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Washington PainManagement Law    Jonathan Ploudré          2011
House Bill 2876
NEJM: Nov 2010
NEJM: Nov 2010
Referral Dose• Morphine: 120mg daily• Methadone: 40mg daily• Oxycodone: 80mg daily• Hydrocodone: 120mg daily• Hydromorphon...
Referral Exclusions• Pain Types: Acute Injury/Post-op,  Palliative, Hospice.• Patient-specific: Stable Non-escalating,  On ...
Let’s Educate!               • AAFP President says, “No” (8/24/2011)               • Diversion accounts for >60% of deaths...
Diversion Screening        Tool
House Bill 2876
?House Bill 2876
Bias
Limbic TiltScrooge                 Tiny Tim
Trust     Trust no one.God Bless us, every one.
Control  Verify Everything. Merry Christmas, Sir.
Where are you?
Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
Basic History• Previous Workup• Previous Treatments (Dose, etc)• (Review Prescription Monitoring Program)• Nature/Location...
Basic History• Previous Workup• Previous Treatments (Dose, etc)• (Review Prescription Monitoring Program)• Nature/Location...
Basic History• Previous Workup     Verify First.              Get records before starting.• Previous Treatments (Dose,no s...
Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
“Framingham of Risk”
Risk Stratification              Etiology       Clear           Unclear              Psych          No Hx           Unstabl...
Risk Stratification              Etiology       Clear           Unclear              Psych          No Hx           Unstabl...
Risk Stratification              Etiology       Clear                                 Patients with no Unclear still       ...
Risk Stratification              Etiology       Clear                                 Patients with no Unclear still       ...
Opioid Risk Tool (ORT)                               Opioid Risk Tool                                                     ...
Opioid Risk Tool                Name                                Opioid Risk Tool (ORT)                                ...
Opioid Risk Tool                Mark each box that applies                                            Female   Male       ...
Opioid Risk Tool                Mark each box that applies                                            Female   Male       ...
Depression ScreeningInteragency Guidelines Preferred: PHQ-9
Alcohol Screening    CAGE adjusted to include drugs•   Have you ever felt you ought to cut down on your drinking    or dru...
Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
Informed Consent• Risks/Benefits• Alternatives• Risks of non-treatment
Informed Consent                   Consent improves                consideration of risks and                      alterna...
Informed Consent•            Provider Bias can show up in  Risks/Benefits               how consent is performed.• Alternat...
Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
Treatment Plan• Improve Function
Treatment Plan                 Get back to work.                   (Biomedical)• Improve Function
Treatment Plan                    Get back to work.                      (Biomedical)• Improve Function Mood, Sleep.      ...
How would we know              that this is working for              you without using the              word ‘pain’?Mark S...
Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
Starting Opioids                ?• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• ...
Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
The 5 A’s                 • Analgesia                 • Adverse Reactions                 • ADLs Improved                 ...
Chronic Pain Opioid FollowupCurrent Analgesic Regimen: ___________________________________________________________________...
ADLs (Function)Surprisingly ReproducibleValidated across culture                          8-10/10                         ...
Pain Interference
Adverse Reactions• Nausea/Vomiting• Constipation• Itching• Mental Cloudiness• Sweating• Fatigue• Drowsiness
Adverse Reactions• Nausea/Vomiting• Constipation      “The hand that writes the prescription                 should write ...
Chronic Pain Opioid FollowupCurrent Analgesic Regimen: ___________________________________________________________________...
Chronic Pain Opioid FollowupCurrent Analgesic Regimen: ___________________________________________________________________...
Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
The Document• Contract or Agreement?• Universal or High-Risk?• Reading Level?
The Document                  I like 12 page contracts                written at 15th grade level in• Contract or Agreemen...
NCFP Treatment                                 Agreement                 • Preferred Brief/Simple over complete/legal.    ...
NCFP Treatment                                 Agreement                 • Preferred Brief/Simple over complete/legal.    ...
You are being prescribed controlled or potentially addictive medications for thetreatment of pain or other health problems...
How’d we do?• 1 page Document (not 10!)            B+• 10th grade reading level (could be  improved)• 1 minute 45 seconds ...
I am being prescribed "controlled medications". These may relieve pain but could causeoverdose or become habit forming. It...
Updated Agreement• 8th grade reading level• 1 minute 15 seconds to read.• We need consensus before we change it.
Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
Urine Toxicology   ~⅓ Addicts missed if you only   look at aberrant behavior.   Self-report of illicit drug use is   unrel...
Urine Toxicology   Increases Cost.   If not careful, can be easy to   mis-interpret.   Can still be tricked — limits to   ...
Google: Employee Drug Testing Ace 12 panel                                             The i-Cup
Point of Care Utox• The ‘iCup’ costs ~$9.• Photocopyable results.• Tests: illicit (cocaine, THC, amphetamine,  Meth, PCP) ...
If only it were that      simple…
Point of Care Limits• Low Sensitivity and Specificity (needs  confirmation in high risk situations)• Cross Reactions cause f...
How to Collect?                 • AAFP Article 2010: Take off outer clothing,                       show what’s in your po...
How to Collect?• AAFP ArticleEven with precautions, these               2010: Take off outer clothing,  show what’s in you...
How to Collect?• What’s your pre-test probability?
False Positives                  • Amphetamines: Buproprion, Propranolol,                        Trazadone …              ...
False Positives• Amphetamines: Buproprion, Propranolol,  Trazadone …• Barbituates: Phenytoin• Benzos: Sertraline, …• LSD: ...
False Negatives• Compliance Caveat: Many opiates are not  well detected with routine urine tox.  Fentanyl, meperidine,Hydr...
Confirmation Tests• More expensive (~$40 each, may need to  do several to clarify based on drug  metabolism)
Just Skip Urine Tox?• Standard of care in Interagency Guidelines.• Standard of care in MQAC
NCFP UTox Policy?           Goes Right Here…
Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
Monitoring Opioids                 ?• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
Consider the 2007 DEA Ruling on Sequential       Prescribing.“Do Not Fill until __/__/__”Allows 90 day prescription of    ...
NCFP ToDo List• Create Initial Chronic Pain Template.• Include Screening Tools in Initial Template.• Update Treatement Agr...
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Washington Pain Law 2011

