CDC Clinical Practice Guidelines for Prescribing Opioids for Pain
Recommendation 8: Before starting and periodically during the continuation of opioid therapy, clinicians should evalu- ate the risk for opioid-related harms and discuss the risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate the risk, including offering naloxone. Recommendation 9: When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose. Recommendation 10: When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and non- prescribed controlled substances. Recommendation 11: Clinicians should use particular caution when prescribing opioid pain medication and benzodiaz- epines concurrently and consider whether the benefits outweigh the risks of concurrent prescribing of opioids and other central nervous system depressants. Recommendation 12: Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.
Assessing risk and addressing potential harms of opioid use
Note : Dowell, et al., 2022.
Healthcare Consideration: State boards of nursing are an excellent source of information for NPs on how state laws and regulations impact practice. NPs and other prescribers must know all the details about advanced practice in their state— from signature authority to the number of CE hours required for licensure. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
All states maintain a prescription drug monitoring program (PDMP) for controlled substances to address overprescribing opi- oids and other controlled substances. Missouri was the last state to create a statewide prescription drug monitoring program with State Bill 63 (SB63, 2021). Prescription drug monitoring programs are a statewide electronic database that tracks all controlled sub- stance prescriptions. State requirements for using PDMPs while prescribing controlled substances vary substantially; however, the White House Office of National Drug Control Policy and the CDC recommend creating and utilizing these programs when prescrib- ing controlled substances, especially opioids. In addition, the CDC's National Center for Injury Prevention and Control is updat- ing the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (CDC, 2022a; Dowell et al., 2016). PDMPs collect controlled substance prescription data from retail pharmacies (in-state, mail order, Internet), hospitals dispensing to emergency department patients (dispensing >48-hour sup- ply), clinicians dispensing controlled substances from an office, and Department of Veterans Affairs pharmacies. Prescription data collected include patient information such as name, date of birth, gender, Social Security number, driver's license num- ber), prescriber's name and DEA registration number, and pre- scription information (dates prescriptions were written and filled, quantity, days supplied, National Drug Code (NDC; provides drug name and strength), and source of payment. PDMPs do not track methadone dispensed at federally regulated clinics; controlled substances dispensed for administration to patients in hospitals, long-term care facilities, jails, or correctional facilities; pseudo- Electronic prescribing of controlled substances (EPCS) In June 2010, the DEA published an interim final rule allowing for the electronic prescribing of controlled substances (EPCS) in all states. States had to meet specific requirements, including certi - fication of the electronic prescribing and pharmacy applications, to sign, transmit, or process the controlled substance prescrip- tions; audits and certification reports for these applications; and two-factor authentication for prescribers (DEA, 2010a). However,
ephedrine (often tracked separately); military pharmacy dispens- ing; or Schedule I substances. Most states share PDMP information with prescribers in other states through a nationwide network. As a result, authorized us- ers can access prescription data such as medications dispensed and doses. PDMPs are tools (1) to promote safe prescribing and dispensing practices for Schedules II–V controlled substances to reduce the number of opioids and other controlled substances available for abuse; (2) that assist law enforcement in reducing drug diversion and illegal prescribing and dispensing; (3) for the health profession’s licensure boards to support licensee reviews and investigations; and (4) for analysis of data that can help iden- tify problematic trends with specific drugs, geographic regions, and patient demographics. The purpose of PDMPs is to (1) improve medication safety for opioids and other controlled substances by allowing clinicians to identify patients who are obtaining controlled substances from multiple prescribers (i.e., doctor shopping), (2) calculate the total amount of opioids prescribed per day, and (3) identify patients who are being prescribed other substances that may increase risk of opioids, such as benzodiazepines (Dowell et al., 2016). How- ever, the effect of PDMPs is uncertain, as studies have reported conflicting results. Suggested improvements to prescription drug monitoring programs include improved clinician training in using PDMPs, prescriber dashboards for higher-risk patients, proactive alerts, mandatory registration, mandatory querying for specific prescriptions, improved interfaces, and integration into electronic medical records (Robinson et al., 2021). implementation of EPCS has been slow; in 2015, only 2.2% of pre- scribers and less than 50% of pharmacies were enabled for EPCS, while over 70% of prescribers and 95% of pharmacies could e- prescribe or accept other prescriptions (AAFP, 2021). Delays in- cluded necessary updates to electronic health records and phar- macy systems and changes to state legislation to allow for EPCS.
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