This document discusses guidelines for monitoring patients on long-term opioid therapy for chronic pain. It outlines using a standardized tool called the "5 A's" to document: 1) Analgesia or pain relief, 2) Adverse reactions, 3) Activities of daily living improvement, 4) Aberrant behaviors, and 5) Overall assessment of risks vs benefits. It also discusses using standardized questionnaires to assess pain interference and function. Regular monitoring with such tools can help optimize treatment and identify any issues requiring intervention.
6. Referral Exclusions
• Pain Types: Acute Injury/Post-op,
Palliative, Hospice.
• Patient-specific: Stable Non-escalating,
On taper, acute flare with expectation of
return to baseline.
• Provider-specific: 12 hours CME every
2 years with 2 hours long acting opioids.
7. Let’s Educate!
• AAFP President says, “No” (8/24/2011)
• Diversion accounts for >60% of deaths.
• AAFP: This could reduce access to pain
management for patients.
ow.ly/1eogjV
16. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan
17. Basic History
• Previous Workup
• Previous Treatments (Dose, etc)
• (Review Prescription Monitoring Program)
• Nature/Location of Pain
• Impact of physical/psychological function
• Respiratory Risks? (OSA, COPD)
18. Basic History
• Previous Workup
• Previous Treatments (Dose, etc)
• (Review Prescription Monitoring Program)
• Nature/Location of Pain
• Impact of physical/psychological function
• Respiratory Risks? (OSA, COPD)
19. Basic History
• Previous Workup Verify First.
Get records before starting.
• Previous Treatments (Dose,no start?)
(What if there’s etc)
• (Review Prescription Monitoring Program)
• Nature/Location of Pain
• Impact of physical/psychological function
• Respiratory Risks? (OSA, COPD)
20. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan
22. Risk Stratification
Etiology Clear Unclear
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbidities COPD, OSA
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik
23. Risk Stratification
Etiology Clear Unclear
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbidities COPD, OSA
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik
24. Risk Stratification
Etiology Clear
Patients with no Unclear still
risk can
divert or abuse prescriptions
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbidities COPD, OSA
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik
25. Risk Stratification
Etiology Clear
Patients with no Unclear still
risk can
divert or abuse prescriptions
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbiditiesmany risksOSA
Patients with COPD, still
need care. Refer to a specialist.
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik
31. Alcohol Screening
CAGE adjusted to include drugs
• Have you ever felt you ought to cut down on your drinking
or drug use?
• Have people annoyed you by criticizing your drinking or drug
use?
• Have you ever felt bad or guilty about your drinking or drug
use?
• Have you ever had a drink or used drugs first thing in the
morning (eye-opener) to steady your nerves or to get rid of
a hangover?
32. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan
34. Informed Consent
Consent improves
consideration of risks and
alternatives.
• Risks/Benefits
• Alternatives Consent can be used as a
• Risks of non-treatment treatment
barrier to
35. Informed Consent
• Provider Bias can show up in
Risks/Benefits
how consent is performed.
• Alternatives
• Risks of non-treatment
36. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan
44. The 5 A’s
• Analgesia
• Adverse Reactions
• ADLs Improved
• Aberrant Behaviors
• Assessment
Stephen Passik
45. Chronic Pain Opioid Followup
Current Analgesic Regimen: ________________________________________
_____________________________________________________________________
Analgesia Improved ADLs
What was your average pain over the past Physical Functioning
week? Family Relationships
Social Relationships
What was your worst pain in the past week?
Mood
What percentage of your pain has been re- Sleep patterns
lieved during the past week? Overall Function
Is the amount of pain relief you are now get-
ting enough to make a real difference in your
life?
Adverse Reactions Aberrant Behaviors
Nausea Purposeful Over-sedation
Vomiting Negative mood change
Constipation Appears intoxicated
Itching Increasingly unkempt or impaired
Mental Cloudiness Involvement in car or other accidents
Sweating Requests for frequent early renewals
Fatigue Increasing dose without authorization
Drowsiness Reports lost/stolen prescriptions
Prescriptions from other doctors
Changes route of administration
Uses medications in response to situa-
tional stressors
Insists on certain medications by name
Contact with street drug culture
Abusing alcohol or illicit drugs
Hoarding (Stockpiling) of medication
Arrested by police or Victim of abuse
Assessment:
Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient.
Continue Same Dose
Titrate Dose
Discontinue/Taper
Change Medications
46. ADLs (Function)
Surprisingly Reproducible
Validated across culture 8-10/10
6-7/10 General
Activities
5/10 Relationships Relationships
Walking Walking
3-4/10 Work Work Work
Sleep Sleep Sleep
Enjoyment Enjoyment Enjoyment Enjoyment
Overall Mood Overall Mood Overall Mood Overall Mood
49. Adverse Reactions
• Nausea/Vomiting
• Constipation “The hand that writes the prescription
should write for something for constipation.”
