_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
chronic pain patients receiving opioid therapy, and the Pain Assessment and Documentation Tool (PADT) was designed to address these shortcomings [46]. The PADT is a clinician- directed interview, with most sections (e.g., analgesia, activities of daily living, adverse events) consisting of questions asked of the patient. However, the potential aberrant drug-related behavior section must be completed by the physician based on his or her observations of the patient. The Brief Intervention Tool The Brief Intervention Tool is a 26-item, “yes-no,” patient- administered questionnaire used to identify early signs of opioid abuse or addiction. The items assess the extent of problems related to drug use in several areas, including drug use-related functional impairment [22]. Urine Drug Tests Drug testing of patients receiving chronic opioid therapy is recommended by many pain medicine societies and government agencies [94]. UDTs may be used to monitor adherence to the prescribed treatment plan and to detect the use of unsanctioned or illicit substances. Testing should target not only the prescribed opioid but also other common drugs of abuse, prescription and illicit. Studies show that unexpected positive UDT results, including the presence of illicit drugs, are often found among patients enrolled in pain management programs. The most commonly used method for initial UDT screening is the class-specific immunoassay (IA). The IA is a qualitative test that detects the presence or absence of a drug class; it can be employed on site in clinic and hospital laboratories and provides rapid results that facilitate early management decisions [1]. However, IA has limited sensitivity and the specificity is compromised by frequent cross-reactivity with other substances, leading to false-positive results [94]. When the screening IA is positive, definitive or confirmatory testing is required, usually by gas chromatography/mass spectrometry, for detection of the specific drug or metabolite. It is important that testing identifies the specific drug, rather than merely the drug class, and the prescribed opioid should be included in the testing protocol.
The frequency of drug testing is a matter of clinical provider judgment based on individual case considerations and patient risk assessment ( Table 2 ). In general, the CDC and the Tennessee practice guidelines recommend confirmation testing prior to initiating chronic opioid therapy and at least twice per year for all patients maintained on opioid treatment [10; 94]. Patients at moderate or higher risk should be tested three to four times per year. Aberrant behavior or unexpected UDT results should prompt additional screening. The Tennessee guidelines provide a detailed discussion of UDT, including causes for false-positive and false-negative results and guidance for interpretation of results [94]. Urine test results suggesting opioid misuse should be discussed with the patient using a positive, supportive approach. The test results and the patient discussion should be documented. CONSULTATION AND REFERRAL Successful pain management or mitigation of problems that arise often require consultation or patient referral to a pain, addiction, or mental health specialist. Clinicians who prescribe opioids should become familiar with opioid addiction treatment options (including licensed opioid treatment programs for methadone and buprenorphine) if referral is needed [1]. Ideally, providers should be able to refer patients with active substance abuse who require prescription pain treatment to an addiction professional or specialized program. In reality, these specialized resources are scarce or non-existent in many areas [1]. Therefore, each provider will need to decide whether the risks of continuing opioid treatment for a patient using illicit drugs outweigh the benefits in terms of pain control and improved function [48]. MEDICAL RECORDS As noted, documentation is a necessary aspect of all patient care, but it is of particular importance when opioid prescribing is involved. All clinicians should maintain accurate, complete, and up-to-date medical records, including all written or telephoned prescription orders for opioid analgesics and other controlled substances, all written instructions to the patient for medication use, and the name, telephone number, and address of the patient’s pharmacy [1]. Good medical records demonstrate that a service was provided to the patient and that the service was medically necessary. Regardless of the treatment outcome, thorough medical records protect the prescriber.
PATIENT RISK LEVEL AND FREQUENCY OF MONITORING
Monitoring Tool
Patient Risk Level
Low
Medium
High
Urine drug test
Every 1 to 2 years
Every 6 to 12 months Three times per year
Every 3 to 6 months Four times per year
State prescription drug monitoring program
Twice per year
Source: [47]
Table 2
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MDTN1726
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