August 23, 2016

The Stearns Benton Medical Society has been working collaboratively with the Central MN Council on Aging since February, 2016 in preparation to launch a new community public health campaign centering on dementia, dementia care and resources and community and provider education.  The center piece of the campaign will be the creation of a permanent Central MN Dementia Resource Center that will be located in St. Cloud, MN.  Although Alzheimer’s disease makes up the majority of dementia cases, there are also several other types of dementia, but we will use the more inclusive term – dementia – to include reference to all dementia types.

Drs. George Schoephoerster and Pat Zook of the Stearns Benton Medical Society have been working with Kathy Gilbride of the Central MN Council on Aging since February, 2016 along with 30 or so other area professionals to clarify a vision for how the Resource Center will work.  The goals of our Central MN Dementia Campaign and the Resource Center will be to 1) Improve access to and quality of care for dementia in our area, 2) Improve quality of life for dementia patients, their caregivers and loved ones, and 3) Move our Central MN community culture towards becoming dementia-friendly and dementia-capable.  We plan to invite all interested community members to the Fall Meeting of the Medical Society along with our member physicians and will announce the formal beginning of our Campaign.  This meeting will be October 11, 2016 at the St. Cloud Holiday Inn, most likely at 5-8 PM.  We will have a nationally recognized expert,  Dr.  Terry Barclay speaking about dementia and community action to ensure best care.

Last Saturday, August 20, the Stearns Benton Medical Society with the help of several area professionals hosted a booth at the Senior Health Expo at the St. Cloud, MN River’s Edge Convention Center.  We provided over 70 free cognitive screenings and received hundreds of completed questionnaires filled out asking attendees for feedback on the concept of a local Dementia Resource Center.  We received an enthusiastic response and shared stories with many patients and caregivers.  We will seek further public input on our campaign and the Resource Center up to and after the kick-off meeting on October 11.  Please call Medical Society Executive Director, Mandy Rubenstein at 320-252-8550 or Pat Zook, MD at 320-492-8207 if you have questions or would like to work on the Campaign or participate on one of the Resource Center’s development committees.

Cenral Minnesota Prescribing Coalition Prescribing Policy, 3/16/2015

Index for Central Minnesota Controlled Substance Prescribing Policy

Introduction……………………………………………………………………………………1

Quick Reference, Office/Clinic…………………………………………………………………2

Quick Reference, ER/Urgent Care………………………………………………………………3

Quick Reference, Hospital………………………………………………………………………4

Policy Goals…………………………………………………………………………………….5

Definitions………………………………………………………………………………………6

Prescribing Tools………………………………………………………………………………..9

Vision of the Prescribing Coalition Policy……………………………………………………..13

References………………………………………………………………………………………14

CME Events……………………………………………………………………………………16

Medical Conditions that may require controlled substance prescriptions………………………19

Medical Conditions that rarely require controlled substance prescriptions…………………….21

Opioid side effects………………………………………………………………………………22

Complications of opioid and other controlled substance prescribing…………………………..23

Options for treatment without controlled substance medications………………………………26

Forms for Tools…………………………………………………………………………………27

Unused medication drop-off sites in Central Minnesota……………………………………….29

Pain management resources….…………………………………………………………………31

Addiction treatment resources………………………………………………………………….33

Psychiatry resources……………………………………………………………………………34

Physiatry resources……………………………………………………………………………..35

Physical therapy resources……………………………………………………………………..36

Counseling resources…………………………………………………………………………..37

Hypnosis resources…………………………………………………………………………….38

Policy for Controlled Substance Prescribing

Central Minnesota Prescribing Coalition, St. Cloud, Minnesota 2015

Introduction:

In April, 2014 the Stearns Benton Medical Society based in St. Cloud, Minnesota convened the first of five collaborative style meetings of medical and related community professionals with a goal to produce a medical community policy offering guidance and standardization of practice for prescribing controlled substance medications.  Though Minnesota’s statistics are not as bad as many other states,  leadership in our medical community recognized an alarming trend of increasing incidence of controlled substance prescribing complications within our State of Minnesota and our own St. Cloud-centered medical community.  We are resolved to reverse the increasing incidence and severity of this medical problem by a community effort led by the Medical Society.  This policy serves as our starting point to guide, support and educate physicians, advanced practice providers, nurses, pharmacists and all the medical professionals or the prescribing and dispensing teams working with controlled substance prescribing in our community.  The Prescribing Coalition also intends to offer public educational opportunities based on the content of the policy.  We believe that by enacting and promoting the policy we will move toward accomplishing the “triple aim” of improving population health, improving access to quality care and reducing health care costs while also reducing the severity and extent of the “opioid crisis” and controlled substance prescribing problems.    This Policy will be a work in progress with regular updates and enhancements expected.

Our community Policy will not attempt to reproduce the work of many expert guidelines published elsewhere and noted in the References section with links provided.  This level of detail would be more likely to provide guidance for clinicians in pain management, mental health and addiction specialties.  However, we recognize that the current shortage of these specialists has made it necessary for more primary care clinicians to take on more responsibility for management of controlled substance prescribing for problems in these clinical areas. The Coalition hopes that this Policy used in conjunction with recognized detailed guidelines from other sources will provide a readily available source of practical guidance and support for our medical community prescribers.

Our participating clinicians asked that we develop Quick Reference Sheets that summarize policy recommendations for differing clinical environments.  These sheets can be used daily at work for clinicians working either in an Office/Clinic, an Emergency Room/Urgent Care or a Hospital practice setting. We expect to offer additional QR sheets in the future, but for now we suggest that you use the one that you find most useful. We present them here at the beginning of the Policy document so you can get going with them right away, but we hope you will review the entire Policy content for additional specific helpful information. Also, please review the References section to find more information and Web links for additional resources.

Quick Reference Sheet – Office/Clinic

Experienced office-based physicians know that no single guideline or policy can offer specific answers for every possible clinical encounter scenario encountered with controlled substance prescribing.  Ultimately, you will have to use your best judgment based on your experience and continuing medical education as you make treatment decisions on the spot each day.

Before you decide to treat with a controlled substance prescription medication:

Evaluate the clinical problem as completely as possible before prescribing

Use a medication risk assessment (tools) in your head or on paper. Consider alternatives or consult if high risk

Assess for medical condition risk for side effects before prescribing. (COPD, OSA, obesity, hypoventilation)

Be sure that the clinical diagnosis justifies the use of controlled substance prescribing

Avoid controlled substances for fibromyalgia, chronic neck or pelvic pain, daily headache, etc.

Consider a non-controlled substance prescription, consultation or use of non-medication modalities.

Consider a prescription medication trial for controlled substance meds for a limited time to determine effectiveness

Consider using all the appropriate tools of the Policy to enhance clinical effectiveness and safety

Set realistic goals of treatment and set a time limit expectation at the first and subsequent visits

Check the Minnesota Prescription Monitoring Program website at the first and subsequent visits

Do schedule appropriately frequent follow up visits after the first prescription

Do strive for consistent treatment based on your clinic policy for all patients at all times

Don’t prescribe at the first visit for chronic conditions.  Await full information and evaluation

Don’t prescribe long-acting opioid drugs to opioid-naïve patients

After you write the first controlled substance prescription:

Schedule frequent visits based on the patient’s needs and risks

Work to standardize controlled substance prescribing practice by all your practice’s clinicians

Be decisive and consistent in response to patient’s violating the terms of the medication treatment agreement

Do continuously improve your prescribing skills with CME and personal research

Work toward medical community standardization of controlled substance prescribing and EMR templates

Stress functional improvement as the primary goal with acute or chronic treatment visits

Refer whenever patients fail to respond, have complications or exhibit aberrant behavior

Quick Reference Sheet – Emergency/Urgent Care

Busy ER and urgent care physicians must evaluate and treat both acute and chronic conditions for which controlled substances may or may not have already been prescribed by other prescribers who may not practice in the same medical community. Care transitions with primary care providers are especially important when care involves treatment with a controlled substance prescription.

Before you decide to treat with a controlled substance prescription medication:

Evaluate the clinical problem as completely as possible and review previous records before prescribing

Use a medication risk assessment (tools) in your head or on paper. Consider alternatives or consult if high risk

Assess for medical condition risk for side effects before prescribing. (COPD, obesity, OSA, hypoventilation)

Do be sure that the clinical diagnosis justifies the use of controlled substance prescribing

Avoid controlled substances for fibromyalgia, chronic neck or pelvic pain, daily headache, etc.

Consider a non-controlled substance prescription, consultation, and use of non-medication modalities.

Discuss the likely expected duration of need of the medication and the importance of follow up visits

Consider using all the appropriate management tools of the Policy to enhance clinical effectiveness and safety

Set realistic goals of treatment, discuss these, side effects and risks with patient and loved ones

Check the Minnesota Prescription Monitoring Program website before first prescription and regularly thereafter

Do strive for standardized, consistent controlled substance treatment by all the providers at your site of practice

Don’t immediately prescribe at the first visit for chronic conditions.  Await full information and evaluation

Don’t prescribe long-acting opioid drugs to opioid-naïve patients whether they are admitted or not

Don’t give IV opioids for chronic pain patients’ exacerbations in ER or after admission

After you write the first controlled substance prescription:

Schedule follow up visits with primary clinic or referrals based upon the patient’s needs and risks

Work to standardize EMR documentation for encounters involving controlled substance meds

Consider a medication treatment agreement or treatment plan for frequent visitors seeking controlled substances

Be decisive and consistent in response to patient’s violating the terms of any medication treatment agreement

Do continuously improve your prescribing skills with CME and personal research

Work toward medical community standardization of controlled substance prescribing

Discharge patients with only enough medication to last until the follow up appointment

Do not replace chronic meds prescribed elsewhere or your prescriptions that patients claim to be lost or stolen

Quick Reference Sheet – Hospital Practice

Hospitalists, surgeons and other specialists practicing in a hospital setting often deal with patients without the benefit of a standing relationship.  This makes for communication challenges with controlled substance prescribing. Care transitions with primary care physicians properly done can improve care quality and patient and clinician experience with controlled substance prescriptions.

Before you decide to treat with a controlled substance prescription medication:

Evaluate (again if necessary) the clinical problem as completely as possible before prescribing

Use a medication risk assessment (tools) in your head or on paper. Consider alternatives or consult if high risk

Assess for medical condition risk for side effects before prescribing. (COPD, obesity, OSA, hypoventilation)

Watch more closely with CO2 and oximetry monitoring if high risk for hypoventilation

Do be sure that the clinical diagnosis justifies the use of controlled substance prescribing

Consider a non-controlled substance prescription, consultation, and use of non-medication modalities.

