1. Opioid Compliance, Documentation, and Monitoring October 9, 2015

2. Objectives  Discuss the need for improving opioid compliance  Review documentation for opioid prescribing  Understand different methods to evaluate opioid compliance  Discuss some of the highlights from Washington state’s “AMDG 2015 Interagency Guideline on Prescribing Opioids for Pain” (AMDG = Agency medical directors’ group)  Discuss Prescription Monitoring Program (PMP) and how to access it through the website

3. The Seattle Times – December, 2011

4. Methadone 10 mg 10 tabs q6 hrs

5. The Seattle Times – December, 2011

6. Methadone and Accidental Deaths

7. Statistics from Washington State Department of Health  http://www.doh.wa.gov/Portals/1 /Documents/5500/RPF- Drg2014.pdf

8. Statistics from Washington State Department of Health

11. Agency Medical Directors’ Group Guidelines  http://www.agencymeddirectors.w a.gov/Files/2015AMDGOpioidGuide line.pdf http://www.agencymeddirectors.w a.gov/Files/2015AMDGOpioidGuide line.pdf  (Information from AMDG used with permission)

12. Interagency Guideline on Prescribing Opioids for Pain  Challenges and important considerations regarding the recommendations from the guidelines:  Some of the recommendation are generalized and do not always apply to individual clinical settings. Not all scenarios have specific recommendations and some of the recommendations have limited evidence as noted in the appendix.  Guidelines do not have to deal with insurances. Some recommendations such as prescribe multiples of 7-day prescriptions for acute phases of pain may run into limitations with those insurance that only allow 2 prescriptions of opioids a month. Also guideline recommendations to use pregablin, duloxetine or other brand name medications are often not authorized or covered by insurances.  Lack of long term data either supporting use of opioids. Difficulty in conducting long term studies on COAT.  Some injuries and disease pathologies may not have a resolution/complete recovery, and may itself be a chronic condition. Limited discussion on guidelines regarding these situations.  Emphasis on close monitoring and follow up with frequent re-assessments of medication needs. May be challenging for a busy practice to follow patients/guidelines consistently.

13. Interagency Guideline on Prescribing Opioids for Pain  Guidelines were developed with an advisory group including academic leaders, pain specialists, and clinicians in both primary and specialty areas.  Primary target is primary care physicians and any provider who treats patients with chronic pain. A secondary target is public and private payers in WA state.  Advisors and contributors including numerous physicians, generally all based in Seattle area, as well as multiple insurance representatives and state agency directors and staff.

14. Interagency Guideline on Prescribing Opioids for Pain  http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf  “Monitoring and vigilance are critical to ensure effective and safe use of opioids for the thousands of Washington residents who are on opioids chronically, especially for those on high doses.” (page 6)  “Uncertain Long-term Efficacy, Clear Evidence of Harm” (page 7)  “Although opioids benefit some patients if prescribed and managed properly for appropriate conditions, from a public health perspective, preventing the next group of Washington residents from developing chronic disability due to unnecessary, ineffective, and potentially harmful COAT is a key objective of this guidline.” COAT=chronic opioid analgesic therapy (page 8)  “Patients who used chronic opioids for at least 90 days were greater than 60% more likely to still be on chronic opioids in 5 years.” (page 9, reference Martin et al, J Gen Intern Med 2011;26:1450-7)

15. Interagency Guideline on Prescribing Opioids for Pain  The guidelines discuss different areas of opioid prescriptions  General recommendations for all pain phases  Prescribing opioids in the acute and subacute phase  Perioperative pain  Chronic non-cancer pain  Reducing/Discontinuing opioid therapy  Recognition and Treatment of opioid use disorder  Management in special populations ( pregnancy, pediatrics, older adults, and cancer survivors)

16. Interagency Guideline on Prescribing Opioids for Pain

17.  Clinical Recommendations: (pages 12, 13)

18. Interagency Guideline on Prescribing Opioids for Pain

19.  Tapering or discontinuing opioid therapy: (Page 36)

20. Interagency Guideline on Prescribing Opioids for Pain  Numerous bullet points on tapering meds are discussed.  Rate of opioid taper (page 37)

21. Interagency Guideline on Prescribing Opioids for Pain  Treating withdrawal of opioids (page 38)

23. Substance Abuse Trends with Heroin  www.samhsa.gov (Substance Abuse and Mental Health Services Administration) www.samhsa.gov

26. Opioid Documentation  Medical history and physical examination  Diagnostic, therapeutic, and laboratory results  Evaluations and consultations  Treatment objectives  Discussion of risks, benefits and limitations of treatments  Details of different treatments and medications  Instructions to the patient  Periodic reviews of outcomes  (Trescot et al. Pain Physician, 2006)