• Itching
• Mental Cloudiness
• Sweating
• Fatigue
• Drowsiness
50. Chronic Pain Opioid Followup
Current Analgesic Regimen: ________________________________________
_____________________________________________________________________
Analgesia Improved ADLs
What was your average pain over the past Physical Functioning
week? Family Relationships
Social Relationships
What was your worst pain in the past week?
Mood
What percentage of your pain has been re- Sleep patterns
lieved during the past week? Overall Function
Having a standard group of
Is the amount of pain relief you are now get-
ting enough to make a real difference in your
life?
Adverse Reactions aberrant behaviors can aid a
Aberrant Behaviors
Nausea
Vomiting team approach to monitoring Purposeful Over-sedation
Negative mood change
Constipation Appears intoxicated
Itching Increasingly unkempt or impaired
Mental Cloudiness Involvement in car or other accidents
Sweating Requests for frequent early renewals
Fatigue Increasing dose without authorization
Drowsiness Reports lost/stolen prescriptions
Prescriptions from other doctors
Changes route of administration
Uses medications in response to situa-
tional stressors
Insists on certain medications by name
Contact with street drug culture
Abusing alcohol or illicit drugs
Hoarding (Stockpiling) of medication
Arrested by police or Victim of abuse
Assessment:
Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient.
Continue Same Dose
Titrate Dose
Discontinue/Taper
Change Medications
51. Chronic Pain Opioid Followup
Current Analgesic Regimen: ________________________________________
_____________________________________________________________________
Analgesia Improved ADLs
What was your average pain over the past Physical Functioning
week? Family Relationships
Social Relationships
What was your worst pain in the past week?
Mood
What percentage of your pain has been re- Sleep patterns
lieved during the past week? Overall Function
Is the amount of pain relief you are now get-
ting enough to make a real difference in your
life?
Adverse Reactions Aberrant Behaviors
Nausea Purposeful Over-sedation
Vomiting
Constipation It’s Not what Negative mood change
Appears intoxicated
you do but
Itching Increasingly unkempt or impaired
Mental Cloudiness Involvement in car or other accidents
Sweating Requests for frequent early renewals
what you
Fatigue Increasing dose without authorization
Drowsiness Reports lost/stolen prescriptions
Prescriptions from other doctors
document.
Changes route of administration
Uses medications in response to situa-
tional stressors
Insists on certain medications by name
Contact with street drug culture
Abusing alcohol or illicit drugs
Hoarding (Stockpiling) of medication
Arrested by police or Victim of abuse
Assessment:
Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient.
Continue Same Dose
Titrate Dose
Discontinue/Taper
Change Medications
54. The Document
I like 12 page contracts
written at 15th grade level in
• Contract or Agreement?10 point type.
• Universal or High-Risk?
• Reading Level I(if College-level OK?”.
just say “Be Nice, are you
really enabling care?)
55. NCFP Treatment
Agreement
• Preferred Brief/Simple over complete/legal.
• Preferred low readability requirement
• Reviewed Evidence about Treatment
Agreements.
• Preferred ‘Non-paternalistic’ tone.
Sloane Winkes, Jonathan Ploudré, 2007
56. NCFP Treatment
Agreement
• Preferred Brief/Simple over complete/legal.
• Preferred low readability requirement
• Is this a barrier to care? No
Reviewed Evidence about Treatment
evidence of efficacy. No ‘Best
Agreements.
Practice’. Highly Variable.
• Preferred ‘Non-paternalistic’ tone.
Sloane Winkes, Jonathan Ploudré, 2007
57. You are being prescribed controlled or potentially addictive medications for the
treatment of pain or other health problems. These may include medications that can be
habit-forming. It is our legal responsibility as health care providers, and our responsibility
to you, to do our best to assure that this medication is being used as safely as possible
and for the purpose for which it is intended.
1.
I will take my medications only as prescribed. I will not share them with or sell them
to anyone else. I will not use recreational or illegal drugs.
2.
My doctor may verify this with periodic pharmacy checks, urine drug screens, and/or
discussion with other health care providers.
3.
I will ask for refills only from my primary doctor and will use only one pharmacy.
4.
I will request refills only when due and realize that processing refill requests may
take 3 working days and may require an office visit.
5.
I will not seek pain medications from the ER or Urgent Care unless there is a new,
acute problem that requires a small supply of medications until I can see my primary
doctor.
6.
I will avoid requesting pain medications outside of regular clinic hours.
7.
I realize that my doctor may not replace lost or stolen medications or prescriptions.
8.
I will treat North Cascade Family Physicians doctors, nurses and staff with courtesy
and expect to be treated with courtesy in return. Failure to do so will result in dismissal
from this clinic.
9.