Discuss the likely expected duration of need of the medication and the importance of follow up after discharge

Consider using all the appropriate tools of the Policy to enhance clinical effectiveness and safety

Discuss and set realistic goals of treatment, discuss side effects and risks with patient and loved ones

Check the Minnesota Prescription Monitoring Program website before first dose or prescription

Do strive for standardized, consistent controlled substance treatment practice by all hospital providers

Don’t prescribe long-acting opioid drugs to opioid-naïve patients especially if also on other sedating meds

Don’t give IV opioids for chronic pain patients’ exacerbations.  Resume oral meds as taken as outpatient

After you write the first controlled substance prescription:

Discharge home with only enough pills to last until the scheduled follow up visit

At discharge, schedule follow up visits with primary clinic or referrals based upon the patient’s needs and risks

Work to standardize EMR documentation in your hospital for encounters involving controlled substance meds

Consider a medication treatment agreement or treatment plan for frequent visitors seeking controlled substances

Be decisive and consistent in response to patient’s violating the terms of any medication treatment agreement

Do continuously improve your prescribing skills with CME, personal research and use of the Policy

Work toward medical community standardization of controlled substance prescribing

Consult with chemical dependency/addiction or mental health specialists with difficult cases

Goals of the Policy:

The goals of the Policy include among others:

1) Improvement in the quality of care and care encounters (including standardized, complete clinical encounter documentation) for patients and medical providers involving prescription or refills of controlled substances in our medical community (Central Minnesota)

2) Reduction of the incidence of death, addiction, disability and suffering in our medical community population resulting from prescription and non-prescription use and abuse of controlled substances

3) Reduction of the incidence of adverse health consequences resulting from medication interactions of controlled substances with other medications or substances

4) Improvement of general access to medical care in our community by reducing the increased consumption of medical resources’ time and effort required for dealing with rising rates of adverse consequences of non-prescription and prescription use of controlled substance medication

5) Improvement in the availability of health care access for all citizens of our diverse community especially for those most affected by adverse health consequences of prescription drug abuse

6) Increased use of the Minnesota Prescription Monitoring Program, medication agreements, informed consent, non-prescription and prescribed other modalities by community physicians and other health workers when indicated to improve the process of controlled substance prescribing in our health community

7) Maintain continuing educational opportunities for physicians and other health providers to maintain the highest standard of care for our community’s patients when the prescribing of controlled substances is indicated.  Education regarding use and documentation of alternative, non-controlled prescribing and non-medication modalities will be an important part of the Coalition’s campaign.

8) Maintain continuing education efforts for all patients in our health community to understand and participate in best practice principles for prescription of controlled substances

9) Improvement of the general health of all persons living in our Central Minnesota health community

10) Reduce the incidence of non-prescription use, abuse, addiction, and diversion of controlled substance prescription medications in our health community.

11) Promote and maintain the Policy with continuous reevaluations and revisions to keep it pertinent and up to date for the needs of our medical community

12) The Coalition will make every effort to avoid deterring physicians and other prescribing clinicians from prescribing controlled substance medications when clinically appropriate.  The Coalition will also strive to avoid allowing our community to stigmatize patients or their medical conditions for which controlled substance medication is indicated.

13) Serve as a resource of support for medical community clinicians who deal with tough issues of controlled substance prescribing every day at work.

14) Create and update a curriculum course on controlled substance prescribing and offer both live and online versions to all new and current prescribing clinicians in our medical community.

15) Continuously work to standardize and improve the practice of controlled substance prescribing in our medical community

16) Get our medical community prescribers to take extra care at that very first prescription for controlled substance medication no matter how routine the clinical problem might seem to be in order to minimize the likelihood of future prescription use complications

 

Definitions:

Several terms used in the Policy are defined here for clarity.

Controlled substance: a drug or chemical whose manufacture, possession or use is regulated by the government.  The DEA (US Drug Enforcement Administration) is responsible for suppressing illegal drug use as specified in the Controlled Substances Act since 1970. These are mostly psychoactive drugs and are divided into 5 schedules based mostly on risk for dependence.

Schedule I controlled substances have no accepted medical use and includes illicit drugs like heroin, LSD, peyote, methaqualone and “Ecstasy”.

Schedule II controlled substances have high potential for abuse and severe dependence.  This includes hydrocodone, oxycodone, fentanyl including Duragesic, Adderall, Ritalin, pentobarbital

Schedule III controlled substances have moderate risk for dependence and include codeine, buprenorphine, ketamine and Depo-Testosterone.

Schedule IV controlled substances are considered to have less potential for abuse and include benzodiazepines like diazepam, alprazolam, lorazepam and also carisoprodol (Soma)

Schedule V controlled substances include cough medicines with codeine

Scheduled drugs: Drugs that are classified by the DEA under any of the 5 schedules as above. Many drugs such as antibiotics, anti-hypertensives and many others are not scheduled.

Definitions continued:

Opioids: a class of chemical drugs that resemble morphine in its pharmacological effects on one or more of 3 known types of opioid receptors predominantly in the brain, nervous system and gastrointestinal tract. The naturally occurring alkaloids in this class are called opiates like what is found naturally in the opium poppy.  Opiates occur naturally. Opioids include similarly acting drugs that are artificially synthesized. Opioids produce pain relief and euphoria and have a lengthy list of possible side effects.

Sedatives: drugs that induce sedation by reducing irritability or excitement by modulating signals within the central nervous system. They include barbiturates, benzodiazepines, “Z” drugs like zolpidem, antihistamines, methaqualone-like drugs, alcohol, trazodone and chloral hydrate

Muscle relaxants: drugs that affect skeletal muscle by reducing tone.  Includes neuromuscular blockers that interfere with impulse transmission at the neuromuscular endplate and have no CNS effect.  They are used to cause paralysis for surgical procedures. Spasmolytic muscle relaxant drugs act in the CNS to reduce skeletal muscle spasticity and the pain it causes.  Spasmolytic drugs include cyclobenzaprine (Flexeril), carisoprodol (Soma), tizanidine, metaxolone, baclofen, and dentrolene.

Benzodiazepines: class of psychoactive drugs that enhance reactivity of the GABAa receptor  to producing sedative, hypnotic, anxiolytic, anti-convulsive and muscle relaxant effects. Short acting benzodiazepines are better suited for insomnia and long acting ones are better for anxiety. Withdrawal after longtime use can be very difficult. Many of its effects are additive with any concomitantly used opioids which can increase the risk of their use together .

Non-prescription use: taking a prescription medication not prescribed as such for the specific person taking it or in a dose or frequency other that what was originally prescribed. Leftover pills in a relative’s medicine cabinet is a common source of diversion that starts a course for addiction and other complications of controlled substance use by someone other than the person that it was originally prescribed for.

Drug abuse: the excessive, maladaptive or addictive use of drugs non-medically despite social, psychological and physical problems stemming from their use.

Substance use disorder: (or drug use disorder) is a condition in which the use of a substance leads to clinically significant impairment or distress in the person using the substance. This usually involves overuse of the substance leading to dependence or other negative and often social consequences either for the user or others.

 

Definitions continued:

Addiction: compulsive engagement in rewarding stimuli in spite of adverse consequences. a primary, chronic disease of brain reward, motivation, memory and related circuitry.  Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This leads to pathologic pursuit of reward and/or relief by substance use or other behaviors.  Addiction is characterized by the inability to consistently abstain, impairment of behavioral control, craving, diminished recognition of significant problems with one’s behavior and personal relationships, and a dysfunctional emotional response.  Relapses and remissions are common.  Progression is common and can lead to more disability and premature death without treatment.  Addiction can involve non-substance behaviors and is not always centered on drugs.

Aberrant behaviors: Behaviors that indicate likely addiction or loss of control with respect to the use of a controlled substance medication, aberrant behaviors do not always mean addiction.  Some of these are rapid escalation of dosage, taking higher doses than prescribed, frequently running out of the med early, obtaining the drug from other sources or multiple pharmacies, or any other violations of the medication treatment agreement.

Drug dependence: an adaptive state associated with a withdrawal syndrome upon cessation of repeated drug use

Diversion: The DEA considers diversion as the use of prescription drugs for recreational purposes.  This implies the use of any prescribed drug for purposes other than what the original prescription authorizes, often by someone other than the original patient who obtained the prescription. The medication prescription was “diverted” from its original purpose.

Tapering: Slowly reducing the dose or frequency of administration of a drug to which a patient has become dependent usually with the goal of discontinuing the drug as soon as possible.  The taper is done to minimize withdrawal symptoms or sudden worsening of the original symptoms.  Reasons for discontinuing the drug could include lack of benefit, the need to add some other drug which might cause problems interacting with the original drug, aberrant behavior, or violation of the medication treatment agreement rules.

Tolerance: diminishing effect of a drug resulting from repeated use at a given dose and a need for increasing doses to achieve the desired effect.  Patients who have tapered off or stopped their controlled substance drug for some reason should be assumed to have lost at least some of their tolerance to it.  These patients would be very high risk for side effects or overdosing if they were to restart the drug at their full previous dose that they were taking before it was stopped.

Prescribing tools:

Prescribers treating patients with controlled substance medications are faced with many challenges when medical problems persist or worsen in spite of initial treatment, patients exhibit aberrant behavior, or the problem develops from acute to chronic without the expected resolution.  Before and after prescribing controlled substances, clinicians would benefit from using any of several clinical tools recommended by experts based upon their best practices recommendations. Not every controlled substance prescription necessitates the use of any or all of these tools.  Straightforward, acute problems like a recently sprained ankle, grief reaction, or flight phobia may not need any of these clinical tools for proper management, but clinicians should always monitor carefully to prevent these acute problems from morphing into much more serious problems like chronic, longstanding medication use, addiction, substance abuse, diversion, drug interactions, side effects, overdose or death. Even if prescribers use none of these other tools, all Minnesota prescribers of controlled substances should regularly go to the website of the Minnesota Prescription Monitoring Program (http://pmp.pharmacy.state.mn.us/) to monitor patients before and after writing a patient’s first controlled substance prescription.

Some of these prescribing tools are:

(Opioid) or Medication risk assessment: A numerically scored test that predicts risk for problems with controlled substances. High risk patients should either be referred or monitored much more closely for problems.  High risk is indicated by history or current substance use disorder, unstable or untreated psychiatric disorder, repeated aberrant drug-related behavior, history of bipolar disorder or PTSD, and past sexual abuse in females

Medical condition risk assessment: Before prescribing controlled substances check for any likelihood or history of medical conditions that might make controlled substance use especially hazardous like morbid obesity, symptoms or treatment of sleep apnea, COPD, hypoventilation or undertreated hypertension. Age past 65 is also higher risk.  Problems like these might necessitate consultation, problem optimization, or closer monitoring for complications like respiratory suppression, hypercapnia, hypoxia and overdose emergencies.

Medication treatment agreement: A detailed agreement that patients sign after informed consent to cover expectations of clinician and patient for controlled substance prescribing. Elements of this agreement include discussion of the medication, risks and possible side effects, goals of treatment, use of the MPMP, need for thorough evaluation of the clinical problem and cooperation with consultations and testing, random urine drug testing, random pill counts, the medical record, consequences of agreement violation, rules for prescription handling like lost prescriptions and use of a single pharmacy, notification of all other providers or medical services, refill policy and the need for regular follow up visits.  The patient, the prescriber and a witness sign the agreement,

Prescribing tools continued:

which is kept in the patient’s chart with a copy provided to the patient.  Clinicians would benefit from ensuring that all colleagues practicing at their clinical site use the same medication treatment agreement form and enforce all agreements in similar fashion.  Clinicians would benefit from ensuring that all colleagues practicing at their clinical site use the same medication treatment agreement form and enforce all agreements in similar fashion.  Reference to this agreement can clarify the situation for a patient claiming bias against them by the prescriber or someone on the treatment team.  Copies taken home by patients and shared with loved ones can clarify the patient’s relationship with the prescribing team and their treatment site policy

Informed consent: A process for obtaining permission from a patient before a treatment or procedure in such a way that ensures that the patient is given full understanding of the treatment and its expectations for the patient and the clinician. It includes risks vs. benefits, expected outcomes, duration of treatment and rules of conduct during treatment.  This informed consent for controlled substance prescribing is usually part of and documented in the medication treatment agreement.

Random pill counts: Patients are called just before their appointments and asked to bring in their pill bottle with the prescribed controlled substance medication.  If counts are not consistent with the latest prescription numbers and dates, this might indicate improper use or diversion.

