Strategies for Appropriate Opioid Prescribing: The Florida Requirement _ _____________________________
• Have there been any other substance (alcohol or drug) abuse problems in the person’s life? An affirmative response should be taken into consideration when prescribing. • Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed? If so, this suggests the pain medication is failing to promote rehabilitation. Daily activity is essential, and the patient may be considered for enrollment in a graduated exercise program. • Is the person in pain able to function (e.g., work, do household chores, play) with pain medication in a way that is clearly better than without? If yes, this suggests the pain medication is contributing to wellness.
opioid medications (e.g., having enough, taking them, dosing schedule)? Pain Assessment and Documentation Tool (PADT) Guidelines by the CDC, the Federation of State Medical Boards (FSMB), and the Joint Commission stress the importance of documentation from both a healthcare quality and medicolegal perspective. Research has found widespread deficits in chart notes and progress documentation for patients with chronic pain who are receiving opioid therapy, and the Pain Assessment and Documentation Tool (PADT) was designed to address these shortcomings [79]. The PADT is a clinician-directed interview, with most sections (e.g., analgesia, activities of daily living, adverse events) consisting of questions asked of the patient. However, the potential aberrant drug-related behavior section must be completed by the physician based on his or her observations of the patient [80]. The Brief Intervention Tool The Brief Intervention Tool is a 26-item, “yes-no,” patient- administered questionnaire used to identify early signs of opioid abuse or addiction. The items assess the extent of problems related to drug use in several areas, including drug use-related functional impairment [72]. Urine Drug Tests UDTs may be used to monitor adherence to the prescribed treatment plan and to detect unsanctioned drug use. They should be used more often in patients receiving addiction therapy, but clinical judgment is the ultimate guide to testing frequency ( Table 2) [81]. The CDC 2016 guideline recommends clinicians should use UDT before starting opioid therapy and consider UDT at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs [44]. However, this recommendation was based on low-quality evidence that indicates little confidence in the effect estimate, and it is not included in the 2022 updated guideline [4]. CONCURRENT USE OF BENZODIAZEPINES In 2021, nearly 14% of persons who died of an opioid overdose also tested positive for benzodiazepines, a class of sedative medication commonly prescribed for anxiety, insomnia, panic attack, and muscle spasm [8]. Benzodiazepines work by raising the level of the neurotransmitter gamma-aminobutyric acid (GABA) in the brain. Common formulations include diazepam, alprazolam, and clonazepam. Combining
Assessment Tools VIGIL
VIGIL is the acronym for a five-step risk management strategy designed to empower clinicians to appropriately prescribe opioids for pain by reducing regulatory concerns and to give pharmacists a framework for resolving ambiguous opioid analgesic prescriptions in a manner that preserves legitimate patient need while potentially deterring diverters. The components of VIGIL are [77]: • Verification: Is this a responsible opioid user? • Identification: Is the identity of this patient verifiable? • Generalization: Do we agree on mutual responsibilities and expectations? • Interpretation: Do I feel comfortable allowing this person to have controlled substances? • Legalization: Am I acting legally and responsibly? The foundation of VIGIL is a collaborative physician/ pharmacist relationship [77; 78]. Current Opioid Misuse Measure (COMM) The Current Opioid Misuse Measure (COMM) is a 17-item patient self-report assessment designed to help clinicians identify misuse or abuse in patients with chronic pain. Unlike the ORT and the SOAPP-R, the COMM identifies aberrant behaviors associated with opioid misuse in patients already receiving long-term opioid therapy [58]. Sample questions include: In the past 30 days, how often have you had to take more of your medication than prescribed? In the past 30 days, how much of your time was spent thinking about
PATIENT RISK LEVEL AND FREQUENCY OF MONITORING
Monitoring Tool
Patient Risk Level
Low
Medium
High
Urine drug test
Every one to two years
Every 6 to 12 months Three times per year
Every three to six months
State prescription drug monitoring program
Twice per year
Four times per year
Source: [81]
Table 2
50
MDFL0627
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