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Webinar 4a: Guide to Rational Opioid Prescribing - ...
Webinar 4a: Guide to Rational Opioid Prescribing - Risk Evaluation and Stratification and its Effect on Initial Treatment Planning
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My name is Dr. James Finch, and I'll be leading off the second module with a presentation on risk evaluation and stratification and its effect on initial treatment planning. If we return to our treatment algorithm, generic to most complex clinical problems, regardless of clinical domain, the first step in chronic pain management is to perform an adequate assessment, both in terms of the pain itself and of considering the use of opioids, the relative risk of using them in this particular situation with this particular patient. That is, the evaluation is to determine if there is a clinical indication for the use of opioids and if there are risks or contraindications to the use of opioids by this individual. An important and often overlooked aspect of both these assessments is an adequate psychosocial evaluation, and we will return to that for more discussion later. But first, we'll look at what are broadly considered indications for opioid therapy. Opioids have always had an accepted use in the treatment of acute pain during the recovery phase from injury or surgery. For some time, there's also been an accepted use of these medications in the pain associated with malignancy, including chronic malignant pain. But for much of modern medicine, there has been little acceptance of using opioids for other chronic pain-related syndromes. However, in the past 20 years, the standard of care has expanded to include the use of opioids in the treatment of chronic nonmalignant pain as well. However, in that setting, recommendations typically emphasize that opioid use should be limited to clinical situations where pain is at least moderate to severe, it has a significant impact on function and overall quality of life, and non-opioid therapy has not given adequate pain relief. In other words, opioids should typically not be a first-line choice for chronic pain management. And to continue on opioids when they have already been started, there should be a history of demonstrated benefit and a history of safe use. Current guidelines also emphasize that adequate attention must be given to the risk assessment as part of that initial and ongoing evaluation process. The bottom line? Potential benefits of opioid use need to outweigh potential risks for their use to be initiated or continued. Some clinicians have been less comfortable with this aspect of the evaluation, with its emphasis on psychosocial as well as physical aspects. They may worry about their own skill or doubt the honesty of the patient. But information for assessing relative risk is available for a number of resources. Without relying solely on subjective impressions or only on patient self-report, these readily available sources of information include not just the standard history and physical exam, but also information available from previous or current clinical providers, information from family members or other significant others, and information from tools developed to help with this particular aspect of the evaluation. One instrument to use when considering the use of opioids is the opioid risk tool. Either as a questionnaire filled out by the patient or as specific questions used as part of a face-to-face clinical interview. It provides important information regarding potential risk, including the presence of a personal or family history of substance abuse or a history of psychiatric difficulties, both of which are well-documented risk factors in relation to safe opioid use. Other somewhat more detailed validated instruments are available and can be used as part of the initial evaluation or during ongoing treatment. I'll make further reference to the DIRE, Diagnosis Intractability Risk and Efficacy Instrument in particular a little later. Prescription monitoring programs are another readily available tool. All states now have some form of online system to access prescription records related to controlled medications, and they're available to clinicians to help assess risk and to monitor patient medication-related behaviors. North Carolina's program is the Controlled Substances Reporting System and is easily accessed online. Similar systems are available in adjoining states, and information about accessing them is available through the North Carolina Prescription Monitoring website. The current widely accepted recommendation is to check a prescription monitoring program prior to prescribing opioids and to check it recurrently while continuing to prescribe. In some states, like North Carolina, this is even a legally mandated practice as part of the standard. A third widely recommended risk assessment tool is the use of toxicology screening, usually via urine drug screening. An inexpensive, readily available, multi-panel, point-of-care urine drug screening can also be a valuable tool during the initial evaluation and risk assessment, at times backed up by lab-based confirmatory testing. It can validate or contradict the patient's self-report regarding prescription or medication use, and give an indication of illicit drug use, either illicit prescription medication use or recreational street drug use. There is particular utility in having the screen results available prior to prescribing opioids or other controlled meds, either through using point-of-service screens, as mentioned, or delaying prescribing until the results are back. A clinician can use these tools along with information from the patient interview and exam, as well as information available from other records, to form a working assessment of a particular patient's level of risk, low, moderate, or high. This table gives an overview of some of the available information from the history and other sources to be considered when assessing relative risk. These categories of information are similar to those in some of the standardized instruments mentioned, particularly the Dyer, but for this discussion, no set method of scoring is implied. However, it proposes a schema for using available information to inform the clinician's working judgment regarding presumed relative risk, along a continuum from low to intermediate to high. To be realistic, it must be noted that elements of this information are sometimes incomplete, vague, or even intentionally obscured. This information is not definitive. It simply provides a presumed working level of risk that may evolve as more information becomes available or as the patient demonstrates subsequent reassuring or worrisome behaviors. You'll also note that there is not a no risk category. The clinician should always consider there to be some level of risk when prescribing opioids. Performing an adequate and conscientious risk assessment is not an end in itself. Presumed relative risk, determined through initial treatment planning, has a direct impact on whether opioids are to be considered or not considered or considered contraindicated, whether it's more appropriate to refer to another clinician or treatment site with a higher level of care, and if opioids are to be used, with what degree and frequency and intensity of monitoring or with what need for ancillary services. So for example, some patients may demonstrate clear and documented evidence of underlying pain, no evidence of substance abuse or psychiatric comorbidities, and are active in terms of productive work and active involvement