Random urine drug screens: At random times and at intervals determined by risk factors for non-compliance, prescribers ask patients to provide urine samples to test for the presence of the prescribed drug and other controlled substances or illicit drugs. Interpretation of these results requires skill and training and the results can be erroneous or inconclusive.  Consult with experts for unexpected or uncertain results.  The results might indicate diversion if the prescribed drug is not found, or indicate violation of the treatment agreement if other prescription or illicit drugs are found.

EMR templates for acute and chronic pain, mental health problems or insomnia should be incorporated into your workplace EMR patient record.  These provide checklists for management documentation and standardizes your medical record methods across your entire practice group.  Eventually, whole medical communities like ours can utilize standardized methods for encounter documentation which should help with consultations and other transitions of care.

Minnesota Prescription Monitoring Program (http://pmp.pharmacy.state.mn.us/) offers an indispensable aid in the management of controlled substance prescribing.  This website is free to use by licensed Minnesota physicians, their treatment team colleagues working with them and pharmacists. Running queries on specific patients reveals a report

Prescribing tools continued:

of all the recorded pharmacy-dispensed prescriptions that a patient has received going back for a designated period, that includes all pharmacies and all prescribers, and the dates and quantities of each controlled substance prescription medication.  These queries may reveal evidence of doctor shopping or use of multiple pharmacies in violation of a treatment agreement, or conversely, might show good compliance with your treatment agreement.

Expert consultation: Prescribers should seek consultation with specialists in pain management, psychiatry, neurology, orthopedics, or counseling among others when confronted with clinical uncertainty or dilemmas dealing with controlled substance prescribing.  Consider consultation before writing the very first prescription if there are any impediments to thorough evaluation including time restraints, patient reluctance, or obtaining previous medical records.  If patients do not favorably respond to initial treatment within the expected period of time, if they exhibit aberrant behavior, signs of addiction or untreated mental illness, or if they violate terms of the medication treatment agreement, then consultation would be indicated.  Part of your treatment agreement should include patient acceptance of consultation when deemed necessary by the prescriber.  Experts in non-medication modalities to alternatively treat medical conditions apart from use of controlled substance meds could also be considered as expert consultants, however, it would be wise to consider their services well before you run into the problems mentioned above.

ICSI: The Institute for Clinical Systems Improvement (https://www.icsi.org/) is the independent, non-profit health care improvement organization that unites clinicians, health plans, employers, policy makers and consumers to bring innovation and urgency to improve health, optimize the patient experience, and make health care more affordable.  It is comprised of 50 medical groups representing 8,000 physicians and is sponsored by three Minnesota non-profit health plans.  Their goals can be summed up by the “triple aim” which states that 3 things need to be accomplished to improve health care in America, 1. Improve population health. 2. Improve quality and the patient experience. and 3. Improve affordability of health care.  The detailed ICSI-derived acute and chronic pain guidelines represent a focal point resource for us in developing our Policy.

Illicit drugs: These are the Schedule I drugs that are illegal to use, possess or sell including heroin, crack cocaine, LSD, peyote, methaqualone and “Ecstasy”.  These drugs are never legally prescribed.

Medical risk assessment: Before prescribing controlled substance medication, prescribers should not only do a medication (opioid) risk assessment to screen for addiction and substance use disorder risk, but should also assess for physical problems or

Prescribing tools continued:

risk for such physical problems that might increase the hazards, risks or side effects of any prescribed controlled substance meds.  Such problems as obstructive sleep apnea especially if not yet diagnosed, morbid obesity, COPD, smoking, use of alcohol, and advanced age may contribute to and worsen controlled substance side effects like hypoventilation, hypoxia, hypercapnia, overdose emergencies, drowsiness and death.  Stabilize or consult on these problems before prescribing controlled substances.  Clinicians should document stability or increased observation if these problems exist.

Guidelines: In depth and detailed recommendations for treatment of a medical problem usually derived from the work of large, multi-talented experts in the field.  Guidelines are less philosophical and more practical, but may contain a lot more detail than the average clinician who treats that condition is likely to need for daily guidance.  Guidelines usually try to offer recommendations that are supported by evidence-based studies.  Guidelines offer valuable opportunity for clinicians to further advance their skills for any clinical problem covered by a guideline.

Policy: General recommendations for managing clinical care in general or in particular for a specific clinical problem like controlled substance prescribing.  The recommendations usually represent summary recommendations on several issues and sub-issues of a clinical problem or crisis discussed with agreed-upon conclusions of a working group like the Central Minnesota Prescribing Coalition.  There may or may not be evidenced-based data in studies to back up the recommendations of a policy, but the urgency of a community health problem (like medical emergencies associated with commonly prescribed drugs) brings community health leadership together to collaborate and come up with consensus best practice recommendations based upon the experience and research of the group’s contributors.  A medical community policy can serve to standardize and improve the management of a given clinical problem throughout the area served by clinicians who work together to continuously improve local medical care.

Informed consent: (Also see Definitions) A process for obtaining permission from a patient before a treatment or procedure in such a way that ensures that the patient is given full understanding of the treatment and its expectations for the patient and the clinician. It includes risks vs. benefits, expected outcomes, duration of treatment and rules of conduct during treatment.  This informed consent for controlled substance prescribing is usually part of and documented in the medication treatment agreement.

Vision of the Central Minnesota Prescribing Coalition for the Controlled Substance Prescribing Policy:

In the future, when our Policy is working to its full potential, we will have a unified medical community that collaborates to continuously improve controlled substance prescribing practice for all of our patients while using and maintaining standardized practice methods, tools and medical documentation while doing so.  Complications of controlled substance prescribing like overdoses, suicides, addiction, diversion, use of illicit drugs, incarceration, other morbidities, death and loss of family and community wellness will all be rare events, occurring far less often than currently.  Prescribing clinicians will then have additional time and energy to provide other medical services to more people when controlled substance prescribing becomes less controversial, more standardized within the medical community, less stressful and less time consuming as fewer and fewer patients rely on less and less controlled substance medication and more on non-controlled substance medication and alternative treatment modalities.  The public will know that medication is only one part of finding resolution for their medical conditions like pain, mental health problems and insomnia. They will come to expect and participate actively in their referrals for adjunctive medical services for help with these problems. Patients will have clear expectations for treatment goals, treatment duration, risks versus benefits, and referral when needed.  They and their prescribers will be familiar with standard treatment tools like medication risk assessments, treatment agreements and plans, and the Minnesota Prescription Monitoring Program. Virtually all prescribers of controlled substances will be accessing the MPMP appropriately and regularly and will get to know pharmacists who regularly dispense these meds for their patients and collaborate with them to continuously improve the process and service of controlled substance prescribing.  Patients needing treatment for addiction, mental health problems or sleep disorders will have no trouble finding expert consultation for treatment and management of their conditions and will be able to easily make appointment for these services that are fully covered by third party payers.  School suspensions and truancy will be at all-time lows as substance abuse disorders become rare in all age groups. Neonatologists and pediatricians will no longer have to supervise drug withdrawal regimens for newborn infants in our hospitals.  The dangerous consequences of controlled substance drug diversion will be extremely rare and patients with leftover or unneeded pills will easily and safely dispose of them at the handy take-back receptacles available at all dispensing pharmacies in our community. Our well known community controlled substance prescribing policy and the consistent, standardized practice methods of our prescribers will spread to surrounding communities to similarly improve controlled substance prescribing across our state, and subsequently, our region of the country.  When the public health and controlled substance prescribing culture of our medical community has fully embraced and enacted the tenets of this Policy we will enjoy a significant step up in population health, and the realized cost savings will further insure additional access by all community members to quality health care.

References:

Listed below are some additional resources and websites for controlled substance prescribing information.  While treatment of pain is mentioned most often, the same principles discussed also apply for treatment of other medical conditions like mental health problems or insomnia.  Thus, the same principles apply for prescribing controlled substances other than opioids.

ICSI Guidelines for Management of Acute Pain

https://www.icsi.org/_asset/dyp5wm/Opioids.pdf

Institute for Clinical Systems Improvement. Updated in 2014.  Minnesota expert-based. 45 pages with significant guidelines detail by Minnesota-based physicians and other professionals

ICSI Guidelines for Management of Chronic Pain

https://www.icsi.org/_asset/bw798b/ChronicPain.pdf

Institute for Clinical Systems Improvement. Updated in 2014.  Minnesota-based experts 106 pages.  Significant guidelines detail by Minnesota-based physicians and other professionals.

 

Minnesota Prescription Monitoring Program

http://pmp.pharmacy.state.mn.us/

The website for running queries on controlled substance use by patients. Clinicians must apply to sign up for themselves and their designated co-workers on their treatment team.

 

Veterans Administration /DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF OPIOID THERAPY FOR CHRONIC PAIN

160 pages used by our St. Cloud, MN VA Hospital.  (2010)

http://www.healthquality.va.gov/guidelines/Pain/cot/COT_312_Full-er.pdf

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non-cancer Pain

http://www.jpain.org/article/S1526-5900(08)00831-6/fulltext

  

References continued:

Federal Guidelines for Opioid Treatment

Over 100 pages with several particular situations covered, but this draft is mostly for opioid treatment program certification, but the information is helpful

http://www.dpt.samhsa.gov/pdf/FederalGuidelinesforOpioidTreatment5-6-2013revisiondraft_508.pdf

Use of Opioids for the Treatment of Chronic Pain – A statement from the American Academy of Pain Medicine.

Not a guidelines but a very good summary of what guidelines should cover

http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf

The American Academy of Pain Medicine’s chronic, non-cancer pain guideline

http://www.dir.ca.gov/dwc/DWCPropRegs/MTUS_Regulations/MTUS_ChronicPainMedicalTreatmentGuidelines.pdf

 

American Chronic Pain Association, Inc.

Very extensive and inclusive document of over 100 pages – (2013)

http://www.theacpa.org/uploads/ACPA_Resource_Guide_2013_Final_011313.pdf

Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine

Pain management from an anesthesiologist viewpoint

http://journals.lww.com/anesthesiology/fulltext/2010/04000/practice_guidelines_for_chronic_pain_management_.13.aspx

 

The Journal of Pain Volume 10, Issue 2 , Pages 113-130.e22, February 2009

References continued:

The Oregon Pain Guidance Group website with guidelines

http://www.opioidprescribersgroup.com/

Excellent website with detailed guidelines.  This group was organized by the Governor of Oregon in response to alarming data on complications of opioid use in their state.  Several videos and other learning materials. Regular posting of CME events on controlled substance prescribing.

ASAM: American Society of Addiction Medicine

(http://www.asam.org/)

Excellent discussion of the definition and physiology of addiction.  Several future CME events are posted.  Numerous detailed articles to review and reference.

CME events:

4th Annual Thoughtful Approach to Chronic Pain: New Horizons, What Clearly Works When: May 29-30, 2015, 8 a.m. – 5 p.m. Where: Smullin Education Center, Campus of RRMC, Medford, Oregon Who: Physicians and Multidisciplinary Primary Care Providers, Occupational Health Providers, Behavioral Health Providers, and Pain Management Providers Flyer: Conference information  as below:

When: May 29-30, 2015, 8:00 a.m.–5:00 p.m., Registration at 7:00 a.m.

