○ Formulation - When prescribing a long- acting or extended relief formulation, STOP: 1) Ensure the patient’s condition warrants this formulation; 2)Ensure the benefits of this formulation outweigh the risks; 3) Consider concurrent medications that my potentiate the effects of the formulation; 4) Ensure the patient has been treated with immediate release opioids for at least one week prior to prescribing or dispensing this formulation; and, 5) Ensure additional risk mitigation strategies are in place. ○ Duration - ■ When treating acute, non-traumatic or non-surgical pain, STOP: 1) Ensure the amount of medication prescribed or dispensed does not exceed the expected duration of the pain, typically 3-7 days, and complies with Colorado law. When prescribing opioids for subacute pain and the treatment of chronic, non-cancer pain
STOP: 1) Reassess pain and function within 30 days of initiating therapy to ensure a clear benefit; and, 2) Ensure the benefits of continued opioid therapy outweigh the risks. ■ If the opioid treatment exceeds 90 days for chronic, non-cancer pain, STOP: 1) Ensure the patient continues to show clinical improvement with opioid therapy; 2) Ensure the benefits of continued opioid therapy outweighs the risk; and 3) Ensure additional risk mitigation strategies are in place.
Risk Mitigations Strategies ● Tools and Trials
● Referral to Pain Management Specialist ● Monitoring and Treatment Agreements ● Concurrent Naloxone Prescribing ● Patient Education Discontinuing Opioid Therapy Treatment for Opioid Use Disorder
BEFORE PRESCRIBING OR DISPENSING
Develop and Maintain Competence Prescribers, including prescribers who dispense, must maintain competence to assess and treat pain to improve function. This includes understanding current, evidenced-based practices and using other resources and tools related to opioid prescribing and dispensing. Pharmacists must maintain competence in the appropriateness of therapy. Prescribers and dispensers should incorporate education courses Diagnose and Evaluate The decision to prescribe or dispense opioid medication to patients may be made only after a proper diagnosis and complete evaluation, which should include an assessment of the pain, functionality and risk, and review of relevant PDMP data. These safeguards should be used prior to initiating treatment for both acute 1 and chronic, non- Prescribers should establish a diagnosis and legitimate medical purpose appropriate for the initiation of treatment for pain management including opioid therapy through a history, physical exam, and/or laboratory, imaging or other studies. A bona fide provider-patient relationship must exist. 2. Assess Risk Prescribers should conduct a risk assessment prior to prescribing opioids, periodically during continuation of opioid therapy, and before increasing dosage or the addition of other medications or upon learning of any factors that may lead to adverse outcomes. Risk assessment is defined as the identification of factors that may lead to adverse outcomes that may include: ● Patient and family history of substance use (drugs including prescription medications, alcohol and marijuana); ● History of opioid use through both patient history and the PDMP; cancer pain. 1. Diagnose
specific to pain management and opioid prescribing and/or dispensing practices into their maintenance of competence plan. See Appendix A.1 on page 43 for a list of resources, courses and tools for developing and maintaining competence.
● Overdose history; ● Patient medication history (among other reasons, this is taken to avoid unsafe combinations of opioids with sedative-hypnotics, benzodiazepines, barbiturates, muscle relaxants, other opioids or to determine other drug-drug interactions) through patient history, PDMP, and Urine Drug Screen, as indicated; ● Mental health/psychological conditions and history; ● Insomnia or other sleep disorders; ● Abuse history including physical, emotional or sexual 13 ; ● Pregnancy or current family planning for women of reproductive age 14 ; ● Health conditions that could aggravate adverse reactions (including COPD, CHF, sleep disordered breathing, including sleep apnea, obesity, age < 18 years or > 65 years, or history of renal or hepatic dysfunction);4 and ● Prescribers and dispensers should observe the patient for any aberrant drug-related behavior and follow-up appropriately if such behavior is exhibited. See the Appendix for a description of aberrant drug-related behaviors. If the assessment identifies risk factors, prescribers should first opt for non-opioid treatment options. If the benefits of opioid therapy outweigh the
Book Code: MDCO1025
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