Chronic Pain Initiative Pain Med Abuse Reduction Community Toolkit

7/27/2019 Chronic Pain Initiative Pain Med Abuse Reduction Community Toolkit

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Chronic Pain Initiative

Tool Kit:

Primary Care

Provider


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Introduction

Community Care of North Carolina (CCNC), in conjunction with non-profit organizationProject Lazarus, is responding to some of the highest drug overdose death rates in thecountry through its Chronic Pain Initiative (CPI). In the past decade, there are increasingindicators that the misuse and abuse of prescription opioid analgesics by patientscontributes to this epidemic. This Primary Care Physician Toolkit is one of three resourcedocuments created through this collaboration to assist medical care providers throughoutNorth Carolina in managing patients with chronic pain. Similar Toolkits have been created

for CCNC Care Managers and hospital Emergency Departments.

While the CPI is initially targeting Medicaid patients, the recommended tools and strategiesare useful for any patient struggling with pain issues. Medical care providers areencouraged to adopt the practices and policies in this Toolkit for all patients, regardless ofpayment source.

While doctors and nurses play a major role in treating chronic pain and preventing overdose

deaths, the responsibility for action goes beyond the clinic. CCNC is working with ProjectLazarus to engage the entire community in preventing overdoses. This public health modelis centered on community coalitions tailored to each locality. The model uses data fromstate health surveillance systems to get a clearer understanding of the nature of theoverdose problem and engages doctors and nurses in both prevention of opioid abuse andoptimal treatment of chronic pain. This public health model has been proven to produceresults in North Carolina, including both dramatic and sustained decreases in prescriptionopioid overdose, and improved access to appropriate opioid pain treatment.

The goals of the Chronic Pain Initiative are to reduce opioid-related overdoses, optimizetreatment of chronic pain and manage substance abuse issues associated with opiod misuse.Many people who have problems with opioid use also have legitimate needs for adequate pain


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Addiction Alert

This article is written out of disappointing experiences with patients in recovery from their addiction who

suffer relapse into drug dependency precipitated by analgesics prescribed by a physician, surgeon, or

dentist.

Scientific evidence is increasing to show that persons with addiction, at least the great majority, have an

underlying neurobiological basis for this disease. Often this problem is due to a genetic variation wherebyalcohol and other drugs are metabolized differently. This metabolic difference is predisposing for an

individual so affected to become addicted. This metabolic difference causes the patient after one exposure

to certain agents to crave repeated dosing. This phenomenon may lead to loss of control of such drug usage

and to progress quickly into addictive behavior.

At The Healing Place of Wake County, a residential recovery facility for homeless persons with addiction,

clients spend 9 to 14 months in which they stop using alcohol and other drugs; learn how to live with

sobriety; and re-establish themselves as sober, self-supporting members of the community. They workdiligently with strong peer support to establish a lifestyle of recovery with total avoidance of alcohol and

other drugs. They become actively affiliated with the recovery network in this community. They are

taught in detail about their disease of addiction including the fact that they need to avoid even one alcoholic

beverage or dose of narcotic. Their metabolic variable makes it advisable for them to avoid both such

agents. They are repeatedly instructed on this precaution.

Even so, with a subsequent scenario whereby these persons suffer pain after injury, surgery, or a dental

procedure; they may be prescribed an analgesic. If such analgesic is in the narcotic family, these patients

may experience an exacerbation of their problem with a precipitous recurrence of their dependency on theirprior substance of choice.

These clients are treated for a variety of medical problems in the clinics at The Healing Place, both at the

mens facility and the womens facility. We carefully avoid both narcotics and benzodiazepines. With rare

exception their pain can be managed with such agents as acetaminophen or ibuprofen. If they do have

intense pain such that narcotics are needed to control the pain, it is advisable for them to return to theDetoxification Unit at either of these facilities for that pain medication to be managed so that a return to

drug dependency does not recur.


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Community Care of Wake and Johnston Counties

Primary Care Physician Toolkit

for Chronic Pain Patients

Table of ContentsI. Local Wake and Johnston County Data

II. Opioids in the Management of Chronic Pain: An OverviewIII. Assessment and Management AlgorithmsIV. Sample Practice PolicyV. Medicaid Provider Portal

VI. Controlled Substance Reporting Systema. Informationb. Application

VII. Medicaid Pharmacy Lock-in ProgramVIII. Concurrent Substance Use Assessment Tools

IX. Patient Treatment Recordsa. Treatment Agreement Samples (Pain Contract)b. Opioid Risk Toolc. Current Opioid Misuse Measured. Chronic Pain Progress Notee. Medication Flowsheet


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Goals

As a community, address the rapidly risingproblem of uncoordinated and excessive use of

prescription pain medications

Change systems of care and prescribing patternsto promote quality and safe care for patients

with chronic pain

Avert unintended deaths and overutilization of

the health care system


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Poisoning Deaths: N.C., 1999-2009*

0

300

600

900

1,200

1,500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

NumberofDeaths Unintentional

Suicide

Homicide

Undetermined

All Poisonings

Source: N.C. State Center for Health Statistics,

Vital Statistics-Deaths, 1999-2009

Analysis by the Injury Epidemiology and

Surveillance Unit

In 1999, the

number of

unintentional

poisoning deaths

was 279; in 2009,

the number of

deaths hadincreased to

1,036.

*Provisional data.


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Percent Change in Rates Between 1999 and 2009

Leading Causes of Injury Deaths: N.C. 1999 to 2009*

Motor Vehicle,

-28.8%

Unintentional Poisoning,

+212.7%

Firearm - Self-Inflicted,

+1.7%

Unintentional Falls,

+68.1%

Firearm - Assault,

-25.3%

-50 0 50 100 150 200 250

Injury

ech/Intent

Percent Difference

Source: N.C. State Center for Health Statistics, VitalStatistics-Deaths, 1999-2009

Analysis by Injury Epidemiology and Surveillance Unit

*Provisional data.


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Wake and Johnston Counties

Between 2000 and 2009, Wake County had357 deaths and Johnston County had 78

deaths due to unintentional poisoning.

Only Mecklenburg County (424 deaths) had

more deaths between 2000 and 2009 than

Wake County


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Primary Cause of Death Due to Unintentional

Poisonings: N.C., 2008

Substance X-Code Number

Non-opioid analgesics X40 7

Anti-epileptic and sedative-

hypnotics

X41 33

Narcotics and hallucinogens X42 726

Drugs acting on the

autonomic nervous system

X43 0

Other /unspecified drugs X44 175

Alcohol X45 57

Organic solvents X46 2

Other gases X47 9

Pesticides X48 1

Other/unspecified chemicals X49 6

X42

72%

X41

3%

X45

6%

X44

17%

X40, X46, X47,

X48, X49

2%

Narcotics

Source: N.C. State Center for Health Statistics, Vital

Statistics-Deaths, 2008Analysis by Injury Epidemiology and Surveillance Unit


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Wake Co. Unintentional Poisonings

Deaths Due to Licit Opioids or Narcotics

0

10

20

30

40

50

60

70

80

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

# of deaths due to drugs,medications, and biologic

substances

# of deaths due to licit

opioids/narcotics *excludes

opium/heroin


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Johnston Co. Unintentional Poisonings

Deaths Due to Licit Opioids or Narcotics

0

2

4

6

8

10

12

14

16

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

# of deaths due to drugs,medications, and biologic

substances

# of deaths due to licit

opioids/narcotics

*excludes opium/heroin


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Source: NC DETECT, 2009Analysis by Injury Epidemiology and Surveillance Unit

Causes of Unintentional Poisoning, NC DETECT:

January June, 2010* (ED Visits = 6, 828)

Alcohol

2%

Cleansing Agents

2%

Corrosives

3%

Gases/Vapors

11%Other &

Unspecified

Substances

5%

Poisonous

Foodstuffs/Plants

16%

Drugs

61%

*Provisional data: final diagnoses may take up tothree months.

Drugs (over-the-counter,prescription, and illicit drugs)

were mentioned in 61% of ED

visits due to unintentional

poisonings.


