Prescribing Safely to Prevent Misuse & Diversion

Transcription

1 Patient-Prvider Agreement fr Onging Use f Cntrlled Medicatin BIRTHDATE: NAME: The use f the fllwing medicine(s) (list medicine names) Is nly ne part f my treatment fr. Primary Prescribing Dctr: What shuld I knw abut this medicatin? This cntrlled medicatin may help me. Opiid pain medicatins ften have side effects, which may include but are nt limited t: Itching Rash Severe cnstipatin Truble urinating r passing stl Depressin getting wrse Prblems thinking clearly Anxiety & Sleep medicine(s) can cause: Dizziness Memry prblems Cmbining drugs can cause: Overdse Truble breathing Death Stimulant medicines (such as fr ADHD) can cause: High bld pressure Fast r irregular heart beats I culd becme addicted t this medicine. If I must stp this medicine fr any reasn, I need t stp it slwly. Stpping it slwly will help me avid feeling sick frm withdrawal symptms. If I decide t stp my medicatin, I will cntact my dctr. If I r anyne in my family has ever had drug r alchl prblems, I have a higher chance f getting addicted t this medicine. If I take this medicine and drink alchl r use illegal drugs I: May nt be able t think clearly Culd risk hurting myself (such as a car crash) Culd becme ill r even die My dctr can nly prescribe this medicine if I d nt use illegal drugs. If I d nt use this medicatin exactly as prescribed, I risk hurting myself and thers. I will nt increase my medicine dse withut being tld t d s by my dctr. This medicine will nt be refilled early. I am in charge f my medicine. I knw my medicine will nt be replaced if it is stlen r lst. I will nt share r give this medicine t ther peple. What can I d t help? Bring my pill bttles with any pills that are left t each clinic visit. When asked, I will give a urine and/r bld sample t help mnitr my treatment. G t appintments and tests set up by my dctr. These may include physical therapy, x-rays, labs, mental health, etc. If I miss my appintments, it may nt be safe fr me t stay n this medicine. If I miss appintments, my dctr may want an ffice visit befre giving refills. Be n time fr appintments. If I arrive late t an appintment fr prescriptin refills, my appintment may be rescheduled. I may nt be given my prescriptin until I am seen by my dctr. Give my dctr permissin t talk t my pharmacy. My dctr will check my prescriptin fill histry by State Pharmacy registries and may call my pharmacy. If my dctr decides that the risks utweigh the benefits f this medicine, my medicine will be stpped in a safe manner. Hw can I get my prescriptins? I can nly get this prescriptin frm my primary prescribing dctr s ffice. I cannt get this medicine frm ther prviders (including the Emergency Department), withut checking with my primary prescribing dctr. Cntrlled-substance prescriptins are mnitred. These prescriptins ften need a paper-prescriptin signed by my dctr that cannt be mailed, faxed, r called t pharmacy. This type f prescriptin takes 24 hurs befre it will be ready fr pick-up frm clinic. I will nly use ne pharmacy t fill these prescriptins. The name f my pharmacy is:. My pharmacy s phne number is:. I will tell my dctr if I change pharmacies. Refills will be given nly during nrmal ffice hurs. Clinic plicy prevents n-call dctrs frm giving cntrlled-substance prescriptins. N refills will be given when the ffice is clsed. I knw that unless my dctr tells me therwise, I need a scheduled appintment t get prescriptin refills. If my dctr decides it is safe fr me t get a refill withut an appintment, nly I r smene I chse (insert name) can pick up a prescriptin frm the clinic. This persn may be asked t shw ID. What are reasns fr ending the agreement? I may nt be able t btain cntrlled prescriptins frm the University f Michigan Health System if I d nt fllw this agreement. I may nt be able t be seen in this r any University f Michigan clinic if I am disruptive r threatening twards staff, r if I engage in illegal activities with prescriptins. I knw that by State f Michigan law, nn-medical use f cntrlled substances (lying t get medicatins, r giving r selling these medicines t thers) is a crime. Patient Signature: Date: Physician Signature: Date: Prescribing Safely t Prevent Misuse & Diversin Patient/Physician Agreement

