1. Sarah Thompson, PharmD, CDOE Director of Clinical Services, Coastal Medical

2. Background 2014 RI opiate overdose rates highest in nation Department of Health draft regulations Pain management is increasingly becoming a primary care issue

3. Defining the Population Patients who are prescribed an opiate for chronic pain management For greater than 28 consecutive days By a Coastal Medical Provider Verified that no other medical providers are also prescribing opiates

4. Patient Identification Data reports Refill requests Record Review Prescription Monitoring Program Urine Tox testing CSA signing Appointment with Pharmacist or Provider Documentation in record Monitoring Urine Tox results sent to PharmD MAs/Pharm Techs verify signed CSAs Practice Level Workflow Opiate Stewardship Approach Consensus from CPC to evaluate Coastal process Asked Pharmacy team to work with pilot practice Clinical Practices Committee Workflow evaluation Testing of CSA Piloted Pharmacy visits Pilot Practice EHR codes PMP access EHR templates Uniform controlled substance policy Development Needs Board Approval of policy Pharmacy and provider led visits Yearly Monitoring Practice wide rollout

5. Controlled Substance Agreement Risks, benefits and side effects of treatment Signs and symptoms of tolerance, physical dependence, and addiction Patient agrees to: Random urine tox screening Notify PCP if another provider prescribes opiate therapy, including ED Receive prescriptions at one pharmacy Follow office policy for refill requests Provide photo identification to pick up prescription

6. EHR Enhancements Problem list codes “CSA: Controlled Substance Agreement” “Controlled substance agreement terminated” Important for Coastal 365 clinic CSA signing template PMP review date Counseling language Adds problem list codes

7. CSA Template Structured date for signing Structured date for PMP review Counseling for use, risks, and benefits of controlled substances

9. CSA Termination Template Structured data fields for: Date of termination Reason for termination Problem list code indicating termination of CSA: Z92.89 Statement indicating the provider will no longer prescribe chronic controlled substances

11. Future Directions Annual monitoring of CSA renewals Monitoring provider sign up for PMP Patient population risk stratification Institute prescribing standards for top pain conditions

12. Sarah Thompson, PharmD, CDOE Director of Clinical Services, Coastal Medical sthompson@coastalmedical.com