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The Ten Most Frequently Cited Drugs in ED Visits Due

to Unintentional Poisonings, NC DETECT : 2010*

570 553

284258 251

201167 163 161

136

0

100

200

300

400

500

600

Benz

odiaz

epin

es

Othe

rOpio

ids

Arom

atic

Analges

ics

Card

iovas

cular

Agen

ts

Horm

oneS

ubstitut

es

Antid

epre

ssan

ts

Othe

rSed

ative

s/Hyp

notics

CNSS

timula

nts

Syste

micAge

nts

Smoo

th/S

kelet

alM

uscle

Agen

ts

Drug Type

Numbe

rofEDVisits

*Provisional data Jan-June: final diagnoses maytake up to three months.

Source: NC DETECT, 2009Analysis by Injury Epidemiology and Surveillance Unit


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*All rates are age adjusted and per 100,000 residents

Wake and Johnston Counties Hospitalizations

and Emergency Department Visits

Due to Unintentional Poisonings

Hospitalizations (2008) ED Visits (2009)

# Rate* # Rate*Johnston 81 51.4 203 119.4

Wake 237 28.7 752 83.3

CCWJC 318 32.6 955 89.2

NC 3752 39.6 9590 101.3


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From Data to Action- YRBS

YRBS= Youth Risk Factor Surveillance System


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Opioids in the

Management

of


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Opioids in the Management of Chronic Pain:

An Overview

The issue of chronic pain is a complicated one, requiring a substantial amount of

knowledge and skill for appropriate evaluation, assessment and management. Diagnostic

expertise is required to rule out a variety of medical and psychiatric conditions including certainmalignancies, neuromuscular pathology, somatization, and malingering. Effective managementmay require consultation within an interdisciplinary team of professionals. Patients may need

any of a number of different classes of medication to manage their pain, including opioid

analgesics.

As outlined by the NC Medical Board above, the proper steps must be taken when

dealing with the difficult issue of opioid use for chronic pain. This informational tool explores

different issues in the management of chronic pain, especially in the use of opioids. Pleasereview and implement these recommendations as appropriate to ensure the highest standard of

f d li f f i

Appropriate treatment of chronic pain may include both pharmacologic and non-pharmacologic

modalities. The Board realizes that controlled substances, including opioid analgesics, may be an

essential part of the treatment regimen.

All prescribing of controlled substances must comply with applicable state and federal law.

Guidelines for treatment include: (a) complete patient evaluation, (b) establishment of a

treatment plan (contract), (c) informed consent, (d) periodic review, and (e) consultation with

specialists in various treatment modalities as appropriate.

Deviation from these guidelines will be considered on an individual basis for appropriateness. --NC Medical Board Position Statement


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When performing labs, consider the use of a urine drug screen or other tests to identify

the presence of illegal drugs, unreported prescribed medication (indicating that the patient may

be seeing more than one provider), or unreported alcohol use.

Management Issues

A holistic plan for managing chronic pain should address five major elements: personalgoals, improving sleep, increasing physical activity, managing stress, and decreasing pain. [ICSI]

The Personal Care Plan for Chronic Pain created by ICSI is a good tool to help address these

issues.

When considering pharmacological treatment for chronic pain, the physician should

consider non-opioid medications as appropriate. If the pain is determined to be neuropathic in

origin, classes such as tri-cyclic antidepressants (e.g. amytriptyline), other anti-depressants (e.g.venlafaxine, bupropion), anticonvulsants (e.g. gabapentin) or corticosteroids may be effective.

Other classes of drugs to consider for the treatment of certain subtypes of chronic pain include

muscle relaxants, anti-spasmodics, anxiolytics, and drugs for insomnia. [ICSI]

Cognitive Behavioral Strategies to Assist Pain Management

Ask the patient to take an active role in the management of his/her pain. Research showsthat patients who take an active role in their treatment experience less pain-related

disability.

Let the patient know that you believe that the pain is real and is not in his/her head. Letthe patient know that the focus of your work together will be the management of his/her

pain. ICSI Patient Focus Group feedback included patient concerns that their provider

did not believe them/their child when they reported pain.


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Have the patient involved in an exercise program or structured physical therapy.

Assist the patient in returning to work. Do this in a step-wise fashion that is not

dependent on level of pain.Fear of movement or fear of pain due to movement is a significant concern for manychronic pain patients. Inactivity or avoidance of movement leads to physical de-conditioning and disability. Try not to rely on sedative or hypnotic medications to treat

the fear many chronic patients show of activity or fear of increased pain. When chronic

pain patients expose themselves to the activities that they fear, which simply means when

they do the things they have been afraid of and avoiding, significant reductions areobserved in fear, anxiety, and even pain level. If patients' fears are excessive, relaxation

strategies may be helpful or referral for more formal and intensive cognitive-behavioraltherapy may be necessary.

--ICSI Assessment and Management of Chronic Pain

The Use of a Pain Contract/Treatment Agreement

Opioids are not benign drugs. Every effort should be made to emphasize the importanceof the patient's responsibilities to manage his or her pain safely. A pain contract, or treatment

agreement, addresses these issues, while proposing strict rules and penalties if the patient doesnot abide by these rules. This written agreement may include:

Goals of therapy--Partial relief and improvement in physical, emotional, and/or socialfunctioning

The requirement for a single provider or treatment team

The limitation on dose and number of prescribed medications and the proscription against

changing dosage without permission; discuss the use of "pill counts"

A prohibition on use with alcohol, other sedating medications, or illegal medicationswithout discussing with provider

Agreement not to drive or operate heavy machinery until medication-related drowsiness


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Contraindications to Initiation of Opioid Therapy

Certain elements of the assessment should raise warning flags concerning the initiation ofopioid therapy. Care must be taken when any of the following risk factors are present:

Acute psychiatric instability or high suicide risk

History of intolerance, serious adverse effects, or lack of efficacy of opioid therapy

Meets DSM-IV criteria for current substance use disorder

Inability to manage opioid therapy responsibly (e.g., cognitively impaired)

Unwillingness or inability to comply with treatment plan

Unwillingness to adjust at-risk activities resulting in serious re-injury

Social instability

Patient with sleep apnea not on CPAP

Elderly patient

COPD patients--VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain

The Importance of Follow-Up

During the titration phase, a lack of response despite increasing doses of opioids may

indicate that the patient has non-opioid responsive pain and opioids should be discontinued.

During the management phase, the opioid dose may continue to increase gradually if the

patient becomes tolerant to the medication. If the physician becomes uncomfortable with the

level of opioids required to manage the patient's pain, he or she is encouraged to refer the patientto any physician who has more expertise in chronic pain management. Consultation should also

be requested when the patient's pain and functional status have not improved substantially afterthree months of opioid therapy.


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Addressing Misuse

Physicians should be equipped to deal with patients who are found to be misusing opioidmedication. Possible responses might include:

Education and discussion along with restatement of the written agreement

Review of the written opioid prescribing agreement

Recommending or insisting on consultation with a pain and/or addiction specialist

Discussion with others involved in the patient's care

Administration of medications under supervision or with the assistance of others

Change of medication or amount dispensed

More frequent clinic contacts

Instituting regular or random urine toxicology screens as a condition for prescriptionrenewal

--VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain

Mental Health Co-Management

Chronic pain conditions result from a complex interaction between biological,psychological and social variables. Biology plays a part in the etiology of pain, but the

perception of pain is shaped by psychosocial contexts. Therefore, mental health co-management

should be considered for optimal improvement in the patients functional status and

psychological health. These approaches focus on the emotional, cognitive and behavioralaspects of chronic pain. General agreement exists that psychological interventions may be the

important adjuvant therapies in the medical management of chronic pain. [Adams et al.] These

interventions, when combined with the comprehensive management plan outlined above, shouldimprove the health of patients with chronic pain and decrease the likelihood of opioid misuse.


