Continuing Education Credit: TEXT: 501-406-0076 Event ID:31219-30782

Pain management agreement violations- How to handle this Masil George, MD Associate Professor, UAMS Department of Geriatrics Associate Professor, UAMS Division of Medical Humanities Director, Geriatric Palliative Care Program, UAMS Medical Director, Baptist Hospice 07/24/2019

Objectives Explain elements of controlled substance agreement and who needs them Describe ways in which patients could potentially violate agreement Discuss with case examples ways to handle pain management agreement violations Explain elements of pain management agreement and who needs them Describe ways in which patients could potentially violate agreement Discuss with case examples ways to handle pain management agreement violations

Opioids for Chronic Pain Chronic pain affects 100 million US adults and is estimated to cost $635 billion each year in treatment, lost wages, and reduced productivity. Opioid therapy for chronic noncancer pain is being called into question. 2016 guideline from the US Centers for Disease Control and Prevention has called for more limited and judicious use of opioids in primary care. Nevertheless, long-term opioid therapy is probably helpful in some circumstances and will likely continue to have a role in chronic pain management for the foreseeable future. Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med 2011

Controlled Substance Agreement (Not Narcotic Contract) The term “controlled-substance agreement” is preferable to “pain contract” or “narcotic contract.” Controlled-substance agreements should be used only in the context of personalized patient counseling and shared decision-making. Objectives of controlled-substance agreements are to improve adherence, obtain informed consent, outline the prescribing policies of the practice, and mitigate risk. Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016 Contracts were being advocated in treating opiate addiction as early as 1981. Since then, the term “narcotic contract” has become widely used, even as most professional guidelines have now moved away from using it. Clinically, the word “narcotic” is imprecise and can refer to substances other than opioids. For example, the US Controlled Substances Act lists cocaine as a narcotic.19 The word also carries a stigma, as law enforcement agencies and drug abuse programs commonly use phrases such as “narcotic task force” or “narcotic treatment program.” On the other hand, the more accurate term “opioid” may be unfamiliar to patients. We recommend using the term “controlled substance” instead. Similarly, the word “contract” can be perceived as coercive, can erode physician-patient trust, and implies that failure to agree to it will result in loss of access to pain medications. For these reasons, we encourage physicians to adopt the phrase “controlled-substance agreement” or something similar. This label accurately reflects the specificity of the treatment and connotes a partnership between patient and physician. Furthermore, it allows the physician to use the agreement when prescribing other controlled substances such as benzodiazepines and stimulants that also carry a risk of addiction, misuse, and adverse effects.

Who Needs a Controlled Substance Agreement Historically, primary care physicians have used controlled-substance agreements inconsistently and primarily for patients believed to be at high risk of misuse. Physicians cannot accurately predict who will misuse or divert medications, controlled substance agreements should be used for all patients prescribed controlled substances. Adams NJ, Plane MB, Fleming MF, Mundt MP, Saunders LA, Stauffacher EA. Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage 2001

Stigmatizing the patient? “Failure to comply with the terms of the contract will risk loss of medication or discharge from the medical practice” mitigate risk, but stigmatize patient. Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Avoid Stigmatization Stigmatization may result in undertreatment of pain, physician refusal to prescribe opioids, and patient refusal to submit to the terms of a one-sided agreement perceived as unfair Framing the controlled-substance agreement in terms of safety and using it universally can minimize miscommunication and unintentional stigmatization. Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Shared Decision Making (1 of 2) 1. Define the problem How is the pain affecting the patient’s quality of life and ability to function? Present and discuss treatment options Consider nonpharmacologic (eg, physical therapy), pharmacologic, and procedural options Discuss benefits, risks, and costs Consider efficacy, adverse effects, availability, monitoring needs, and other risks Explore the patient’s values and preferences Discuss ideas, concerns, and outcome expectations Discuss the physician’s treatment recommendations Base recommendations on medical knowledge and patient preferences Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Shared Decision Making (2 of 2) 6. Discuss the patient’s ability to follow through on the treatment plan Can the patient realistically adhere to appointments, tests, and referral plans? 7. Clarify understanding Consider the patient’s health literacy and assess the patient’s understanding of options 8. Make or defer decision Make a treatment plan or delay until additional input (eg, from family) can be gathered 9. Arrange follow-up Create a plan to follow up and modify or continue the treatment decision Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Checklist for Chronic Opioid Therapy Shared responsibilities: Goals – Functional #1, #2, #3 Treatment Choices- PT/ Exercise/ Counselling/ Acupuncture Side effects, risk of overdose- What to do Honesty- Safely control pain Monitoring for safety- UDS (know the lab/ False +ve, False –ve), PMP Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Checklist for Chronic Opioid Therapy Patient responsibilities: 8. Inform physician of new medications 9. Will remain reachable by physician 10. If change is needed, will discuss with physician 11. Will only take as prescribed, will use one pharmacy, understand stolen/ lost policy 12. Will not mix with alcohol or other drugs 13. Will store safely, wont share 14. If I get pregnant, will inform physician Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Checklist for Chronic Opioid Therapy Physician responsibilities: 15. Will listen to patient stories and help them with their personal goals 16. Will recognize when opioids are doing more harm than good 17. I will remain reachable (current phone # for office) 18. My office and I will remain available for when patients need help 18. I will ensure that patient knows office rules and how to ask for refills 19. I will teach my patients how to take medications safely 20. If I believe opioids are no longer safe or helpful, I will safely stop prescribing Tobin DG, Keough Forte K, Johnson MCGee. Breaking the pain contract: A better controlled- substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016

Clinical Management Multidisciplinary approach for management of substance abuse, providing access to mental health professionals who specialize in addiction therapy. Suspect abuse (frequently nurse), alert provider, assess with empathic and truthful conversation. Establish clear treatment goals (if patient is experiencing a life threatening illness, a harm-reduction approach may need to be used). Consider long acting, abuse- deterrent medications. Follow up frequently. Passik, Steven D (01/2005). "Managing pain in patients with aberrant drug-taking behaviors."The journal of supportive oncology (1544-6794)

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Clinical Case # 1 Mr. Smith is a 72 y/o with multiple medical problems including DM, HTN, CHF, COPD, CVA, and Chronic pain syndrome (secondary to OA, DM neuropathy, and CRPS). He lives with his wife and is very active. His chronic pain is managed optimally with Fentanyl 12.5 mcg transdermal patch every 72 hours, and hydrocodone 7.5 mg every 4 hours/ PRN. He says he is compliant with his medications. His Routine Urine Drug screen is negative.

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Clinical Case # 2 Ms. Harvey is a 68 y/o with remote history of cervical cancer. She lives independently and continues to work part time. She was on Oxycontin 60 mg bid and oxycodone 10 mg every 6 hours for several years. Currently she takes opioids for chronic back pain and her PCP has started tapering her opioids. Her urine drug screen is positive for marijuana, she runs out of her prescriptions before its time, and her son reported that she is also using alcohol excessively.

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Clinical Case # 3 Mr. Jones is a 59 y/o M with h/o gun shot injury, chronic low back pain and h/o substance use disorder. He is disabled and lives alone. He is on hydrocodone 10 mg q 4 hours/ PRN pain. His UDS has been positive for methamphetamine, cocaine, PCP on various occasions and consistently negative for opioids.

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Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Activity Code: 31991-30782