2 Opiid Risk Tl Opiid Risk Tl Item Family histry f substance abuse: Mark Each Bx That Applies Item Scre if: Female Male Alchl Illegal drugs Prescriptin drugs Persnal histry f substance abuse: Alchl Illegal drugs Prescriptin drugs Age (mark bx if years ld) 1 1 Histry f preadlescent sexual abuse 3 0 Psychlgical disease: Attentin deficit disrder, bsessivecmpulsive disrder, biplar, schizphrenia 2 2 Depressin 1 1 Ttal scre Ttal scre risk categry Lw risk: 0 3 Mderate risk: 4 7 High risk: 8 Fr further infrmatin see Webster LR, Webster RM. Predicting aberrant behavirs in piidtreated patients: Preliminary validatin f the Opiid Risk Tl. Pain Medicine, 2006; 6(6): Prescribing Safely t Prevent Misuse & Diversin

3 Tls t Assess Pain Disability Assessment Tls Pain disability is frequently the primary utcme measure when evaluating the efficacy f pain interventins. A general assessment f pain disability can cnsist f ne questin: On a scale f 0 10, hw much des yur pain prevent yu frm ding what yu want t d?, (0 = n interference t 10 = cmplete interference, I can t d anything ). Fr selected patients a mre detailed assessment f specific aspects f functining may be useful t assess disability and t evaluate changes ver time. Tw cmmnly used self-reprt measures are: Pain Disability Index (PDI): asks patients t rate their level f disability n a 10 pint scale fr 7 areas f life functin. Oswestry Lw Back Pain Scale: asks patients t rate disability n a 5 pint scale fr 10 functins (available at Lw%20Back20Pain%20Scale.pdf).Cpies f these tw instruments are attached. Prescribing Safely t Prevent Misuse & Diversin

4 Pain Disability Index (PDI) Assessment Tls The rating scales belw are designed t measure the degree t which aspects f yur life are disrupted by chrnic pain. In ther wrds, we wuld like t knw hw much yur pain is preventing yu frm ding what yu wuld nrmally d r frm ding it as well as yu nrmally wuld. Respnd t each categry by indicating the verall impact f pain in yur life, nt just when the pain is at its wrst. Fr each f the 7 categries f life activity listed, please circle the number n the scale that describes the level f disability yu typically experience. A scre f 0 means n disability at all, and a scre f 10 signifies that all f the activities in which yu wuld nrmally be invlved have been ttally disrupted r prevented by yur pain. Family/hme respnsibilities: This categry refers t activities f the hme r family. It includes chres r duties perfrmed arund the huse (e.g., yard wrk) and errands r favrs fr ther family members (eg, driving the children t schl). N Disability Wrst Disability Recreatin: This categry includes hbbies, sprts, and ther similar leisure time activities. N Disability Wrst Disability Scial activity: This categry refers t activities that invlve participatin with friends and acquaintances ther than family members. It includes parties, theater, cncerts, dining ut, and ther scial functins. N Disability Wrst Disability Occupatin: This categry refers t activities that are a part f r directly related t ne s jb. This includes nnpaying jbs as well, such as that f a husewife r vlunteer wrker. N Disability Wrst Disability Sexual behavir: This categry refers t the frequency and quality f ne s sex life. N Disability Wrst Disability Life-supprt activity: This categry refers t basic life-supprting behavirs such as eating, sleeping, and breathing. N Disability Wrst Disability Frm: Pllard CA. Preliminary validity study f the pain disability index. Percept Mt Skills. 1984;59(3):974. Prescribing Safely t Prevent Misuse & Diversin