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Assessment

and

Management


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Suggested PCP Clinical Management Flow for Chronic Pain Initiative

Patient Identifies Pain as Chief Complaint

Medicaid patient

Yes No

Nurse/Admin Access Provider Portal

Determine Medications, Visit History,Presence of CPI Indicator and Pain Agreement

MD Assessment of patient

Determine etiology of pain per Assessment Algorithm (e.g. Neurological, Musculoskeletal, Dental)

Review Portal information, if MedicaidReview CSRS, if appropriate

Treat immediate, acute pain as appropriate

Need for immediate, acute, on-site treatment (e.g. acute trauma)

Yes No


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AssessmentAlgorithm

* Pain types and

contributing factors are

not mutually exclusive.

Patients frequently do

have more than one

type of pain, as well as

overlapping

contributing factors.

Patient has chronic pain

Critical first step: assessment

History and physical

Key questions

Pain and functional assessment tools

Specialty

referral/consult

Other assessment

Work and disability issues

Psychological and spiritual assessment

Contributing factors and barriers

Screen for depression and substance

abuse

Determine biological

mechanisms of pain*

Is there a correctable

medical, neurological

or surgical cause of

pain?

yes

no


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ManagementAlgorithm

General management:

develop plan of care and set goals

using the biopsychosocial model

Physical rehabilitation and

psychosocial management with

functional goals

Pharmacologic management Behavior management Physical rehabilitation

Level I treatment:

neuropathic pain

See neuropathic painmanagement

algorithm (next page)

Level I treatment:

muscle pain

Meds to consider: Tricyclic antidepressants

(for short term pain and

insomnia)

Cyclobenzaprine

(fibromyalgia)

Duloxetine (fibromyalgia)

Level I treatment:

inflammatory pain

Pharmacotherapy not withinscope of this guideline.

Consider referral to a

specialist.

Level I treatment:

mechanical/compressive pain

Meds to consider: NSAIDs (short term)

Noradrenergic and

noradrenergic/serotoninergic

antidepressants for pain

Muscle relaxants

Opioids rarely needed

Primary care to measure goals

and review plan of care


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ManagementAlgorithmNeuropathicPain

Neuropathic Pain

Disease specific measures

Tighter glucose control indiabetes

Use of disease-modifying

agents in MS

Surgery, chemotherapy, or

radiation therapy for nerve

decompression

Infection control (e.g. in HIVinfection, herpes zoster,

Lyme disease)

Drug Therapy

Anticonvulsants

Tricyclic antidepressants

Mexiletene HCl

Clonazepam

Corticosteriods

Dextromethorphan

Opioids

Behavioral Therapy

Biofeedback

Hypnosis

Guided imagery

Other relaxation techniques

Cognitive-behavioral therapy

Symptom management

Local or regional treatment Systemic treatment


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Department Policy Name: Patient Care-Chronic Pain Management

Department Policy #: PC 8-4 Approval Date: 8/10/05 CEO Signature:

Policy Revision History

Revision Date: Revision #: 4/29/11 Revision Description: patient re-evaluationtime was changed to every three months

instead of every six months

I. PURPOSE

WHSI recognizes that principles of quality medical practice dictate that patients have access toappropriate and effective pain relief. The appropriate application of up-to-date knowledge and treatment

modalities can serve to improve the quality of life for those patients who suffer from pain as well as

reduce the morbidity and costs associated with untreated or inappropriately treated pain. For the purposesof this policy, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment,

and the continued use of ineffective treatments.

The diagnosis and treatment of pain is integral to the practice of medicine. WHSI encourages providersview pain management as a part of quality medical practice for all patients with pain, acute or chronic,and it is especially urgent for patients who experience pain as a result of terminal illness. All providers

should become knowledgeable about assessing patients pain and effective methods of pain treatment, as

well as statutory requirements for prescribing controlled substances. Accordingly, this policy have beendeveloped to clarify WHSIs position on pain control, particularly as related to the use of controlledsubstances, to alleviate provider uncertainty and to encourage better pain management.


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III. DEFINITIONS

Acute Pain- Acute pain is the normal, predicted physiological response to a noxious chemical, thermalor mechanical stimulus and typically is associated with invasive procedures, trauma and disease. It isgenerally time-limited.

Addiction- Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and

environmental factors influencing its development and manifestations. It is characterized by behaviorsthat include the following: impaired control over drug use, craving, compulsive use, and continued usedespite harm. Physical dependence and tolerance are normal physiological consequences of extendedopioid therapy for pain and are not the same as addiction.

Chronic Pain- Chronic pain is a state in which pain persists beyond the usual course of an acute diseaseor healing of an injury, or that may or may not be associated with an acute or chronic pathological processthat causes continuous or intermittent pain over months or years.

Pain- An unpleasant sensory and emotional experience associated with actual or potential tissue damageor describe in terms of such damage.

Physical DependencePhysical Dependence is a state of adaptation that is manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing

blood level of the drug, and/or administration of an antagonist. Physical dependence, by itself, does notequate with addiction.

PseudoaddictionThe iatrogenic syndrome resulting from the misinterpretation of relief seekingbehaviors as though they are drug-seeking behaviors that are commonly seen with addiction. The relief

seeking behaviors resolve upon institution of effective analgesic therapy.

Substance Abuse

Substance is the use of any substance(s) for non-therapeutic purposes or use ofmedication for purposes other than those for which it is prescribed.


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A. Guidelines and SafeguardsWHSI has adopted the following criteria and safeguards from the Federation of State MedicalBoards and the Management of Chronic Non-Malignant Pain Position Statement from the NCMedical Board when evaluating the treatment of pain, including the use of controlled substances:

1. Evaluation of the PatientA medical history and physical examination must be obtained,evaluated, and documented in the medical record. The medical record should document the nature

and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases orconditions, the effect of the pain on physical and psychological function, and history of substanceabuse. The medical record also should document the presence of one or more recognized medicalindications for the use of a controlled substance.

2. Treatment Plan- The written treatment plan will state objectives that will be used to determinetreatment success, such as pain relief and improved physical and psychosocial function, andshould indicate if any further diagnostic evaluations or other treatments are planned. Aftertreatment begins, the provider should adjust drug therapy to the individual medical needs of each

patient. Other treatment modalities or a rehabilitation program may be necessary depending onthe etiology of the pain and the extent to which the pain is associated with physical and

psychosocial impairment.

3. Informed Consent and Agreement for TreatmentThe provider will discuss the risks and

benefits of the use of controlled substances with the patient, persons designated by the patient orwith the patients surrogate or guardian if the patient is without medical decision-makingcapacity. The patient should receive prescriptions from one provider and one pharmacy. The

prescribing provider will implement a Pain Management Contract with all patients takingcontrolled substances for chronic non-malignant pain outlining patient responsibilities, including

but not limited to:a. urine/serum medication levels screening when requested;

b. number and frequency of all prescription refills; and


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b. diagnostic, therapeutic and laboratory results,

c. evaluations and consultations,

d. treatment objectives,

e. discussion of risks and benefits

f. informed consent (including WHSI Pain Management Contract),

g. treatments,

h. medications (including date, type, dosage and quantity prescribed documented andregularly updated on the medication flowsheet),

i. Instructions and agreements (Pain Management Contract) andj. periodic reviews.

Records should remain current and be maintained in an accessible manner and readily

available for review.

7. Compliance With Controlled Substances Laws and Regulations- To prescribe, dispense or

administer controlled substances, the provider must be licensed in NC and comply withapplicable federal and state regulations. Providers are referred to the Providers Manual of the

U.S. Drug Enforcement Administration and the NC Medical Board website(www.ncmedboard.org) for specific rules governing controlled substances as well as applicable

state regulations.

8 Patient will be seen by their WHSI provider at lest every three months and more often if


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QUESTIONS?


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CONTROLLEDSUBSTANCESREPORTING

SYSTEM

NORTH CAROLINA DIVISION OF MENTAL HEALTH,DEVELOPMENTAL DISABILITIES AND

SUBSTANCE ABUSE SERVICES

QUESTIONS?Contact the Drug Control Unit(919) 733-1765

Johnny Womble

[email protected]

William [email protected]

www.dhhs.state.nc.us/MHDDSAS/controlledsubstance/www.sa4docs.org

State of North Carolina - Beverly Eaves Perdue, GovernorDepartment of Health and Human Services

Lanier M. Cansler, SecretaryDivision of Mental Health, Developmental Disabilities and Substance Abuse Services

www.ncdhhs.gov/mhddsas/

The Department of Health and Human Services does not discriminate on the basis of race, color,national origin, sex, religion, age or disability in employment or the provision of services.

