McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 1: Deciding to Initiate Opioid Therapy

R02. Recommendation Statement

No. Recommendation Keyword
R02 Before initiating opioid therapy, consider using a screening tool to determine the patient’s risk for opioid addiction. (Grade B). Addiction-risk screening
  • R02. Discussion
  • R02. Summary of Peer-Reviewed Evidence

R02. Discussion

A comprehensive history when considering opioids for CNCP includes a thorough review of the patient’s alcohol and other substance use. This history is important in assessing the patient’s risk for opioid misuse or addiction and various screening tools can help with this determination. Most of the screening tools have not been studied in depth, validated, or been compared to each other but the Opioid Risk Tool (ORT) is widely used. (See Appendix B-2: ORT.)

The ORT provides a scoring mechanism that translates the patient’s responses into a low, moderate or high risk categorization. It relies on identifying personal or family history of alcohol and substance abuse as well as personal psychiatric history.

See Appendix B-1 for examples of interview guides and assessment tools that may be used to supplement a comprehensive history of alcohol and substance use.

R02. Summary of Peer-Reviewed Evidence

1. Some screening questionnaires for risk of opioid misuse and abuse have demonstrated high sensitivity and specificity. However, samples used were small and unrepresentative.

The Opioid Risk Tool, in a preliminary study (Webster 2005), demonstrated high sensitivity and specificity for predicting individuals presenting to a pain clinic who were at risk for developing aberrant behaviors related to their opioid use. The ORT assessed personal and family history of substance abuse, age, history of preadolescent sexual abuse, depression, and other psychiatric history and categorized patients as low, moderate or high risk.

A systematic review of predictors for opioid misuse concluded that none of the screening tools can be recommended with confidence, because the samples were small and unrepresentative (Turk 2008). A personal history of abuse of illicit drugs or alcohol remains the strongest predictor of opioid misuse and abuse.