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:
- 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.
- b) Acute care, first visit (for pain, mental health, insomnia) EMR templates that incorporate all the elements recommended in the community prescribing policy.
- c) Follow up visit templates that include all the recommended elements of the community prescribing policy in the EMR medical record
- 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.
- e) A medication risk assessment tool preferably with a numerical score that can be updated in the patient record with each visit if indicated
- 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
- g) Contact information for recommended controlled substance certification courses and CME events to maintain and advance clinician skills and competence.
- 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.
- 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.