Where: Smullin Education Center

Rogue Regional Medical Center, 2825 E. Barnett Road, Medford, OR

Who: Physicians and Multidisciplinary Primary Care Providers, Occupational Health Providers, Behavioral Health Providers, and Pain Management Providers

Tuition: Physicians $195 for 2-day registration or $100 for 1-day registration;

Multidisciplinary/Other $165 2-days or $85 1-day

Early Bird Tuition: Save 10% on tuition if registering before March 15, 2015

CME events continued:

Late Fee/ Walk-In Tuition: Add $50 to rate if registering after May 15, 2015

Scholarships available, contact Michele Schaefer at mschaefer66@gmail.com before May 15, 2015

Purpose: The appropriate treatment of chronic pain is an evolving, and sometimes controversial, practice. This conference will present factual information concerning the use of opioids in Oregon, community effects of opioid prescribing, current best practices for the treatment of chronic pain, and how medicine and community justice interface around prescription opioids use.

CME and CEUs available. For information call: Continuing Medical Education, (541) 789-4837

 

The ASAM Annual Conference

April 23-26, 2015   Hilton Austin │500 East 4th Street │Austin, TX 

Overview

Addiction is a chronic brain disease and there are treatments available to help patients.

What is ASAM?

ASAM is a professional society representing over 3,200 physicians and associated professionals dedicated to increasing access and improving the quality of addiction treatment; educating physicians, other medical professionals and the public; supporting research and prevention; and promoting the appropriate role of physicians in the care of patients with addiction.

What is the NEW ASAM 46th Annual Conference – Innovations in Addiction Medicine and Science

The ASAM Annual Conference is the nation’s premiere event providing the latest innovations and scientific developments in Addiction Medicine. The annual conference has been re-named (formerly the ASAM Medical-Scientific Conference, nicknamed Med-Sci) to reflect some exciting new changes in format and structure to provide learning in a more interactive, casual and fun environment.

 

CME Events continued:

Pre-Conference Courses – Thursday, April 23, 2015

8:00 am – 5:30 pm (Additional Fees Apply)

The ASAM Fundamentals of Addiction Medicine is a practical, case-based course designed to support primary care providers in their clinical treatment of patients at risk for or with substance use disorders (SUD).

8:00 am – 5:30 pm (Additional Fees Apply)

This year’s conference will examine evidence-based methods of pain management that involve minimal or no use of prescription opioids. Experts in the field will use innovative teaching methods to demonstrate different treatment approaches.

CME events continued:

Questions? Contact ASAM’s Education Department

American Society of Addiction Medicine 4601 North Park Avenue Upper Arcade, Suite 101 Chevy Chase, MD 20815-4520 Education Department Phone: 301-656-3920 | Fax: 301-656-3815 | Email: education@asam.org | Web: www.asam.org

Medical conditions that may require controlled substance medication include:

Acute pain from an injury, surgery or some incident medical problem at the time lasting less than 3 months.  Clinicians still need to consider a medication risk assessment and do as thorough a workup as possible before that first prescription.  Ask yourself if this patient is more likely than average to get into trouble with controlled substance use or to have more side effects.  Many patients addicted to controlled substance meds got started with an innocent prescription for a sprained ankle or similar simple problem.  The very first prescription and follow up may offer the most significant opportunity for clinicians to prevent complications from controlled substance prescribing. Always discuss the expected duration of use of the pain med before the first prescription and at each follow up visit.  Be sure patients return for scheduled follow up visits.

Chronic pain for any reason lasting more than 3 months or has taken longer than expected to resolve.  More of the tools for management may be needed (see Tools section) as patients may have seen other providers before you see them for this problem.  Patients may not have realistic treatment goals and expectations at this point.  Consider consultation if they do not improve in function and symptoms within a reasonable timeframe or if they exhibit aberrant behavior.  Adjunctive, non-medication modalities and non-controlled substance meds are more likely to be of benefit earlier on in the clinical course and may help prevent progression from acute to chronic pain. Studies fail to show consistent effectiveness for use of opioids for chronic pain.

Mental health problems include various types of depression, anxiety, attention deficit disorder, schizophrenia, behavior disorders, substance abuse disorders, and others.  These diagnoses may be indication for additional vigilance on your part when prescribing controlled substances.  Sedation and other serious side effects of any controlled substance med might potentially be

Medical conditions that may require controlled substance medication cont’d:

worsened when mental health condition meds are taken at the same time.  Most opioid medication risk assessment tools score past drug abuse and serious psychiatric problems as very high risk for complications for giving a controlled substance prescription.  Benzodiazepines used extensively in our population by prescription or in non-medical use for anxiety, sleep or illicitly are involved in up to half of all serious medication overdose cases.  Prescribing opioids to patients on benzodiazepines is fraught with numerous serious potential problems.  If this is clinically necessary, most primary care clinicians should consider expert consultation or calling the mental health prescriber to negotiate the best solution.  Prescribing initially for patients with known substance abuse disorders should be done only after consultation with an expert consultant in pain management, addiction medicine or mental health treatment.  Antidepressant prescriptions are commonly provided in primary care and are generally safe at modest doses, however, higher doses, drug combinations, atypicals and drugs used for psychosis, bipolar disorder and ADD or ADHD may be problematic unless the prescriber is very familiar with their everyday use.  Many primary care clinicians are comfortable prescribing meds for ADD and ADHD.  Be sure to watch for problems as children move into adulthood.

Anxiety is commonly seen and managed in primary care practices.  Many forms of anxiety will respond to non-prescription methods such as counseling, exercise, yoga, or relaxation techniques.  Many other patients with anxiety will respond to treatment with an antidepressant and some of the non-prescription methods.  Use of benzodiazepines in low dose for short term problems is usually safely handled in primary care, but higher and escalating doses, increased use of alcohol or illicit drugs, or legal problems signal problematic use warranting clinical intervention.  Since withdrawal from benzodiazepines is so often associated with a very prolonged and symptomatic course, it is best that alternatives to their use be considered wherever possible.  Most patients who make it through benzodiazepine withdrawal after many months or years of chronic use state that their quality of life improves substantially once they are totally weaned off.  They remain at great risk for relapse especially if used non-medically. Complete withdrawal can take as long as 1-2 years.

Insomnia comes in many forms and for many reasons.  Use of the “Z” drugs for sleep, like zolpidem (Ambien), eszopiclone and zaleplon can be very problematic when used with opioids or benzodiazepines.  Benzodiazepines are not recommended for sleep based upon how they interact unfavorably with sleep physiology, however many patients take them for this reason.  Taking opioids or any of the Z-drugs while also taking benzodiazepines can contribute to over sedation and overdose risk, especially in patients over age 65 or in those who drink alcohol especially to excess.  There are several non-medication strategies to improve sleep such as improving sleep hygiene, relaxation measures, treating depression with cognitive behavioral therapy, etc.  If medication is necessary for sleep, any of the several antidepressant meds like trazodone, amitriptyline or mirtazapine might prove to be useful without as much risk for over

Medical conditions that may require controlled substance medication cont’d:

sedation or overdose emergencies.  It is very difficult to wean patients off of zolpidem (Ambien). If this is really the only medication that “works” for a given patient, consider consultation with either a counselor experienced in sleep disorder treatment or a sleep medicine specialist.

Muscle spasm can be very severe and persistent for common conditions like fibromyalgia and biomechanical back or neck pain, but use of drugs like opioids, benzodiazepines, soma, baclofen and others can usually be avoided except in unusual or severe neurologic disease cases.  Non-medication modalities like physical therapy, massage, relaxation training, meditation, and others can be very helpful with or without over the counter analgesics like acetaminophen.  When necessary, non-controlled prescriptions for cyclobenzaprine, gabapentin, and antidepressants among others may be helpful without the greater risks of opioids or benzodiazepines.

Special medical conditions including attention deficit disorder, severe restless leg syndrome, neuropathy of many types, and severe neuromuscular disease may require chronic use of controlled substance medications.  Even with clear cut indications, however, clinicians still need to monitor these patients closely for the same complications of treatment with opioids or other controlled substance medications that other medical conditions can develop into.

Medical conditions that should rarely be treated with controlled substances include:

Fibromyalgia, chronic daily headache, neck pain or back pain, pelvic pain, anxiety associated with depression, insomnia, depression, substance abuse disorders and situational stress.  These conditions are more appropriately treated with other meds or alternative non-medication measures. Once opioids or benzodiazepines have been utilized by a patient for several months or years, dependence is likely present and may require an addiction or pain management specialist to help with taper and withdrawal as withdrawal can be lengthy and dangerous.  These chronic conditions are often accompanied by problems sleeping, but the addition of the “Z” drugs for sleep (like zolpidem (Ambien), eszopiclone, and zaleplon) makes the risk much greater still, and these should be avoided in combination with benzodiazepines or opioids.  Insomnia can often be treated with several non-medication alternative treatments and practices.  If these are unsuccessful, then safer medication like trazodone, gabapentin, antidepressants or spasmolytics like cyclobenzaprine might be effective.  Refer patients with treatment resistant insomnia to a sleep medicine specialist, psychiatrist or counselor as indicated for further evaluation if these safer drugs are not helpful in conjunction with non-medication methods.

Studies continue to demonstrate the lack of effectiveness of opioids for chronic pain.  Most patient who have been on long term opioids for chronic pain feel much improved quality of life once they have been safely tapered and withdrawn from their pain meds.

Medical conditions that should rarely be treated with controlled substances:

Again, prescribers have the very best opportunity to prevent prescription drug use complications at that very first visit for the problem being evaluated.  Our instinct as clinicians is to relieve suffering, but making sure that the problem really does warrant the use of controlled substance medication is probably most important at this first clinical encounter.  Setting realistic goals and expectations at this time is vital toward minimizing risk for prescription complications later in the clinical course.

 

Side effects of opioid drugs:

Opioid drugs are very effective at relieving acute pain.  However, there are many potential side effects that should always be reviewed with patients before the first prescription and during follow up.  The list of side effects should appear in your medication treatment agreement.

Side effects include sedation, constipation, nausea, increased fall risk, incoordination, confusion, sedation, dizziness, vomiting, physical dependence, tolerance, respiratory depression, delayed gastric emptying, hyperalgesia, immunologic and hormonal dysfunction, muscle rigidity, and myoclonus.

Tolerance to the side effects of constipation and nausea may fail to develop and may cause discontinuation if severe.  Side effects are amplified by use of alcohol, illicit drugs, several prescription drugs, fatigue, advanced or young age, medical and mental health problems, higher doses and prolonged use.  Use of long acting opioids in opioid-naïve patients can be very dangerous especially when patients are taking other sedative drugs or substances.  Most overdose emergencies involve ingestion of more than a single controlled substance, many of which are prescription medications.

Studies have not shown effectiveness of long-term opioid use for chronic pain.  In spite of this, patients continue to take opioids, often for years, for mood improvement, recreational use or just because they have become dependent on them and suffer withdrawal when they try to taper or reduce dosage.  Most experts consider it to be chronic use beyond 3 months of use, or taking them beyond the time expected for clinical improvement.  Some degree of dependence can occur very quickly, even before three months of regular use.  Patients taking opioids post-operatively for routine surgeries often suffer minor withdrawal symptoms when they try to come off the drugs as their surgery sites heal in just two or three weeks.

One of opioids’ most serious side effects is respiratory depression leading to hypercapnia and then subsequent hypoxia and its consequences of coma and death.  This can occur when patients take more than the prescribed dose on their own decision or if they take illicit or sedative drugs at the same time.  However, under certain circumstance, either in the hospital or in an outpatient

Side effects of opioid drugs, continued:  

setting, patients can suffer respiratory depression and its consequences after prescriber-ordered doses.  These circumstances include prescribing oral long-acting opioids to opioid-naïve patients, patients with medical risks for hypoventilation like COPD, morbid obesity, frail status, advanced age, sleep apnea (diagnosed or not), and concomitant use of sedative medication.