10/09 - 2000 of this document were printed at $0.25 each. [First Printing]

FACTS ABOUTCONTROLLEDSUBSTANCESIn 2008, more than 16 million controlled substanceprescriptions were written and dispensed in ourstate.

More than 5 million (5,297,074) individualpatients were recorded as having been dispensed aprescription for a controlled substance.

Number of prescriptions in the database is35,376,972.

Number of deaths from controlled substanceaccidental poisoning: January- December 2008: 798 January - June 2009: 443


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Dos and Donts for Prescribers and Dispensers Using the NC

Controlled Substances Reporting System

DO

Check the database prior to prescribing or dispensing a controlled substance. Discuss any findings of concern directly with your patients but dont give them a

copy, have them contact us).

Listen to your patients when they say the system is in error, and contact us to helpverify if there are questions.

Notify your patients that you use the system. Learn about SBIRT (Screening, Brief Intervention and Referral for Treatment)

and use with your patients.

Use behavioral contracts with patients where appropriate. Report forgeries to law enforcement. Inform us of non-reporting pharmacies.

DO NOT

Use the CSRS to exclude potential patients prior to engaging them. Discharge patients without intervening and attempting to refer for substance abuse

treatment or pain management. Have office people check the CSRS for you. Refer suspected Dr. Shoppers to police (you may call us) where your only

source of data is the CSRS. Give information to law enforcement from the CSRS (except for forgeries).

Believe information from the CSRS is the gospel truth. There can be errors. CSRSis a TOOL.


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Article 5E.

North Carolina Controlled Substances Reporting System Act.

90-113.70. Short title.

This Article shall be known and may be cited as the "North Carolina Controlled SubstancesReporting System Act." (2005-276, s. 10.36(a).)

90-113.71. Legislative findings and purpose.

(a) The General Assembly makes the following findings:(1) North Carolina is experiencing an epidemic of poisoning deaths from

unintentional drug overdoses.(2) Since 1997, the number of deaths from unintentional drug overdoses has

increased threefold, from 228 deaths in 1997 to 690 deaths in 2003.(3) The number of unintentional deaths from illicit drugs in North Carolina hasdecreased since 1992 while unintentional deaths from licit drugs, primarilyprescriptions, have increased.

(4) Licit drugs are now responsible for over half of the fatal unintentionalpoisonings in North Carolina.

(5) Over half of the prescription drugs associated with unintentional deaths arenarcotics (opioids).

(6) Of these licit drugs, deaths from methadone, usually prescribed as ananalgesic for severe pain, have increased sevenfold since 1997.

(7) Methadone from opioid treatment program clinics is a negligible source ofthe methadone that has contributed to the dramatic increase in unintentionalmethadone-related deaths in North Carolina.

(8) Review of the experience of the 19 states that have active controlledsubstances reporting systems clearly documents that implementation of thesereporting systems do not create a "chilling" effect on prescribing.

(9) Review of data from controlled substances reporting systems help:a. Support the legitimate medical use of controlled substances.b Id tif d t di i f ib d t ll d b t


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(2) "Controlled substance" means a controlled substance as defined in G.S.90-87(5).

(3) "Department" means the Department of Health and Human Services.(4) "Dispenser" means a person who delivers a Schedule II through V controlled

substance to an ultimate user in North Carolina, but does not include any ofthe following:a. A licensed hospital or long-term care pharmacy that dispenses such

substances for the purpose of inpatient administration.b. A person authorized to administer such a substance pursuant to

Chapter 90 of the General Statutes.c. A wholesale distributor of a Schedule II through V controlled

substance.

(5) "Ultimate user" means a person who has lawfully obtained, and whopossesses, a Schedule II through V controlled substance for the person's ownuse, for the use of a member of the person's household, or for the use of ananimal owned or controlled by the person or by a member of the person'shousehold. (2005-276, s. 10.36(a).)

90-113.73. Requirements for controlled substances reporting system.

(a) The Department shall establish and maintain a reporting system of prescriptions for

all Schedule II through V controlled substances. Each dispenser shall submit the information inaccordance with transmission methods and frequency established by rule by the Commission.The Department may issue a waiver to a dispenser that is unable to submit prescriptioninformation by electronic means. The waiver may permit the dispenser to submit prescriptioninformation by paper form or other means, provided all information required of electronicallysubmitted data is submitted. The dispenser shall report the information required under thissection on a monthly basis for the first 12 months of the Controlled Substances ReportingSystem's operation, and twice monthly thereafter, until January 2, 2010, at which time

dispensers shall report no later than seven days after the prescription is dispensed in a format asdetermined annually by the Department based on the format used in the majority of the states

i ll d b i


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(a) Prescription information submitted to the Department is privileged and confidential,is not a public record pursuant to G.S. 132-1, is not subject to subpoena or discovery or anyother use in civil proceedings, and except as otherwise provided below may only be used forinvestigative or evidentiary purposes related to violations of State or federal law and regulatoryactivities. Except as otherwise provided by this section, prescription information shall not bedisclosed or disseminated to any person or entity by any person or entity authorized to reviewprescription information.

(b) The Department may use prescription information data in the controlled substancesreporting system only for purposes of implementing this Article in accordance with itsprovisions.

(c) The Department shall release data in the controlled substances reporting system tothe following persons only:

(1) Persons authorized to prescribe or dispense controlled substances for thepurpose of providing medical or pharmaceutical care for their patients.(2) An individual who requests the individual's own controlled substances

reporting system information.(3) Special agents of the North Carolina State Bureau of Investigation who are

assigned to the Diversion & Environmental Crimes Unit and whose primaryduties involve the investigation of diversion and illegal use of prescriptionmedication and who are engaged in a bona fide specific investigation related

to enforcement of laws governing licit drugs. The SBI shall notify the Officeof the Attorney General of North Carolina of each request for inspection ofrecords maintained by the Department.

(4) Primary monitoring authorities for other states pursuant to a specific ongoinginvestigation involving a designated person, if information concerns thedispensing of a Schedule II through V controlled substance to an ultimateuser who resides in the other state or the dispensing of a Schedule II throughV controlled substance prescribed by a licensed health care practitioner

whose principal place of business is located in the other state.(5) To a court pursuant to a lawful court order in a criminal action.( ) h i i i f di l i f f d i i i h


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this section to another person (i) authorized to prescribe or dispense controlled substancespursuant to Article 1 of Chapter 90 of the General Statutes and (ii) authorized to receive thesame data from the Department under subsection (c) of this section.

(h) Nothing in this Article shall prevent persons licensed or approved to practicemedicine or perform medical acts, tasks, and functions pursuant to Article 1 of Chapter 90 ofthe General Statutes from retaining data received pursuant to subsection (c) of this section in apatient's confidential health care record. (2005-276, s. 10.36(a); 2009-438, s. 2.)

90-113.75. Civil penalties; other remedies; immunity from liability.

(a) A person who intentionally, knowingly, or negligently releases, obtains, or attemptsto obtain information from the system in violation of a provision of this section or a ruleadopted pursuant to this section shall be assessed a civil penalty not to exceed five thousand

dollars ($5,000) per violation. The clear proceeds of penalties assessed under this section shallbe deposited to the Civil Penalty and Forfeiture Fund in accordance with Article 31A ofChapter 115C of the General Statutes.

(b) In addition to any other remedies available at law, an individual whose prescriptioninformation has been disclosed in violation of this section may bring an action against anyperson or entity who has intentionally, knowingly, or negligently released confidentialinformation or records concerning the individual for either or both of the following:

(1) Nominal damages of one thousand dollars ($1,000). In order to recover

damages under this subdivision, it shall not be necessary that the plaintiffsuffered or was threatened with actual damages.

(2) The amount of actual damages, if any, sustained by the individual.(c) A health care provider licensed, or an entity permitted under this Chapter that, in

good faith, makes a report or transmits data required by this Article is immune from civil orcriminal liability that might otherwise be incurred or imposed as a result of making the reportor transmitting the data. (2005-276, s. 10.36(a).)

