Department of Veterans Affairs Memorandum 626-05-119-04
VA TennesseeValley Healthcare System December 27, 2005
OPIOID MEDICATIONS FOR CHRONIC PAIN
1. PURPOSE: To establish a consistent, effective, and safe mechanism for prescribing opioids in the long-term management of patients with chronic pain. To establish and validate compliance with the opioid agreement. To establish policy, procedures, and responsibility of caregivers and patients in the management of chronic pain.
2. POLICY: The Department of Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) is committed to providing timely, appropriate, safe and effective pain management for veterans with chronic pain, defined as patients requiring daily opioid management past 90 days. It is a routine part of the primary care of a patient to control pain. This includes prescribing and administering potentially addicting opioid medications to manage chronic pain over a long period of time under appropriate circumstances.
3. RESPONSIBILITIES:
a. Physicians: All VA physicians and dentists licensed by the Drug Enforcement Agency, and/or are assigned an Internal Substance Control Number to prescribe and administer opioids, are responsible for utilizing opioids to relieve pain according to federal and state guidelines. Maintenance opioid analgesia is provided to patients with chronic pain who meet the following criteria:
(1) The patient with a significant pain, defined as a score of 4 on the Numerical Rating Scale or greater than that tolerable to the patientand there are no other appropriate treatment alternatives immediately available;
(2) And/or the patient’s medical record clearly documents opioid analgesia as the most clinically appropriate long term treatment option for the patient’s medical condition. This documentation includes supporting diagnostic examinations and tests, expert medical opinions as well as repeated failure to respond to alternative treatments.
(3) The medical record clearly documents that the patient agrees to include opioid analgesia in the treatment plan, fully understands the risks and benefits, and is informed of the process for dispensing opioids.
(4) A baseline pain clinic drug screen is obtained.
b. Physician Extenders:
(1) Assess and document the appropriateness of their primary patients as candidates for long term use of opioids for relief of chronic pain according to the above guidelines.
(2) Consult with appropriate physicians and facilitate the prescription process collaboratively with the pharmacy as appropriate to the individual's Scope of Practice.
(3) Monitor the use of opioid prescriptions in collaboration with the primary provider.
c. Pharmacist:
(1) Notify the provider if more than one provider/team is prescribing opioids for the same patient.
(2) Reinforce “Opioid Analgesic Agreement” as appropriate. (See paragraph 4.b.)
(3) Educate the patient about the prescribed medication.
(4) Notify the provider if the patient request refills prior to the allowed time.
(5) Notify the responsible provider if the patient is abusing, deviating from, or having problems adhering to the Opioid Agreement.
d. The Chief of Staff is responsible for overall coordination of opioid medications.
e. Controlled Substance Review Team:
(1) Monitors this policy and facilitates implementation.
(2) Reviews individual patient situations by consult and mediates controversial situations.
4. PROCEDURES:
a. One provider/team provides opioids for patients with cancer or acute pain. Opioid treatment for acute pain is discontinued within one month, unless there is objective evidence of an ongoing disease process. When opioid analgesics are required on a regular basis (i.e., greater than 240 doses of a short-acting opioid per month), agents with a long duration of action (e.g., morphine sustained-release) should be preferred over short-acting agents (e.g., oxycodone with acetaminophen).
b. The Opioid Analgesic Agreement (Attachment I) is triggered for patients receiving opioid medication beyond 90 days. The agreement is executed annually, is reviewed with the patient by the provider and signed by both the provider and the patient. A copy of the agreement isgiven to the patient, retained in the patient record and documented in the CWAD Patient Postings (Crisis Note, Warnings, Allergies, Adverse Reactions, and Advance Directives). The documentation in the CWAD occurs either by the physician or delegated to the nurse practitioner, physician extender, or nurse.
c. A baseline pain clinic drug screen is obtained. Confirmation of a positive pain panel screen will result in discussion of the results by the provider with the patient. All testing results are documented in the patient’s medical record. Patients refusing pain panel screens are not candidates for a controlled substance therapy.
d. After drug selection, doses are administered on a scheduled basis. Several weeks are agreed upon as a period of initial dose titration between the provider and patient. Improvement in function is stressed and the patient and provider agree to at least partial analgesia without escalating doses as the appropriate goal of therapy.
(1) Failure to achieve at least partial analgesia at relatively low initial doses in the non-tolerant patient raises questions about the potential treatability of the pain syndrome with opioids.
(2) Emphasis is given to improved physical and social function as measurements of improved analgesia.
e. Patients are seen by the provider at regularly scheduled appointments, at minimum every six months. Patients are assessed for the efficacy of treatment, adverse drug effects, bowel regimen and the appearance of either misuse or abuse of the drugs at regular scheduled appointments. The results of the assessment are clearly documented in the medical record.
f. Transferring the responsibility of opioid prescription from one provider to another is well documented in the medical record.
g. The primary care team establishes a baseline for implementing pharmacological
interventions with an initial pain panel screen using the procedure for specimen collection.
h. Patients with a positive initial urine drug screen receive further education of the risks and benefits and the process for dispensing opioids, with appropriate documentation.
i. Pain medication continues for a period not exceeding one month, allowing patient to
cease inappropriate drug use. Reevaluation, by a random urine drug screen is completed. Appropriate pharmacological interventions are then evaluated by the primary care physician.
j. Established patients receiving opioids with an unexpected positive result on the urine drug screen are referred to a drug treatment program and the Controlled Substance Review Team (CSRT).
k. The primary care provider evaluates appropriate pharmacological interventions and alternative treatments. The patient is offered detoxification, consults to Substance Abuse Treatment Program, Mental Health Clinic, other specialties, and other alternatives of treatment, such as: aqua therapy, biofeedback, physical therapy evaluation, among others and if deemed necessary, a consult to the Pain Resource Nurse and a Pain Clinic.
l. Periodic random pain panel screening occurs to assure appropriate medication usage.
m. Substance abuse treatment and /or mental health consultation is requested by the primary care provider in cases of suspected substance misuse or potential addiction.
n. Tapering and discontinuation of opioid therapy is recommended for evidence of drug hoarding, acquisition of drugs from other physicians, uncontrolled dose escalation, drug abuse or other aberrant behaviors. A recent conviction of drug abuse or trafficking shall result in an automatic termination of controlled substances. Alternative pain management strategies are offered.
5. REFERENCES:
Addiction: PartI. “Benzodiazepines – Side Effects, Abuse Risk, and Alternative.” The American Family of Physicians. April 2000.
Addiction: Part II. “Identification and Management of the Drug-Seeking Patient”, The AmericanFamily of Physicians. April 2000.
“Urine Drug Testing in Primary Care, Dispelling the Myths and Designing Strategies”, CaliforniaAcademy of Family Physicians. August 31 2002. Principles of Addiction Medicine. 3rd Edition. American Society of Addiction Medicine. 2003.
6. RESCISSION: None
7. RESPONSIBILITY AND REVIEW DATE: The Chief, Pharmacy Service will review by August 30, 2008.
/s/ David N. Pennington, FACHE 2/2/2006
David N. Pennington, FACHE
Director
Attachment
Distribution: A
1