POLICIES AND PROCEDURES. Lead Department/Committee: (Refer also to GFHS Narcotic Treatment Protocols) Statement of Need

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1 POLICIES AND PROCEDURES Lead Department/Committee: Behavioral Health Title: Long Term Narcotic Treatment with Opiate Pain Meds, Stimulants, and/or Benzodiazepines Original Date: 08/01/2013 Last

1 1 POLICIES AND PROCEDURES Lead Department/Committee: Behavioral Health Title: Long Term Narcotic Treatment with Opiate Pain Meds, Stimulants, and/or Benzodiazepines Original Date: 08/01/2013 Last Revision Date: 1/1/2014 Approved by: A. Blanchett/S. Ocloo (Refer also to GFHS Narcotic Treatment Protocols) Statement of Need Behavioral Health will begin seeing patients annually for assessment when they are receiving long-term treatment with opiates, stimulants, and/or benzodiazepines. Long term treatment is defined by 12 consecutive months or longer. The purpose of this assessment is both prevention and remedial. We hope to be able to recognize potential or existing misuse or abuse of these prescriptions and help reduce risk to the patient and liability on the part of the provider. Identifying Patients Patients are required to see their medical providers every three months to obtain refills for opiates, stimulants, and benzodiazepines. When patients present for these routine appointments, the medical providers will provide a letter informing them that a referral is being made to our Behavioral Health department and they should be receiving a call soon from our referral coordination team to schedule an appointment. The rationale for this assessment is explained in the letter along with potential consequences for not following through. (See Attachment 1) Treatment Protocol Behavioral Health Consultants will have designated slots on their schedules for these assessments and they will be noted in PMG as BH/Controlled Sub Assessment. When the referral coordination office contacts the patient, the caller should note whether this person is a new Behavioral Health patient (not seen within 12 months for a or 90791). In that event, the patient should be instructed to come minutes early to complete intake forms. (See Attachment 2)

2 2 A Pre-Assessment questionnaire (See Attachment 3) will be administered when the patient is completing other Behavioral Health intake forms prior to seeing the consultant. This questionnaire is to test their knowledge of the medications they are taking and if they are aware of the risks associated with controlled substance prescriptions. The assessment process will include the standard components of a thorough Behavioral Health evaluation but with special emphasis on risk factors, including family and personal history of substance abuse and environmental issues. Behavioral Health will be focusing on misuse as well as abuse potential. Misuse can easily occur due to cognitive impairment which may be related to intellectual functioning, issues with memory, over-medicating, or sedation caused by these specific medications. After the assessment, a Post-Assessment questionnaire (See Attachment 4) will be administered to determine if the patient is now able to identify which of their medications are controlled substances, the risks associated with these medications, if they would consider counseling to learn non-narcotic strategies to manage anxiety, symptoms of attention-deficit, and/or pain, and if they have identified other issues they would like to work on in counseling. In the event of the latter two situations, they will be given a follow up appointment. The patient will also be given a controlled substance informational sheet that summarizes important points made during this intervention (See Attachment 5). The medical provider will be notified of findings immediately following the assessment. While the BH consultant will not make recommendations specific to continuing or discontinuing a medication, the note will include risk factors and other information believed important to the medical provider in making treatment decisions, including violations of the GFHS Narcotic Contract. This information will be conveyed via an EHR patient message and the medical provider is to save it to the chart. The BH coordinator will keep a list of patients seen by Behavioral Health for these assessments. This list will periodically be compared to the list of referrals coming through our referral coordinators in order to determine compliance rate. Attachments: Letter to patient Information for patients on controlled substances Pre-Assessment Questionnaire Post-Assessment Questionnaire Review Date Revised Date Changes Made By Approved By 8/1/2013 A. Blanchette/S. A. Blanchette/S. Ocloo 1/1/2014 A. Blanchette A. Blanchette

3 3 ATTACHMENT 1 Date Dear Patient: According to your medical chart, you have been prescribed at least one controlled substance medication for a year or longer for the treatment of pain, attention-deficit symptoms, and/or anxiety. Because there are many risks involved with long term treatment with these medications, the organization is requiring you to meet with one of our Behavioral Health Consultants in order to see how you are managing your prescriptions and coping with your chronic pain, symptoms of attention-deficit, and/or anxiety. This assessment is an annual requirement to continue these medication(s). You will be receiving a telephone call from our Gaston Family Health Services referral coordinator to schedule this appointment, so please make sure we have an accurate phone number on file. The main Behavioral Health facility is located at 409 S. Oakland St., Gastonia (behind our Third Avenue clinic). Bessemer City Healthcare patients may be seen at the clinic in Bessemer City. In the event you do not hear from our referral coordinator within a reasonable amount of time, please call the Behavioral Health office at to arrange this important appointment. Again, the primary purpose of this evaluation is your safety and general well-being. Therefore, non-compliance with this requirement may result in your pain, attention-deficit, and/or anxiety medication being discontinued. Thank you for your cooperation, as we take steps to improve our standards in patient care. Sincerely, Shirley Ocloo, MD Director of Medical Services Anita Blanchett, LCSW Director of Behavioral Health

