Title: Pain Management Policy and Guideline
Approval Date: / Review: Annual
Effective Date: / Category:
I. Purpose
The CLINIC NAME providers avoid prescribing opioids whenever possible, in order to minimize the possibility of dependence, decrease disability, improve function and minimize the serious problems, such as overdose, addiction and diversion that opioids can lead to for the patient and for the community.
II. Policy:
The CLINIC NAME is committed to providing effective and appropriate treatment for pain to our patients. Although opioids can potentially benefit some patients if prescribed and managed properly for appropriate conditions, from a public health perspective, preventing chronic disability and dependence for our patient due to unnecessary, ineffective, and potentially harmful opiate prescriptions, is the purpose of CLINIC NAME Pain Policy.
CLINIC NAME providers will follow evidence-based guidelines and avoid the use of opioids as first line agents for routine musculoskeletal condition. They will instead rely on early intervention strategies using alternative treatments whenever possible. Even with acute low dose opioids, patients are at increased risk for developing an opioid use disorder. There is no completely safe opioid dose. Evidence shows that patients who use opioids for 90 days are 60% more likely to still be using opioids in 5 years. There is little evidence to support chronic opioid therapy as improving function and improving pain, and there is ample evidence of its harm. Therefore, CLINIC NAME providers follow stringent guidelines when considering initiating opioid therapy, and always consider the alternatives first. At this time, except where noted below, CLINIC NAME does not manage chronic pain with opioids.
III. Procedure:
A. When providers are considering initiating opioid therapy, they are to consider whether the patient has acute, chronic or terminal pain.
1. Acute/Subacute pain—pain that is associated with a known injury/cause/event/surgery with acute pain lasting 0-6 weeks, and subacute pain lasting 6-12 weeks
2. Chronic Pain with Terminal Illness—patient will die in the foreseeable future (expected within 12 months) and cause is irreversible, patient is declining treatment, or patient is not responding to known treatment
a. Pain management in line with hospice procedures.
b. This is usually not managed at CLINIC NAME.
3. Chronic Pain-lasting longer than 3 months
a. CLINIC NAME Providers avoid prescribing opioids for chronic pain, and will generally refer to outside specialists, however exceptions may be made (see below).
B. Pain Treatment Guidelines
1. Acute Pain-
a. There are multiple options for treating acute pain, including oral medications (NSAIDs, muscle relaxants, muscle relaxants or TCA’s), splinting, exercise, heat and cold, referrals for physical therapy, which we can provide for our patients. Opioids may be prescribed for acute pain, as determined by the provider, after these alternatives are considered.
2. Chronic Pain
a. When evaluating chronic pain, alternative therapies will be explored first. These include oral medications (NSAIDs, muscle relaxants, muscle relaxants, TCA’s, SSRI’s or duloxetine), splinting, exercise, heat and cold, referrals for physical therapy, acupuncture, massage and counseling.
b. Patients will be referred to trusted partners in the community for chronic pain management when the provider deems it appropriate after reasonable exploration of other options.
i CLINIC NAME preferentially refers to Courage Kenny Golden Valley for patients who understand that they will not be on long term opioids
ii Other patients may be referred to MAPS or HCMC Pain Clinic, but should understand that opioids may be prescribed, and they will likely be recommended for procedures
iii Do NOT refer to: ADD PERTINENT PAIN CLINIC / PROVIDER NAMES HERE
c. CLINIC NAME providers may consider treating a patient with chronic pain with opiates under certain conditions:
i When the provider is following the recommendations of a pain clinic or specialist (eg. rheumatologist or neurologist), or short term when bridging a patient until they can be seen by a specialist or at a pain clinic
ii if the patient is unable to tolerate NSAIDS due to age or to renal insufficiency
iii When the primary care provider consults with the provider team, and it is deemed appropriate.
