Clinical Pathway for Starting Long-Term Use of Controlled Substances

* The pt’s risk classification can change at any time after the initial classification, at the PCP’s discretion. For example, a “Low Risk” patient who loses a prescription or who continues to use alcohol might be moved to the “Moderate Risk” category. See Risk Stratified Treatment Protocols for classification details.

** Note the SOAPP is very sensitive and not very specific, so will produce many false positives. Do not use the SOAPP as a stand-alone risk assessment tool.

*** Controlled Substance Agreement (CSA) may be completed by the PCP or BHC or nurse (using the PCP’s plan). Pt should be given a copy.

**** The Orientation visit can be conducted by the BHC or nurse. Completion of this visit must occur before starting meds for “Moderate Risk” patients.

Risk-Stratified Treatment Protocols

Low Risk / Moderate Risk / High Risk
Indicators / Indicators / Indicators
<7 on the SOAPP and
<3 drug-related aberrant behaviors and
Clinical judgment suggests low risk / 7 on the SOAPP, or
3 drug-related aberrant behaviors, or
past history of substance use problems and Clinical judgment suggests moderate risk / Current addiction problem, or
Treated for addiction within the past year, or
Suspected or convicted of selling/diverting prescription drugs or forging/altering prescriptions, or
Positive drug screen at the initial visit, or
2 DWI convictions in the past 2 years, or
Uncontrolled behavioral disorder, or
Threatening, belligerent behavior in the clinic, and
Clinical judgment suggests high risk
Protocol / Protocol / Protocol
Infrequent UDS / Frequent UDS (including non-pain visits) / No treatment with controlled substances
Flexibility in type of medication used (short-acting vs long-acting) / Strongly encourage long-acting meds only (if short-acting, use regularly timed low dose) / Chronic Pain Group and other modalities strongly encouraged
3-month refills ok / Refill only 1 month at a time
Chronic Pain Group and other modalities strongly encouraged but not required / Chronic Pain Group attendance each month is mandatory (may get RF there)
Must attend Orientation before starting meds
Require pt to bring meds to each follow-up for pill count