Update on the 2015 Agency Medical Directors’ Group’s (AMDG’s) Interagency Guideline on Prescribing Opioids for Pain

Goals for Guideline Update Help primary care providers prescribe opioids safely and effectively Prevent chronic disability and harm related to opioid use Prevent inappropriate transition from acute or sub-acute to chronic opioid use Broaden application of the guideline to more population groups

2010 Guideline 2015 Guideline Primary focus was on chronic non-cancer pain Expands focus to include opioid use in acute, subacute, and perioperative pain phases and in special populations. Recommended 120mg daily MED as a “yellow flag” dose as a strategy to prevent adverse events and overdose by advising providers to seek a consultation with a pain specialist. Remains the same, plus adds guidance for safe prescribing at any dose, based on new studies showing significant risks occurring at lower doses.

2010 Guideline 2015 Guideline Two main sections: Initiating, transitioning, and maintaining patients on chronic opioid analgesic therapy (COAT) with principles of safe prescribing, and Optimizing treatment for patients on > 120mg daily MED with brief sections on getting consultations, aberrant behaviors, tapering, and discontinuing COAT. Seven sections: Recommendations for All Pain Phases Clinically Meaningful Improvement in Function Expanded discussion on dosing threshold Non-opioid Options for Pain Management Opioids in the Acute and Subacute Pain Phases Opioids in the Perioperative Phase Continued…

2010 Guideline 2015 Guideline Two main sections: Initiating, transitioning, and maintaining patients on chronic opioid analgesic therapy (COAT) with principles of safe prescribing, and Optimizing treatment for patients on > 120mg daily MED with brief sections on getting consultations, aberrant behaviors, tapering, and discontinuing COAT. Seven sections: Opioids in Chronic Non-cancer Pain (similar to previous guideline) New section on tapering / discontinuing COAT New section on recognizing and treating substance use disorder New sections on opioid use during pregnancy, neonatal abstinence syndrome, opioid use in children and adolescents, in older adults, and in cancer survivors.

2010 Guideline 2015 Guideline Organized as narrative information and recommendations with evidence in citations. Organized with each section having specific clinical recommendations with supporting narrative evidence sections with citations. Bookmarks and hyperlinks are inserted throughout the guideline.

2010 Guideline 2015 Guideline Appendices: Opioid Dose Calculations & Calculator Screening Tools Tools to Assess Pain and Function Urine Drug Testing for COAT Consultative Assistance for WA State Payers Patient Education Resources Sample Doctor-patient Agreement for COAT Additional Resources to Streamline Clinical Care Emergency Department Opioid Guidelines Renamed: Validated Risk Factor Screening Tools and combines former appendices B and C. How to use the Prescription Monitoring Program Chronic Pain Syndromes in Cancer Survivors Diagnosis-based Pharmacotherapy for Pain Patient Education Resources (updated) Renamed: Clinical Tools and Resources and combines former appendices G, H, and I AGREE criteria

Pain across the life span Opioids during pregnancy and neonatal abstinence syndrome – Alyssa Stephenson-Famy MD, UW Children and adolescents – Gary Walco PhD, Seattle Children’s Hospital Older adults - Deb Gordon DNP, UW Opioid use in cancer survivors – Pam Davies ARNP, Seattle Cancer Care Alliance and UW These sections add new dimensions to the AMDG guideline, since state agencies These sections were written by guest authors, as opposed to a collaborative workgroup. They provide guidance that will help the primary care provider understand the presentation, risks and needs of these patients. They provide clinical recommendations and evidence, like all the other sections, including the role of specialists and consultants. They do not provide a comprehensive set of recommendations for specific cases and situations, but include resources for further information.

Remaining Timeline April 17 – May 1: Draft of the guideline is open for public comment. May 2 – 10: Review public comments; make final changes (last chance) May 11 – June 1: Prepare for publication online June 5: Publish guideline online June 12: Primary Care Pain Conference

Bree Collaborative Preliminary vote to endorse AMDG guideline when it is final Final vote to endorse will expand reach of new guideline to all providers and payers Next meeting is May 20th.

Evidence-based Primary Pain Care One day conference on June 12, 2015 23 speakers and panelists Primary care providers to specialists The opioid epidemic now and into the future Three participatory panels: Lessons from the Primary Care Front Lines Opioid Use in Special Populations Pain Care Innovations in Health Care Systems

Information on the opioid conference and access to the draft opioid guideline are both available at: http://www.agencymeddirectors.wa.gov/. Public comments on the draft opioid guideline close at 5:00pm May 1, 2015.