________________________________ Substance Use Disorders and Pain Management: MATE Act Training
• 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. Assessment Tools 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 com- ponents of VIGIL are: • 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 [155]. The Current Opioid Misuse Measure (COMM) is a 17-item patient self-report assessment designed to help clinicians iden- tify misuse or abuse in patients being treated for 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 [145]. 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)? Guidelines by the CDC, the Federation of State Medical Boards (FSMB), and the Joint Commission stress the impor- tance of documentation from both a healthcare quality and medicolegal perspective. Research has found widespread defi-
cits in chart notes and progress documentation with patients with chronic pain receiving opioid therapy, and the Pain Assessment and Documentation Tool (PADT) was designed to address these shortcomings [156]. 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. 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 [157]. 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 4 ) [158]. The CDC 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 [125; 127]. However, this recommendation was based on low- quality evidence that indicates little confidence in the effect estimate. Initially, testing involves the use of class-specific immunoas- say drug panels [132]. If necessary, this may be followed with gas chromatography/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 pathologist. 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 chromatog- raphy coupled to tandem mass spectrometry confirmation. Urine test results suggesting opioid misuse should be discussed with the patient using a positive, supportive approach. The test results and the patient discussion should be documented.
PATIENT RISK LEVEL AND FREQUENCY OF MONITORING
Monitoring Tool
Patient Risk Level
Low
Medium
High
Urine drug test
Every 1 to 2 years
Every 6 to 12 months
Every 3 to 6 months
State prescription drug monitoring program
Twice per year
Three times per year
Four times per year
Source: [158]
Table 4
59
MDNJ1525
Powered by FlippingBook