__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
4. OFFICE POLICIES, PROCEDURES, AND IMPLEMENTATION Initiating opioid trial:
• Monitor “5 A s” (analgesia, activities, aberrant behaviors, and adverse effects) • Emphasize consultation during treatment management with complex pain conditions or serious comorbidities • Perform electrocardiogram in patients to receive methadone • Know that antidepressants may increase risk of cardiac death when co-prescribed with methadone UTAH CONTROLLED SUBSTANCE DATABASE: Prescribers are required to check the prescription drug- monitoring program, called the Utah Controlled Substance Database (https://dopl.utah.gov/csd/index.html), before issuing the first prescription of an opioid to a patient, unless the prescription is written for 3 or fewer days, the prescriber has prior knowledge of the patient’s prescription history, or the prescription is written for a 30-day post-surgery supply. For ongoing opioid prescriptions, prescribers are required to periodically check the database or similar records. PRESCRIPTION DURATION/DOSAGE LIMITS: As of October 2018, at least 33 states have enacted legislation related to opioid prescription limits [5]. Utah law limits first-time opioid prescription to a seven-day supply for acute, noncomplex, non-chronic pain conditions [3][5]. Exceptions are for surgeries when the provider has determined that a quantity exceeding seven days is needed, in which case the provider may prescribe up to a 30-day supply (partial fill at the provider’s discretion). The seven-day limit does not apply in cases of complex or chronic conditions that are documented as such in the medical record [5]. Utah does not have a statutory limit on milligram doses per day [5]. Utah’s prescribing limits are set in state statute rather than being directed by health departments or regulatory boards, although other bodies may create their own evidence-based policies related to opioid prescribing [5]. References 1. Utah Department of Health Indicator-Based Information System for Public Health Web site. 2021; https://ibis.health. utah.gov/ibisph-view/indicator/complete_profile/PoiDth. html. Accessed October 13, 2022. 2. Utah Department of Health (2018). Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. https://dopl.utah.gov/ pharm/opioid_guidelines.pdf. Accessed October 13, 2022. 3. U.S. Department of Health and Human Services. Factsheet: Utah’s Oversight of Opioid Prescribing and Monitoring of Opioid Use. February 2019; https://oig.hhs.gov/oas/reports/ region7/71805115.asp. Accessed October 13, 2022. 4. Federation of State Medical Boards (FSMB). Guidelines for the chronic use of opioid analgesics. April 2017; https://www. fsmb.org/opioids/. Accessed October 13, 2022.
Before issuing an initial opioid prescription (including no opioid in the past year), a prescriber must discuss with the patient or the patient’s parent or guardian [2]: • Risks of addiction and overdose • Dangers of taking with alcohol, benzodiazepines, and other central nervous system depressants • Reasons why the prescription is necessary • Alternative treatments that may be available • Associated risks This discussion is not required for: • Treatment of active cancer • Care from a licensed hospice • Medication for treatment of substance abuse or opioid dependence Treatment recommendations for chronic pain [2]. • Check disease-specific guidelines for recommendations of treatments for specific diseases or conditions • Re-check urine drug screens in 1-2 months if “the condition started with acute pain and there is consideration for chronic use ” • Educate family members and caregivers about the patient’s treatment goals and plan • Prevent prescription fraud ‒ Write on tamper-resistant paper or e-prescribe ‒ Write legibly ‒ Keep in records for minimum of two years, as required by Drug Enforcement Administration • Consider that a clinically meaningful threshold for pain and function score is 30% improvement during reevaluation • Avoid parenteral opioids (with exceptions for inpatient and palliative care) • Evaluate risks associated with sleep apnea and adjust treatment ‒ Assess risk and strongly consider formal screening ‒ Risk factors include congestive heart failure and obesity ‒ Mild sleep apnea: careful monitoring, titration ‒ Moderate or severe sleep apnea: avoid prescribing opioids ‒ Provide naloxone with sleep apnea risk ‒ Counsel family members
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