5 Oswestry Lw Back Pain Scale Assessment Tls Please rate the severity f yur pain by circling a number belw: Instructins: Please circle the ONE NUMBER in each sectin which mst clsely describes yur prblem Sectin 1 Pain Intensity 0. The pain cmes and ges and is very mild. 1. The pain is mild and des nt vary much. 2. The pain cmes and ges and is mderate. 3. The pain is mderate and des nt vary much. 4. The pain cmes and ges and is severe. 5. The pain is severe and des nt vary much. Sectin 3 Lifting 0. I can lift heavy weights withut extra pain. 1. I can lift heavy weights but it gives extra pain. 2. Pain prevents me lifting heavy weights ff the flr. 3. Pain prevents me lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined. (e.g., n a table). 4. Pain prevents me lifting heavy weights but I can manage light t medium weights if they are cnveniently psitined. 5. I can nly lift very light weights at mst. Sectin 5 Sitting 0. I can sit in any chair as lng as I like. 1. I can sit nly in my favrite chair as lng as I like. 2. Pain prevents me frm sitting mre than 1 hur. 3. Pain prevents me frm sitting mre than ½ hur. 4. Pain prevents me frm sitting mre than 10 minutes. 5. I avid sitting because it increases pain immediately. Sectin 7 Sleeping 0. I get n pain in bed. 1. I get pain in bed but it des nt prevent me frm sleeping well. 2. Because f pain my nrmal nights sleep is reduced by less than ne-quarter. 3. Because f pain my nrmal nights sleep is reduced by less than ne-half. 4. Because f pain my nrmal nights sleep is reduced by less than three-quarters. 5. Pain prevents me frm sleeping at all. Sectin 9 Traveling 0. I get n pain when traveling. 1. I get sme pain when traveling but nne f my usual frms f travel make it any wrse. 2. I get extra pain while traveling but it des nt cmpel me t seek alternate frms f travel. 3. I get extra pain while traveling which cmpels t seek alternative frms f travel. 4. Pain restricts me t shrt necessary jurneys under ½ hur. 5. Pain restricts all frms f travel. Sectin 2 Persnal Care (Washing, Dressing, etc.) 0. I wuld nt have t change my way f washing r dressing in rder t avid pain. 1. I d nt nrmally change my way f washing r dressing even thugh it causes sme pain. 2. Washing and dressing increase the pain but I manage nt t change my way f ding it. 3. Washing and dressing increase the pain and I find it necessary t change my way f ding it. 4. Because f the pain I am unable t d sme washing and dressing withut help. 5. Because f the pain I am unable t d any washing and dressing withut help. Sectin 4 Walking 0. I have n pain n walking. 1. I have sme pain n walking but it des nt increase with distance. 2. I cannt walk mre than 1 mile withut increasing pain. 3. I cannt walk mre than ½ mile withut increasing pain. 4. I cannt walk mre than ¼ mile withut increasing pain. 5. I cannt walk at all withut increasing pain. Sectin 6 Standing 0. I can stand as lng as I want withut pain. 1. I have sme pain n standing but it desn t increase with time. 2. I cannt stand fr lnger than 1 hur withut increasing pain. 3. I cannt stand fr lnger than ½ hur withut increasing pain. 4. I cannt stand fr lnger than 10 minutes withut increasing pain. 5. I avid standing because it increases the pain immediately. Sectin 8 Scial Life 0. My scial life is nrmal and gives me n pain. 1. My scial life is nrmal but it increases the degree f pain. 2. Pain has n significant effect n my scial life apart frm limiting my mre energetic interests, e.g., dancing, etc. 3. Pain has restricted my scial life and I dn t g ut very ften. 4. Pain has restricted my scial life t my hme. 5. I have hardly any scial life because f the pain. Sectin 10 Changing Degree f Pain 0. My pain is rapidly getting better. 1. My pain fluctuates but is definitely getting better. 2. My pain seems t be getting better but imprvement is slw. 3. My pain is neither getting better r wrse. 4. My pain is gradually wrsening. 5. My pain is rapidly wrsening. Prescribing Safely t Prevent Misuse & Diversin