90-113.76. Commission for Mental Health, Developmental Disabilities, and SubstanceAbuse Services to adopt rules.

h i i f l l h l l i bili i d b b


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Instructions for completing the Prescriber / Dispenser Database AccessRequest:

1. Information on the form must be legible2. Fill in all of the information requested, or the request may be denied3. Your DEA # will be your user name4.

You should propose a password Passwords must be at least 8 characters in length Passwords must NOT contain dictionary words or a name Passwords must contain at least one (1) capital letter and one (1) lowercase letter and one (1)

number. For example:

H82bYb07 Acceptable Bob12345 Not acceptable rsmith07 Not Acceptable

5. After completing the access request, have it notarized and mail the access request, thesigned privacy statement and a copy of your current drivers license to:

NC CSRS

3008 Mail Service CenterRaleigh, North Carolina 27699-3008


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Prescriber / Dispenser Database Access

New Update Terminate

Name (First, MI, Last, Suffix (Jr., Sr., III))

Professional Title State Board License Number

Facility Name DEA Number (Hospital Residents add DEA extension #)

Facility Address City, State, Zip Code

Area Code & Telephone Number Area Code & Fax Number

Email Address Proposed Password

Signature Date

North Carolina Department of Health and Human Services

Division of Mental Health, Developmental Disabilities andSubstance Abuse Services


Mail Service Center 3008

Raleigh, NC 27699-3008Phone: (919) 733-1765

Fax: (919) 508-0983


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Privacy Statement

Statutory Authority:

Article 5E, 90-113.70 the North Carolina Controlled Substances Reporting System Act, requires the Department of Health and HumanServices to establish and maintain a controlled substances prescription reporting system of dispensed prescriptions for all Schedule II-V controlled substances. The purpose of this legislation is to improve the States ability to identify controlled substances abusers ormisusers and refer them for treatment, and to identify and stop diversion of prescription drugs in an efficient and cost effective mannerthat will not impede the appropriate medical utilization of licit controlled substances.

Access to Information:NCGS 90-113.74. (c) (1) authorizes DHHS to release data from the Controlled Substances Reporting System to persons authorized toprescribe or dispense controlled substances for the purpose of providing medical or pharmaceutical care for their patients.

NCGS 90-113.74. (c) (3) authorizes DHHS to release data from the Controlled Substances Reporting System to Special agents of theNorth Carolina State Bureau of Investigation who are assigned to the Diversion & Environmental Crimes Unit and whose primary dutiesinvolve the investigation of diversion and illegal use of prescription medication and who are engaged in a bona fide specificinvestigation related to enforcement of laws governing licit drugs. The SBI shall notify the Office of the Attorney General of NorthCarolina of each request for inspection of records.

Unlawful Disclosure:

Prescription information in the Controlled Substances Reporting System is privileged and confidential, is not a public record pursuant toG.S. 132-1, is not subject to subpoena or discovery or any other use in civil proceedings, and except as otherwise provided in Article5E may only be used for investigative or evidentiary purposes related to violations of State or federal law and regulatory activities

North Carolina Department of Health and Human Services

Division of Mental Health, Developmental Disabilities and

Substance Abuse Services


Mail Service Center 3008

Raleigh, NC 27699-3008Phone: (919) 733-1765

Fax: (919) 508-0983


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An Information Service of the Division of Medical Assistance

North Carolina

Medicaid Pharmacy

Newsletter

Number 186 September 2010

In This Issue...

Implementation of a Recipient Management Lock-In Program


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September 2010

Implementation of a Recipient Management Lock-In Program

N.C. Medicaid will implement a recipient management lock-in program. The N.C.

Administrative Code, 10A NCAC 22F.0704 and 10A NCAC 22F.0104, along with 42 CFR431.54 and the Medicaid State Plan supports the States development of procedures for the

control of recipient overutilization of Medicaid benefits, which includes implementing a recipientmanagement lock-in program. Recipients identified for the lock-in program will be restricted to asingle prescriber and pharmacy in order to obtain opioid analgesics, benzodiazepines, and certainanxiolytics covered through the Medicaid Outpatient Pharmacy Program.

N.C. Medicaid recipients who meet one or more of the following criteria will be locked into one

prescriber and one pharmacy for controlled substances categorized as opiates or benzodiazepinesand certain anxiolytics for a period of one year:

1. Recipients who have at least ONE of the following

a. Benzodiazepines and certain anxiolytics: more than six claims in two consecutive

months

b. Opiates: more than six claims in two consecutive months

2. Receiving prescriptions for opiates and/or benzodiazepines and certain anxiolytics from

more than three prescribers in two consecutive months

3. Referral from a provider, DMA or CCNC.

The process of identifying recipients for the program began in July. Recipients who meet the

criteria will be notified by letter and asked to choose a prescriber and a pharmacy. The recipientmust obtain all prescriptions for these medications from their lock-in prescriber and lock-in

pharmacy in order for the claim to pay. Additionally, the prescribers NPI will be requiredon

the pharmacy claim. Submitting the prescribers DEA will cause the claim to be denied.

Claims submitted by a prescriber or filled at a pharmacy other than the one listed on the lock-infile will be denied. The recipient may not change their lock-in prescriber or pharmacy without

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September 2010

Recipient Management Lock-in Program Emergency Fill

The N.C. Medicaid Program will reimburse an enrolled Medicaid pharmacy for a 4-day supply of

a prescription dispensed to a recipient locked into a different pharmacy and prescriber in responseto an emergent situation. The emergency supply is limited to a 4-day supply. The provider will

be paid for the drug cost only, and the recipient will be responsible for the appropriatecopayment. A 3 in the Level of Service field (418-DI) should be used to indicate that thetransaction is an emergency fill.

Only one emergency occurrence will be reimbursed per lock-in period. Records of the dispensing

of emergency supply medications are subject to review by DMA Program Integrity. Paid

quantities for more than a 4-day supply are subject to recoupment.

Recipient Notifications

Medicaid and N.C. Health Choice recipients are notified of benefit and coverage changes through

monthly mailings. Copies of the notifications are available on DMAs website athttp://www.ncdhhs.gov/dma/pub/consumerlibrary.htm .

The notification that was mailed to recipients in August 2010 outlined a number of changes to theN.C. Medicaid Program and to the N.C. Health Choice Program.

Medical Services

Medicaid recipients were notified of the following changes to the N.C. Medicaid Program formedical services:

Limitations to refills for lost prescriptions


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NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE

PHARMACY LOCK-IN REFERRAL FORM

This form is used for referring North Carolina Medicaid recipients with possible medication over utilizationto the Recipient Management Lock-in Program to evaluate the need for possible lock-in to one prescriber

and one pharmacy. Please fax this form along with any supporting documentation to 919-715-1255. For

questions regarding the use of this form, call 919-855-4300. Please note this completed form contains

Protected Health Information (PHI) and should be handled in accordance with HIPAA regulations.

Referral Information

Referral Source:[] Medicaid Provider[] CCNC Network Employee

Referral Name: ___________________

Referral Phone: ___________________Date of Referral: __________________

Please include contact information for appeals support.

Recipient Information

Recipient Name: ________________________________________________

Recipient Medicaid ID: ________________________________________________Recipient DOB: ________________________________________________

Reason for Referral


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SBIRT SCREENING TOOLS

Recommended Substance Abuse Screening Tools for Primary Care Settings in NCThere are a number of substance abuse screening instruments that have been validated in diverse patient populations.

These include, but are not limited to the AUDIT, AUDIT-C, MAST, DAST, CRAFFT, CAGE, CAGE-AID, ASSIST, TWEAK, and T-ACE. Different tools are appropriate for different settings and patient populations. To facilitate communication and

collaboration between primary care practices and between primary care and specialty behavioral health, two

instruments with wide applicability have been chosen and recommended to primary care practices in NC. These tools

are the AUDIT-C (with one additional drug use question) and the CAGE-AID. The AUDIT-C has been successfully

implemented throughout the VA healthcare system. The CAGE-AID is widely used and is included on many electronic

medical record systems. It is recommended that screening begin with a prescreen.

