Opioid policies - TH

SAMHSA

Substance Abuse and Mental Health Services Administration

Policy Scope Exclusions

The policy is not intended for patients in active cancer treatment, palliative, or end-of-life care.

Opiate and Benzodiazepine Concurrent Use

These two classes of medications should not be taken or prescribed together for a non-terminal patient.

NYS Prescription Monitoring Program

A state program that all providers are required by NYS to check before writing a controlled medication.

Medent Pain Assessment and Documentation Tool

A tool that must be completed every 3 months for patients prescribed chronic opioids. It includes measurements of analgesia, activities of daily living (physical functioning, relationships (family and social), mood, sleep patterns, and overall functioning, adverse events, and potential aberrant drug-related behavior

Controlled Substance Agreement Review

Agreements for opiates used for chronic pain must be completed and reviewed annually.

Urine Drug Screen Frequency

A test collected at least every 3 months for patients on opiates, benzodiazepines, stimulants, and controlled hypnotics.

Narcan Prescription Threshold

Narcan must be prescribed with any opiate prescription greater than or equal to $90\,MME/day$. Should just be presfcribed for everyone especially of greater than or equal to 50 mme/day

Chronic Pain Management Guidelines

Protocols establishing standards for effective management of chronic pain using medications.

Withdrawal Symptoms and examples of them

Physical and psychological symptoms that occur when a patient stops taking a substance they are dependent on. sweating and goosebumps, anxiety, irritability, cravings, n/v/d or decreased appetite, tremor, watery eyes, runny nose, sneezing, yawning and disturbed sleep

Why and how do we taper?

prevent withdrawal, about 10% per month

Patient Education on Opioids

Information provided to patients about the risks, benefits, and proper use of opioid medications.

Risk Assessment Tools

Tools used to evaluate a patient's risk factors for substance abuse and addiction. such as the PADT (pain assessment and documentation tool). We also use the DAST and the Craft in peds/adolescents

Non-Pharmacological Interventions

Therapeutic options for managing pain that do not involve medication, such as physical therapy.

Dependence vs. Addiction

Physical dependence - biological adaptations (tolerance and withdrawl). You can be physically dependent on a substance w/o being addicted such as with a beta blocker. Addiction - behavioral condition characterized by the compulsive use of a substance despite severe negative consequences (loss of a job, legal issues, damaged relationships). Addiction often involves physical dependence, it is defined primarily by a loss of behavioral control

Long-Term Opioid Use Risks

Potential adverse effects associated with prolonged use of opioid medications, including tolerance and increased sensitivity to pain.

Behavioral Therapies for Addiction

Psychological treatments aimed at changing patterns of substance use and addressing underlying behavioral issues.

Risk Mitigation Strategies

Approaches designed to minimize the potential for opioid misuse and dependence among patients prescribed these medications.

Substance Use Disorder (SUD)

A medical condition characterized by an individual's inability to stop or control the use of a substance despite negative consequences.

Care Coordination in Pain Management

A collaborative approach among healthcare providers to ensure comprehensive and continuous care for patients experiencing pain.

Opioid Stewardship Programs\n\n

Initiatives aimed at ensuring the appropriate prescribing and use of opioids, while minimizing risks of misuse and addiction.

Patient-Centered Care in Pain Management

An approach that involves patients in decision-making about their pain treatment and management strategies, prioritizing their preferences and values.

Psychoeducation for Patients

Providing patients with information about mental health and substance use issues to enhance their understanding and coping strategies.

Patient Risk Factors for Addiction

Specific factors to assess in patients that could lead to a higher risk of substance abuse.

Continuous Monitoring for Opioid Therapy

Ongoing evaluation of a patient's response to opioid therapy to ensure safety and effectiveness.

Public Health Initiatives for Pain Management

Programs aimed at educating the community about pain management and reducing stigma associated with pain and addiction.

Role of Mental Health in Pain Management

Importance of addressing psychological aspects in the management of chronic pain conditions.

Controlled Substance Agreement Review

Agreements for benzodiazepines and opiates used for chronic pain must be completed and reviewed annually for quality and compliance.

Narcan Prescription Threshold

Narcan must be prescribed with any opiate prescription greater than or equal to $90\,MME/day$ to mitigate overdose risk.

Urine Drug Screen Frequency

A test that must be collected at least every 3 months for patients prescribed opiates and other controlled substances to monitor compliance and safety.

Risk Mitigation Strategies

Approaches developed to minimize the potential for opioid misuse and dependence while maintaining effective pain management.

Management of Withdrawal Symptoms

Guidelines for addressing the physical and psychological symptoms that occur when a patient ceases use of a substance they are dependent on.

