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Table 1 Outline of the recommendations of the health system’s opioid management policy

From: Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project

Item Summary of the Policy-recommended Components
Recommended components of opioid therapy management
Problem List 1. Document diagnosis of chronic pain and source of pain
2. Document information related to relevant prescribed medications:
a. Details of opioid prescription, with allowed quantity per given time period
b. Name and location of designated pharmacy
c. Date when treatment agreement was most recently signed
d. Urine drug testing findings
3. PDMP review: date of last review, finding summary, e.g., consistent or inconsistent with prescription record
4. Document care plan
5. Add comments helpful to other providers, e.g., those covering in your absence
6. Update at least annually and when any changes occur
Care Plan Components 1. Treatment goals: pain severity (BPI), function (BPI/other)
2. Treatment plan (medications, exercise, physical or occupational therapy, mental health related therapies, CAM therapies, specialty consults)
3. Contingency plan for care outside PCP office
4. Update at least annually and when any changes to care plan
1. Serves as informed consent to long-term opioid therapy
2. Scan new or updated signed treatment agreement into the EHR
3. Update treatment agreement annually and when any changes to care plan
4. Deactivate treatment agreement after opioids are no longer prescribed
Urine Drug Testing 1. Complete urine drug testing annually or more frequently as needed
2. Perform confirmatory testing for unexpected results of a screening test
3. Document findings
Prescription Refills 1. Prescription for controlled substances should be filled at one agreed upon pharmacy, which is noted in the treatment agreement
2. Prescriptions for Schedule II medications can be mailed to pharmacy only
3. Patient may sign a release form to designate up to 2 appointees who can pick up prescriptions for Schedule II medications with photo ID
PDMP 1. Document findings of the PDMP database review at least annually.
Approach to treatment agreement violation
Minor Infractions 1. Patient should be contacted by prescribing provider; discussion documented
2. Reassess and update care plan and treatment agreement as needed
Major Infractions Follow minor infraction steps above; in addition:
1. If opioid therapy is discontinued, provide, when appropriate:
a. opioid taper instructions and prescription(s) to accomplish the taper
b. prescriptions for non-opioid medications for opioid withdrawal symptoms
2. Document reason for the discontinuation of opioid therapy
3. Deactivate treatment agreement when opioid treatment is completed
4. Communicate with other treating clinicians
5. Contact Patient Relations; discuss placing a flag, if needed, in medical record by the Department of Pharmacy
6. Continue non-opioid treatment
7. If all care is planned to be terminated, discuss “No further service” with Patient Relations
Suspected Misuse or Use Disorder 1. Consider referring to addiction medicine specialist
2. If safe, continue modified or current opioid therapy until plan is in place with addiction specialist
3. Consider following the steps as for major violation of the treatment agreement
  1. BPI Brief Pain Inventory, CAM Complementary and Alternative Medicine, EHR Electronic Health Record, PCP Primary Care Provider, PDMP Prescription Drug Monitoring Program