Inappropriate prescription opioid analgesia takes several forms: failure to recognize an appropriate indication, inadequate dose titration, excessive opioid dosing, and continued prescription opioid use despite evidence that efficacy is lacking [1]. Appropriate opioid prescribing is essential to achieve pain control; to minimize patient risk of abuse, addiction, and fatal toxicity; and to minimize societal harms from diversion. The foundation of appropriate prescription opioid use encompasses a thorough patient assessment, treatment planning, and follow-up and monitoring. Essential for proper patient assessment and treatment planning is comprehension of the clinical concepts of opioid abuse and addiction, their behavioral manifestations in pain patients, and how these potentially problematic behavioral responses to opioids both resemble and differ from physical dependence and pseudo-dependence. Prescriber knowledge deficit has been identified as a key obstacle to appropriate opioid prescribing and, along with gaps in policy, treatment, attitudes, and research, contributes to widespread inadequate treatment of pain [2].

The Tennessee Chronic Pain Guidelines enumerate several key principles to follow when initiating opioid therapy [94]. Practitioners should bear in mind that prior opioid therapy alone is not sufficient reason to continue opioids, and reasonable non-opioid treatments should be tried first. When prescription opioids are considered for women of childbearing age, providers should educate the patient about the risks of opioid use during pregnancy, including the risk of physical dependence and withdrawal in the newborn; upon initiation of opioid therapy, the provider should recommend reliable contraception. A urine drug test (UDT) should be performed before initiating any opioid or benzodiazepine during pregnancy [94]. A thorough clinical examination, including appropriate laboratory testing and other elements supporting the plan of care, should be documented in the medical record. Patients shall not be treated by the use of controlled substances through telemedicine.

Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1,94]:

The initial evaluation is intended to establish a current diagnosis that justifies the need for opioid medication. After this determination is made, it is important to assess the patient's risk for drug misuse and develop and document a treatment plan, including a discussion of treatment goals.

Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state Controlled Substance Monitoring Database (CSMD), and from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses (Table 1). A UDT should be performed prior to initiating opioid treatment.

The initial evaluation is intended to establish a current diagnosis that justifies the need for opioid medication. After this determination is made, it is important to assess the patient's risk for drug misuse and develop and document a treatment plan, including a discussion of treatment goals.

The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a 24-item, patient-administered questionnaire that assesses history of alcohol/substance use, psychologic status, mood, impulsivity, cravings, and stress. It uses a five-point rating scale for each response and classifies patients as low or high risk in relation to potential aberrant drug-related behaviors and the appropriate extent of monitoring [19].

The state of Tennessee has developed two types of disposal activities designed to control access and promote safe, convenient, and responsible disposal of prescription drugs [94]. The first is a system of permanent prescription drug collection boxes located within law enforcement agencies (in compliance with DEA regulations) where community members can safely deposit drugs in a secure manner. The goal is to establish at least one permanent prescription drug collection box in all 95 counties of the state. The second activity involves community one-day "take-back" events wherein the public is encouraged to discard unwanted and outdated medications including prescription drugs from their homes. These events serve to raise public awareness of the prescription drug epidemic and encourage the use of local permanent disposal sites available year-round. A map showing the locations of permanent drug collection boxes can be found online at https://tdeconline.tn.gov/rxtakeback.

Research has more closely defined the location of prescribed opioid diversion into illicit use in the supply chain from the manufacturer to the distributor, retailer, and the end user (the pain patient). This information carries with it substantial public policy and regulatory implications. The 2015 National Survey on Drug Use and Health asked non-medical users of prescription opioids how they obtained their most recently used drugs [51]. Among persons 12 years of age or older, 40.5% obtained their prescription opioids from a friend or relative for free, 34.0% got them through a prescription from one doctor (vs. 17.3% in 2009–2010), 9.4% bought them from a friend or relative, and 3.8% took them from a friend or relative without asking [51]. Less frequent sources included a drug dealer or other stranger (4.9%); multiple doctors (1.7%); and theft from a doctor's office, clinic, hospital, or pharmacy (0.7%) (vs. 0.2% in 2009–2010) [51].

In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [48,54,55]:

Behaviors with a lower level of evidence for their association with opioid misuse include [48,54,55]:

The DEA is responsible for formulating federal standards for the handling of controlled substances. In 2011, the DEA began requiring every state to implement electronic databases that track prescribing habits. Specific policies regarding controlled substances are administered at the state level [60].