9
Table 3. Universal Precautions in Chronic Cancer Pain
Management
Steps Strategies Comment
1. Assess and
stratify risk
of opioid
misuse
Assess:
• Review of medical records including
diagnosis
• Interview (consider risk factors such
as age, personal or family history
of alcohol or drug abuse, major
psychiatric disorder, history of sexual
abuse)
• Examination
• Screening questionnaires
• Review of prescription drug
monitoring program data
• Urine drug screening
• All patients should
undergo risk assessment
• Although many
questionnaires have
been developed to
predict aberrant
behavior or addiction,
the clinical assessment
is generally used in
practice
• Risk stratification and
adherence monitoring
are illustrated in Table 4
2. Decide
whether
or not to
prescribe
Risk of diversion:
• Low → prescribe
• High and the controlled drug is
preferred but not a standard of care →
do not prescribe
• High and the controlled drug is the
standard of care and no reasonable
alternatives exist → proceed only if
controls and adherence monitoring can
be established to ensure that diversion
is not occurring
Risk of drug abuse:
• Low → prescribe
• Moderate or high: decision to prescribe
requires a critical analysis of:
▶ whether the severity of the pain
is meaningfully compromising
physical or mental well-being,
▶ whether there are reasonable
alternatives that may ameliorate
pain with manageable risk, and
▶ whether the nature of the drug abuse
risk is more (eg, relapse of heroin
abuse) or less (eg, pattern of early
refills) serious
Proceed only if:
• Prescribing protocol
and adherence
monitoring
commensurate with
the risk can be put in
place, and
• The patient is
educated about the
purpose of these
strategies and the plan
to modify prescribing
or discontinue the
drug if abuse occurs
• Do not prescribe
unless warranted by
the severity of the
pain experience, there
are no reasonable
alternatives, and
the risk of abuse
or diversion is
manageable
3. Minimize
risk
• Structure treatment in a manner
that establishes an appropriate level
of adherence monitoring and helps
patients avoid nonadherence
• Always optimize adjuvant analgesics,
nonpharmacologic and interventional
approaches; psychological support
for treatment of psychiatric illness,
anxiety, depression, sleep disorders
Adherence monitoring is
illustrated in Table 4
