Initial Prescribing

From Clinicaltools.com

Contents 1 Course 2: Initial Prescribing 1.1 Practice Gap/Need 1.2 Goal 1.3 Core Competencies & Clinical Skills 1.3.1 A. Use a Prescribing Strategy 1.3.2 B. Develop Treatment Agreements 1.3.3 C. Informed Consent and Patient Education 1.4 Case Studies/Standardized Patients 2 New courses:

Course 2: Initial Prescribing

Minimizing Risk of Substance Use Disorders When Initially Prescribing Controlled Substances to Pain Patients

Practice Gap/Need

Co-morbid substance abuse affects 20 to 40% of patients on opioid therapy for chronic pain (Katz, et al., 2003; Manchikanti et al., 2001). Non-medical use of opioids is high: an estimated 4.7 million people over age 12 have used opiate pain medication in the past month, according to the 2008 National Survey on Drug Use and Health, which represents a slight increase over the past 5 years (SAMHSA, 2009).

The importance of preventing, identifying and treating substance abuse when managing chronic pain with opioids is well documented (Compton, 2008). However, a 2004 national survey of 979 physicians for a report on diversion by the National Center on Addiction and Substance Abuse at Columbia University (CASA) identified a number of deficiencies in both competency and practice in substance abuse practices that are important in pain management. For instance, nearly half of physicians do not ask about prescription drug abuse when taking an initial health history at a patient's first visit and physicians with more training in pain and addiction are more likely to ask for this information (CASA, July 2005, p. 53). The same survey found that nearly 25% of physicians do not discuss the possibility of addiction when prescribing a controlled substance (CASA, July 2005, p. 54). In CASA's national survey of 648 primary care physicians in 1999, only 30.2% felt "very prepared" to diagnose prescription drug abuse and rates were even lower for alcoholism (19.9%) and illegal drug use (16.9%) (CASA, April 2000, p. ii. The same survey found that very few physician (2.1%) feel that treatment is very effective for illegal drug abuse (CASA, April, 2000, p. iii).

In CASA's report on the problem of diversion, they recommended that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance abuse and addiction (CASA, July 2005, p. 100). In addition, the National Institute on Drug Abuse (NIH) has identified a need for increased education and training for physicians in the identification and treatment of comorbid pain and substance abuse (NIDA RFP 093, 2008). However, The majority of 979 physicians surveyed in 2004 by the National Center on Addiction and Substance Abuse at Columbia University (CASA) did not receive training, either in medical school or in CME, in identifying prescription drug abuse and addiction (CASA, JULY 2005, pp. 90-91). Additionally, the majority of physicians either did not receive any training for prescribing controlled drugs or received a maximum of a few hours training (CASA, July 2005, p. 90). Only a minority of physicians use medication contracts with patients suspected of abusing (CASA, July 2005, p. 95). Furthermore, physicians are inconsistent in their approach to prescribing opioids for pain patients (Merrill, et al., 2002).

A multidisciplinary panel, after a review of the evidence chronic opioid therapy in chronic non-cancer pain, recommended that physicians follow certain guidelines when prescribing opioids; many of the recommendations were designed to reduce the risk of addiction and other substance abuse (Chou, et al. 2009). According to these guidelines, ideally, physicians should screen every pain patient for substance abuse or risk of substance abuse (Chou, et al. 2009). Physicians should use first line pain therapies first, and only use opioids when they are indicated (Chou, 2009). Physicians should structure treatment so that the risk of developing addiction is minimized and modify treatment structure when risk is identified (Chou et al, 2009). Physicians should follow certain baseline precautions with every chronic pain patient requiring chronic opioic therapy (Gourlay et al, 2005).

Clinicians should prescribe opioid pain medications with caution to prevent pain patients from developing substance use disorders (Compton, 2008) and should keep the risks of opioids in mind when prescribing them (Chou et al, 2009).

Goal

After identifying a need for a controlled substance to treat pain and assessing risk for addiction as described in the Screening/Assessment course, the learner will be able to minimize the risk of pain patients developing substance use disorders through best practice approaches to prescribing opioids and other controlled substances.

Core Competencies & Clinical Skills

After completing this course, the learner will be able to:

A. Use a Prescribing Strategy

Use a prescribing strategy that minimizes risk of pain medication abuse/addiction

1. Set goals of treatment (a basis for measuring success or failure and exiting if not successful)
2. Check patient history in prescription drug monitoring data base if available
3. Consult with specialists as needed (pain, addiction, mental health)
4. Use first-line medications for treating pain condition before prescribing opioids
5. Choose the least-addictive drug that will adequately manage the pain
6. Prescribe the lowest dose that will adequately manage the pain
7. Prescribe opioids in combination with other effective medications and treatments
8. Prescribe opioids in short time intervals and refill pain medication only with verification of continued pain diagnosis and/or impaired function
9. Prescribe extended release formulations of opioids for patients with constant pain in order to minimize the reward effect and provide more stable blood levels
10. Re-evaluate effectiveness of pain treatment periodically and change medication if needed
11. Identify a treatment "home" for the patient, that is, the physician who will oversee and coordinate treatment
12. Identify a single prescribing physician if possible and single dispensing pharmacist

B. Develop Treatment Agreements

Develop signed treatment agreements describing expectations and obligations for the patient and the provider

1. Discuss with the patient the necessity of establishing a treatment agreement
2. Develop the core components of a written treatment agreement
3. Describe expectations of the patients that best minimize risk
4. Discuss consequences with the patient of breaking a treatment contract
5. Be aware of legal issues surrounding treatment agreements
6. Include exit strategies that describe in advance the criteria for stopping opioids

C. Informed Consent and Patient Education

Provide appropriate informed consent and use patient education to minimize opioid misuse

1. Inform pain patients of the risk of substance use disorders with use of prescription opioids
2. Explain that the risk of substance use disorders is present even when there is legitimate pain
3. Discuss proper use of opioid pain medications and the dangers of self-medication and chemical coping
4. Advise patients of opioid toxicity and potentially harmful interactions
5. Advise patients of harm from changing form of opioid drug delivery (e.g. insuflation or injecting)
6. Provide patient education materials about correct use of opioids, including side effects and risks

Case Studies/Standardized Patients

Case 1: Martin Migraine - 34YOHM

• Chief Complaint: Needs more migraine medication
• Narrative: Martin takes topamax daily and triptans and prescription opioids approx 2-4 times/week when he has a migraine attack.
• Opioid Issue: Risk for substance abuse and decreased effectiveness due to anxiety
• Relevant Past Medical, Psychosocial, Family History: A 12 year history of migraines and is a highly anxious person.
• Competency Covered: A

Case 2: Wendy Whiplash - 34YOWF

• Chief Complaint: Pain from whiplash suffered during a recent car accident
• Narrative: Wendy's pain has persisted for several weeks since being evaluated in an emergency department after a car accident. She says the pain is severe and interfering with sleep, driving, and her work. She is a new patient.
• Opioid Issue: Risk for substance abuse due to family history of substance abuse
• Relevant Past Medical, Psychosocial, Family History: Mother addicted to Valium for many years
• Competency Covered: B

Case 3: Barb Bad Knee - 60YOWF

• Chief Complaint: Knee pain
• Narrative: Barb's orthopedic surgeon recommended knee replacement, but she needs to postpone it for at least a year due to family circumstances for which she has temporarily moved to the area. She experiences severe pain when walking and often when not walking.
• Opioid Issue: Risk for substance abuse due to lack of her usual social support
• Relevant Past Medical, Psychosocial, Family History: Is staying with a daughter who is seldom home and does not know anyone in the area
• Competency Covered: C