6 Example Clinical Plicy Clinic Plicy Regarding Patients n Lng-term Cntrlled Substances (piids, benzdiazepines and stimulants) New Patients with a Histry f Lng term Use f a Cntrlled Substance Befre a new patient with a histry f lng-term cntrlled substance prescriptin use receives the first prescriptin frm a clinic physician, ur clinic recrd must cntain: the medical recrds, urine cmprehensive drug scan, MAPS search results and, if lng term use is anticipated, a cmpleted cntrlled substance cntract. Plicies Regarding Patients Medical recrds. These new patients must prvide medical recrds dcumenting previus medical wrk-up regarding the cmplaint necessitating these prescriptins and ntes frm previus physicians that prescribed these medicatins. Obtain relevant medical recrds frm previus prviders. The patient is respnsible fr having this infrmatin sent. This clinic will prvide t the patient frms fr release f infrmatin alng with the fax number and mailing address f ur clinic. The previus physician s ffice shuld send the infrmatin directly t this clinic. This clinic will als prvide t the patient the clinic phne number t verify that the patient s medical recrds have been received and t make appintments. The Initial clinic nte shuld fllw the suggested frmat utline and must be cmplete fr elements f the Past, Family and Scial histries that culd put a patient at risk fr medicatin prblems. It shuld include a detailed prescriptin histry (last time/date cntrlled substance taken). Urine cmprehensive drug screen ( DRUG COMP ). DRUG COMP is cmbined immunassay screening and gas chrmatgraphy/mass spectrscpy that tgether detect specific synthetic piids alng with mrphine/cdeine, benzdiazepines and drugs f abuse such as amphetamines, THC, and ccaine It will als detect many cmmn prescriptin meds such as tramadl, cyclbenzaprine, and TCAs. (A SAMHSA Drug 5 r Drug 6 immunassay screen is inadequate due t difficulty f interpretatin and prblems with false psitives and negatives.) Order a DRUG COMP screen fr all new patients. T avid false negatives, infrm the lab in the test rder if a specific piid shuld be present (particularly methadne, fentanyl and buprenrphine). DRUG COMP specimen is cllected in the clinic. Patients shuld nt wear cats and ther uter clthing r take purses, bags, backpacks int the bathrm. The nurse r prvider shuld cnfirm prmptly that the specimen is apprpriately warm and shuld send it directly t the lab, nt give it t the patient t deliver. Check cnsistency between screen results and patient histry and that n illicit drugs are present. Michigan Autmated Prescriptin System (MAPS). Search the state s nline database f prescriptin fills cntrlled substances (MAPS: fr the patient s filling histry. Physicians shuld register at Cntrlled Substance Cntract/Infrmed Cnsent lng term use. At the visit when the first prescriptin is prvided fr a cntrlled substance, if lng term use is anticipated the prvider shuld initiate with the patient cmpletin f the clinic s cntrlled substance cntract/infrmed cnsent. The cmpleted cntract is scanned t the medical recrd, labeled Cntrlled Substance Cntract, and nted n the Prblem List in the PSL (Prblem Summary List). Prescribing Safely t Prevent Misuse & Diversin

