Table 4. Items to Perform and Document in the Patient Record When Prescribing Opioid Therapy for Chronic Pain 18,32,38,52,53a 1. Signed informed consent 2. Signed opioid treatment agreement(s) 3. Pain and medical history Chief complaint Treatments tried and patient response Past laboratory, diagnostic, and imaging results Comorbid conditions (e.g., medical, substance-use, psychiatric, mood, sleep) Social history (e.g., employment, marital, family status, substance use) Pregnancy status or intent, contraceptive use 4. Results of physical exam and new diagnostic and imaging tests Review of systems Pain intensity and level of functioning One or more indications for opioid treatment Objective disease/diagnostic markers 5. Results of opioid risk assessment prior to prescribing opioids Clinical interview or any screening instruments Personal history of SUD, mental health disorder Family history of SUD, mental health disorder Co-management or treatment referral for patients at risk for SUD Treatment or referral for patients with active OUD Treatment or referral for patients with undiagnosed depression, anxiety, other mental health disorders 6. Treatment goals for pain relief, function, quality of life 7. Treatments provided With risk-benefit analysis after considering available nonpharmacologic and non-opioid pharmacologic options All medications prescribed (including the date, type, dose, and quantity) All prescription orders for opioids and other controlled substances whether written or telephoned 8. Prescription of naloxone, if provided, and rationale 9. Results of ongoing monitoring toward pain management and functional goals Consider risk for dangerous drug-drug interactions Consider risk for misuse with opioids Collaborate on transition with primary prescriber if opioids previously prescribed 12. Results of initial and ongoing UDT 13. Counseling and instructions to the patient and significant others Directions for medication use Ongoing discussions of risks and benefits Adherence to prescribed therapies, including results of UDT and PDMP checks Actions taken regarding aberrant medication use (e.g., document results, collaborate with multidisciplinary team, institute taper) 14. Referrals given and notes on consultations for specialists in pain, SUD, mental-health, and medical comorbidities 15. Notes on continuing, revising, or discontinuing opioid therapy (e.g., titrate, rotate, taper, OUD management) 16. Authorization for release of information to other treatment practitioners SUD = substance-use disorder OUD = opioid-use disorder; PDMP = prescription drug-monitoring programs; UDT = urine drug testing Considerations for the Prescriber: Ongoing Opioid Therapy 1. Opioid medication prescriptions should be obtained from a single provider/ practice and filled by a single pharmacy. 10. Presence and treatment of adverse events 11. Results of initial and ongoing PDMP checks
3. Any patients on large doses of opioid medications should be referred to a Pain Management specialist. 4. Patients should be observed for any findings suggesting aberrant medication-taking behaviors. 5. Opioid medications should be discontinued when risks of continued treatment outweigh the benefits. These risks could include aberrant medication taking behavior, lack of efficacy, or side effect severity. Medications may require a taper to prevent withdrawal symptoms.
2. Follow up visits should document analgesia effectiveness, reports of activities of daily living, medication side effects, compliance with the specified medication schedule, review of a Controlled Substance Monitoring Database and the patient’s affect.
Book Code: TN24CME
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