27. Opioid Documentation  Should also include:  Continual re-evaluation of disease process and treatment progress  Patient compliance  Reason for treatment of plan  Decisions and reasons for modifying treatment plan  Side effects  Drug interactions  Treatment alternatives

28. Methods of Improving Compliance  Opioid agreement forms  Pill Counts  Pharmacy, ER, primary care, specialty records  State monitoring methods  Use opioid risk tools  Assess functional outcomes  Work with other specialties including Psychology, Psychiatry, etc.  Laboratory testing including urine drug testing, blood tests, etc

29. Opioid agreement forms  All patients prescribed chronic opioids should be given an agreement form  Informed consent should also be done at the time of initiation of narcotic medications  Recommend updating and reviewing the agreement form with the patient on a regular basis (every 6-12 months or more frequently)

30. Pill Counts  Randomly count how many pills the patient has throughout the month  Patients are called and told to bring in prescriptions  Nurse verifies the type of pill and counts the pills  Limitations include  “Pill Banks”  Patients unable to come in due to …  “Pill Banks” are locations where patients may “rent out” the pills they are supposed to have in case they are called in for a pill count

31. Opioid Risk Tools  By Dr. Lynn Webster  Evaluates Family history, personal history, age, preadolescent sexual abuse, and past or current psychological disease  Stratifies into low, moderate, and high risk

32. Opioid Risk Tools  Use CAGE questions  Cut down dosage  Annoyed by criticism  Guilty  Eye-opener

33. Functional Outcomes  Assessment of functional outcomes  Oswestry Disability Index  SF-12 or SF-36  See also AMDG opiod guidelines for other resources

34. Psychology and Psychiatry  Consultations and treatment to address underlying psychiatric co-morbidities  Assess compliance and encourage patient responsibility

35. Laboratory Testing  Urine drug tests  Qualitative  Quantitative  Serum drug tests (blood)  Other drug tests  Hair (head hair can detect substances that have been used up to 90 days ago, and body hair can potentially detect up to 1 year of substance use)  Saliva  Sweat (tested with a sweat sample after applying a sweat patch to a patient)  Breath (for alcohol)

39. Prescription Monitoring Program  Prescription monitoring website for controlled substances  Users can start by going to www.wapmp.orgwww.wapmp.org  For new users, wapmp.org has a link to register for PMP access  Current login website is now https://secureaccess.wa.gov/https://secureaccess.wa.gov/  After logging in the website will redirect to the Washington PMP website

40. All access to Prescription Review is through the Secure Access Washington (SAW) security gateway. To access Prescription Review you will need to complete the following steps: 1. Set up a SAW account (if you don’t already have one) 2. In SAW, request the PMP service you desire 3. Complete identity verification in SAW. Once successfully completed you’ll be automatically passed to the PMP for the next step. 4. Register for your PMP account by filling out the online registration form. Users with existing PMP accounts will be able to link to their active PMP account by selecting “I am an existing WA PMP user” Providers looking to set up a PMP account please start here: Prescription Review HomepagePrescription Review Homepage Here Are A Few Helpful Resources for Account Registration and Linking: Secure Access Washington (SAW) Website How To / Training Video for SAW Helpful Resources on the Prescription Monitoring Program Website Prescription Review Homepage This does not apply to uploader accounts or the way that uploaders access the system for reporting. Slide from Washington State Department of Health; Used with Permission

47. Washington State Department of Health DOH’s Goals for Washington’s PMP Help Prevent Prescription Drug Overdoses! Give practitioners an additional tool that provides more information for making patient care decisions. Data can help healthcare providers recognize patterns of misuse and addiction ensuring SBIRT opportunities are not missed. Make sure those in need of scheduled prescription drugs receive them. Educate the population on the dangers of misusing prescription drugs. Curb the illicit use of prescription drugs. Used with Permission

48. Washington State Department of Health Key PMP Practices to Consider DELEGATE prescription look-up to other staff to save time TRAIN your staff by using a PMP champion REGISTER accounts for all appropriate staff with the PMP RETAIN documentation by placing a copy in the patient file or into an EHR system Used with Permission

49. Washington State Department of Health Post PMP Review Action Steps For at risk patients: TALK with the patient to determine reasons for at risk behaviors – SBIRT opportunity? COORDINATE care with the other providers listed on the report CONSIDER using a patient treatment agreement VERIFY the prescriptions listed match your records REFER your patient to treatment or other specialty care EDUCATE patients on the risks of opioid overdose Used with Permission

50. Summary  Opioid management can be challenging  We have tools that may help improve compliance and safety  AMDG Guidelines  WA PMP Program  Consultations when needed  Appropriate documentation is essential for long term management  Constant re-evaluation of patients who are on COAT is essential. Does the therapy continue to “make sense”  Continual assessment of opioid compliance