Ongoing Management of Opioids

Introduction

Workforce Safety & Insurance (WSI) utilizes ODG by MCG’s treatment guideline involving the ongoing management of opioids. The following policy is an excerpt from ODG by MCG’s pain section last accessed 09/25/2020. 

Policy

WSI will enforce the following treatment guideline involving ongoing management of opioids. 

Recommendation 

Actions should include:

1. Prescriptions from a single practitioner taken as directed, and all prescriptions from a single pharmacy. 
2. The lowest possible dose should be prescribed to improve pain and function. 
3. Office: Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include: current pain; the least reported pain over the period since last assessment; average pain; intensity of pain after taking the opioid; how long it takes for pain relief; and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, or improved quality of life. Information from family members or other caregivers should be considered in determining the patient's response to treatment. The 4 A’s for Ongoing Monitoring: Four domains have been proposed as most relevant for ongoing monitoring of chronic pain patients on opioids: pain relief, side effects, physical and psychosocial functioning, and the occurrence of any potentially aberrant (or nonadherent) drug-related behaviors. These domains have been summarized as the "4 A's" (analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors). The monitoring of these outcomes over time should affect therapeutic decisions and provide a framework for documentation of the clinical use of these controlled drugs. (Passik, 2000) 
4. Home: To aid in pain and functioning assessment, the patient should be requested to keep a pain diary that includes entries such as pain triggers, and incidence of end- of-dose pain. It should be emphasized that using this diary will help in tailoring the opioid dose. This should not be a requirement for pain management. 
5. Use of drug screening or inpatient treatment with issues of abuse, addiction, or poor pain control. (Webster, 2008) 
6. Documentation of misuse of medications (doctor-shopping, uncontrolled drug escalation, drug diversion). 
7. Continuing review of overall situation with regard to nonopioid means of pain control.
8. Consideration of a consultation with a multidisciplinary pain clinic if doses of opioids are required beyond what is usually required for the condition or pain does not improve on opioids in 3 months. Consider a psych consult if there is evidence of depression, anxiety or irritability. Consider an addiction medicine consult if there is evidence of substance misuse. (Sullivan, 2006) (Sullivan, 2005) (Wilsey, 2008) (Savage, 2008) (Ballantyne, 2008)