laws and regulations.
Documentation and communication	Risk assessment and management should be viewed as integral to safe and effective prescribing	Document: Plan for monitoring and education of patient and family Monitoring of drug-related behavior on a regular basis Response should aberrant behavior occur	Open discussion of the need for universal risk management with other clinicians is valuable to reduce the risk of stigmatizing patients.

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