__________________________________________________ Responsible Prescribing of Controlled Substances
Current Opioid Misuse Measure (COMM) The Current Opioid Misuse Measure (COMM) is a 17-item patient self-report assessment designed to help clinicians iden- tify misuse or abuse in chronic pain patients. Unlike the ORT and the SOAPP-R, the COMM identifies aberrant behaviors associated with opioid misuse in patients already receiving long-term opioid therapy [19; 34]. 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 opioid medications (e.g., having enough, taking them, dosing schedule)? Pain Assessment and Documentation Tool (PADT) The Pain Assessment and Documentation Tool (PADT) is a clinician-directed interview designed to facilitate ongoing evaluation of patient pain and documentation of pain man- agement. The PADT contains questions related to four areas: analgesia, activities of daily living, adverse events, and aberrant drug-related behavior. Only the potential aberrant drug-related behavior section must be completed by the physician based on his or her observations of the patient; all other questions are directed to the patient [35]. Urine Drug Tests UDTs may be used to monitor adherence to the prescribed treatment plan and to detect unsanctioned drug use. Non- compliance to an opioid treatment plan is a risk factor for misuse and diversion and should be considered when deciding whether or not to continue therapy. UDTs should be used more often in patients receiving addiction therapy, but clinical judgment and individual patient consideration is the ultimate guide to testing frequency [24]. The CDC recommends that clinicians consider the benefits and risks of UDT and/or other toxicology testing before starting opioid therapy and at least annually thereafter to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs [2]. Initially, testing involves the use of class-specific immunoassay drug panels. If necessary, this may be followed with gas chro- matography/mass spectrometry for specific drug or metabolite detection. It is important that testing identifies the specific drug rather than the drug class, and the prescribed opioid should be included in the screen. Any abnormalities should be confirmed with a laboratory toxicologist or clinical patholo- gist. Immunoassay may be used point-of-care for “on-the-spot” therapy changes, but the high error rate prevents its use in major clinical decisions except with liquid chromatography coupled to tandem mass spectrometry confirmation [24]. Before ordering toxicology testing, including urine drug tests, clinicians should have a plan for responding to unexpected results and should explain to patients that toxicology testing will not be used punitively but instead is intended to improve their safety. Clinicians should also explain expected results and ask patients about use of prescribed medications and other substances and ask whether there might be unexpected results. This will provide an opportunity for patients to provide
information about changes in their use of prescribed opioids or other drugs. Urine test results suggesting opioid misuse should be discussed with the patient using a positive, sup- portive approach. The test results and the patient discussion should be documented [2]. CONSULTATION AND REFERRAL It is important to seek consultation or patient referral when input or care from a pain, psychiatry, addiction, or mental health specialist is necessary. Clinicians who prescribe opioids should become familiar with opioid-specific treatment options (including licensed opioid treatment programs for methadone and office-based opioid treatment for buprenorphine) if refer- ral is needed [1]. Ideally, providers should be able to refer patients with active substance abuse who require pain treatment to an addiction professional or specialized program. In reality, these specialized resources are scarce or non-existent in many areas. Therefore, each provider will need to decide whether the risks of con- tinuing opioid treatment while a patient is using illicit drugs outweigh the benefits to the patient in terms of pain control and improved function [1]. DOCUMENTATION As noted, documentation is a necessary aspect of all patient care, but it is of particular importance when opioid prescribing is involved. All clinicians should maintain accurate, complete, and up-to-date medical records, including all written or tele- phoned prescription orders for opioid analgesics and other controlled substances, all written instructions to the patient for medication use, and the name, telephone number, and address of the patient’s pharmacy [1]. Good medical records demonstrate that a service was provided to the patient and that the service was medically necessary. Regardless of the treatment outcome, thorough medical records protect the prescriber. When documenting an opioid treatment plan, the first step is adherence to state and federal laws pertaining to the prescrip- tion of controlled substance prescribing. A prescription for a controlled substance must include the following information [36; 37]: • Date of issue • Patient’s name and address • Practitioner’s name, address, and DEA registration number • Drug name
• Drug strength • Dosage form
• Quantity prescribed • Directions for use • Number of refills (if any) authorized (schedule II drugs may not be refilled) • Manual signature of prescriber
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