____________________________ Responsibilities and Requirements of Prescribing Schedule II Opioid Drugs
Pain Assessment and Documentation Tool (PADT) Guidelines by the CDC, the Federation of State Medical Boards (FSMB), and the Joint Commission stress the impor- tance of documentation from both a healthcare quality and medicolegal perspective. Research has found widespread defi- cits in chart notes and progress documentation with patients with chronic pain 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]. CONCURRENT USE OF BENZODIAZEPINES Patients who are unable to undergo dental treatment due to excessive fear, anxiety, or phobias and who do not respond to dental behavior modification techniques require pharma- cotherapy. In many cases, this involves the use of benzodiaz- epines, such as diazepam, triazolam, and lorazepam. However, in patients who are also prescribed opioids, there are risks. In 2019, 16% of persons who died of an opioid overdose also tested positive for benzodiazepines [44]. Combining benzodi- azepines with opioids is unsafe because both classes of drug cause central nervous system depression and sedation and can decrease respiratory drive—the usual cause of overdose fatality. Both classes have the potential for drug dependence and addiction. The CDC recommends that dentists avoid prescribing benzodiazepines concurrently with opioids when- ever possible [10]. CONSULTATION AND REFERRAL It is important to seek consultation or patient referral when input or care from a pain, psychiatry, addiction, or mental health specialist is necessary. Dentists who prescribe opioids should become familiar with opioid addiction treatment options (including licensed opioid treatment programs for methadone and office-based opioid treatment for buprenor- phine) if referral is needed [1]. Ideally, providers should be able to refer patients with active substance abuse who require pain treatment to an addiction professional or specialized program. In reality, these special- ized resources are scarce or non-existent in many areas [1]. Therefore, each provider will need to decide whether the risks of continuing opioid treatment while a patient is using illicit drugs outweigh the benefits to the patient in terms of pain control and improved function [48].
• Diminished appetite • Short attention span or inability to concentrate • 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]. Sat- isfactory therapy is indicated by improvements in pain, func- tion, 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.
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 com- ponents of VIGIL are: • V erification: Is this a responsible opioid user? • I dentification: Is the identity of this patient verifiable? • G eneralization: Do we agree on mutual responsibilities and expectations? • I nterpretation: Do I feel comfortable allowing this person to have controlled substances? • L egalization: Am I acting legally and responsibly? The foundation of VIGIL is a collaborative physician/phar- macist 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 iden- tify misuse or abuse in patients being treated for chronic pain. 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 ques- tions 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)?
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