Medication Assisted Therapy (MAT)

A treatment approach that combines medications with counseling and behavioral therapies for substance use disorders. Buprenorphine, methadone, vivitrol

CDC Guidelines for Prescribing Opioids

Recommendations from the Centers for Disease Control and Prevention aimed at ensuring safer and more effective prescribing of opioids for chronic pain management. Specifically prefer non opioids, use immediate release first, not extended release, duration limits, must do less than 7 days and less than 3 is usually ok, and avoid concurrent benzos, be very cautious about doses greater than or equal to 50 mme, use harm reduction (edu about overdose prevention and Narcan)

SAMHSA Role

The Substance Abuse and Mental Health Services Administration provides resources and guidance for substance use disorder treatment and prevention.

Medent Pain Assessment Tool

A tool required for assessment and documentation of chronic pain in patients on opioid therapy, completed every 3 months.

Behavioral Therapies for Addiction

Psychological treatments that focus on changing patterns of substance use and addressing related behavioral issues.

Purpose of the Policy

The purpose of the policy is to ensure safe and effective prescribing practices, minimize risks of misuse, and provide guidelines for managing patients with chronic pain.

Opiate Prescribing Guidelines

Set of rules for healthcare providers regarding the appropriate use of opioids for pain management.

Reasons for Tapering

Tapering is necessary to minimize withdrawal symptoms and facilitate safe discontinuation of medications.

Monitoring During Tapering

Regular assessments and follow-ups are essential to evaluate the patient's response to dosage reductions and manage any arising symptoms.

Patient Education on Tapering

Informing patients about the tapering process, potential withdrawal symptoms, and the importance of adherence to the schedule.

Outside Provider Benzodiazepine Protocol

The Organization provider must document that risks of taking both opioids and benzodiazepines were clearly discussed with the patient.

New Prescription Duration Limit

7 days

Controlled Substance Agreement

A signed document required in the chart for all patients on controlled substances.

Agreement Review Frequency

Controlled substance agreements for benzodiazepines and opiates used for chronic pain must be reviewed annually.

Urine Drug Screen Frequency

Collected at least every 3-months for patients on opiates, benzodiazepines, stimulants, and controlled hypnotics.

Missed Appointments Policy

If a patient regularly misses follow-ups, controlled substance medication should be tapered and discontinued.

Narcan Prescription Requirement

Must be prescribed with any opiate prescription $\geq 90\,\text{MME/day}$.

90 MME/day

The threshold of Morphine Milligram Equivalents per day at which a Narcan prescription is mandatory.

Palliative Care Consultation

Strongly recommended when prescriptions exceed 3 months due to active cancer or end-of-life care.

What are the DSM-V criteria for Substance Use Disorder (SUD)?

The criteria include: 1) Impaired control over substance use; 2) Social impairment in fulfilling major obligations; 3) Risky use of the substance; 4) Pharmacological indicators such as tolerance and withdrawal symptoms.

What factors increase a patient's chance of addiction to opiates?

Factors include: 1) History of overdose; 2) History of substance use disorder; 3) High opioid dosages (greater than or equal to 50 MME/day); 4) Presence of high-risk combinations of medications.

What is DAST?

DAST is a 10-question screening tool that identifies risk for substance use disorder by assessing loss of control, social impact, risky behavior, and physical consequences. At Trillium, we use it within an SBIRT framework to triage patients from brief intervention to full treatment referral.

What are the risk groups for the DAST?

no risk, at risk, moderate risk, high risk

What are the domains the DAST touches on?

• Use patterns (nonmedical use, poly-substance use)

• Loss of control (can’t stop, withdrawal)

• Psychological impact (guilt)

• Social/functional impact (family problems, neglect)

• Consequences

  • Legal (illegal activity)

  • Physical (blackouts, medical issues)

SBIRT =

screening, brief intervention, referral to treatment - Everyone gets screened, some get a brief conversation, a smaller group get referred for treatment

What is the time line for Trillium?

1983 Aids Rochester, 1989 CHN, 1990 CHN get RW funding, 2010 Aids Rochester and CHN merge and become Aids care, 2013, rebranded to Trillium 2016 became a FQHC-LAL, 2025 became full FQHC

When was I appointed interim CMO? Formal CMO?

6/2021; 3/2022

What’s included in the PADT

1. Analgesia, Activity or Function, Adverse Effects, Aberrant Behaviors (misuse risk)

What are some examples of Aberrant Behaviors?

• Early refill requests

• Lost/stolen prescriptions

• Multiple prescribers/pharmacies

• Non-adherence to treatment plan

• Concerning PDMP findings

• UDS inconsistencies

What does PEG stand for?

Pain intensity, Enjoyment of life, General Activity