Opioid Compliance, Documentation, and Monitoring October 9, 2015.
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Transcript of Opioid Compliance, Documentation, and Monitoring October 9, 2015.
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Opioid Compliance, Documentation, and
MonitoringOctober 9, 2015
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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
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The Seattle Times – December, 2011
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The Seattle Times – December, 2011
Methadone 10 mg 10 tabs q6 hrs
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The Seattle Times – December, 2011
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Methadone and Accidental Deaths
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Statistics from Washington State Department of Health
http://www.doh.wa.gov/Portals/1/Documents/5500/RPF-Drg2014.pdf
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Statistics from Washington State Department of Health
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Statistics from Washington State Department of Health
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Statistics from Washington State Department of Health
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Agency Medical Directors’ Group Guidelines
http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
(Information from AMDG used with permission)
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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.
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Interagency Guideline on Prescribing Opioids for Pain
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.
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Interagency Guideline on Prescribing Opioids for Pain
http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
“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)
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Interagency Guideline on Prescribing Opioids for Pain
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)
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Interagency Guideline on Prescribing Opioids for Pain
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Interagency Guideline on Prescribing Opioids for Pain
Clinical Recommendations: (pages 12, 13)
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Interagency Guideline on Prescribing Opioids for Pain
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Interagency Guideline on Prescribing Opioids for Pain
Tapering or discontinuing opioid therapy: (Page 36)
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Interagency Guideline on Prescribing Opioids for Pain
Numerous bullet points on tapering meds are discussed.
Rate of opioid taper (page 37)
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Interagency Guideline on Prescribing Opioids for Pain
Treating withdrawal of opioids (page 38)
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Substance Abuse Trends with Heroin
www.samhsa.gov (Substance Abuse and Mental Health Services Administration)
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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)
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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
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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
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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)
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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
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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
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Opioid Risk Tools
Use CAGE questions
Cut down dosage
Annoyed by criticism
Guilty
Eye-opener
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Functional Outcomes
Assessment of functional outcomes
Oswestry Disability Index
SF-12 or SF-36
See also AMDG opiod guidelines for other resources
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Psychology and Psychiatry
Consultations and treatment to address underlying psychiatric co-morbidities
Assess compliance and encourage patient responsibility
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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)
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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
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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
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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
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Washington State Department of Health
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
Used with Permission
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Washington State Department of Health
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
Used with Permission
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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