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

Opioid Compliance, Documentation, and

MonitoringOctober 9, 2015

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

The Seattle Times – December, 2011


Methadone 10 mg 10 tabs q6 hrs


Methadone and Accidental Deaths

Statistics from Washington State Department of Health

http://www.doh.wa.gov/Portals/1/Documents/5500/RPF-Drg2014.pdf




Agency Medical Directors’ Group Guidelines

http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

(Information from AMDG used with permission)





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.


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.



“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)




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)



Clinical Recommendations: (pages 12, 13)



Tapering or discontinuing opioid therapy: (Page 36)


Numerous bullet points on tapering meds are discussed.

Rate of opioid taper (page 37)


Treating withdrawal of opioids (page 38)

Substance Abuse Trends with Heroin

www.samhsa.gov (Substance Abuse and Mental Health Services Administration)

http://www.samhsa.gov/

www.samhsa.gov

http://www.samhsa.gov/

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)

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

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

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)

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

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

Opioid Risk Tools

Use CAGE questions

Cut down dosage

Annoyed by criticism

Guilty

Eye-opener

Functional Outcomes

Assessment of functional outcomes

Oswestry Disability Index

SF-12 or SF-36

See also AMDG opiod guidelines for other resources

Psychology and Psychiatry

Consultations and treatment to address underlying psychiatric co-morbidities

Assess compliance and encourage patient responsibility

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)

Prescription Monitoring Program

Prescription monitoring website for controlled substances

Users can start by going to www.wapmp.org

For new users, wapmp.org has a link to register for PMP access

Current login website is now https://secureaccess.wa.gov/

After logging in the website will redirect to the Washington PMP website

http://www.wapmp.org/

https://secureaccess.wa.gov/

Prescription ReviewIs Accessed Via

Secure Access Washington 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 desire3. 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 Homepage

Here Are A Few Helpful Resources for Account Registration and Linking:

Secure Access Washington (SAW) WebsiteHow To / Training Video for SAWHelpful Resources on the Prescription Monitoring Program WebsitePrescription 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


https://secureaccess.wa.gov/

https://www.youtube.com/playlist?list=PLWlxlU5yW802EQFRPepDCU_6_O8DU7zvn

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/SAWIntegration


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


Key PMP Practices to ConsiderDELEGATE 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



Post PMP Review Action StepsFor 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 reportCONSIDER using a patient treatment agreementVERIFY the prescriptions listed match your recordsREFER your patient to treatment or other specialty careEDUCATE patients on the risks of opioid overdose


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

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

Documents

prescribing opioids

pain guidelines

pain amdg

opioid prescribing

prescriptions of opioids

guideline recommendations

pain http

chronic pain