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PERIODIC REVIEW AND MONITORING When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [1]. This can include input from family members and/or the state PDMP. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. At every visit, chronic opioid response may be monitored according to the “Five A’s” [1; 32]: • Analgesia • Activities of daily living (e.g., physical, psychological, and social functioning) • Adverse or side effects • Aberrant or abnormal drug-related behaviors • Affect (i.e., patient mood) Signs and symptoms that, if present, may suggest a problem- atic response to the opioid and interference with the goal of functional improvement include [32]: • Excessive sleeping or days and nights turned around • Diminished appetite • Short attention span or inability to concentrate • Mood volatility, especially irritability • Lack of involvement with others • Impaired functioning due to drug effects • Use of the opioid to regress instead of re-engaging in life • Lack of attention to hygiene and appearance • Escalation of pain • Continual dose escalation • Increasing number of medications prescribed to treat the side effects of opioids The decision to continue, change, or terminate opioid therapy is based on progress toward treatment objectives and absence of adverse effects and risks of overdose or diversion. Satisfac- tory therapy is indicated by improvements in pain, function, and quality of life. Brief assessment tools to assess pain and function may be useful, as may UDTs. Treatment plans may include periodic pill counts to confirm adherence and mini- mize diversion [1]. Involvement of Family Family members of the patient can provide the clinician with valuable information that better informs decision making regarding continuing opioid therapy. Family members can observe whether a patient is losing control of his or her life or becoming less functional or more depressed during the course of opioid therapy. They can also provide input regard- ing positive or negative changes in patient function, attitude, and level of comfort. The following questions can be asked of family members or a spouse to help clarify whether the patient’s response to opioid therapy is favorable or unfavorable [32]:
• Is the person’s day centered around taking the opioid medication? Response can help clarify long-term risks and benefits of the medication and identify other treatment options. • Does the person take pain medication only on occasion, perhaps three or four times per week? If yes, the likelihood of addiction is low. • Have there been any other substance (alcohol or drug) use 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. • Does the person smoke? If yes, smoking increases pain and reduces effectiveness of opioids. Smokers tend to take higher doses of opioids and have greater risks for problems and addiction. Smoking itself is an addictive behavior and therefore, a risk for opioid addiction. Opioids should be carefully considered in individuals that smoke.
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 anal- gesic prescriptions in a manner that preserves legitimate patient need while potentially deterring diverters. The components of VIGIL are [33]: • 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/phar- macist relationship.
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