Prescreen QuestionsDo you drink alcohol? Have you ever experimented with drugs, including prescription drugs? If yes to either question,

proceed with screen.

AUDIT-C plus drug questionThe AUDIT-C consists of the first 3 questions of the 10 item AUDIT (Alcohol Use Disorders Identification Test). The

AUDIT-C , which can be self-administered or be part of an interview, identifies harmful alcohol use and has cross-cultural

validity.

The AUDIT-C is scored on a scale of 0-12 points. A score of 4 points or more for men and a score of 3 points or more for

women are considered positive for alcohol misuse. Using these cutoff points in family medicine settings, sensitivity is .86

and specificity is .89 for men with .73 sensitivity and .91 specificity for women. The VA system requires follow-up

counseling/brief intervention for scores of 5 or more. (See scoring rubric on back of this sheet.)

Q#1: How often did you have a drink containing alcohol in the past year?

Q#2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?

Q#3: How often did you have six or more drinks on one occasion in the past year?

In North Carolina, particularly in primary care settings that serve an indigent population, drug use (both


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SBIRT SCREENING TOOLS

CAGE-AID OverviewThe CAGE-AID is a conjoint questionnaire where the focus of each item of the CAGE questionnaire was expanded from

alcohol alone to include alcohol and other drugs.

Clinical Utility

Potential advantage is to screen for alcohol and drug problems conjointly rather than separately.

Scoring

Regard one or more positive responses to the CAGE-AID as a positive screen.

What is the AUDIT-C?The AUDIT-C is a 3 question screen that can help identify patients with alcohol misuse. The AUDIT-C is scored on a scale

of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered

positive for alcohol misuse; in women, a score of 3 points or more is considered positive. Generally, the higher the

AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her health and safety.

The VA's performance measure requires brief counseling for alcohol use for any patient who scores 5 points or more on

the AUDIT-C. The AUDIT-C questions are:

Q#1: How often did you have a drink containing alcohol in the past year?

Never (0 points)*

Monthly or less (1 point)

Two to four times a month (2 points)

Two to three times per week (3 points)

Four or more times a week (4 points)

Q#2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?


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AUDIT- C

Lea las preguntas tal como estn escritas. Registre las respuestas cuidadosamente. Empiece elcuestionario AUDIT diciendo Ahora voy a hacerle algunas preguntas sobre su consumo debebidasalcohlicas durante el ltimo ao. Explique qu entiende por bebidas alcohlicas utilizandoejemplos tpicos como cerveza, vino, vodka, etc. Codifique las respuestas en trminos deconsumo (bebidas estndar). Marque la cifra de la respuesta adecuada en el recuadro de laderecha.

1. Con qu frecuencia consumi alguna bebida alcohlica?Nunca (0 puntos)Una o menos veces al mes (1 punto)De 2 a 4 veces al mes (2 puntos)De 2 a 3 veces a la semana (3 puntos)4 o ms veces a la semana (4 puntos)

2. En el ltimo ao, Cuntas bebidas alcohlicassuele tomar en un da de consumo normal?Nunca 0*1 2 (0 puntos)3 4 (1 punto)5 6 (2 puntos)7, 8, 9 (3 puntos)

10 ms (4 puntos)


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El AUDIT-C es una evaluacin de 3 preguntas la cual nos ayuda a identificar pacientes que abusan del

alcohol. El puntuaje del AUDIT-C se basa en una escala de 0-12 puntos (puntajes de 0 reflejan ningn uso

de alcohol en el ltimo ao). En los hombres, un puntaje de 4 puntos ms es considerado positivo enel abuso del alcohol; en las mujeres, un puntaje de 3 puntos ms es considerado positivo en el abuso

de alcohol. Generalmente, cuanto ms alto sea el puntaje en el AUDIT-C, ms alta es la probabilidad de

que el consumo de alcohol del paciente est afectando su salud y seguridad.

La medida de rendimiento del VA requiere consejera breve sobre el uso del alcohol para cualquier

paciente cuyo puntaje sea de 5 ms puntos en el AUDIT-C.

*Si los pacientes son evaluados mediante una entrevista, y la respuesta a la pregunta #1 delAUDIT-C es nunca, puede colocar puntajes de 0 en las preguntas 2-3. Si el AUDIT-C esadministrado por escrito o por la red (internet) sin saltarse preguntas (para que los que nobeben, salten las preguntas #2-3), una opcin de 0 bebidas es usualmente aadida a lapregunta #2.

AVISO: Un S a la pregunta sobre el uso de drogas que acompaa el AUDIT-C constituye una

evaluacin positiva.


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Cuestionario CAGE-AID adaptado para incluir drogas

Fecha: ____/_____/_____

1. Alguna vez ha sentido que debera disminuir o reducir su uso de alcohol y/o drogas?Alcohol: S _____ NO _____

Drogas: S _____ NO _____

2. Se ha sentido alguna vez molesto por las crticas de la gente acerca de su uso de alcoholy/o drogas?

Alcohol: S _____ NO _____

Drogas: S _____ NO _____

3. Alguna vez se ha sentido culpable o mal debido a su uso de alcohol y/o drogas?


Drogas: S _____ NO _____

4. Alguna vez ha necesitado alcohol y/o drogas temprano en la maana para estabilizar susnervios o ayudarlo con la resaca)?


Drogas: S _____ NO _____


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Patient Treatment Records:1. Treatment Agreement

(Pain Contract)

2. Opioid Risk Tool

3. Current Opioid Misuse Measure

4. Chronic Pain Progress Note


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Opioid Agreement

I understand that Dr. _____________________________ is prescribing opioid medication to help me manage

chronic pain that has not responded to other treatments. The goal of this medication is to lead to partial relief

from pain, so that my physical, emotional, and social function will improve. If my activity level or generalfunction gets worse, the opioid may be stopped or changed to something else. The risks, side effects and

benefits of opioid treatment have been explained to me and I agree to the following instructions. Failure to

follow these instructions will result in stopping the medication.

1. I will participate in any other treatments recommended by my provider. I will be ready to decrease or stop

the opioid medication when other effective treatments become available.

2. I will take my medications exactlyas prescribed and will not change the medication schedule or dosage

without advance approval from my provider. I will provide my medication for pill counts at theprovidersrequest. I will not request early refills.

3. I will keep regular appointments at the clinic.

4. All opioid and other controlled drugs for pain must be prescribed only by Dr.______________________.

5. I will inform the clinic within one business day if I am hospitalized for any reason, or if I have another

condition that requires the prescription of a controlled drug (like narcotics, tranquilizers, barbiturates, or

stimulants).

6. I will choose one pharmacy where all of my prescriptions will be filled.

Pharmacy Name: ________________________________

Phone Number: ________________________________

Fax Number: ________________________________

Address: ________________________________

________________________________

7. I understand that lost or stolen prescriptions will not be replaced, so I will keep my prescription and


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Sample Pain Management Contract

Patient Name ________________________ Medical Record Number ______________________

Physician Name _______________ Diagnosis Requiring Medications: ___________________________

I agree to abide by the following guidelines for managing my prescription(s) for pain medications:

I will only request and receive opioid (narcotic) pain medications for management of my pain from_______________________.

I agree to inform any other provider (doctor, nurse practitioner, physicians assistant) participating in mycare of this agreement. If another provider wishes to suggest changes in pain management, they cancontact my primary provider during regular business hours, but no changes will be made without such

contact. I will not request refills prior to the next regularly scheduled visit with my provider. I understand that if

my medications are lost or stolen, they will not be refilled prior to the next refill date. If I use up mysupply of medications before the date of the next refill, I understand that I will not receive extramedications. In this case I understand that I may suffer symptoms of withdrawal. I will inform my doctor

in a timely manner if I have an increased need for pain medication or have difficulty taking the medication

as prescribed. If I find that the current dose of pain medication is no longer adequate, I will discuss thissituation with my doctor at a scheduled visit.

I agree to follow my providers recommendations for other pain relieving therapies (physical therapy, etc).I understand that if I do not make a reasonable attempt to adhere to other therapies my clinician maydecide to discontinue prescribing opioids.

