Changing the Tide. An EMR facilitated process supporting safe and effective prescribing and de-prescribing of controlled drugs

Transcription

1 Changing the Tide An EMR facilitated process supporting safe and effective prescribing and de-prescribing of controlled drugs Ken Hahlweg MD, CCFP, FCFP Assistant Professor Department of Family Medicine

2 Conflicts of Interest I d rather be gardening! Otherwise, no conflict of interest to declare

3 Objectives Discuss the challenges inherent in prescribing and de-prescribing controlled drugs Identify system gaps that perpetuate prescribing angst and misadventure Present an EMR facilitated clinic process that is both patient-centred and prescriber friendly

4 The Encounter Fraught with Dilemmas Is there a clinical indication or not? Is there patient benefit or harm? Am I being fair or am I biased? Do I take a hard line and if I do, will the patient come back? Is the patient being honest or is there a hidden agenda? Am I supporting or undermining my colleague s practice? How can I achieve common ground and maintain my integrity as a care provider? Am I doing the right thing?

5 Shared decision making Patient s ideas Common Ground Physician s ideas

6 Patient Ideas Shared Relieves pain Relieves anxiety Manages sleep Improves quality of life Improves functioning Impairs memory Impairs sleep Impairs sexual functioning Constipation Withdrawal symptoms Fear of dependency or addiction Tolerance

7 Patient Ideas Not Shared Source of income Means to obtain drug of choice Method of coping

8 Prescriber Ideas Shared Indication Appropriateness Effectiveness Harms vs Benefits Therapeutic relationship built on trust Prescriber responsibilities Patient responsibilities

9 Prescriber Ideas Not Shared Is the patient being honest Substance misuse and abuse suspicion Suspicion of diversion and community harm Is the patient s interpretation of benefit coloured by drug dependence Is the patient splitting and/or manipulating

10 Shared decision making Patient s ideas Appropriate Safe Effective Physician s ideas

11 System supports for prescribing controlled drugs 2017 Guidelines (NOUGG- National Opiate Use Guideline Group) Opiate Risk Assessment tool Continuing Medical Education Manitoba Prescribing Practices Program (M3P) E-chart Opiate contract templates and management tools Ashton Manual (benzo.org.uk) Comprehensive urine drug testing

12 System gaps for prescribing controlled drugs Patients who are chronic users of opiates, benzos and other controlled substances are seen as undesirable patients and have difficulty finding a primary care provider that will accept them Tools to support safe and effective prescribing of controlled substances generally directed at the individual prescriber Few system supports exist for practice groups prescribing to defined practice population Frustration exists when patients transition between care providers both within and without practice groups

13 Northern Connection Medical Centre Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Patient s ideas Opiate/Benzo Plan Physician s ideas

14 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Definitions: This policy is a voluntary binding agreement between the physicians of NCMC. Acute is defined as less than two weeks and as a distinct occasion Chronic is defined as anything other than acute A Plan refers to a chronic opiate and benzodiazepine prescribing plan made by the patient s primary (most responsible) clinic physician. A prescribing contract refers to an agreement by the patient to limit his/her behaviour(s) in specific ways.

15 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Accepted indications for prescribing: Harm reduction for dependent users Tapering down/off for therapeutic purposes (either no or a soft indication for prescribing, dependency, tolerance, cognitive side effects, risk for falling etc.) Therapy for chronic pain and/or mental health diagnoses in selected patients.

16 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 1. All patients being prescribed more than two weeks worth of any opioid or benzodiazepine in one year should have a Plan documented by their prescribing primary care provider. 2. The existence of a Plan should be documented in free text with the words opiate plan or benzo plan under the indication diagnosis in the Problem List (History of Problems). If more than one indication exists, the existence of the plan should be documented for both diagnoses eg chronic pain syndrome AND opiate dependence.

17 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 3. The Plan itself should be documented in the Encounter Notes, labeled as opiate plan or benzo plan, and the note should be linked to the primary indication diagnosis in the Problem List. 4. When the Plan is updated or superseded by a new Plan this should be documented in a new note in the Encounter Notes. This updated Plan should also be labeled as opiate plan or benzo plan, and the note should be linked to the primary indication diagnosis in the Problem List. The most recent Plan can be found by selecting the indication diagnosis from the Problem List and identifying the most recent version.

18 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 5. Only the primary (most responsible) physician should initiate chronic prescribing. Any other prescriber should limit their prescription to less than two weeks and require follow-up with the primary physician rather than extending use beyond two weeks. 6. The primary physician is responsible to review the Plan and update documentation at least yearly.

19 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 7. The Plan should at a minimum communicate the following: a. Whether the Plan is: a mandatory taper (hard taper) a taper as tolerated by the patient (soft taper) a maintenance plan at the same dose a plan for titration to clinical effect (including the option of increasing the dose) or a plan for no prescribing except for acute use under exceptional circumstances. b. The timeframe for the plan should be documented if it is other than one year.

20 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 8. Optional elements of the Plan include: Medication prescription intervals (before a new visit is required) Medication dispensing intervals Regular urine drug screens and frequency thereof A prescribing contract

21 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 9. If other care providers note that any of the expectations of this policy are not being met they are to send a task to the primary physician alerting them to this fact and requesting that this be addressed 10. No physician is required to prescribe a medication that they feel is unsafe for the patient or the community under any circumstances

22 NCMC Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Expectations of Care Providers: 11. If other caregivers have concerns about the Plan potentially harming the patient or others they are to communicate their concerns to the primary physician 12. Other caregivers are expected to support the Plan as long as they feel it is safe. This may include prescribing within the limits of the Plan, or making an interim Plan until the Plan can be reassessed by the primary physician

23 Applying the NCMC Policy on Chronic Opiate and Benzodiazepine Prescribing Task your colleague if: No plan Concerns about plan appropriateness Lack of clarity to plan Plan out of date

24 Applying the NCMC Policy on Chronic Opiate and Benzodiazepine Prescribing The patient without a plan Options for colleagues: Make an interim plan Refuse to prescribe at all Prescribe for a short period bridging the patient to a visit with their primary health care provider

25 Northern Connection Medical Centre Consensus Policy on Chronic Opiate and Benzodiazepine Prescribing Patient s ideas Opiate/Benzo Plan Physician s ideas

26 Objectives Discuss the challenges inherent in prescribing and de-prescribing controlled drugs Identify system gaps that perpetuate prescribing angst and misadventure Present an EMR facilitated clinic process that is both patient-centred and prescriber friendly

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