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
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:
- a) Providing the highest quality of compassionate care for medical conditions that at times call for the prescription of controlled substance medications.
- b) Improving and maintaining quality of life and function of patients with medical conditions that require the prescription of controlled substance medication.
- c) Achieving and maintaining the clinical proficiency of all controlled substance prescribers and their treatment team members who treat patients with these medical conditions
- d) Reducing the number of prescriptions for controlled substances to a most appropriate level
- e) Initiate and continue with ongoing prescriber and public education on best practice use of controlled substance medication including adjunctive and alternative treatments
- 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.
- 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.
- 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:
- a) That there are no evidence-based studies to corroborate specific guideline recommendations
- 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.
- c) Discuss the need for and acceptance of community and practice entity standards for controlled substance prescribing
- d) Discuss how practice entities can monitor their clinicians for controlled substance prescribing policy adherence.
- e) Recommend frequent appropriate use of the Minnesota Prescription Monitoring Program website
- 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
- 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
- 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.
- i) Suggest that the spirit of legal and purposeful clinical collaboration be promoted for individual clinicians and practice entities within the medical community
- j) Set and monitor for progress toward treatment goals that stress a patient’s functionality level over symptom control
- 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
- m) Suggests discussing expected duration of need for a controlled substance medication at the very first and subsequent visits.
- 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:
- a) Checklists for initial and subsequent visit documentation for controlled substance prescribing incorporated into EMR
- b) Opioid (controlled substance) risk assessment tool to be applied at first and subsequent visits
- 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.
- d) Informed consent signed as part of the medication treatment or material risk notice
- e) Material risk notice signed by patient as standalone document or as part of medication treatment agreement
- 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.