Opioid Prescribing & Monitoring Paula Cook, MD

Objectives Review the guidelines for opioid prescribing and gain the skills to implement an evidence based controlled substance monitoring program Examine State’s prescription monitoring data programs (PDMP’s or CSDB or “DOPL”)

The challenge 11-54% Americans with chronic pain Primary care providers prescribe most of their medications (IOM medical home model) Long term opioid therapy lacks evidence for effectiveness Risks may outweigh benefits 1 in 4 patients receiving chronic opioids have OUD

Controlled substance monitoring programs Evidence based Increase safer prescribing Formalize risk evaluation and mitigation Reduce burden of prescribers Help identify prescription drug diversion Help assess, treat and/or refer addicted patients

CDC Guidelines for Prescribing Opioids for Chronic Pain March, 15 2016 The guidelines include 3 Sets of Recommendations: When to initiate or continue opioids Safely prescribe, follow-up with and discontinue opioids How to assess risks and address harms associated with opioids

Guidelines used to create the CDC guidelines American Pain Society/American Academy of Pain Medicine Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain (2009)4 Utah State Clinical Guidelines on Prescribing Opioids for Treatment of Pain (2009)5 Veterans Affairs/Department of Defense Management of Opioid Therapy for Chronic Pain (2010)6 Washington State Agency Medical Directors Group Interagency Guideline on Opioid Dosing for Chronic Noncancer Pain (2010)7 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Noncancer Pain (2011)8 American College of Occupational and Environmental Medicine Guidelines for the Chronic Use of Opioids* (2011)9 New York City Department of Health and Mental Hygiene Opioid Prescribing Guidelines (2011)10 American Society of Interventional Pain Physicians Guidelines for Responsible Opioid Prescribing in Chronic Noncancer Pain (2012)11

Basic tenants of a CSMP Conduct a physical exam, pain history, past medical history, and family/social history Conduct urine drug testing, when appropriate Consider all treatment options, weighing benefits and risks of opioid therapy, and using opioids when alternative treatments are ineffective Start patients on the lowest effective dose Use short acting formulations Implement pain treatment agreements

Basic tenants of a CSMP cont Monitor pain and treatment progress with documentation; using greater vigilance at high doses Use safe and effective methods for discontinuing opioids (e.g., tapering, making appropriate referrals to medication-assisted treatment, substance use specialists, or other services) Use data from Prescription Drug Monitoring Programs (PDMPs) to identify past and present opioid prescriptions at initial assessment and during the monitoring phase

Follow -up Assess: progress towards treatment goals; check the 4 A’s: ANALGESIA; ADL’S; ADVERSE EFFECTS; ABERRENCY. (also Affect, ongoing risk and drug interactions) Check: physical exam; pill bottles, UDS, PDMP report Reschedule: follow up visit for no longer than 3 months, sooner for dose change, high dose, >1 controlled substance, or any risk factors

High Risk patients High dose >50 MME/day Personal or family history of substance abuse History of overdose Benzodiazepine use Depression Age >65 Sleep-disordered breathing Renal or hepatic impairment

Urine Drug screens Initially (always) and with random follow up visits and prescription pick up (1-2x a year depending on risk) Utilize random call in UDS for high risk patients for abuse/misuse or diversion Send for confirmation Know metabolites, possible false positives/negatives Utilize random UDS not to “fire”patients

PDMP’s

References ASAM National Practice Guideline. ASAM Board of Directors. June 1, 2015 CDC Opioid Prescribing Guidelines for Chronic Pain. March 2016. Substance Abuse and Mental Health Administration. National Survey on Drug Use and Health. 2014 US Department of Health and Human Service. Surgeon General Report. http://turnthetiderx.org/ CDC Injury and Prevention Control. https://www.cdc.gov/drugoverdose/epidemic/ Management of Chronic Pain and Opioid Misuse: A Position Paper from the AAFP. American Family Physician. 2017: 95(7). 458-459 Utah Division of Substance Abuse and Mental Health 2016 Executive Summary https://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-20160125-a.pdf

Butler SF, Fernandez K, Benoit C, et al Butler SF, Fernandez K, Benoit C, et al. Validation of the Revised Screener and Opioid Assessment for Patients in Pain (SOAPP-R). J Pain 2008; 9: 360-372 AAFP: Pain Management and Opioid Abuse. A Public Health Concern. Position Paper. http://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/opioid-abuse-position-paper.pdf SAMHSA. Tip 54. Managing Chronic Pain in people with or in recovery from substance use disorders.