Initial Prescribing

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Contents 1 Course 2: Initial Prescribing 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Use a Prescribing Strategy 1.3.2 Objective B. Develop Treatment Agreements 1.3.3 Objective C. Informed Consent and Patient Education 1.4 Case Studies/Standardized Patients

Course 2: Initial Prescribing

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

Need

Many clinicians do not prescribe opioid pain medications with the caution needed to prevent pain patients from developing substance use disorders.

The majority of physicians either did not receive any training for prescribing controlled drugs or received a maximum of a few hours training (CASA, 2005). Only a minority of physicians use medication contracts with patients suspected of abusing (CASA, 2005). Physicians are inconsistent in their approach to prescribing opioids for pain patients (Merrill, et al., 2002)

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.

Objectives

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

Objective 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

Objective 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

Objective 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.
• Objective 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
• Objective 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
• Objective Covered: C