We often encounter new patients who have been on opioids and/or benzodiazepines for many years.  Many of these patients have either no diagnosis for their pain or have diagnoses that normally do not justify the use of these meds.  Some had reasonable need for these meds far in the past, but have never been questioned about their long term use even, when the original incident problem should have resolved long ago.  Most of these patients are likely dependent on their opioid or sedative meds when you see them as new patients wanting a “refill”.  What they really need from you at times like this is much more than a refill.  For patients like this, even a mini-intervention will take much more of your time than was likely scheduled, but patients should be questioned about their history and the problem for which the meds were prescribed initially.  You should refer them to an addiction expert, and should not feel pressured to prescribe what they ask for at this first visit.  Do an opioid risk assessment, a medical condition risk assessment, as complete a problem evaluation and history as possible. Have them read and sign a medication treatment agreement and agree to close follow up if you do decide to treat them until they can see the consultant.  If they are high risk, insist on referral without writing a prescription, especially if they are currently abusing alcohol or illicit drugs.  Do not treat before obtaining their full history for this controlled substance prescription or before checking the Minnesota Prescription Monitoring website for their prescription history.  You might also want to do a urine drug screen to check for the prescribed drug and for evidence of any illicit drug use.

Complications of opioids and other controlled substance use:

Chronic use:

Most long term users of controlled substance meds are dependent on them when we see them as new patients.  Their original problem should have resolved by the time we see them in most cases.  Are they now just dependent or addicted?  If successfully withdrawn from their meds, would they still have the original problem?  If the original problem persists, can we convince them to pursue another evaluation and treatment course without using controlled substances?  These and other questions were of uppermost concern for the health professionals participating in our Prescribing Coalition’s earliest meetings.  Long term use of opioids and sedative meds presented daily dilemmas for all physicians, whether they worked in ER/Urgent care, hospital or office settings.  These dilemma situations are made more stressful for clinicians and patients because of the full schedules of our local addiction and psychiatry experts whose consultation

Complications of opioids and other controlled substance use, cont’d:

appointments are fully scheduled out for several months.  If primary care clinicians had easier access to these services, it would certainly be much better to co-manage these patients along with one of these experts in charge, compared to our current situation.  Primary care has to make management decisions for chronic, long term use patients as they sit in our exam rooms sometimes while showing medication withdrawal symptoms.  Fixing reimbursement and resource availability problems will go a long way towards solving chronic use problem cases.  Until these fixes are accomplished, clinicians can best bolster themselves with knowledge and practice of the tenets of this Policy and their preferred choice of clinical prescribing guidelines, some of which are posted in the “References” section of this Policy.

Dependence: (See “Definitions” section)

This happens for many of the patients taking controlled substance meds for extended periods, but can happen quickly in some patients. Higher doses make dependence more likely, but even relatively low doses of opioid and benzodiazepines can rapidly cause dependence with the occurrence of significant symptoms of withdrawal with abrupt cessation.

Addiction: (See “Definitions” section)

The craving of dependence can change behaviors to focusing on obtaining the substance desired at any cost – legal, financial, or personal. Aberrant behaviors can originate from dependence on the meds originally prescribed even for a reasonable indication in a low-risk patient.

Diversion: (See “Definitions” section)

This is how many people start down the path toward drug dependence and addiction.  They experiment with pills they find in a relative or friend’s medicine cabinet.  People who are addicted can divert their prescriptions by giving or selling them to someone else.  Emergency room parking lots can be a popular place for cash transaction diversions.  People using diverted drugs often have no medical supervision, making their situation even more dangerous if they also use alcohol, illicit drugs, or other controlled substance medication.

Overdose:

When doses of a drug are high enough to cause serious side effects like respiratory insufficiency, drowsiness, incoordination or others, this emergency is called an overdose.  Overdoses range in severity from having troubling side effects to death usually from respiratory suppression.  Antidote meds like naloxone for opioids and flumazenil for benzodiazepine overdoses can be helpful and even lifesaving for naloxone. Use of flumazenil is controversial for serious overdoses in long-time users because of the risk of inducing seizures.  Many US cities have allowed trained first responders including police and firefighting personnel to administer various formulations of naloxone for serious, suspected opioid overdose emergencies.

Complications of opioid and other controlled substance use, cont’d:

Drug interaction:

Interaction of controlled substance meds with other prescription meds can cause significant side effects that clinicians may not suspect if the patient has not divulge use of the other meds.  The other meds may have been prescribed elsewhere, or taken via diversion.  The use of illicit drugs and alcohol may add to the risk for drug interaction.  Accessing the MPMP website will at least reveal the prescription history for this patient’s other prescribed drugs.  If you suspect current abuse of illicit drugs or alcohol, it would be best to defer on any controlled substance prescribing, until the patient has been seen and evaluated by an expert consultant.  Patients often assume that office clinicians have “all their medical records” on our computers even when we are seeing them for the first time in our state.  When asked for a list of “their meds”, many patients do not include all their meds for various reasons, necessitating extra effort to discovery any possible conflicts with whatever controlled substance you are now considering prescribing.  Interaction symptoms can include and of the symptoms listed under “Opioid Side Effects”.  If helpful family members accompany the patient, often they will notice side effects before the patient will.  Their observations can offer helpful clues.

Aberrant behaviors:

These occur in drug-dependent patients with addiction.  Their day is driven by uncontrollable craving which can cause behavior changes that characterize the craving state.  Aberrant behaviors include diversion of theirs or other’s meds, early refill requests, claims of lost or stolen meds, undisclosed other sources of the meds, and use of illicit drugs.

Personal loss:

Persons stuck in a pattern of aberrant behaviors driven by craving and drug dependence often suffer personal loss events like divorce, legal problems, bankruptcy, loss of friends, job loss or employment problems and depression.  Many patients in treatment programs have no one left to support them in sobriety during aftercare.

Death:

This is the ultimate, worst complication of controlled substance use.  Over 16,000 people in the US die annually of drug overdose events, the majority of which involve multiple substances, mostly (often diverted) prescription meds and some illicit drugs.  Many overdose deaths occur in young adults who started their drug abuse with diverted prescription meds from a relative’s medicine cabinet.

 

Options for treatment without controlled substance medication:

Exercise and physical fitness: Can improve pain up to 30-60%. Patients without understanding of exercise basic principles or with significant disability might benefit from working with a physical therapist or exercise personal trainer experiences with disabled patients.

Physical therapy: Several physical therapy modalities and techniques besides exercise can contribute significant relief for acute and chronic pain, anxiety and muscle spasm, and sleep problems.

Cognitive behavioral therapy, mindfulness therapy: Can improve pain 30-50%.  Our medical community has several professionals able to provide these options for your patients not only as a part of pain management, but also for mental health and sleep problems.  Relaxation training while very beneficial for many patients, can be a component of counseling for anxiety, depression and other mental health problems.

Sleep restoration: Can improve pain up to 30-40 %.  Several of our community counseling experts can train your patients to improve the quality of their sleep.

[Opioids, tricyclics, and anti-epileptic meds contribute less than 30% to pain relief]

Pain management centers: Clinics specializing in direct treatment modalities for painful conditions can be very helpful for acute and chronic pain offering several injection, ablation procedures, counter-stimulation devices and sometimes – medication management.  Referring patients earlier in the course of their painful condition is likely to improve their odds for successful outcome, however, success should be measured by achievement of reasonable treatment goals like degree of return to function as opposed to estimated pain scale progress.

Clinical support:

Patients who can continue to see their primary care clinicians even if they are co-managing their patients clinical problem with an expert consultant, can be expected to benefit from the continued support and medical treatment of their primary care clinician.  Especially if their primary clinician is knowledgeable regarding the treatment of chronic conditions like chronic pain, mental health issues and drug dependence, this type of clinical support would be expected to enhance the effectiveness of the consultant’s treatment and management.  If the primary care clinician just continues to see the patient for other medical conditions and does not co-manage with the expert, the patient still benefits from maintaining this clinical relationship and receiving the extra support.  Patients being treated for chronic pain, mental health issues or drug dependence often have no one else to freely talk about their issues due to the sensitive nature of these problems.

 

Suggested forms for Controlled Substance Prescribing:

Opioid (controlled substance) Risk Assessment Tool:

Use this scoring tool to assess for prescribing risk before and after the first prescription visit. There are several similar tools used elsewhere you might use instead, but it would be useful for our medical community to settle on one like this one for consistency in our medical records.

Mark each box that applies to your patient

Family history of substance abuse:                Female:            Male:

Alcohol                                                                          1                     3

Illegal drugs                                                                   2                   3

Prescription drugs                                                          4                   4

 

Personal history of substance abuse:

Alcohol                                                                           3                   3

Illegal drugs                                                                    4                   4

Prescription drugs                                                           5                   5

Age between 16-45 years:                                              1                   1

History of pre-adolescent sexual abuse:                         3                   0

 

Psychological disease:

ADD, OCD, bipolar, schizophrenia                                2                   2

Depression                                                                     1                   1

Scoring (or risk number): 0-3 = low risk         _________________________

4-7 = moderate risk

>8 = high risk

Suggested forms for Controlled Substance Prescribing:

Medication (opoid) Treatment Agreement:

To be added later:

Unused medication drop-off sites for St. Cloud area:

Stearns and Benton County Permanent unused drug drop-off sites

Law enforcement office locations

Stearns County:

1) Stearns County Law Enforcement Center

http://www.co.stearns.mn.us/LawPublicSafety/SheriffServices/PublicSafety/MedicationDropBox

807 Courthouse Square, St. Cloud, MN 56303 Monday – Friday, 8:00AM – 4:30PM, Call 320-259-3700

2) Waite Park Police Department

http://www.ci.waitepark.mn.us/index.asp?Type=B_BASIC&SEC=%7B3FBCF595-36DE-494A-8262-D6CD7E9D7160%7D

19 13th Ave N, Waite Park MN 56387 Monday – Friday, 7:30AM – 4:30PM, Call 320-251-3281

3) Sartell Police Department

http://www.sartellmn.com/police-department

310 2nd St S, Sartell, MN 56377 Monday – Friday, 7:30AM – 6:00PM, Call 320-251-8186

4) Melrose Police Department

http://www.cityofmelrose.com/index.asp?SEC=25D69E90-1EBF-4209-9157-38FC8A55B03D&Type=B_BASIC

225 1st Street NE, Melrose, MN 56352 Monday – Friday, 8:00AM – 4:30PM, Call 320-256-7211

Unused medication drop-off sites for St. Cloud area, continued:

 

5) Paynesville Police Department

http://www.paynesvillemn.com/

221 Washburne Avenue, Paynesville, MN 56362 Monday – Friday, 8:30AM – 4:30PM, Call 320-243-3714

Benton County:

1) Foley, Minnesota.  The Benton County Sheriff’s office

http://www.co.benton.mn.us/County_Sheriff/Drug_Disposal.php

The Benton County Sheriff’s Office has a medication disposal site located in their main lobby at 581 Highway 23, Foley, MN 56329.

