COPIC Comment: Guidelines and resources to address opioid prescribing
by Ted J. Clarke, MD Chairman & CEO, COPIC Insurance Company
The issue of opioid dependence and addiction has been pushed to the forefront of health care in recent years and presents an ongoing challenge for medical providers. In response, we have seen guidance strategies released by public agencies that provide useful risk management advice and medical tools that can assist them to better understand the issue and make informed decisions.
Centers for Disease Control and Prevention guidance
Published in March 2016, the “CDC Guideline for Prescribing Opioids for Chronic Pain” report is directed at primary care physicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care. In particular, the following are some key points noted in the report that are relevant to opioid prescribers:
1. Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain, and clinicians should consider opioid therapy only if benefits for pain and function outweigh risks.
2. When starting opioid therapy, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
3. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
4. Clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible.
Another useful CDC resource is the “Calculating Total Daily Dose of Opioids For Safer Dosage” guide available online.
Colorado Medical Board policy
In October 2014, Colorado’s “quad boards” of medicine, dentistry, nursing and pharmacy adopted the Joint Policy for Prescribing and Dispensing Opioids. The policy recommends additional safeguards be put in place when prescribing and dispensing exceeds the following evidence-based thresholds that have been associated with adverse outcomes:
• 90 days in duration,
• 120 MME (note that the CDC now places this at ≥90 MME), or
• Certain formulations such as transdermal or long-acting preparations.
The policy also describes the following recommendations prior to the consideration of initiating opioid therapy. Recall that documenting the prescriber’s considerations of all these elements is critical in the defense of a subsequent medical board or medical liability action.
1. Diagnose – Prescribers should establish a diagnosis through history, physician exam and/or laboratory, imaging and/or other studies in the setting of a genuine provider-patient relationship.
2. Assess risk – The policy discusses an expectation of the assessment of risks associated with adverse outcomes such as patient or family history of alcohol or substance use disorder, patient medication history (especially concurrent benzodiazepines), mental health conditions and history, abuse history (physical, emotional or sexual), and concurrent health conditions increasing the risk of adverse outcomes (COPD, CHF, sleep apnea, elderly, hepatic or renal insufficiency).
3. Assess pain – The assessment should not only be about nature, intensity and location, but should also include an assessment of its impact on physical and psychological function.
4. Review the Colorado Prescription Drug Monitoring Program.
Additional resources available through COPIC
The Opioid Crisis Part I – The Pain That Won’t Go Away: This seminar examines the scope of the opioid problem and uses the guidance of the CDC, FDA, medical boards and other best practices to describe practical approaches to practice more safely with opioids.
The Opioid Crisis Part II – Strategies for Reducing the Burden: In response to the opioid epidemic and the role of health care professionals in it, this seminar reviews the reasoning and criteria for opioid dose reduction and discontinuation while teaching techniques to encourage patient buy-in with a focus on overcoming fear and resistance.
SCOPE of Pain (FDA REMS-Compliant): This online educational program will help you safely and competently use opioids, if appropriate, to manage your patients with chronic pain. Key areas covered include assessing for opioid misuse risk; counseling patients about opioid safety, risks and benefits; monitoring patients prescribed opioids for benefit and harm; and safe discontinuation of opioids.
Interested in hosting a COPIC seminar at your practice? Contact Carmenlita Byrd at email@example.com or (800) 421-1834, ext. 6131. Register for seminars and access online programs at www.callcopic.com/education.
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