We do have some chronic pain patients, but not as many as other facilities. Our goal is that we do not have anyone on more than 60 short acting meds. We recommend that if you have a patient that is requiring more than 60 short-term narcotics a month they be moved over to a long acting agent. Here at YKHC we have the long acting narcotics Kadian/Oxycontin/MS Contin. Short term narcotics—this includes tramadol, Vicodin, Percocet, and T#3.
We are working on a program to stop using Kadian and switch all Kadian patients to MS Contin. Our current guideline recommends not starting any patients under 45 on chronic narcotic pain and to use the Opioid Risk Tool and PQRSTU questions on a visit with chronic pain patients.
Use the Pre completed note – 1st Pain Evaluation to make sure you ask the correct questions when seeing a pain patients.
Our guideline on Assessing a patient with chronic pain lays out our requirements before a controlled substance agreement can be used – Physical Therapy, Assessment with IMPACT – BH prior, trial of non narcotic medications, etc before narcotics are considered.
We have a controlled substance agreement we ask patients to sign every six months. With a controlled substance agreement you should suggest Behavioral Health, and/or Physical Therapy/ IMPACT Pain assessment and you may tie monthly refills to completing these appointments. As often as possible have all narcotic refills completed with the primary care provider. If that is unable to happen, either talk to the PCP or one of the other providers on the pain contract or make sure to only prescribe what is on the pain contract.
Please make sure when doing a pain agreement with a patient to talk about our strict policy of not using marijuana or other illegal substances, as well as alcohol while taking narcotics. We utilize pill counts and urine tox screens to help up monitor how patients meds are being taken. We have a 3-strike policy for being permanently cancelled for a controlled substance agreement. Strikes are decided upon by the Interdisciplinary Chronic Pain Committee that meets monthly and letters are sent out by the committee to notify the patient of strikes. Monthly we have a Pain Patient Review meeting were we go over how many strikes people have and discuss cases.
If a patient has 3 strikes in a 12 months period they can be permanently cancelled from ever receiving chronic narcotics here. After a one year grace period they can send the committee a letter to see if they can be reconsidered.
Outpatient/SRC Clinic Controlled Medication Management Policies
1. All providers are always able to refer patients to the pain committee. Order a refer to PAIN COMMITTEE in RAVEN or message the pharmacists – Michael Stamper /Jason Byrd.
2. Any patient questions regarding pain management issues should be referred to the Bethel case management team- not individual providers. If patients call an SRC or questions about their meds and prescription refills they need to call the pharmacy and Alan Miller 543-6652.
We are trying to decrease the burden of multiple phone calls about refills and questions on you and let pharmacy assist with it.
3. Letters regarding pain management will only be sent out by the pain committee, not by individual providers. The pain committee is an interdisciplinary committee constructed to take away any individual responsibility in the pain decisions regarding our patients. Any communication regarding agreements being cut off or warnings really need to come from that entity – not from any specific provider.
4. The Pain committee will be in charge of monitoring all strikes and keeping excel spreadsheets - not individual providers. This again is to allow case managers who have the time to track and monitor these patients. Any information about a positive drug screen etc can be forwarded to Pharmacy – Michael Stamper/Jason Byrd our narcotic pharmacists.
5. Providers are not responsible for monitoring the illegal drug activity in their villages – that is a law enforcement issue. Our job as health care providers is to provide compassionate treatment of our patients. Some of the patients will be do illegal things with their medication. Let the law enforcement experts deal with that. If you feel that diversion is occurring – you can report it to the troopers – they can further investigate it.
5. Patients who are uncooperative or harassing with staff will be given a strike. This will be added to the controlled medicine agreement guideline.
6. SRC providers will do pain contracts if needed - but whenever needed will refer 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. Pharmacy will assist him in tracking refills and strikes, expired pain agreement etc.
7. Each SRC provider should only be scheduled one controlled medicine contract a day and it should a 30 appointment.
8. Patients on Kadian/Oxycontin/MS Contin who do not like it will be instructed to lower their dose as recommended by pharmacy and try that for several months. Patients will not be switched after a one month trial of Kadian/Oxycontin/MS Contin back to their short term narcotics without a long term trial of Kadian.
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