8:00 AM – 4:30 PM, Monday-Friday. Call at 320-968-5000

2) The Sauk Rapids Police Department.

http://www.ci.sauk-rapids.mn.us/index.asp?Type=B_BASIC&SEC={EC1F1FCD-29CC-46D8-B1AC-19CFD4D4CB7F}

The Sauk Rapids Police Department is located at the Sauk Rapids Government Center (250 Summit Ave. N, Sauk Rapids,  MN 56379)

8:00 AM – 4:30 PM, Monday – Friday. Call 320-251-9451

Pain Management Resources, Central Minnesota:

CDI Pain Care: http://www.mycdi.com/central_minnesota/sartell/cdi_pain_care/?gclid=CNH1o8-XqMQCFQ8waQod71EAZA

166 19th St. South, Suite #100, Sartell, MN 56377, 320-251-0609

We have expanded our pain management program to include a comprehensive service offering through a new program: CDI Pain CareThomas Cohn, M.D., a physiatrist with more than 20 years’ experience, joins our physician practice to lead the CDI Pain Care team. Dr. Cohn and his Pain Care specialists will work with your provider to help you coordinate care and provide conservative pain services, including CDI’s experienced team of injection and imaging specialists. Thomas G. Cohn, M.D. is a board certified physiatrist at Center for Diagnostic Imaging (CDI) in the St. Cloud area. Dr. Cohn created the Minnesota Physical Medicine Blog to educate people on their options for pain management. Location

166 19th Street South Suite #100 Sartell, MN 56377

Scheduling: 320-251-0609 Fax: 320-251-3806 Contact Us

Hours

Mon-Fri 6:30am-10pm, Sat 7am-3pm (MR only)

Location

166 19th Street South Suite #100 Sartell, MN 56377

Scheduling: 320-251-0609 Fax: 320-251-3806 Contact Us

Hours

Mon-Fri 6:30am-10pm, Sat 7am-3pm (MR only)

Location

166 19th Street South Suite #100 Sartell, MN 56377

 

Center For Pain Management: http://www.centerforpainmanagement.org/

166 19th Street South, Suite # 101,Sartell, MN 56377, 320-230-7788

519 22nd Avenue East, Alexandria, MN 56308, 320-219-7611

15620 Edgewood Drive, Suite 200, Baxter MN 56425, 218-270-3111

Satellite offices: St. Cloud:

St. Cloud Hospital, 1406 6th Avenue North, St. Cloud MN 56303, 320-230-7788 CentraCare Plaza, 1900 CentraCare Circle, St. Cloud MN 56303, 320-230-7788

We have locations in Sartell, a fast growing suburb just north of Saint Cloud, and also in Baxter, Alexandria, and soon in Bemidji. All of our pain physicians are specialized in Interventional Pain Management. Our Goal is to put you in control of your pain and give you back control of your life! Our mission is to provide top quality, compassionate interventional management for people in pain. To accomplish this mission, our goals include assisting patients in their efforts to minimize pain and suffering while improving their quality of life, increase function and gain control over their lives again. Physicians: Dr. Sam Elghor, Dr. Ramon Sotto, Dr. Ranjun Dey and Dr. Jeff Anderson.

Pain Management Resources, Central Minnesota, Continued:

IPPMC Interventional Pain & Physical Medicine Clinic:

http://www.ippmc.com/home.php

2301 Connecticut Avenue South, Sartell, MN 56377, 320.229.1500

Thomas Kowalkowski, Fellow of ABPM&R, DO,FIPP Medical Director

Mission, Values & Goals: At Interventional Pain and Physical Medicine Clinic our mission is to improve quality of life by reducing pain and suffering in order to maximize function. Our physicians are dedicated to the practice of interventional pain medicine. We are dedicated to offering the highest standard of care based on patient outcomes. Our medical practice strives to establish an individual approach, which is based on teamwork and a multidisciplinary model of care. IPPMC has a personable friendly staff with strong family and community ties whose primary goal is to help their patients.

David Bradley, DO Physiatry, St. Cloud Medical Group, North Campus

251 County Road #120, St. Cloud, MN 56303, (320) 202-8949

Our Physical Medicine and Rehabilitation department at St. Cloud Medical Group specializes in interventional spine procedures, pain management, electrodiagnostic studies, and musculoskeletal disorders. Our goal is to provide quality care to patients age 15 and older who have acute, subacute, and chronic pain problems. We provide the proper work-up and treatment of patients with neck and back pain. The treatments include use of medications, physical therapy, manipulation, and fluoroscopic-guided injections.

Dr. Carol J Showalter MD

http://www.vitals.com/doctors/Dr_Carol_Showalter/credentials#ixzz3UNSOkjjM

Dr. Showalter is affiliated with 2 hospitals. Hospital Affiliations:

Abbott – Northwestern Hospital Inc 800 E 28th St, Minneapolis, MN 55407

Saint Cloud Veterans Affairs Medical Center 4801 Veterans Dr, Saint Cloud, MN 56303

 

Pain Management Resources, Central Minnesota, Continued:

Dr. Steven R Sabers MD Physiatrist (physical, rehabilitation), Pain Management Specialist

1900 Centracare Cir, Suite 1325, Saint Cloud, MN 56303, 952-814-6600

http://www.vitals.com/doctors/Dr_Steven_Sabers/office-locations#ixzz3UNUDFboO Hospital Affiliations:

Fairview Southdale Hospital 6401 France Ave S, Minneapolis, MN 55435

Abbott – Northwestern Hospital Inc 800 E 28th St, Minneapolis, MN 55407

United Hospital

Sister Kenny Rehabilitation Institute 800 E 28th St, Minneapolis, MN 55407

Scott Andrews MD Anesthesiologist (pain control), Pain Management Specialist 29 years of experience

4801 Veterans Dr, Saint Cloud, MN 56303, 320-252-1670 http://www.vitals.com/doctors/Dr_Scott_Andrews_2.html#ixzz3UNWHh7fp

 

Addiction Medicine Resources:

Stephen S. Swenson, MD Addiction Medicine, CentraCare Health

St Cloud Hospital Recovery Plus, Addiction Treatment Center,

Address: 713 Anderson Avenue, Saint Cloud, MN 56303

Phone:(320) 229-3760

 

Addiction Medicine Resources, Continued:

St. Cloud Metro Treatment Center

524 25th Ave. North, St. Cloud, MN 56303, Phone: (320) 202-1909 Fax: (320) 202-1910

Colonial Management Group, LP (CMG) is a unique organization of sixty-four (64) private outpatient substance abuse treatment clinics that have been successfully treating opiate dependence since 1986. CMG operates as outpatient clinics specifically designed for persons addicted to the opioid class of drugs, including prescription pain medications and heroin. Patients are enrolled into a comprehensive program, which includes individual and group counseling to address psychological and social needs in addition to their chemical dependence.

For more information, please contact Jesse Rueckert, Program Director stcloudmetro@cmglp.com
Psychiatry Resources:

Dr. Jon C Bowar MD

Adult Mental Health Services, 1900 Centracare Cir, Saint Cloud, MN 56303, 320-229-4908 Dr. Terri T Gerdes MD

Adult Mental Health Services, 1900 Centracare Cir, Saint Cloud, MN 56303, 320-229-4977 Roger P Handrich MD

Central Minnesota Mental Health, 1321 13th St N, Saint Cloud, MN 56303, 320-252-5010 Dr. Matthew C Mcclure DO

Recovery Plus, 713 Anderson Avenue, St. Cloud, MN 56303, (320) 203-8701 Dr. Chris K Moellentine MD

St. Cloud Hospital, 1900 Centracare Cir, Saint Cloud, MN 56303, 320-229-4977 Dr. Timothy R Rasmussen MD Psychiatrist

110 2nd St S, Ste 301, Waite Park, MN 56387, (320) 252-2976
Psychiatry Resources, Continued:

Dr. John M Schmitz MD

1900 Centracare Cir, Saint Cloud, MN 56303, 320-229-4977

Dr. Joel P Spalding MD

1900 Centracare Cir, Saint Cloud, MN 56303, (320) 229-4945 Dr. Stephen S Swenson MD Psychiatrist, Addiction Medicine Specialist

713 Anderson Ave, Saint Cloud, MN 56303, (320) 229-3760

Physiatry Resources:

Mr. Thomas Jeffrey Balfanz MD

Physicians Neck & Back Clinic, 158 19th Street South, Sartell, MN, 56377, (320) 253-5385

Dr. David D Bradley DO

251 County Rd 120, Saint Cloud, MN 56303, (320) 202-8949, 320-529-4741 Kelly Sauer Collins MD

1406 6th Avenue N, Saint Cloud, MN

Mr. Jeffrey James Derr MD

1406 6th Avenue N, Saint Cloud, MN

Thomas Christopher Kowalkowski DO

2301 Connecticut Avenue South, Sartell, MN 56377, (320) 229-1500

Dr. Steven R Sabers MD

1900 Centracare Cir, Suite 1325, Saint Cloud, MN 56303, 952-814-6600

Ramon Paulino Sotto MD

Center for Pain Management, 166 19th Street S; Suite 101, Sartell, MN 56377, 320-230-7788

Physiatry Resources, continued:

Dr. Mark J Thibault MD

Physicians Neck & Back Clinic, 158 19th St S, Sartell, MN 56377, (320) 253-5385 Physical Therapy Resources:

Advantage Chiropractic, 32 32nd Ave S, Saint Cloud, MN 56301, (320) 310-4929, http://www.advantagechiro.net/

CentraCare Health Rehabilitation Serviced, 1900 CentraCare Circle, St. Cloud, MN 56303, (320) 229-4922, http://www.centracare.com/services/rehabilitation-services/physical-therapy/

Hjort Chiropractic, 3700 W Division St Suite 101, Saint Cloud, MN 56301, (320) 251-3450, http://www.hjortchiropractic.com/

Kinesis Physical Therapy, Inc., 1521 Northway Drive Suite 116, Saint Cloud, MN 56303-1274, (320)654-9838, http://www.kinesisphysicaltherapy.com/

Northern Star Therapy, 251 Cty Rd 120 Ste A, St. Cloud, MN 56303, (320) 259-5429, http://www.northernstartherapy.com/

Northern Star Therapy, South Location, 1301 33rd St S, Suite 210, St. Cloud, MN 56301 (320) 240-6955

NovaCare Rehabilitation, 2251 CONNECTICUT AVENUE SOUTH, SARTELL, MN 56377 (320) 529-0036

NovaCare Rehabilitation, 402 RED RIVER AVENUE NORTH, COLD SPRING, MN 56320, (320) 685-7269

NovaCare Rehabilitation, 600 COUNTY ROAD 75, CLEARWATER, MN 55320,

(320) 558-6661

St Cloud Orthopedics, 1901 Connecticut Ave South, Sartell, MN 56377, 320-259-4100, http://www.stcloudorthopedics.com/

Spinal Rehab Clinic Inc., 225 North Benton Dr. Suite 105, Sauk Rapids, MN 56379,          (320)-252-2225, http://spinalrehabclinic.com/

SPOT Rehabilitation & Home Health Care, 2835 W Saint Germain St Ste 300, Saint Cloud, MN 56301, (320) 259-4151, http://spot-rehab.com/

Physical Therapy Resources, Continued:

Woodlands Chiropractic, 1521 Northway Dr. Suite 111, St Cloud, MN 56303, (320) 240-0300, http://woodlandschiro.com/

Counseling Resources:                       

Center for Psychological Services, 600 South 25th Ave. Suite 109, St. Cloud, MN 56301, (320) 255-0343, http://www.scpsychologicalservices.com/home

Chandler Counseling & Consulting, 1204 7th Street South , Lake View Business Center, Saint Cloud, Minnesota 56301, (320) 358-6455,  http://stcloudcounselingtherapy.com/

Milestone Counseling Inc., 630 Roosevelt Road, Suite #104, Saint Cloud, Minnesota 56301, (320) 839-8744, Ms. Toni Murphy, Psychologist , MS , LP

New Day Counseling, PLLC, Linda C. Scherer, 720 8th Ave N , Saint Cloud, Minnesota 56303, (320) 434-2094, Clinical Social Work/Therapist , MSW , LICSW