in their treatment. Others may be less clear in terms of underlying pathology or reason for persistence of the pain and have comorbid mental health conditions that put them at increased risk. Still others may immediately demonstrate themselves to be at high risk based on active substance abuse, unstable mood, or high risk environment. Treatment planning clearly requires adaptation depending on these initially identified levels of risk. For example, those considered to be at low relative risk may be appropriate for infrequent visits, refill of prescriptions between visits, infrequent use of drug screening, and relying on the patient's self-report without contact with family members. Those whose perceived risk is moderate may require more frequent visits, no use of refills, more use of drug screenings, and requiring information from an ancillary contact such as a responsible family member. Finally, for individuals who present with evidence of high risk, the use of opioids or any other control meds must be carefully weighed in terms of safe use, and if used, they would require much closer and more involved monitoring strategies. The decision process for any clinician presented with these different categories of relative risk will of course depend on a clinical judgment, but also on the particular clinician's comfort zone for dealing with these issues, based on his or her knowledge, available resources, and experiences. This comfort zone will also vary across individuals in different areas of specialty training. Some will find it judicious to only use opioids with relatively low risk patients. Others may choose to use opioids even with those considered to be at relatively high risk, such as those with a past or current substance use problem, because of their training, experience, or availability of ancillary resources to make such prescribing reasonable in terms of risk. Later, Dr. Prattken will also discuss how these relative risk levels may also impact choices related to what opioids are used and how they are used. Consideration of the use of referral and collaborative multimodal treatment should be part of the treatment plan from the beginning, not something that is only added after medications have failed or the patient has demonstrated problematic behaviors. Some possible considerations for collaborative treatment might be potential benefits of initiating referral for ancillary non-medication treatment. Are there indications for co-treatment for psychiatric issues? Are there indications for co-treatment for substance use disorders? Another important referral option for the high-risk patient with a history of current or even prior opioid addiction is considering the use of buprenorphine, a partial agonist opioid considered relatively safe and effective for those individuals, both as an analgesic and to help with their opioid addiction. We'll address this in more detail in a following module. Most guidelines now recommend that after identifying an appropriate diagnosis and screening for risk, the next risk mitigation strategy is the use of an opioid management treatment agreement as part of routine informed consent, typically discussed and signed prior to initiating opioid prescribing. The use of these written agreements has been shown to decrease opioid misuse in various medical treatment settings. It's recommended that these treatment agreements be framed in terms of mutual responsibilities of the patient and the clinician with the goal being good clinical care and continued access to medication if it is effective and needed. While terms of the agreement should put in place means to recognize aberrant behaviors, language should clarify boundaries but avoid absolutist language such as any positive drug screen for illicit drug use will result in discharge from the practice and should allow room for the use of clinical judgment when responding to perceived problems. Recommended core elements of this process and its documentation include framing the use of opioids as a therapeutic trial with the goal of pain management and functional improvement, emphasizing active involvement in a multimodal approach, stressing the importance of ongoing monitoring to demonstrate and document the benefit and safe use of the medications. Other common elements include identifying only one clinician or practice to prescribe opioid medication, the patient does not change doses without prior discussion with the clinician, clarifying the practice policy on refills, the patient agreeing to consultations or referrals as needed, agreeing to not use illegal drugs, agreeing to urine drug screening or pill counts as needed, and the patient may be asked to identify a responsible person to confirm behavior related to medication use. The elements included in treatment agreements may be adapted or emphasized as needed. These elements are presented to individual patients as an accepted standard of care, applied universally to all patients receiving chronic opioid therapy rather than to one particular individual. This means it's not a matter of trust or singling out one individual but a matter of accepted and recommended standard of care. A number of templates are available for pain management agreements or informed consent documents that can be adapted in written or electronic format to fit a particular practice setting. One online resource for these materials is the Practitioner Clinical Support System or PCSS. Another important component of this informed consent and treatment agreement process is educating the patient and preferably the family as well on the issues related to risk such as drug interactions, the potential for impairment, the need for safe and secure management of the medication, and the risks and signs of overdosage. This final element clearly requires attention to education of the family, not just the patient, and should clarify the steps that may be needed in case of impairment or accidental overdose. In this regard, there's increased support for discussing and making naloxone available as a means to prevent inadvertent death from opioid overdose. In closing, it is important to recognize the benefit of collaborative care models in dealing with chronic pain and the potential roles and contributions of other health care professionals in addressing this public health challenge. Thank you.
Video Summary
Dr. James Finch presents on risk evaluation and stratification in chronic pain management and its effect on initial treatment planning. He emphasizes the importance of assessing the clinical indication for opioids and considering the risks and contraindications associated with their use. Dr. Finch discusses the expanded use of opioids in treating chronic nonmalignant pain but highlights that they should not be a first-line choice. He also discusses various tools available for risk assessment, such as the opioid risk tool, prescription monitoring programs, and toxicology screening. Treatment planning should consider the patient's level of risk and may include referral, collaborative treatment, and the use of opioid management treatment agreements. Education for patients and families on risk factors and overdose prevention is crucial. Collaborative care models are recommended for addressing chronic pain.
Keywords
risk evaluation
opioids
chronic pain management
treatment planning
collaborative care models
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Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 and grant no. 1H79TI085588 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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