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Continuing Education for Health Professionals

WV: Best Practices for Prescribing Controlled Substances and Preventing Drug Diversion, 3 units

Module 7

Periodic Review and Monitoring of Patients

Any treatment for pain should periodically be reviewed and evaluated by the clinician. New information about the patient’s state of health, condition or cause of pain, psychosocial and mental health, nature of pain is noted, and the patient’s overall health and level of function. The clinician should look at the patient’s dosage, the medication schedule (to determine if the patient is indeed taking the prescription as directed and whether the current treatment should be continued or modified). This decision depends on evaluation of the progress toward the treatment objectives previously outlined in the plan of care. At such a review, it is critical to reinforce correct medication usage.

When possible, collateral information about the patient’s response to opioid therapy may be obtained from family members or other close contacts, as well as review of the state PDMP. The patient may be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted. As the patient is stabilized in the treatment regimen, followup visits may be scheduled as indicated by stability and risk level. Monitoring plans for a given patient should take into account the generally increased risk for dependence developing a substance use disorder and misuse the longer the patient uses them.

Continuation, modification, or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life. Information from family members or other caregivers may be considered in evaluating the patient’s response to treatment. Use of measurement tools to assess the patient’s level of pain, function, and quality of life may be helpful in documenting therapeutic outcomes (WVBM, 2017).

Monitoring Treatment

Regular monitoring and ongoing assessment to determine if the treatment plan is on track and the patient is achieving results is essential. Providers should incorporate the following practices in their patient monitoring:

  • Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
  • Clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
  • Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
  • Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
  • Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether patients are receiving opioid dosages or dangerous combinations that put them at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
  • When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
  • Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder. (CDC, 2017b)

Identifying Diversion and Drug-Seeking Behaviors

The purpose of risk assessment is to determine the likelihood that a patient will develop or display aberrant drug-related behaviors. Healthcare providers must be observant at all times for signs of nonadherance to treatment plans and dosage instructions. Aberrant drug-related behaviors include the following:

  • Escalating the dose without a clinician’s order, especially rapidly escalating the dose. Psychoactive tolerance develops quickly, forcing a drug abuser to take more of the medication to achieve the same effect, often in doses significantly higher than a therapeutic dose for pain. In contrast, analgesic tolerance develops slowly. It would be expected that patients with stable pain would stay on the same dose for months or years.
  • Taking the drug in larger doses than prescribed and running out of medication early. Patients abusing opioids may aggressively request refills earlier than expected or request additional doctor visits.
  • Acquiring opioids from sources other than by order of the clinician, such as an emergency department, acquiring additional doctors, or buy purchasing the drug on the street.
  • Altering or acquiring prescriptions by means of theft, fraud, or purchase.
  • Using the drug in any method other than that which was prescribed, such as by snorting, injecting, or chewing oral medications for quicker effect. (CAMH, 2011)

As is evident above, not all aberrant drug-related behaviors by patients signify addiction. They may instead signify that the patient:

  • Is experiencing increased pain
  • Has accidentally been misusing the medication by taking more than intended
  • Is developing a physical tolerance to the opioid analgesic, which is not as effective as it once was
  • Is rationing doses to save money, for example, or selling doses for income
  • May have someone in his or her household or living situation who is stealing medication from the patient (Corsini & Zacharoff, 2014)

Clinicians need to look closely to determine the reason for the unexpected or aberrant behaviors. Such behaviors are important clinical signs.

It is important to consider all behaviors, and the multitude of reasons that patients may not take their medications as they are prescribed. Understanding the specific reason for each unexpected behavior can help the clinician to take the correct next step, and make decisions that help minimize risk, improve safety, and most of all benefit the patient (Corsini & Zacharoff, 2014).

General Symptoms of Narcotic Abuse

Healthcare professionals must be on the lookout for the following signs and symptoms of opioid use disorder:

  • Analgesia (feeling no pain)
  • Sedation
  • Euphoria (feeling high)
  • Respiratory depression (shallow or slow breathing)
  • Small pupils
  • Nausea, vomiting
  • Itching or flushed skin
  • Constipation
  • Slurred speech
  • Confusion or poor judgment

Tools for Monitoring Ongoing Opioid Therapy

Prescribers have a number of tools at their disposal to help with ongoing assessment of chronic pain patients who are receiving opioid analgesic therapy. Here are a few of those tools.

Addiction Behaviors Checklist (ABC)

Developed by Bruce D. Naliboff with support from VA Health Services Research and Development, this is a 20-item, yes/no assessment tool that can increase a provider's confidence in determinations of appropriate vs. inappropriate opioid use (Wu et al., 2006).

Opioid Risk Tool (ORT)

Developed by Lynn Webster, this questionnaire filled out by the patient allows healthcare professionals to determine risk of addiction to prescription opioid medication (Webster, n.d.).

Pain Medication Questionnaire (PMQ)

This is a 26-item self-report assessment tool for ongoing monitoring of aberrant behaviors. It helps clinicians to identify whether a long-term chronic pain patient is exhibiting aberrant behaviors associated with opioid medication misuse (Dowling et al., 2007).

Prescription Drug Use Questionnaire (PDUQ)

The PDUQ assesses problematic opioid misuse, abuse, and dependence in chronic pain patients. Evidence suggests the PDUQ’s key screening indicators are excellent predictors for the presence of addiction (Compton et al., 2008).

DAST Drug Abuse Screening Test

A self-administered questionnaire consisting of 28 items with binary (yes/no) answers created by Harvey A. Skinner in 1982. Scores of 6 or more indicate the presence of substance dependence or abuse with satisfactory measures of reliability and high levels of validity, sensitivity, and specificity (Yudko et al., 2007). A shorter 10-question DAST (DAST-10) is also used.

Current Opioid Misuse Measure (COMM)

A 17-item patient self-assessment that helps clinicians identify whether a patient, currently on long-term opioid therapy, may be exhibiting aberrant behaviors associated with misuse of opioid medications. Since the COMM examines concurrent misuse, it is ideal for helping clinicians monitor patients' aberrant medication-related behaviors over the course of treatment (Butler et al., 2007).

Urine Screens

Periodic and unannounced drug testing (including chromatography) are useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs. Drug testing is an important monitoring tool because self-reporting of medication use is not always reliable and behavioral observations may detect some problems but not others. It is strongly recommended that patients being treated for addiction be tested as frequently as necessary to ensure therapeutic adherence, but for patients being treated for pain, clinical judgment trumps recommendations for frequency of testing (WVBM, 2017; FSMB, 2017).

Urine screening can indicate drug diversion, misuse, or abuse, and the presence of an illegal drug might indicate addiction. Any nonprescribed opioid use may signal drug abuse or doctor shopping. Of course, providers using routine urine drug screening must remember that all diagnosis and treatment must be based on a careful assessment of the patient. UDS tools can deliver false negatives or false positives.

Ideally, urine drug screening is part of the patient-prescriber agreement that is already in place. Clinicians should be aware of the limitations of available tests (such as their limited sensitivity for many opioids) and to order tests appropriately. For example, when a drug test is ordered, it is important to specify that it include the opioid being prescribed.

Test results that suggest opioid misuse should be discussed with the patient. It is helpful to approach such a discussion in a positive, supportive fashion, so as to strengthen the relationship between the patient and the clinician and encourage healthy behaviors (as well as behavioral change where that is needed). It is recommended that both the test results and subsequent discussion with the patient be documented in the medical record (WVBM, 2017).

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