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How Opioid Misuse Develops into Substance Use Disorder

person dispensing prescription opioid into their hand

Any person who takes opioids is at risk of developing substance use disorder. Determining candidacy for opioid therapy requires careful assessment and a thorough understanding of what risk factors make a patient higher risk for misuse. When a provider considers prescribing opioids, the risk versus benefit analysis becomes very important. If it is determined that the benefit of opioid treatment outweighs the risks, then safe initiation of opioids, routine assessment, and compliance monitoring become the primary tools to keep patients safe.

Gina Cooper, Toxicology Director with DRUGSCAN, describes the important role a provider plays in preventing substance use disorder, along with the tools to help them do so.

“A variety of factors may make a patient a poor candidate for an opioid prescription. Family history of substance use disorder, personal history of substance use disorder, and other environmental factors can be signs that opioids are not the best course of action for a patient,” said Cooper.

Cascade of Opioid Misuse

There isn’t one clear path to substance use disorder. However, for people whose difficulty begins with an opioid prescription for pain management, there is often a progression that begins with varying degrees of medication misuse and abuse. Following this time of medication misuse and abuse is when substance use disorders can begin.

Substance use disorder is an eclectic, individual disease that takes many forms. Below is one example of the progression of medication misuse to substance use disorder.

  1. Patient sustains an injury and is determined to be a poor candidate for many treatment modalities.
  2. Provider initiates opioid therapy.
  3. Patient is unable to work or continue the same social activities they have been used to as a result of the injury/pain and eventually is diagnosed with comorbid depression.
  4. Patient begins sporadically taking more medication than is prescribed to help with anxiety and sleep.
  5. Patient continues escalating the dose on their own.
  6. Patient seeks additional opioids from friends and family or purchases them from illicit sources.
  7. Patient may begin experimenting with different routes of administration, such as crushing and /or snorting.
  8. Patient is unable to get enough opioids. They may begin taking additional substances together with the opioid, such as benzodiazepines or alcohol.

Preventing Substance Use Disorder

It is the responsibility of the healthcare provider to monitor their patients for signs of potential misuse. But when should they start looking? Cooper says before any opioids are even prescribed.

Once a patient is prescribed opioids, there are steps the healthcare provider must take in an effort to prevent substance use disorder. 

“The overarching theme in healthcare that early detection allows for early intervention and leads to better outcomes holds true here. Providers must watch for signs of medication misuse so the appropriate interventions can be put in place,” said Cooper.

1. Pay Close Attention to Behaviors

After prescribing opioids to a patient, the provider should pay close attention to their behaviors and monitor for signs of misuse. Certain signs can be telling that the patient is not following the treatment plan as prescribed.

Signs of Misuse

  • Changes in appearance. Weight changes, lack of hygiene, appearing tired, or any prominent changes in physical appearance.
  • Sedation. Slower movements, slurred or slowed speaking, decreased alertness or any signs of acute impairment
  • Changes in work or life habits. Missing appointments, missing shifts at work, or signs of an unusually erratic schedule.
  • Mood changes. Quick changes in mood that are unusual for the patient.
  • Loved ones at appointment. A close friend or family member attending the patient’s appointment may bring concerns to a provider’s attention.

While there are many ways a provider can detect opioid misuse, many early signs are easily masked or missed at a doctor’s appointment and better detected in a patient’s day-to-day life. Since healthcare providers aren’t always around their patients, there are other ways to detect pathways to misuse, including toxicology.

2. Pay Close Attention to Medication Depletion

A telling sign of potential opioid misuse is irregular patterns of medication depletion. If a provider prescribes 90 days’ worth of opioids and the patient requests a refill at 60 days, a provider should be on alert. In this case, the patient may be misusing the medication, selling it, or giving it away.

How can a provider tell whether a patient is taking too much, too little, or depleting their supply far too early? Prescription drug monitoring, or toxicology testing, can be a useful tool in learning more about a patient’s recent drug use.

3. Toxicology: The Only True Measure

Toxicology testing is the most valuable tool a provider has for determining what medications and other substances a patient has been exposed to. It is an objective way to know what a patient has taken within the days leading up to the test.

While there are many signs—physical, mental, emotional—that a provider can look for in their patient to detect opioid misuse, these tells are all subjective.

From a patient safety perspective, knowing what the patient took and how much is invaluable. For example, if a patient is prescribed a hydrocodone-containing medication, but has a urine drug screen that is positive for both hydrocodone and oxycodone, the patient is at an increased risk for medication side effects, overdose, and death. Toxicology testing is the only tool that will provide this potentially life-saving information.

When a toxicology report comes back from the lab, it is an opportunity to evaluate a patient’s progress in treatment. It is also a crucial time to intervene if there are warning signs of misuse, including being positive for non-prescribed medications, illicit substances, and alcohol.

Read Our Blog: Patient Adherence — How to Know What Medications Your Patients Are Taking 

What is Toxicology?

With DRUGSCAN’s toxicology technology, Urine Drug Testing is used as a tool to gather information that can reveal whether a patient is engaging in medication misuse and is at risk for adverse events and substance use disorder.

After retrieving a urine sample from the patient, it is sent to a lab where 98% of results are available in 24 to 48 hours. Color-coded, online reports are then made available to providers with information on the patient’s current drug use.

When providers have toxicology as a tool, they can discover misuse of a prescribed substance right when it starts to prevent the cascade of opioid misuse.

Read Our Blog: Four Steps to Responsible Urine Drug Testing

Addressing Potential Misuse

It can be very difficult for a provider to address misuse once a patient is suffering from substance use disorder. At this point specialty treatment, possibly including inpatient detox are often needed. That’s why it’s so important to look for signs of medication misuse and intervene as soon as possible.

Detecting misuse early using tools like toxicology and coaching patients to help them stay on track is the best way to prevent substance use disorder and potentially life-threatening habits.

Check Out DRUGSCAN's Prescription Drug Monitoring Services

Toxicology & Prescription Drug Monitoring Experts

With more than 35 years of testing experience, DRUGSCAN is dedicated to helping you make crucial decisions that affect the health and safety of your patients or employees with increased confidence. Our CAP-accredited and SAMHSA- and CLIA-certified lab operates 24/7, with all testing performed in-house – getting you the results you need fast and efficiently so you can focus on what matters most, your patients.

To get started with DRUGSCAN today, please contact us or call 1.800.235.4890.

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