St. Cloud Hospital Recovery Plus, 713 Anderson Avenue, St. Cloud, MN 56303,                (320) 229-3760,   http://www.centracare.com/locations/profile/?id=1

The Village Family Service Center, Stearns Financial Center, 4140 Thielman Lane, Suite 303, St. Cloud, MN 56301, (320) 253-5930

Processus – Counseling Center, 110 2nd Street South, Suite 301, Waite Park, MN 56387, 320-252-2976 http://processus-counseling.com/home/2788065

 

ProFound Therapy, 720 8th Ave N. St. Cloud, MN 56303 Fax: (320)251-0217, 320-266-1693 Nicole Otis, M.A., LMFT

Solutions Behavioral Healthcare, 423 Great Oak Dr., Waite Park, MN 56387, (320) 281-5305, http://www.solutionsinpractice.org/

Hypnosis Resources:    

New Way Hypnosis Clinic:  110 South 2nd Str. Suite 208, Waite Park, MN  56387,            (320) 255-9680, http://www.hypnosisclinic.net/

ONE Holistic Wellness: 320.250.9402, Anne M. Brady C.T.C. ®, M.T., Reiki Master, Energetic Wellness Facilitator

St. Cloud Hospital Recovery Plus, 713 Anderson Avenue, St. Cloud, MN 56303, 320-229-3760 E. J. Calvert, MS,LPLICSW,  

http://www.centracare.com/providers/profile/?id=667#OfficeInformation                    

February 24th Meeting of CM Prescribing Coalition Packed With Policy Input

Tuesday, February 24, 2015 Meeting packs Atwood meeting room.  Plan to attend the next meeting of the Prescribing Coalition on Tues, March 24, 2015 at 6:00PM

The Central Minnesota Prescribing Coalition convened at Atwood Center, SCSU on this date to finalize recommendations for our Central Minnesota Controlled Substance Prescribing Policy, which will be posted here later today as tentative in preparation for our meeting next week, March 24th.  At that time, we expect some adjustments to be made as a result of that meeting and some expected popular feedback, but we will leave the Policy online as we make additions and enhancements.

Next week, on Tuesday, March 24, 2015, at 6:00 PM, in the Glacier Room at Atwood Center, SCSU the Prescribing Coalition will meet again to review the Policy and strategize on how to bring it to our medical community and introduce our work to the public.  We need to keep the momentum going with the great representation across medical and professional stakeholders in the controlled substance process.  We had to get extra chairs for last month’s meeting where we had good discussion of this issue and meeting the goals of the Coalition.  Please call Mandy to RSVP for the next March 24th meeting at 320-252-8550. And while you have your phone schedule out, think about attending our Spring Forum in late April (28th or 30th?), where we hope to have a program on related topics and formally present the Policy to the medical community.

Agenda for Central Minnnesota Prescribing Coalition, Tuesday, February 24, 2015

Proposed agenda for Tuesday’s meeting at the Glacier Room, Atwood Center, SCSU at 6:00 PM

Agenda

Central Minnesota Prescribing Coalition

Atwood Glacier South, SCSU, February 24, 2015

1) Welcome and introduce new participants, experts

2) Our vision of the ideal, effective community Controlled Substance Prescribing Policy

3) Discuss global issues of a medical community Controlled Substance Prescribing Policy

  • a) Where does it reside? How will we as a medical community use this?
  • b) How to make revisions and update as need arises?
  • c) A model for each clinical entity (group) to make their own policy?
  • d) How detailed and directive should it be?
  • e) How to reach all clinicians? How to reach the public with instructional message?
  • f) How does the Policy relate to our controlled substance prescribing course?
  • g) Legal issues

4) Discussion of the preliminary draft documents we have online and hard copy for review

5) Work on/discuss each section of the elements of an ideal policy. More sections likely will be needed and several may be combined. Each section needs input.

6) Assign each of the full section development work to volunteers

7) Plan next meeting in one month to discuss weighting, order and combining or splitting sections into a first draft

Please consider/edit or add to these Basic Principles of Controlled Substance Prescribing before our meeting February 24th, 2015

Please review these basic controlled substance prescribing principles and bring your suggestions for additions, editions, subtractions or improvements to the Glacier Room, Atwood Center, St. Cloud State University, February 24th, 2015 at 6:00 PM.

Basic Principles of Opioid and Controlled Substance Prescribing

Central Minnesota Prescribing Coalition – 2015

1) With no accepted evidenced-based studies to guide controlled substance prescribers, medical communities can best address the current national, state and local morbidity and mortality complications of opioid and other controlled substance prescribing by developing their own policy as a recommended best practice guide for clinical practices and individual clinicians.  Goals of the policy include care quality and clinical outcomes improvement, but also provision of common ground for enhanced clinical collaboration within the medical community as we struggle with the dilemma of wanting to relieve patient symptoms without creating additional problems and complications from our treatment.

2) Prescribers’ best opportunity to prevent acute care patient problems from becoming chronic, difficult problems associated with chronic controlled substance use is at the very first clinical encounter.  Acute pain from injury or surgery, anxiety or insomnia associated with adverse life events can become chronic problems associated with complications of the controlled substance prescriptions we first write at the initial visit.  Possible complications including addiction, intoxication, DUI, side effects, drug interactions, abuse, diversion, overdose and death must be considered and discussed with patients at the time of the first prescription.  Also, prescribers should make an assessment of medication risk for each patient before that first prescription.

3) Prescribers should not be pressured into controlled substance prescribing until completing a full and accurate assessment of the patient’s problem.  This might include receiving and reviewing any and all previous assessments and treatments for the same problem.  This would also include obtaining a full clinical history and appropriate physical exam, a medication use risk assessment, medication history, a search on the Minnesota Prescription Monitoring Program, contact with previous treating clinicians, and consideration of a medication treatment agreement as indicated.  These steps before prescribing controlled substances can be difficult and time consuming, but offer the best tools for management long term in the continuum of care for individual patients in our medical community.

4) Each practice entity (ER’s, Urgent Care Centers, medical offices) should have its own policy adapted from the medical community policy that guides its prescribing clinicians in their use of controlled substance prescriptions. Clinicians should expect to continuously improve their prescribing skills in this area with CME events or regular recertification courses.  Each practice could offer regular courses just like HIPPA, fraud and abuse, and employee safety courses.  A medical director or an oversight or quality committee could oversee controlled substance prescribing by their clinicians and serve as resource for challenging cases and to discover and correct prescribing within the practice that deviates from the policy recommendations.

5) Prescribers and their treatment team members should be encouraged to regularly utilize the Minnesota Prescription Monitoring Program and practices should monitor for proper and sufficient use within their clinic or treatment facility.

6) Prescribers should become and remain familiar with all community treatment resources for pain management, mental health services, pharmacies, pharmacists, therapeutic modalities, and other alternatives or adjuncts to controlled substance prescribing.  This would include building relationships with the providers of these services in order to facilitate quality and efficiency of patient management.

7) Policies governing controlled substance prescribing at clinics, ER’s, urgent care centers and other practice sites should include as appropriate for their practice as many as possible of  the elements of the medical community policy including:

  1. a) Full incorporation of controlled substance prescribing and management EMR templates for the medical record that are very similar to those of other clinics and treatment centers in the medical community.
  2. b) Acute care, first visit (for pain, mental health, insomnia) EMR templates that incorporate all the elements recommended in the community prescribing policy.
  3. c) Follow up visit templates that include all the recommended elements of the community prescribing policy in the EMR medical record
  4. d) A fully developed medication use agreement that covers risks including side effects vs. benefits of the medication being prescribed, clinic policy on random drug testing and pill counts, policy on refills and PMP use, and general behavior expectations including grounds for tapering off medication or discontinuing of services.
  5. e) A medication risk assessment tool preferably with a numerical score that can be updated in the patient record with each visit if indicated
  6. f) Listing of all community resources for pain management, mental health, and therapeutic modalities that clinicians can use as alternatives or adjuncts to controlled substance prescribing
  7. g) Contact information for recommended controlled substance certification courses and CME events to maintain and advance clinician skills and competence.
  8. h) Expectations of clinicians to follow the policy, maintain proficiency, use the MN PMP properly and regularly, use the tools for assessment and monitoring, and collaborate with other providers in the community who co-manage patients.
  9. i) Acknowledgement of the medical community policy as guidance and delineation of the role of a supervisory medical director or committee to monitor their clinicians’ prescribing.

Prepare for the Central Minnesota Prescribing Coalition meeting Tuesday, February 24, 2015 at 6:00 PM at Atwood Center, Glacier Room at St. Cloud State University

Please review this draft document that is preliminary to writing our medical community policy on controlled substance prescribing.  Please review this before our meeting February 24th and consider working to fill in your comments or suggestions for any or all of the 25 sections of information.  We felt that dividing the policy into sections would facilitate our work to finalize a written policy by allowing participants to work more on the sections that they are either most knowledgeable on or most interested in without getting lost in all the other sections.  Please call Pat Zook at 320-492-8207 if you have questions or would like to discuss our current status ahead of the February 24th meeting.

Sections of a Medical Community Policy For Controlled Substance Prescribing

Definitions:

Prescribers include physicians, advanced practice providers, nurses, pharmacists, social workers, counselors and any other professionals of any treatment team involved in the process of prescribing or dispensing of controlled substance medication.

Medical community includes all medical and associated professionals contributing to the practice of any form of healthcare in a geographic and functional area centered in St. Cloud and extending out as far as the living place of any of our patients who identify with and receive medical care from any of our clinicians.

Practice entity describes any prescribing site or group of clinicians practicing as a collective business such as a hospital, emergency room (ER), urgent care center, surgical care center, pain treatment center, pharmacy, clinic or similar group

Each of the following should be considered and covered by any policy that we develop for guidance on the prescribing of controlled substance medication in our community.  The necessary elements are divided into sections to allow for individual discussion and consideration while building the policy.  Their order and depth will need to be decided later.

1) Global medical community perspective.

How do all prescribing sites interact and cooperate to provide the best service with the best outcomes for patients of our medical community?

Each prescribing site will need to provide their own education and enforcement for policy adherence among their prescribers.

Practice entities (Prescribing sites) include Hospitals, hospitalist groups, emergency rooms, urgent care centers, surgical centers, oral surgery centers/groups, dental offices/groups, medical offices/groups, campus health services (colleges, technical colleges), volunteer medical service sites (i.e. Place of Hope), private and public school nurse practices, nursing homes, workplace clinics, jails and any other treatment centers

Goals of the Policy are described including:

  1. a) Providing the highest quality of compassionate care for medical conditions that at times call for the prescription of controlled substance medications.
  2. b) Improving and maintaining quality of life and function of patients with medical conditions that require the prescription of controlled substance medication.
  3. c) Achieving and maintaining the clinical proficiency of all controlled substance prescribers and their treatment team members who treat patients with these medical conditions
  4. d) Reducing the number of prescriptions for controlled substances to a most appropriate level
  5. e) Initiate and continue with ongoing prescriber and public education on best practice use of controlled substance medication including adjunctive and alternative treatments
  6. f) Build and maintain a medical community environment most conducive to consistency of practice and ongoing clinical outcomes improvement in a collaborative fashion that supports individual prescribers and their treatment sites/groups while also improving controlled substance prescribing in our community.
  7. g) Reduction of overdose instances, drug diversion, addiction, medication side effects, duplicative care, morbidity, mortality and patient and family suffering associated with prescribed controlled substances.
  8. h) Provide for current and ongoing standardized training and continuing education of all current and any future new controlled prescribers of controlled substance medication in our medical community

2) Hospital perspective:

Several issues and services unique to hospital medical care must be covered by our community policy. These include hospital surgery, hospitalist services, other inpatient care, community and population health issues, public health and epidemiologic data, provider education, provider certification and personal health, dealing with non-community patients, first line of health patient contact.  The hospitals offer the potential for medical community standardization of practice.  Hospitals are often called upon to provide service to patients with chronic pain or other chronic conditions that have been treated with controlled substance medications by different providers both from within and outside of our proximal community.

