Prescription Opioids and Pain Management: The Tennessee Guidelines _ ______________________________
• Mood volatility, especially irritability • Lack of involvement with others • Impaired functioning due to drug effects • Use of the opioid to regress instead of re-engaging in life • Lack of attention to hygiene and appearance The decision to continue, change, or terminate opioid therapy is based on progress toward treatment objectives and absence of adverse effects and risks of overdose or diversion [1]. Satisfactory therapy is indicated by improvements in pain, function, and quality of life. Brief assessment tools to assess pain and function may be useful, as may UDTs. Treatment plans may include periodic pill counts to confirm adherence and minimize diversion. Special considerations and documentation are required when opioids are prescribed for a patient of child-bearing age who has capacity for pregnancy [9]): • A method to prevent unintended pregnancy should be discussed. • The patient should be advised that they be on a method to prevent unintended pregnancy, preferably a long-acting contraceptive method. • The treatment agreement shall include the expectation that the patient will tell the provider if they become pregnant or plans to become pregnant. • If they plan to become pregnant, they shall be referred to an obstetrician. • When a UDT is performed, results must be documented in the medical record. Additional specific guidance on managing opioid therapy during pregnancy is available in the Tennessee Guideline Appendix [94]. Involvement of Family Family members of the patient can provide the clinician with valuable information that better informs decisions regarding continuing opioid therapy. Family members can observe whether a patient is losing control of his or her life or becoming less functional or more depressed during the course of opioid therapy. They can also provide input regarding positive or negative changes in patient function, attitude, and level of comfort. The following questions can be asked of family members or a spouse to help clarify whether the patient’s response to opioid therapy is favorable or unfavorable [24]: • Is the person’s day centered around taking the opioid medication? Response can help clarify long-term risks and benefits of the medication and identify other treatment options. • Does the person take pain medication only on occasion, perhaps three or four times per week? If yes, the likelihood of addiction is low.
• Have there been any other substance (alcohol or drug) abuse problems in the person’s life? An affirmative response should be taken into consideration when prescribing. • Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed? If so, this suggests the pain medication is failing to promote rehabilitation. Daily activity is essential, and the patient may be considered for enrollment in a graduated exercise program. • 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
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 components 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/ pharmacist relationship [25]. Current Opioid Misuse Measure (COMM) The Current Opioid Misuse Measure (COMM) is a 17-item patient self-report assessment designed to help clinicians identify misuse or abuse in chronic pain patients. Unlike the ORT and the SOAPP-R, the COMM identifies aberrant behaviors associated with opioid misuse in patients already receiving long-term opioid therapy [26]. 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)? Pain Assessment and Documentation Tool (PADT) Guidelines by the CDC, the Federation of State Medical Boards (FSMB), and the Joint Commission stress the importance of documentation from both a healthcare quality and medicolegal perspective. Research has found widespread deficits in chart notes and progress documentation with
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