1. Opioid Prescribing & Monitoring
Paula Cook, MD

2. 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”)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. PDMP’s

13. 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.
CDC Injury and Prevention Control.
Management of Chronic Pain and Opioid Misuse: A Position Paper from the AAFP. American Family Physician. 2017: 95(7)
Utah Division of Substance Abuse and Mental Health 2016 Executive Summary

14. 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:
AAFP: Pain Management and Opioid Abuse. A Public Health Concern. Position Paper.
SAMHSA. Tip 54. Managing Chronic Pain in people with or in recovery from substance use disorders.