4 4 Attachment 2 Gaston Family Health Services Information for Patients on Controlled Substances 1. Controlled substance medications commonly prescribed by primary care: Opiate Pain Medications: Hydrocodone/Vicodin, Oxycodone/Percocet, Fentanyl, Tylenol with Codeine, Lortab, Norco, Morphine, or others as prescribed (Note: Other non-narcotic medications that are considered high risk include Tramadol, Soma, and Fioricet) Benzodiazepines (Tranquilizers): Valium/Diazepam, Klonopin/Clonazepam, Ativan/Lorazepam, and Xanax/Alprazolam, or others as prescribed Stimulants for the treatment of Attention Deficit, Narcolepsy, or other conditions: Adderall, Ritalin, Concerta, Dexedrine, Methylin, Vyvance, or others as prescribed Note: Ambien is considered non-narcotic, but there is controversy regarding the dependency factor associated with its regular use. 2. Potential Risks associated with Controlled Substances (Risks which render a patient at higher risk of overdose or other complications.) a. Current use of alcohol, street drugs, or non-prescribed controlled substance medications. b. History of addiction/alcoholism. c. Sharing of medication between family and friends. d. Respiratory diagnoses: Smoking/COPD/Emphysema/Asthma/Sleep Apnea. e. Kidney dysfunction or liver disease. f. Taking both a narcotic or another sedating pain medication along with a tranquilizer (benzodiazepine medications) prescribed or non-prescribed. g. Current or past experience with depression.

5 5 h. With stimulants, potential heart complications and risk of developing blindness with glaucoma. 3. Suggested Components of an Overdose Prevention Plan: a. Take your medications exactly as prescribed. b. Do not consume alcohol, illicit substances, or other controlled substances than those prescribed by your medical provider. c. If you live with friends or family, make sure someone else knows you are taking these medications. d. If you find yourself taking more than prescribed, ask someone in your household to monitor and/or administer your medications according to the prescribed frequency. e. If you live alone, make sure a close friend or relative is aware you are taking these medications. f. If you have problems remembering whether you took your medication(s), ask someone else to help you keep track or make a written chart and track yourself. g. If you are depressed and having thoughts of self-harm, tell someone immediately. h. If you suspect you have taken too many pills, call 911 immediately. The medical and behavioral health providers at Gaston Family Health Services understand that regular use of these medications, more often than not, result in dependency. If at any point you feel you want to discontinue these medications and try managing your symptoms through non-narcotic means, we are here to help you. Please do not hesitate to talk to your medical or behavioral health provider.

6 6 Attachment 3 Gaston Family Health Services Behavioral Health/Controlled Substance Prescription Assessment Pre-Assessment Questionnaire (Please Circle Your Response) 1. Do you know which medication(s) you are taking that are classified as controlled substances? 2. Are you aware of risk factors associated with these medications? Yes or Somewhat or No 3. Do you know could happen and what you should do if you take too many of these medications (more than prescribed)? 4. Do you feel your anxiety, symptoms of attention-deficit disorder, and/or pain are well-managed by your current medication(s)? Anxiety Yes or Somewhat or No or N/A Attention-Deficit Yes or Somewhat or No or N/A Physical Pain Yes or Somewhat or No or N/A Patient Signature DateAttachment 4

7 7 Attachment 4 Gaston Family Health Services Behavioral Health/Controlled Substance Prescription Assessment Post-Assessment Questionnaire (Please Circle Your Response) 1. Can you now identify which medications you are taking that are classified as controlled substances? 2. Are you more knowledgeable about risks associated with these medications? Yes or Somewhat or No 3. Are you more knowledgeable about what could happen and what you should do if you take too many of these medications (more than prescribed)? 4. If you do not feel your anxiety, symptoms of attention-deficit disorder, and/or pain are well-managed by your current medication(s), would you consider participating in counseling to learn non-narcotic strategies that may help manage your symptoms? 5. Do you have other related or non-related problems that you want to work on in counseling? (If Yes, please describe in a few words: Patient Signature Date

Effective Date: May 19, Revised Date: August 18, Policy Number: MED Policy 313. Pain Management Long Term Opioid Use

Effective Date: May 19, Revised Date: August 18, Policy Number: MED Policy 313. Pain Management Long Term Opioid Use Effective Date: May 19, 2008 Revised Date: August 18, 2015 Approved by: Thomas M Tocher, MD, MPH, Chief Clinical Officer Policy Number: MED Policy 313 Title: Pain Management Long Term Opioid Use POLICY