_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
• Have children or other dependents at home who have access to medication • Will have difficulty accessing emergency medical care while on prescription opioid The Tennessee Chronic Pain Guidelines recommend that clinicians should incorporate into the management plan strategies to mitigate risk, including the offer of naloxone for use by patients (or family members) when factors that increase the risk for opioid overdose are present [94]. The best way to ensure access to naloxone is to simultaneously prescribe the medication at the same time a prescription for an opioid is written. It is recommended that prescribers provide a prescription for naloxone hydrochloride or another drug approved by the FDA for the complete or partial reversal of an opioid event to a patient at risk. A licensed healthcare practitioner in Tennessee may prescribe naloxone for a patient, when acting in good faith and exercising reasonable care, both with an opioid prescription or at any time following the prescription of an opioid [94]. Effective July 1, 2022, Tennessee law requires healthcare prescribers to offer naloxone to patients when certain conditions are met: a) the provider prescribes more than a three-day supply of an opioid; and b) the provider prescribes an opioid medication concurrently with a prescription by the same provider for benzodiazepine; or the patient presents with an increased risk for overdose, including a history of overdose, a history of substance use disorder, or being at risk for returning to a higher dose of opioid medication to which the patient is no longer tolerant [94]. This provision does not apply to an opioid prescription that is written as part of a patient’s palliative care treatment. Healthcare Provider Education Clinical care providers who prescribe naloxone are expected to be well-informed and to use reasonable care, including receipt of training regarding how to administer naloxone. This can be achieved through completion of the online overdose prevention education program offered by the Tennessee Department of Health. Information on naloxone training for healthcare professionals is available at https://www.tn.gov/ health/health-program-areas/health-professional-boards/ csmd-board/csmd-board/naloxone-training-information.html. Additional information and guidance on use of naloxone in primary care and emergency department settings can be found through Prescribe to Prevent at https://prescribetoprevent.org. Patient Education Patients may receive naloxone from a dispensing licensed pharmacist educated on the proper use of naloxone and authorized in accordance with the State Collaborative Pharmacy Practice Agreement between a pharmacist and a prescriber [94]. The pharmacist is expected to educate and train the patient or caregiver in the proper use of naloxone and should do so “face-to-face” if the patient or caregiver are present. Training on administration of naloxone for the general public can be found at https://www.tn.gov/health/
health-program-areas/health-professional-boards/csmd-board/ csmd-board/naloxone-training-information.html. The CDC also offers naloxone training as a full module (one hour) or as separate mini-modules of shorter duration. This resource is available at https://www.cdc.gov/overdose-prevention/hcp/ toolkits/naloxone.html.
ONGOING OPIOID TREATMENT AND MONITORING
When the decision is made to continue opioid treatment for chronic pain, care providers should regularly assess clinical progress and monitor the patient for signs of drug abuse, misuse, or diversion. The Tennessee practice guidelines emphasize that a single provider should handle all chronic opioid therapy and all prescriptions should be filled by a single pharmacy. Opioids should be used at the lowest effective dose. A provider should not use more than one short-acting opioid concurrently; if it is deemed necessary to do so, then the medical reasons shall be clearly documented [94]. Patients who require opioid doses of 120 mg MEDD or greater should be referred to a pain specialist for consultation and/or management. An unannounced UDT should be performed at least every six months [94]. Prescribers should be knowledgeable of federal and state opioid prescribing regulations. Issues of equianalgesic dosing, close patient monitoring during all dosage changes, and cross- tolerance with opioid conversion should be considered. If necessary, treatment may be augmented, with preference for non-opioid and immediate-release opioids over long-acting/ extended-release opioids. A protocol for tapering the opioid should be implemented when the drug is no longer needed [16]. Clinical follow-up at regular intervals should include reassessment for changes in pain character and intensity, general health, and function [1]. This can include input from family members and/or the CSMD. Appropriate documentation of a CSMD query should be included in the medical record. During the initiation phase and following any changes to the dosage or agent used, patient contact should be increased. At every visit, the clinical response to therapy should be discussed and documented in the medical record, in reference to the “5 A’s” [1; 23; 94]: • Analgesia
• Activities of daily living • Adverse or side effects • Aberrant drug-related behaviors • Affect (i.e., patient mood)
Signs and symptoms that, if present, may suggest a problematic response to the opioid and interference with the goal of functional improvement include [24]: • Excessive sleeping or days and nights turned around • Diminished appetite • Short attention span or inability to concentrate
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