I understand that in the event of an emergency where I am seen by another provider at a different facilityand that provider prescribes pain medications, I agree to notify my provider immediately.

I agree to use only the following pharmacy: ____________________________ located at_______________________, telephone number _____________________, for the filling of all my painmedication prescriptions.

I will bring all unused pain medications to every office visit, including all current prescription vials. I will not sell or share any opioid pain medications. hil hi i i ff ill b l h l illi i d f hi


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Opioid Risk Tool

Male Female

Family history (parents and siblings):

Alcohol abuse _____(3) _____(1)

Illegal drug use _____(3) _____(2)Prescription drug abuse _____(4) _____(4)

Personal history:

Alcohol abuse _____(3) _____ (3)

Illegal drug use _____(4) _____ (4)

Prescription drug abuse _____(5) _____ (5)

Mental health:

Diagnosis of ADD, OCD, bipolar, schizophrenia _____ (2) _____ (2)

Diagnosis of depression _____ (1) _____ (1)

Other:

Age 16-45 years _____ (1) _____ (1)

History of pre-adolescent sexual abuse _____ (0) _____ (3)

Total _____ _____


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Signs and Symptoms of Intoxication

Emotional Volatility

Evidence of Poor Response to Medications

Addiction

Healthcare Use PatternsProblematic Medication Behavior

A quick and easy to administer patient-self assessment

17 items

Simple to score

Completed in less than 10 minutes

Validated with a group of approximately 500 chronic pain patients on opioid therapy

Ideal for documenting decisions about the level of monitoring planned for a particular patient orjustifying referrals to specialty pain clinic.

The COMM is for clinician use only The tool is not meant for commercial distribution

Current Opioid Misuse Measure (COMM)

The Current Opioid Misuse Measure (COMM) is a brief patient self-assessment to monitor chronicpain patients on opioid therapy. The COMM was developed with guidance from a group of pain andaddiction experts and input from pain management clinicians in the field. Experts and providers

identified six key issues to determine if patients already on long-term opioid treatment are exhibitingaberrant medication-related behaviors:

The COMM will help clinicians identify whether a patient, currently on long-term opioid therapy,may be exhibiting aberrant behaviors associated with misuse of opioid medications. In contrast, theScreener and Opioid Assessment for Patients with Pain (SOAPP) is intended to predict whichpatients, being considered for long-term opioid therapy, may exhibit aberrant medications behaviorsin the future. Since the COMM examines concurrent misuse, it is ideal for helping clinicians

monitor patients aberrant medication-related behaviors over the course of treatment. The COMMis:


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As for any scale, the results depend on what cutoff score is chosen. A score that is sensitive indetecting patients who are abusing or misusing their opioid medication will necessarily include anumber of patients that are not really abusing or misusing their medication. The COMM wasintended to over-identify misuse, rather than to mislabel someone as responsible when they are not.This is why a low cut-off score was accepted. We believe that it is more important to identify patientswho have only a possibility of misusing their medications than to fail to identify those who are actuallyabusing their medication. Thus, it is possible that the COMM will result in false positives patients

identified as misusing their medication when they were not.

The table below presents several statistics that describe how effective the COMM is at differentcutoff values. These values suggest that the COMM is a sensitive test. This confirms that theCOMM is better at identifying who is misusing their medication than identifying who is notmisusing. Clinically, a score of 9 or higher will identify 77% of those who actually turn out to be athigh risk. The Negative Predictive Values for a cutoff score of 9 is .95, which means that mostpeople who have a negative COMM are likely not misusing their medication. Finally, the Positivelikelihood ratio suggests that a positive COMM score (at a cutoff of 9) is nearly 3 times (3.48 times)as likely to come from someone who is actually misusing their medication (note that, of thesestatistics, the likelihood ratio is least affected by prevalence rates). All this implies that by using acutoff score of 9 will ensure that the provider is least likely to miss someone who is really misusingtheir prescription opioids. However, one should remember that a low COMM score suggests thepatient is really at low-risk, while a high COMM score will contain a larger percentage of falsepositives (about 34%), while at the same time retaining a large percentage of true positives. Thiscould be improved, so that a positive score has a lower false positive rate, but only at the risk ofmissing more of those who actually do show aberrant behavior.

Scoring Instructions for the COMM

To score the COMM, simply add the rating of all the questions.

A score of 9 or higher is considered a positive

COMM Please answer each question as honestly as possible Keep in mind that we are only


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Please answer the questions using the

following scale: Never Seldom Sometimes Often Very Often0 1 2 3 4

1. In the past 30 days, how often have youhad trouble with thinking clearly or hadmemory problems?

O O O O O

2. In the past 30 days, how often do peoplecomplain that you are not completing

necessary tasks? (i.e., doing things thatneed to be done, such as going to class,work or appointments)

O O O O O

3. In the past 30 days, how often have youhad to go to someone other than yourprescribing physician to get sufficient painrelief from medications? (i.e., another

doctor, the Emergency Room, friends,street sources)

O O O O O

4. In the past 30 days, how often have youtaken your medications differently fromhow they are prescribed?

O O O O O

5. In the past 30 days, how often have youseriously thought about hurting yourself?

O O O O O

6 In the past 30 days how much of your O O O O O

COMM Please answer each question as honestly as possible. Keep in mind that we are onlyasking about the past 30 days. There are no right or wrong answers. If you are unsure about howto answer the question, please give the best answer you can.


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Please answer the questions using thefollowing scale: Never Seldom Sometimes Often Very Often

0 1 2 3 4

11. In the past 30 days, how often haveothers been worried about how yourehandling your medications?

O O O O O

12. In the past 30 days, how often haveyou had to make an emergency phone callor show up at the clinic without anappointment?

O O O O O

13. In the past 30 days, how often haveyou gotten angry with people?

O O O O O

14. In the past 30 days, how often haveyou had to take more of your medicationthan prescribed?

O O O O O

15. In the past 30 days, how often haveyou borrowed pain medication fromsomeone else?

O O O O O

16. In the past 30 days, how often haveyou used your pain medicine for symptomsother than for pain (e.g., to help you sleep,improve your mood, or relieve stress)?

O O O O O

17. In the past 30 days, how often haveyou had to visit the Emergency Room?

O O O O O

COMM


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Responda las preguntas usando la siguienteescala: Nunca Rara Vez A veces A

menudoMuy amenudo

0 1 2 3 4

1. En los ltimos 30 das, con qu frecuenciaha tenido inconvenientes para pensar conclaridad o ha tenido problemas de memoria

O O O O O

2. En los ltimos 30 das, con qu frecuenciaalguien se ha quejado de que usted nocumple con sus responsabilidades (porejemplo, cumplir con lo que debe hacer, comoir a clase, al trabajo o a una cita)?

O O O O O

3. En los ltimos 30 das, con qu frecuenciaha tenido que recurrir a otra persona (que no

sea el mdico que le receta su medicacin)para lograr suficiente alivio del dolor conmedicamentos (es decir, otro mdico, la salade emergencias, amigos, en la calle)?

O O O O O

4. En los ltimos 30 das, con qu frecuenciaha tomado sus medicamentos de maneradiferente de como se los recetaron?

O O O O O

5. En los ltimos 30 das, con qu frecuenciaha pensado seriamente en hacerse dao?

O O O O O

COMM

Responda a cada pregunta con la mayor sinceridad posible. Tenga en cuenta que las preguntasse refieren nicamente a los ltimos 30 das. No hay respuestas correctas ni incorrectas. Si noest seguro acerca de cmo responder a una pregunta, proporcione la mejor respuesta quepueda.


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Please answer the questions using thefollowing scale: Never Seldom Sometimes Often Very Often

0 1 2 3 4

11. En los ltimos 30 das, con qufrecuencia otras personas se han preocupadopor la manera en que maneja susmedicamentos?

O O O O O

12. En los ltimos 30 das, con qufrecuencia ha tenido que hacer una llamadatelefnica de emergencia o acudir a la clnica

sin cita?