3) Emergency room perspective:

Emergency room medical care, though usually done within a hospital does present some unique issues for clinicians working there to deal with.  Without the benefit of long-standing doctor-patient relationships, ER clinicians are at a disadvantage communicating with patients especially regarding treatment decisions and disagreements over prescriptions.  Patient satisfaction scoring does not incent ER clinicians to discuss at length or negotiate for alternative medication or treatments for pain, mental health problems or insomnia problems.  Serious trauma and illness presentations at random times make for more stress on clinicians who are often pressed for time.  In this setting, assessing patients’ needs and risks for controlled substance prescriptions is usually very subjective by default and accessing the Prescription Monitoring Program takes additional valuable time. The frequent visitors demanding controlled substance prescriptions present a difficult problem especially when these patients have no available primary care records or available provider to contact.
4) Urgent Care perspective:

Similar to ER since urgent care clinicians also serve as a first line of health contact often with non-community based patients.  Patients they see may or may not have a primary provider in our medical community.  Urgent care centers have many of the same issues as an ER but without the larger number of supporting coworkers or law enforcement backup.  As in the ER, deciding which drugs in what quantity to prescribe presents a dilemma for prescribers working here.  Contact with patients’ primary care clinician is not always feasible.

4) Surgery Center perspective:

Independent surgeons and members of their team must choose which pain medication and quantity for each post-op patient.  Anesthesia must assess for prescribed or illicit drug affects pre-operatively and watch for complications that might occur with anesthetics.  The center medical director might have less than ideal control over the prescribing practices of each of the independent surgeons using their facility.

5) Pain treatment center perspective:

Pain clinics have many of the same concerns as surgery centers plus the added risk of many different types of treatment procedures.  Not all pain treatment centers are willing to monitor patients for controlled substance prescriptions and medication risk.  Primary care physicians often are left with the responsibility of controlled substance prescribing for their patients receiving care at these centers.  This presents opportunity for care discontinuity.  Medication treatment agreements copies should be on file at both the pain center and primary care center.

5) Clinics/group perspective:

This is usually where the patient’s primary care clinician works in a standard medical office setting.  Clinic offices might do many procedures like surgery centers do and therefore have many of the same concerns regarding pre and post-op care.  The primary care office is more often than not the place where the very first controlled substance prescription is written and therefore has the best opportunity to prevent acute medical treatment from becoming chronic problems complicated by controlled substance problems like addiction, diversion or non-medical use.

6) Oral surgery and dental office/group perspective:

Have similar issues as surgery centers and clinic practices.  An opportunity to educate patients so as to prevent acute care and post-op controlled substance use from becoming chronic use.

7) Student Health Centers perspective:

St. Cloud State University and St. Cloud Technical College, St. John’s and St. Bens, professional schools see many patients in the prime age group that struggles most with substance use disorders.  Problems with alcohol or marijuana use, stimulants and date rape drugs, and the possibility of pregnancy confound the usual problems of controlled substance prescribing.

8) Nursing homes perspective:

These practice entities are where controlled substance prescriptions are ordered by many different clinicians from multiple clinics.  Diversion supervision to prevent it can be more of a problem where staff turnover is high.  There is on-site opportunity to educate patients and family members on medication safety and diversion prevention.

9) Hospice and Home Care practice perspective:

Nurses are not allowed to dispose of unused controlled substance meds when prescriptions change or a patient dies.  Until the laws covering this are changed opportunities for diversion or environmental contamination abound.  Controlled substance doses can be much higher during end of life care. There is educational opportunity here to prevent diverson.

10) Other community medical care sites perspective:

County services, Place of Hope sites, Senior services sites often provide ad hoc services with less clinical continuity if staffed by volunteers.

11) Law enforcement and public safety perspective:

Includes City, County, State and Federal authorities, law enforcement and first responders who serve as first line caregivers where complications of controlled substance prescribing occur.

The local law enforcement centers are in charge of the permanent unused medication drop-off sites in our counties and enforce laws regarding controlled substance misuse and complications

12) Social Services perspective:

Professionals who deal with the social consequences of adverse outcomes associated with the complications of controlled substance prescriptions.

13) Schools and their health services at all levels from pre-school through college perspective:

Sites where there is opportunity for education about controlled substances.  Social and physical consequences of controlled substance misuse may show up here.  Students who trade, share or buy prescription medications from each other are more likely to misuse controlled substance medication in the future

14) Faith communities and ethnic group perspective:

Same concerns and opportunities as for schools, plus certain ethnic groups that seem to suffer disproportionately more adverse consequences of controlled substance misuse and prescription complications.

15) Description of the extent and prevalence of the problems of controlled substance prescription  use and abuse:

Local, State and national data on overprescribing of controlled substances and the resulting consequences

16) The controlled substance medications:

Description of the drug Schedules and various classes of controlled substance meds, physiologic effects, side effects, and interactions with other meds, alcohol, marijuana and illicit drugs.  Main drug classes include medications for pain, mental health disorders, insomnia and “other” for unique, less common diagnoses for which these meds might be indicated, such as using narcotics for severe restless leg syndrome when all else has failed. Discuss principles of short-acting vs. long acting drugs.  Discuss overdoses and antidotes for these (i.e. naloxone, flumazenil).

17) The policy should describe the medical community’s vision of the best outcome and daily usefulness of a community controlled substance prescribing policy. It should include a description of all of the benefits of having such a policy.  It should also include a description of how individual clinics and treatment centers can use the community policy as a guide in creating their own controlled substance policy as appropriate for their particular practice, but in such a manner that promotes consistency of practice throughout the medical community.

18) The policy should have a community directory of all of the available resource treatment services for either the direct treatment for medical conditions for which controlled substances might be prescribed, or for alternative modalities for managing these ailments.  It should list the clinicians available for these modalities, contact information as well as their qualifications and skills.

19) References to controlled substance prescripton training and CME resources.  The Medical Society will help sponsor development and updating of a controlled substance training course with both live and online versions for which appropriate CME hours will be available.  The Medical Society website will have references to other online or live CME courses around the country.  Some of these additional courses might be more useful for particular specialties such as anesthesiology or pain management specialists.

20) General principles of controlled substance prescribing including:

  1. a) That there are no evidence-based studies to corroborate specific guideline recommendations
  2. b) Cover the need for EMR support with templates for acute care vs. follow up care visits with incorporation of all of the appropriate tools to screen and monitor patients for using controlled substance prescriptions.
  3. c) Discuss the need for and acceptance of community and practice entity standards for controlled substance prescribing
  4. d) Discuss how practice entities can monitor their clinicians for controlled substance prescribing policy adherence.
  5. e) Recommend frequent appropriate use of the Minnesota Prescription Monitoring Program website
  6. f) Recommend appropriate referral when patient is high risk for complications as a result of using a medication risk assessment tool, or when a patient demands controlled substance prescriptions when not appropriate for the clinical problem at hand, or is not progressing clinically or if complications of treatment occur like clinical deterioration, serious side effects, addiction, diversion, non-prescription use, illicit drug use, or evidence of non-compliance with treatment agreements
  7. g) Encourage doing the right thing in spite of the current administrative use of patient satisfaction surveys that value expediency and pleasing patients over appropriate clinical judgment
  8. h) Suggest that all controlled substance prescribers stay current with continuing medical education and other resources to maintain proficiency in this aspect of medical care.
  9. i) Suggest that the spirit of legal and purposeful clinical collaboration be promoted for individual clinicians and practice entities within the medical community
  10. j) Set and monitor for progress toward treatment goals that stress a patient’s functionality level over symptom control
  11. k) Stress the need for informed consent and all the available prescribing tools. This implies discussion of material risk side effects.

l) Discussion of medical conditions that are not considered to be good indications for controlled substance use like fibromyalgia, pelvic pain, chronic headache, etc. Stress the need to be sure that the first prescription for a controlled substance is made for a justified indication and that patients are screened for medication use risk before that first prescription

  1. m) Suggests discussing expected duration of need for a controlled substance medication at the very first and subsequent visits.
  2. n) Discusses the dangers of prescribing multiple classes of controlled substances to the same patient such as prescribing benzodiazepines and sleeping pills to patients on long-acting narcotics

21) Controlled substance prescribing tools should be incorporated into the EMR templates, and be recommended and discussed including:

  1. a) Checklists for initial and subsequent visit documentation for controlled substance prescribing incorporated into EMR
  2. b) Opioid (controlled substance) risk assessment tool to be applied at first and subsequent visits
  3. c) Medication Treatment Agreement to be signed after informed consent and due consideration by the patient at the appropriate time in the course of treatment for the problem at hand.
  4. d) Informed consent signed as part of the medication treatment or material risk notice
  5. e) Material risk notice signed by patient as standalone document or as part of medication treatment agreement
  6. f) Physical risk assessment tools to detect potentially serious problems with

Obstructive sleep apnea, COPD, or other conditions associated with hypercarbia or hypoxia

  • g) Random urine drug testing to determine medication compliance
  • h) Random pill counts to monitor for medication compliance
  • i) Minnesota Prescription Monitoring Program website to check for polypharmacy or doctor      shopping

22) Discussion on how to use and react to results of random drug testing

23) Recommendations for making referrals when needed

24) Discussion of a supervisory medical director’s role in oversight for adherence to the policy at each clinical entity

25) A directory of all of the permanent law enforcement sites for drop-off of unused medications for safe, environmentally friendly disposal.

AMA’s Online CME-accredited Courses for Controlled Substance Prescribing

Consider taking any or all of  the AMA’s CME-accredited courses on controlled substance prescribing.

You can go online to the AMA website to find and take these courses.  A small charge is required for CME accreditation for each of the 12 modules.  Over 14 hours of prescribed credit is available if you take all of the modules.  The modules are for pain management, but the same principles apply to prescribing for any controlled substance.  See the page below taken from the AMA website.

Pain Management CME series

The American Medical Association (AMA) developed a Pain Management Continuing Medical Education (CME) resource in 2003, revised in 2007 and again in 2010. To date, approximately 155,000 CME certificates have been issued for the online version of this program, and 65,000 for the print version, with an additional 26,000 certificates issued to non-physicians, primarily physician assistants.

The 2013 revision of the online training, totaling 14.5 AMA PRA Category 1 Credits™, is now available.  The course materials acknowledge the growing controversy surrounding the appropriate prescribing of opioids for patients with chronic noncancer pain. Each year more than 16,000 Americans die from overdoses in which opioids are implicated, and the medicines are involved in about 400,000 emergency department visits annually, according to federal government estimates.

Access to the course materials is free. Physicians can complete the modules that address the specific needs of their practices and patients. Those who are interested in obtaining CME credit must register, and a $6.00 fee will be charged per module.

The 2013 revision of this series was made possible by the Prescribers’ Clinical Support System for Opioid Therapies (PCSS-O), a three-year grant funded by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment.

The PCSS-O is a collaborative project led by the American Academy of Addiction Psychiatry with the AMA, the American Dental Association, the American Osteopathic Academy of Addiction Medicine, the American Psychiatric Association, the American Society for Pain Management Nursing, and the International Nurses Society on Addictions. These organizations are providing training and education on safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction.