1. A System to Manage Long Term Opioid Prescribing in the Primary Care Setting Joy Nassar, MD University Medicine Foundation November 16, 2015

2. The Initial Chronic Pain Visit 1.) Document the history around the patient’s pain: Cause Previous Work Up Prior Medications Tried Alternative treatments (PT, acupuncture, etc.) 2.) Put Chronic Pain on the Problem List 3.) Review and Sign Pain Contract 4.) Complete an Opiate Risk Stratification Tool 5.) Review the patient’s history of controlled substances from the Prescription Monitoring Program (PMP) 6.) Agree on functional goals 7.) Choose Type and Frequency of Medication 8.) Establish plan for follow up

4. The Initial Chronic Pain Visit 1.) Document the history around the patient’s pain: Cause Previous Work Up Prior Medications Tried Alternative treatments (PT, acupuncture, etc.) 2.) Put Chronic Pain on the Problem List 3.) Review and Sign Pain Contract 4.) Opiate Risk Stratification Tool 5.) Review the patient’s history of controlled substances from the Prescription Monitoring Program (PMP) 6.) Agree on functional goals 7.) Choose Type and Frequency of Medication 8.) Establish plan for follow up

6. Pain Contract: Set the Stage Opiates are dangerous. Special monitoring is necessary. Opiates may help improve function, they will not eliminate pain. The state, pharmacies and insurance all track opiates. The provider will be monitoring.

7. Pain Contract: Establish Expectations Take opiates as prescribed. Only get opiates from one provider. Will not share or sell opiates. Will not use illicit substances. Will be honest about alcohol use. If function does not improve then opiates may be discontinued.

8. Pain Contract: Explain Refills and Monitoring Explain refills: Always fill at the same pharmacy. Lost or stolen medications are not filled early. Prescriptions are given on a schedule, during office hours. Explain Monitoring: Will need visits specifically for refills and monitoring. UDS periodically

9. The Initial Chronic Pain Visit 1.) Document the history around the patient’s pain: Cause Previous Work Up Prior Medications Tried Alternative treatments (PT, acupuncture, etc.) 2.) Put Chronic Pain on the Problem List 3.) Review and Sign Pain Contract 4.) Opiate Risk Stratification Tool 5.) Review the patient’s history of controlled substances from the Prescription Monitoring Program (PMP) 6.) Agree on functional goals 7.) Choose Type and Frequency of Medication 8.) Establish plan for follow up

10. Tools for Improving Opioid Oversight: Risk Stratification https://www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf

11. SOAPP-SF > Or = 4 is a positive test. https://www.nhms.org/sites/default/files/Pdfs/SOAPP-5.pdf

12. Opioid Risk Stratification SOAPP – 24 Current Opioid Misuse Measure

13. Follow up Chronic Pain Visits Set aside office visits specifically to discuss chronic opioid use Review the controlled substance history on the PMP Review functional goals Make medication adjustments or stop medication Review SE of medication Ask in visit the last time the person took their opiate UDS Consider referral to Pain Management Specialist

14. Benefits to Having a System Goal is to identify and highlight opiate misuse and abuse. – No system, pain contract or frequent UDS have been shown to decrease opiate overdose, diversion or alter addiction risk. – These are considered best practices in the face of an opiate epidemic with little data to drive care. These measures have been shown to improve physician comfort, decrease anxiety around opiate prescribing.

15. Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152:712-720. Canada, Robin E, Dirocco, Danae and Day, Susan. "A Better Approach to Opioid Prescribing in Primary Care". Journal of Family Practice 63 (6) 2014 Centers for Disease Control and Prevention (CDC). CDC grand rounds: prescription drug overdoses - a US epidemic. MMWR Morb Mortal Wkly Rep. 2012;61:10-13.