O O O O O

13. En los ltimos 30 das, con qufrecuencia se ha enojado con otras personas?

O O O O O

14. En los ltimos 30 das, con qufrecuencia ha tenido que tomar una mayorcantidad de medicamento que la recetada?

O O O O O

15. En los ltimos 30 das, con qufrecuencia ha pedido prestadosmedicamentos para el dolor a otra persona?

O O O O O

16. En los ltimos 30 das, con qufrecuencia ha usado su medicacin paraaliviar sntomas que no eran de dolor (p. ej.,como ayuda para dormir, para mejorar el

estado de nimo o para aliviar el estrs)?

O O O O O

17 E l lti 30 d O O O O O

N th t C it C N t k


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Northwest Community Care NetworkPROGRESS NOTE: CHRONIC PAIN MANAGEMENT

Patient Name: _______________________

DOB: __________________________

ANALGESIA

Scale of 0-10 (0 = no pain; 10 = worst painimaginable) rank:

1. What was your pain level on average during thepast week? _____

2. What was your pain level at its worst during the

past week? _____

3. Compare your average pain during the past

week with the average pain you had before youwere treated with your current pain relievers. What

percentage of your pain has been relieved? _____

4. Is the amount of pain relief you are now

obtaining from your current pain relievers enoughto make a real difference in your life?Yes _____ No _____

ADVERSE EVENTS

Is patient able to tolerate current pain relievers?Yes _____ No _____

Is patient experiencing any side effects fromcurrent pain relievers? (i.e. constipation, itching,

Date of Visit: _________________________

Chart Number: ________________________

ACTIVITIES OF DAILY LIVING

Physician observation comparing usual functioningduring the past month with usual functioning

before being treated with current pain reliever(s):

B = Better S = Same W = Worse

Physical functioning: _____

Family relationships: _____

Social relationships: _____

Sleep patterns: _____

POTENTIALLY ABERRANT DRUG-

RELATED BEHAVIOR

Using EtOH? Yes No

Using illicit drugs? Yes No

Requests frequent early

renewals Yes NoIncreased dose without

authorization Yes NoReports lost or stolen

prescriptions Yes No

Northwest Community Care Network


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Chronic Pain Medication Flowsheet

Patient Name: ___________________Treatment Agreement in Place? _________________ DOB: ________________________

Pharmacy Home: _____________________________ Chart No: ___________________

Date Medicine Dose Instructions Refills Drug Testing

Performed?

Medicine

Count?

CSRS*

Contacted?

Naloxone

*CSRSControlled Substances Reporting System


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Assessment and Management of Chronic Pain Guideline Summary

Personal Care Plan for Chronic Pain

1. Set Personal Goals

Improve ICSI Functional Activity Score by _____ points by: Date ________

Return to specific activities, tasks, hobbies, sports by: Date ____________1. __________________________________________

2. __________________________________________

3. __________________________________________

Return to limited work /or normal work by: Date ________________2. Improve Sleep (Goal: ______ hours per night, Current: ____hours per night)

Follow basic sleep plan1. Eliminate caffeine and naps, relaxation before bed, go to bed at target bed time __________

Take night time medications1. __________________________________________

2. __________________________________________

3. __________________________________________

3. Increase Physical Activity

Attend Physical Therapy (days per week ________)

Complete daily stretching (____ times per day, for ____minutes)

Complete Aerobic exercise / Endurance exercise1. Walking (____ times per day, for ____minutes) or Pedometer (_____ steps per day)

2. Treadmill, bike, rower, elliptical trainer (____ times per week, for ____ minutes)

3. Target heart rate goal with exercise _______ bpm

Strengthening1. Elastic, hand weights, weight machines (____ minutes per day, ____ days per week)

4. Manage Stress - list main stressors ____________________________________________________

Formal interventions (counseling or classes, support group or therapy group)

Name: _______________________

Date: ____________________Date of Birth: ______________

MR #: ___________________


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Assessment and Management of Chronic Pain

Second Edition/March 2007

Functional Ability Questionnaire

Instructions: Circle the number (1-4) in each of the groups that best summarizes your ability.

Add the numbers and multiply by 5 for total score out of 100.

________ Self-care ability assessment1. Require total care: for bathing, toilet, dressing, moving and eating

2. Require frequent assistance

3. Require occasional assistance4. Independent with self-care

________ Family and social ability assessment

1. Unable to perform any: chores, hobbies, driving, sex or social activities2. Able to perform some

3. Able to perform many

4. Able to perform all

________ Get-up-and-go ability assessment1. Able to get up and walk with assistance, unable to climb stairs

2. Able to get up and walk independently, able to climb one flight of stairs

3. Able to walk short distances and climb more than one flight of stairs

4. Able to walk long distances and climb stairs without difficulty Lifting ability assessment

Name: ______________________

Date: _______________________

Date of Birth: ________________MR #: _________________________


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Urine Drug Screen

ToolkitCommunity Care of Wake and Johnston

Counties

This is a tool that may be used to assist providers in prescribing medications safely

when treating individuals with chronic pain.

2012


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TABLE OF CONTENTS

Introduction to the Urine Drug Screen Toolkit...3

I. Core Elements.......................................................................................................................... 4

Information for Staff............................................................................................................. 5-6

Information for Patients ....................................................................................................... 7-8

II. Polices and Procedures ............................................................................................................ 9

a. Preparing the office ............................................................................................................... 10

b. Routine Procedure ................................................................................................................. 10

c. Performing the Test ............................................................................................................... 10

III. Reading and Interpreting the Results ............................................................................. 12

a. Reading & Interpreting .......................................................................................................... 13

b. Special Consideration ............................................................................................................ 13

i. Abnormal Results: Negative for Prescribed Medication ....................................................... 13

ii. Abnormal Result: Positive for an Unprescribed/Illicit Substance ......................................... 13

IV. Documenting Results...14


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Introduction

This Urine Drug Screen Toolkit is a resource that may be used

to assist medical care providers in treating and managing

individuals with chronic pain.

These are some recommendations and you are encouraged to

adopt and utilize practices in this toolkit that you find helpful.


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I. CORE ELEMENTS


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Information for Staff

Who to Test

Patients on chronic opiate regimen

New patients already on narcotics

Patients that you inherit

Suspicious/ unusual behavior: Pseudo-addiction

Patients with a history of addiction or currently in recovery

When to Test

Frequency: The decision on how often to collect samples is up to the practitioner andcan vary depending on the individual patient. For example, take into account patient

characteristics such as:

o Patient behavioro Past positive testso Indications of abuse or addiction

Schedule: Research suggests it is best practice to collect samples on an unannounced

basis. Two to three collections per year may be enough for pain patients who do not show

signs of abnormal behavior

First Visit

At the beginning of the visit-before a prescription is written

Before starting controlled substances

Change in medication type or dosageDecline in patients level of functioning/mental status


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Common adulterants typically produce telltale signs of tampering: Drano, bleach andvinegar change the specimen's pH outside the normal range, goldenseal tea causes the

specimen to turn brown, soap causes the specimen to become cloudy or bubble when

shaken, table salt forces the samples relative density out of the normal range.

If results are positive, for illicit substances or prescription medications that are notprescribed, it should be discussed in a non-judgmental, supportive way with the patient to

see if there might be another cause of the positive result. Sometimes detecting an illicitsubstance can be used as a motivation to change.

A referr al to addiction speciali st should be considered and is strongly encouraged to rul e

in or out any substance abuse or dependency issues.


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[Practice Letter head/logo]

Our practice is committed to delivering high

quality and safe care to our patients.

A growing patient safety problem is

unintended overdoses and deaths amongpatients using prescribed pain medications.

In response to this problem patients who are


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Information for Patients

Your doctor wants to make sure you are receiving safe and quality care. Under somecircumstances you may be asked to provide a urine sample while you are receiving

treatment.

Q. How Can Testing My Urine Help My Doctor?

A. Urine screens are used as a tool to help your doctor learn more information about the

medications in your system. The information in your results can help the doctor detect dangerous

drug interactions and protect you from any risk. The doctor uses your result

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Chronic Pain Initiative Pain Med Abuse Reduction Community Toolkit

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