CDC Opiate Prescription Guidelines

[southerndoc]

Recommendations:

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
   
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically mean- ingful improvement in pain and function that outweighs risks to patient safety.
   
3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
   
4. When starting opioid therapy for chronic pain, clinicians should prescribe imme- diate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
   
5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increas- ing dosage to ≥50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to ≥90 MME per day.
   
6. 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 7 days will rarely be needed.
   
7. Clinicians should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
   
8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use are present.
   
9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combina- tions that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
   
10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
    
11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
    
12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid-use disorder.
    

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[Janders]

Mass just signed into law a similar set of suggestions... we can no longer Rx more than 7d of opiates for initial therapy (without an excuse). Not that I did that from the ED...

Also have to specifically warn patients of the dangers if you Rx schedule II drugs.

The fun part is that in 3.5mo all patients presenting with OD / narcan use must have a formal substance abuse screening (by psych or similar) within 24 hours and prior to discharge. A bit of a problematic and unfunded mandate, though I appreciate the effort.

I have generally been in favor of these restrictions on our practice... pragmatic I am. I'm tired of seeing OD deaths, and I enjoy being able to tell chronic pain patients who abuse the ED that it is NOT good medicine just to give them another #15 oxys blindly.

 

[filhodeinferno]

Recommendations:.

1. 
   
   
   • Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
     .
     [*]Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically mean- ingful improvement in pain and function that outweighs risks to patient safety.
     .
     [*]Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
     .
     [*]When starting opioid therapy for chronic pain, clinicians should prescribe imme- diate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
     .
     [*]When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increas- ing dosage to ≥50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to ≥90 MME per day.
     .
     [*]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 7 days will rarely be needed..
     .
     [*]Clinicians should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
     .
     [*]Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use are present.
     .
     [*]Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combina- tions that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
     .
     [*]When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
     .
     [*]Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
     .
     [*]Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid-use disorder. .
     

This is nice, but would be nice if hospital admin gets on board with this. My guess is that many ED docs will continue to be liberal with narcs to avoid getting written up by patients.

 

[Vandalia]

West Virginia hospitals have come up with opioid prescribing rules that went into effect in the last couple of weeks. Of most significance, for chronic pain, the most an ED physician can prescribe is enough to last to the next business day. Since the hospitals themselves have implemented the rules, we will see if they stick. And since the same rules apply to everyone, it should theoretically eliminate the Press-Ganey penalty, since it doesn't matter what your absolute scores are, it is what they are relative to everyone else.

http://www.workcompwire.com/2015/12...es-guidelines-for-use-prescribing-of-opioids/

(It is still too wishy-washy, but at the very least it provides physicians with "impeachment evidence" if the hospital administration tries to demand a different practice pattern.)

Indiana passed a law that at the end of 2014 that all chronic pain patients must have several UDS a year, a SOAPP-R assessment yearly, and the controlled substances database checked at every visit. Unfortunately, it suffers from at least three problems: First, the physicians who weren't complying in the first place probably still aren't. They plan to bank their millions and disappear when the state starts snooping around. Second, too many details were written into the law: you have to use SOAPP-R even if something better comes around, and you have to use UDS even if something more effective is developed five years from now. And since it is tough to change laws, this will probably end up like the law that you have to have a man with a red flag walking ahead of you if you drive a car on city streets. Or that all government agencies must provide data to the GAO on 5 1/4" floppy disks. Finally, it is a bit too "one size fits all." A 95 year old bed-ridden patient with dementia probably doesn't need a UDS every month.

But at least it is a start. If physicians checked the controlled substance prescribing database with every prescription it would probably solve most of the problems. And not getting patients started on opiates. However, I am concerned - with good reasons - that if you suddenly cut off patients who have been somewhat successfully receiving opiates for years you have just increased business for the heroin salesmen. A patient is just as dead if they overdose on oxycodone or heroin.

 

[Brahnold]

Indiana passed a law that at the end of 2014 that all chronic pain patients must have several UDS a year, a SOAPP-R assessment yearly, and the controlled substances database checked at every visit. Unfortunately, it suffers from at least three problems: First, the physicians who weren't complying in the first place probably still aren't. They plan to bank their millions and disappear when the state starts snooping around

How can physicians earn money from writing prescriptions? An office visit nets you X dollars whether you end up writing a prescription or not, right?

 

[gutonc]

How can physicians earn money from writing prescriptions? An office visit nets you X dollars whether you end up writing a prescription or not, right?

But if the only reason you see these people is to write narcotic Rx's (aka...you're running a pill mill) then you absolutely profit from it. If you're not the candy man, they're not coming back to see you.

 

[gman33]

What would be the harm/benefit of eliminating outpatient narcotics?
Some people who could really use them would be out of luck, but would there be a greater benefit to the population as a whole.

Maybe it could be as strict as running a methadone clinic.
You need to show up somewhere and get your daily dose.

To really change the prescribers behavior, you have to change the incentives.
By that I mean press gainey and other forms of complaints.
I'd gladly stop writing all scripts tomorrow if I wouldn't catch hell.

 

[Vandalia]

How can physicians earn money from writing prescriptions? An office visit nets you X dollars whether you end up writing a prescription or not, right?

Easy. There is a local (within 100 miles, that is considered "local") "pain medicine" physician who charges $500 (cash) for what would essentially be level 2 follow-up visits. Plus another $600 for dip-stick urine tests. Now this is not New York or Hollywood. If someone can afford to pay those prices every three months... something isn't right.

 

[Janders]

An office visit nets $x from an insurance company or medicaid.

Oh wait, you refuses to accept any insurance, are a cash-only small business, and charge $100 per monthly 5 minute visit for #120 oxys for chronic pain?

CHA-CHING...