Category:Chronic Pain: Difference between revisions

Overview

We do have some chronic pain patients, but not as many as other facilities.

Our current guideline recommends not starting any patients <45 years old on chronic narcotic pain medications. You should use the Opioid Risk Tool (Ad Hoc form) and PQRSTU questions with chronic pain patients.

For any patients on chronic controlled substances, we have a controlled substance agreement we ask patients to sign every 6 months. Along with a controlled substance agreement, you should require Behavioral Health assessment, Physical Therapy assessment, and ACT Pain Assessment. You may tie monthly refills to completing these appointments.

Each week, one Outpatient provider is assigned to refill all controlled substances that are due that week. You may be refilling controlled substances for someone you have never seen. The pharmacy does the chart review and communicates what medication is due to be refilled, when it was last refilled, when the CSA expires, and if there has been unusual activity on the Alaska Prescription Drug Monitoring Program.

If a patient has more than 60 doses of a short-acting narcotic pain medication each month, the recommendation is to change to a long-acting agent.

Please make sure when doing a controlled substance agreement with a patient to talk about our strict policy of not using marijuana, alcohol, or illegal substances while taking narcotics. We utilize pill counts and urine toxicity screens to help us monitor how patients’ medications are being taken.

We have a three strike policy for a controlled substance agreement being permanently cancelled. Strikes are decided upon by the Interdisciplinary Chronic Pain Committee, which meets monthly and reviews all chronic pain patients. Letters are sent out by the committee to notify the patient of any strikes and consequences. If a patient has three strikes in a 12-month period, they can be permanently cancelled from receiving chronic narcotics here at YKHC. After a one year grace period, they can send the committee a letter to ask to be reconsidered.

Complete the Opioid Risk Tool ad hoc form and for the HPI, include the ..hpichronicpain autotext to make sure you ask the correct questions when seeing pain patients.

Outpatient/SRC Clinic Controlled Medication Management Policies

The Pain Committee is an interdisciplinary committee constructed to adopt the responsibility of pain management for our chronic pain patients, effectively removing individual provider responsibility for e.g., discontinuing a pain contract.

Letters regarding pain management will only be sent out by the Pain Committee, not by individual providers. Any communication regarding agreements being cut off or warnings really need to come from that entity, not from any specific provider.

The Pain Committee, not individual providers, will be in charge of monitoring pain contracts, contract infractions (i.e., strikes), and keeping records. Any information about a positive drug screen etc., can be forwarded to our Chronic Pain Pharmacist.

Any provider may refer a patient to the Pain Committee by placing a referral in PowerChart/FirstNet (Refer to Pain Committee Internal)

Questions regarding pain management issues should be referred to the Chronic Pain Pharmacist, not to individual providers.

The Chronic Pain Pharmacist will assist in tracking refills, strikes, expired pain agreement etc.

To help reduce the call burden on providers, patients calling with questions about narcotic refills should be referred to the pharmacy.

Providers are not responsible for monitoring illegal drug activity. That is a law enforcement issue. Our job as health care providers is to provide compassionate treatment for our patients. Some of the patients will do illegal things with their medication, but let the law enforcement experts deal with that. If you suspect that diversion is occurring, you can report it to the Bethel PD or State Troopers (for villages) and they can investigate.

SRC providers may do pain contracts if needed, but may also refer patients to the Pain Committee for recommendations if there are questions. If there are patients who are requesting long term narcotics that you feel uncomfortable with, do not prescribe them and feel free to refer that patient to the Pain Committee.

We also have a Medically Assisted Treatment (MAT) Program for opioid use disorder. You may refer patients for an assessment by the MAT team via:

• PowerChart (Refer to MAT Committee),
• Tiger Connect (MAT Committee), or
• 543-6772 (Opioid Case Manager).

Resources/References

• 10 Steps to Managing Chronic Pain (pdf)
• Chronic Pain Overview 2017 (PowerPoint Presentation)
• Suboxone Presentation: Buprenorphine and the Treatment of Opiate Addiction in Primary Care 2017 (PowerPoint Presentation)
• Heroin Presentation 2015 (PowerPoint Presentation)
• Chronic Pain YKHC Clinical Protocol

YKHC Clinical Guidelines