COMMENTARY

New Standard of Care for Prescribing Opioids

Carolyn Buppert, MSN, JD

Disclosures

April 16, 2015

In This Article

Guideline Specifics and Common Elements

The guidelines differ a bit, but there are some common elements found in most of the guidelines for the evaluation and management of a patient with chronic, non-cancer pain when an opioid medication is being considered.

Initial Patient Evaluation

  • Conduct and document a pain history, a medical history, and family/social history, at minimum.

  • Perform and document a physical examination.

  • Check the state's prescription drug monitoring program site to determine whether the patient has been getting prescriptions filled for opioids. States differ in their requirements that clinicians use the prescription drug monitoring program; in some states it is mandatory, while in others it is encouraged.

  • Use one of the accepted tools to determine the patient's level of risk for abuse. An example of such a tool is the opioid risk tool (ORT).

  • Conduct a urine drug screen.

  • Pregnancy test must be negative.

  • If the patient already is on opioids, obtain records from the patient's previous provider.

  • Establish and document a diagnosis that justifies the prescription.

Choice of Medication

  • Try a nonopioid first, such as a nonsteroidal anti-inflammatory drug. Document the trial.

  • Avoid methadone, unless you are working in a methadone treatment/maintenance program.

  • Use an online morphine milligram equivalent (MME) calculator to arrive at the MME for the patient's dose. If reaching 120 MME/day, taper the dose or obtain a pain specialist's consultation. (Some guidelines have a lower threshold and some have a higher threshold.)

Negotiation With the Patient

  • Tell patients that pain medication prescriptions are a trial, to last no longer than 90 days, unless improvement is documented. This will necessitate the setting of treatment goals and monitoring for improvement.

  • Write a treatment plan, including the patient's goals of care and the patient's agreement to take the drug as ordered, safeguard the supply, not obtain medication from another provider, and give at least 72 hours of notice before refills are needed. The patient also should agree to urine testing, agree not to share the medication with others, and agree that the treatment is a 90-day trial, without promise of continuation.

  • Obtain informed consent, in writing, to the risks of treatment.

Monitoring

  • Conduct monthly visits at which time the patient's progress is documented.

  • At each visit, assess the 5 A's:

    • Analgesia

    • Activity (function, overall quality of life)

    • Adverse events

    • Aberrant behavior

    • Affect

  • Use accepted tools to measure pain intensity, functional status, mental health, and level of disability, to assess improvement or lack thereof, and document results.

  • Taper and discontinue the treatment if the patient's pain fails to improve within 90 days, if there are intolerable side effects, quality of life does not improve, functioning deteriorates, or there is aberrant medication abuse.

The implication of the new guidelines is that clinicians should select a set of guidelines and follow them. Check to see whether your state health department or medical board has published pain management or opioid prescribing guidelines, and use one of those to guide your practice. If there is no applicable state or medical board guideline, use one of the pain society's guidelines or the American Academy of Neurology guidelines.

Many states have laws, in addition to guidelines, dictating clinician behavior when prescribing controlled substances. Clinicians should check with their state's health department about their state's requirements for prescribing, and should follow any regulations. If a clinician has well-established patients whose evaluation and management don't conform with the new guidelines, steps should be taken to bring those patients' treatment into compliance with at least one relevant set of guidelines.

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