C. General Guidelines for Opioid Prescribing
1. Assessment for Chronic Pain should always include:
a. A problem focused physical exam
b. A review of past medical history, social and family history history
c. A review of MH and CD history
d. A Maine Health Assessment – OR ANOTHER ASSESSMENT FOR HEALTH THAT INCLUDES PAIN
e. Pain assessment tools: http://www.agencymeddirectors.wa.gov/AssessmentTools.asp
f. A review of records from other clinics or from specialists
2. Prescriptions Guidelines For Opioid Therapy
a. No opioids or controlled substances are prescribed on the first visit to the clinic.
b. Lost medications are not replaced.
c. Opioids are not prescribed by the on call provider, nor by other clinic providers (unless the primary provider is on leave).
d. When opioid therapy is anticipated to last longer than a couple days, it should be prescribed in multiples of 7 days supplies, or so that patients do not run out on the weekends.
e. Gabapentin is initiated only for diabetic neuropathy, and patients are maintained at doses no higher than 300mg three times daily. Any higher must be reviewed with the provider team.
f. Every patient must be checked on the Prescription Monitoring Program prior to any prescription for opioids.
g. A urine toxicology to be performed at least quarterly for any patient considered for opioids:
i If the urine toxicology is positive for any illicit or non-prescribed substances, further opioid prescriptions are disallowed, a diagnosis of chemical abuse is entered in the patient chart and patient is offered a referral to a Behavioral Health Integration Specialist for SBIRT services
ii If the urine toxicology is negative for prescribed opioids, further opioid prescriptions are disallowed and a pop-up flag is entered in the patient chart.
iii Refer to chart of urine metabolites for interpretation http://www.paineducation.vcu.edu/documents/UDTbyOpioidPrescribed.pdf
h. No controlled substances are to be prescribed over the phone or on call.
i. Frequent follow up
i Schedule II opioids will only be prescribed for a week at a time;
ii Schedule III and IV opioids may only be prescribed for a month at a time, and may not exceed 20 morphine equivalent dose (MED) daily;
j. Morphine Equivalent Doses will be considered when prescribing opioids and calculating patient risk, with a mind to always keep patients below 10 MED (http://agencymeddirectors.wa.gov/mobile.html).
3. Do not prescribe opioids if patient:
a. Has opioid prescriptions filled from more than one clinic
b. Urine toxicology screen shows evidence of not using medicine as prescribed
c. Is not participating in the other aspects of the treatment plan related to pain
d. PMP demonstrates multiple prescriptions for multiple providers.
e. If not honest regarding use of opioids or illicit substances.
4. In the exceptional cases where a patient is considered for opioids at NACC as a part of the treatment of chronic pain, they must understand and agree to the conditions for which NACC is willing to prescribe opioids. These conditions are intended to increase safety and to reduce risks associated with long-term opioid use. Patients receiving chronic opioids will be educated on the following expectations. Patients must:
a. Participate in a treatment plan.
b. Take their medications as prescribed.
c. Patients must engage in some form of mental health support.
d. Keep appointments and take care of their general medical health.
e. Maintain respectful interactions with all staff and patients.
f. Receive information about risks associated with long-term use and opioid overdose.
g. Consent to random drug screening, as requested.
h. Schedule follow-up visits before leaving the clinic at each visit.
i. Ensure that their prescriptions are secure.
j. Not receive controlled substances from other providers
k. Attend appointments for follow up and referrals.
l. Participate in requested chemical dependency assessments.
Resources:
Web-based Opioid Dose Calculator http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm
Infographic Summary of 2015 Interagency Guideline on Prescribing Opioids for Pain: http://www.agencymeddirectors.wa.gov/Files/FY16-288SummaryAMDGOpioidGuideline_FINAL.pdf
Washington State Guideline on Prescribing Opioids for Pain (2015) http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
Questions most asked: http://www.agencymeddirectors.wa.gov/Files/2006FAQV8.pdf http://www.agencymeddirectors.wa.gov/opioiddosing.asp
References:
Washington State Guideline on Prescribing Opioids for Pain (2015) http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
http://www.med.umich.edu/1info/FHP/practiceguides/pain/policy.pdf
NAME OF CLINIC Pain Management Guideline
Medical Policies and Procedures Manual Effective 9/21/2015. Page 4 of 5