The following behaviors, which may include an abnormal urine drug screen, abusive
behavior toward staff, selling medications or forging a prescription, in addition to abuse or
violation of this agreement and the medication(s) it applies to may result in dismissal from
North Cascade Family Physicians and you will receive no further controlled
medication(s).
58. How’d we do?
• 1 page Document (not 10!) B+
• 10th grade reading level (could be
improved)
• 1 minute 45 seconds to read.
• MQAC: Add safeguarding. Other additions.
59. I am being prescribed "controlled medications". These may relieve pain but could cause
overdose or become habit forming. It is my doctor's duty to make sure these
medications are being used as safely as possible and as intended.
• I will ask for refills only from my primary doctor. I will use only one pharmacy.
• I will take my medications only as prescribed.
• I will not share them or sell them to anyone. I will safeguard prescriptions.
• I will not abuse alcohol, recreational or illegal drugs.
• My doctor may check on me by calling pharmacies or doing drug tests. My doctor may
discuss my medications with my other providers. Other providers may also report
violations back to my personal doctor. My doctor could even contact the authorities if
illegal activities are suspected.
• My refills may take 3 working days and might require an office visit. I will not request
refills after hours.
• I will not seek pain medications from the ER or Urgent Care unless there is a new,
acute problem. Then I will only get a small supply until I can see my primary doctor.
• My doctor may not replace lost or stolen prescriptions. My doctor may not refill
medications early if I run out.
• I may be dismissed from the clinic or have my medications stopped if there is a major
problem. Major problems include abnormal drug test results, abusive behavior toward
staff, selling medications or forging a prescription.
60. Updated Agreement
• 8th grade reading level
• 1 minute 15 seconds to read.
• We need consensus before we change it.
62. Urine Toxicology
~⅓ Addicts missed if you only
look at aberrant behavior.
Self-report of illicit drug use is
unreliable.
Limited evidence shows could
reduce aberrant behaviors.
63. Urine Toxicology
Increases Cost.
If not careful, can be easy to
mis-interpret.
Can still be tricked — limits to
‘hard science’, sooner or later
it comes back to trust.
65. Point of Care Utox
• The ‘iCup’ costs ~$9.
• Photocopyable results.
• Tests: illicit (cocaine, THC, amphetamine,
Meth, PCP) other prescription misuse
(benzo, barbituates, tri-cyclics) and opiates
(opiates, Methadone, Oxycodone,
Propoxyphene.
• Most drugs detected in last 1-3 days.
• Temperature Strip, Checks 3 Adulterants.
67. Point of Care Limits
• Low Sensitivity and Specificity (needs
confirmation in high risk situations)
• Cross Reactions cause false positives
• False Negatives due to higher thresholds.
68. How to Collect?
• AAFP Article 2010: Take off outer clothing,
show what’s in your pockets, wash hands
under supervision, place bluing agent in
toilet and turn off water supply to the
testing site.
• Mayo Clinic Proceedings: If adulteration is
suspected or results fall outside these
ranges, another specimen should be
collected under direct, observed
supervision
Google: “AAFP Urine Drug Screening”, “Mayo Proceedings Urine Drug”
69. How to Collect?
• AAFP ArticleEven with precautions, these
2010: Take off outer clothing,
show what’s in your pockets, wash hands
under supervision, still be bluing agent if
test can place evaded. Easily in
you use Google.
toilet and turn off water supply to the
testing site.
• Mayo Clinic Proceedings: If adulteration is
suspected or results fall outside these
ranges, another specimen should be
collected under direct, observed
supervision
72. False Positives
• Amphetamines: Buproprion, Propranolol,
Trazadone …
• Barbituates: Phenytoin
• Benzos: Sertraline, …
• LSD: Amitriptyline, Doxepin, Reglan,
If you’re not careful with
confirmation, false positives
Sertraline, Verapamil, …
can disrupt therapy and trust.
• PCP: Dextromethorphan, …
• Propoxyphene: Methadone, Doxylamine, …
73. False Negatives
• Compliance Caveat: Many opiates are not
well detected with routine urine tox.
Fentanyl, meperidine,Hydrocodone,
methadone, oxycodone, buprenorphene,
and tramadol.
74. Confirmation Tests
• More expensive (~$40 each, may need to
do several to clarify based on drug
metabolism)
75. Just Skip Urine Tox?
• Standard of care in Interagency Guidelines.
• Standard of care in MQAC
79. Consider the 2007 DEA
Ruling on Sequential
Prescribing.
“Do Not Fill until __/__/__”
Allows 90 day prescription of
Schedule II Opioids.
The Glam Shot
80. NCFP ToDo List
• Create Initial Chronic Pain Template.
• Include Screening Tools in Initial Template.
• Update Treatement Agreement
• Create a Utox process
• Create capability to interpret abnormal
Utox screens.