7 Established Patients Using a Cntrlled Substance Use the attached Established Patient Visit Checklist (cpy als in the UMHS Chrnic Pain guideline). New patient criteria. All established patients must meet the abve criteria fr new patients. Lst prescriptins: N lst prescriptins will be replaced. Early refills. N early refills will be given. Pill cunts with urine screen. Ask the patient t bring existing pill bttles (with remaining pills, fr a pill cunt) and submit a urine cmprehensive drug screen (DRUG COMP) in the fllwing situatins: Twice yearly fr all chrnic nn-malignant pain patients receiving piids nce during January- June and anther July-December. Patient requesting early prescriptin fr example, ging n vacatin, emergency trip ut f state, had t change pharmacies. Patient behavir cncerning fr intxicatin by illicit drugs. Patient requesting refill n cntrlled substance we have never prescribed. Persn ther than patient requesting refill r picking up prescriptin. Patient cannt state directins as prescribed fr taking medicatin. Patient nt permitted t speak with physician alne (ther peple wn t leave examining rm). Patient s physical exam r histry cncerning fr misuse f cntrlled substance r illicit drug use. Clinic receives infrmatin frm a pharmacy r ther health care prvider cncerning fr patient btaining cntrlled substances frm multiple physicians. Prblem results f urine cmprehensive drug screen ( DRUG COMP ). (Nte: A Drug 6 immunassay screen is inadequate.) Diversin drug screen negative fr drugs prescribed. If diversin is suspected, prescribing cntrlled substances is illegal. N prescriptin will be prvided by any member ur practice. A repeat test must be cmpleted within 48 hrs. Multiple surces drug screen psitive fr cntrlled substances nt being prescribed by ur practice. The patient appears t be receiving piids frm multiple physicians. Members f ur practice will nt cntinue t prescribe cntrlled substances fr these patients. Illegal/illicit drugs psitive screen. Abslutely n cntrlled prescriptin will be prescribed. Cntrlled substances cannt be safely prescribed in patients taking illicit drugs, including cannabis. Disrderly behavir in clinic. Abusive behavir tward clinic staff, r disruptive behavir interfering with the care f ther patients will nt be tlerated. Call a yellw card fr any threatening behavir. The patient may be dismissed frm ur clinic permanently. Terminate cntrlled substance prescriptins. The fllwing patient behavirs will result in terminating these prescriptins. Nte terminatin f cntrlled substances in the CareWeb PSL. Fails t cmply with drug testing as requested, including secnd fllw-up test in timely manner Fails t cmply with medical evaluatin f pain cmplaint: diagnstic tests requested (e.g., radilgy tests, EMG, stress test) and referrals (e.g., neurlgy, neursurgery, physical r ccupatinal therapy, pain specialist/anesthesia, psychlgy r psychiatry). Des nt reprt treatment with piids/cntrlled substances by ther physicians Has drug testing results nt cnsistent with clinic physician s prescriptin plan: -Prescriptins patient reprts taking daily are nt detected n screen. -Patient tests psitive fr cntrlled substances nt prescribed by clinic. - Patient tests psitive fr illicit substances, particularly ccaine patients shuld be referred fr drug treatment. Misses mre than tw appintments (n shw) per year withut prper cancellatin Prescribing Safely t Prevent Misuse & Diversin

8 Plicies Regarding Patients Visit Checklist fr Established Patients n Lng-term Cntrlled Substances Determine level f adherence t bth pain and general medical management plans (medicatins, physical therapy, lifestyle interventins, etc.). Dcument prgress tward functinal gals and pain respnse. Evaluate fr adverse effects f medicatins (NSAIDs, adjuvants, piids) Assess fr red flag drug-taking behavir. Review written pain management agreement fr patients at risk. Check MAPS quarterly. Order a urine cmprehensive drug screen ( DRUG COMP ) n all patients twice per year nce during January-June and anther July-December, Review management plan: refine functinal gals, titrate effective medicatins, stp ineffective medicatins (including NSAIDs and piids), mdify nn-interventinal mdalities, review expectatins. Assure that a Treatment Agreement (Cntract) is scanned t the recrd, labeled Cntrlled Substance Cntract and nted n the PSL Prblem List. Evaluate fr apprpriate bundaries in therapeutic relatinship. Cnsider referral t Cmprehensive Pain Management Center fr evidence f addictin behavir, failure t reach functinal gals despite adherence t plan, rapidly escalating r very high dse piid needs, r pr psychlgical adjustment t symptms. Prescribing Safely t Prevent Misuse & Diversin