Screening for and assessment of opioid use

Ask all new patients routinely and others (adolescents and adults) opportunistically and periodically about prescribed and illicit opioid use, as part of a general screen for disorders of substance use and gambling; these disorders are common and often co-exist. Patients may be unaware that their use, particularly of prescribed opioids, is harmful. Others are reluctant to disclose disorders of use or addictive behaviour, often due to fear of stigma. Screening and assessment of substance use and addictive behaviours outlines history-taking (including use of the ASSIST-Lite tool), examination, and investigations that should be considered in a broad review of substance use and addictive behaviour.

Diagnostic questionnaires may be used as part of assessing the extent and impact of use. The OWLS tool can be considered to assess prescription opioid use; for illicit opioids, the Severity of Substance Dependence tool, can be usedPicco, 2020.

Table 1. The OWLS screening for a disorder of prescribed opioid use
Question	Response	Score
In the past 3 months did you use your opioid medicines for other purposes, for example to help you sleep or help with stress or worry?	Not at all	0
	A little	1
	Quite a lot	1
	A great deal	1
In the past 3 months did opioid medicines cause you to feel slowed down, sluggish or sedated?	Not at all	0
	A little	1
	Quite a lot	1
	A great deal	1
In the past 3 months did opioid medicines cause you to lose interest in your usual activities?	Not at all	0
	A little	1
	Quite a lot	1
	A great deal	1
In the past 3 months did you worry about your use of opioid medicines?	Not at all	0
	A little	1
	Quite a lot	1
	A great deal	1
Total score [NB1]
Note: NB1: A score of 3 or more indicates the person is likely to meet criteria for a disorder of opioid use; further assessment is warranted. Reproduced from Picco L, Middleton M, Bruno R, Kowalski M and Nielsen, S. Validation of the OWLS, a Screening Tool for Measuring Prescription Opioid Use Disorder in Primary Care. Pain Medicine 2020; 21(11):2757-2764 by permission of Oxford University Press. URL.

After initial screening, assess the extent and impact of opioid use, by determining:

how much, how often and by what route opioids are used¹
patterns of use, including any past efforts to reduce
withdrawal symptoms (current and past)
potential harms, including self-harm, accidental overdose, impacts on relationships, work and child protection concerns.

Opioid withdrawal symptoms and signs are likened to a ‘bad case of the flu and gastro together’. Symptoms usually peak at around day 2 to day 3 and are largely resolved after 5 to 7 days. Subjective symptoms of opioid withdrawal are more sensitive indicators of a need for medical intervention than objective signs, which may be modest. For additional details, see the Subjective Opiate Withdrawal Scale and the Clinical Opiate Withdrawal Scale at the National Centre for Education and Training on Addiction website.

Assessment of the extent and impact of use can categorise opioid use as hazardous, harmful or dependent. Advice from or referral to pain or addiction specialists is recommended for assessment of complex issues such as substance use in chronic pain.

Table 2. Symptoms and signs of opioid withdrawal
Symptoms [NB1]
agitation, anxiety insomnia sweating (diaphoresis) musculoskeletal pain abdominal cramps diarrhoea nausea vomiting hot flushes, cold flushes cravings to use opioids
Signs [NB1]
elevated heart rate enlarged pupils (mydriasis) teary eyes (epiphora) runny nose (rhinorrhoea) sweating tremor restlessness yawning ‘gooseflesh’ (piloerection)
Note: NB1: Symptoms are more sensitive indicators of opioid withdrawal than signs.

¹ Although evaluating dose and frequency of opioid use are part of the assessment of whether use is controlled, they are not criteria in their own rights for determining opioid dependence and they do not determine dosing requirement in medication-assisted treatment of opioid dependence.Return