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An overview of implementing the new Washington Pain Law for a family medicine practice.

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  • Transcript of "Washington Pain Law 2011"

    1. 1. Washington PainManagement Law Jonathan Ploudré 2011
    2. 2. House Bill 2876
    3. 3. NEJM: Nov 2010
    4. 4. NEJM: Nov 2010
    5. 5. Referral Dose• Morphine: 120mg daily• Methadone: 40mg daily• Oxycodone: 80mg daily• Hydrocodone: 120mg daily• Hydromorphone: 30mg daily• Oxymorphone: 40mg daily
    6. 6. Referral Exclusions• Pain Types: Acute Injury/Post-op, Palliative, Hospice.• Patient-specific: Stable Non-escalating, On taper, acute flare with expectation of return to baseline.• Provider-specific: 12 hours CME every 2 years with 2 hours long acting opioids.
    7. 7. Let’s Educate! • AAFP President says, “No” (8/24/2011) • Diversion accounts for >60% of deaths. • AAFP: This could reduce access to pain management for patients.ow.ly/1eogjV
    8. 8. Diversion Screening Tool
    9. 9. House Bill 2876
    10. 10. ?House Bill 2876
    11. 11. Bias
    12. 12. Limbic TiltScrooge Tiny Tim
    13. 13. Trust Trust no one.God Bless us, every one.
    14. 14. Control Verify Everything. Merry Christmas, Sir.
    15. 15. Where are you?
    16. 16. Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
    17. 17. Basic History• Previous Workup• Previous Treatments (Dose, etc)• (Review Prescription Monitoring Program)• Nature/Location of Pain• Impact of physical/psychological function• Respiratory Risks? (OSA, COPD)
    18. 18. Basic History• Previous Workup• Previous Treatments (Dose, etc)• (Review Prescription Monitoring Program)• Nature/Location of Pain• Impact of physical/psychological function• Respiratory Risks? (OSA, COPD)
    19. 19. Basic History• Previous Workup Verify First. Get records before starting.• Previous Treatments (Dose,no start?) (What if there’s etc)• (Review Prescription Monitoring Program)• Nature/Location of Pain• Impact of physical/psychological function• Respiratory Risks? (OSA, COPD)
    20. 20. Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
    21. 21. “Framingham of Risk”
    22. 22. Risk Stratification Etiology Clear Unclear Psych No Hx Unstable Mood Addiction No Hx Active Addiction Medical No Comorbidities COPD, OSA Social Good Support Isolated/Chaos Activity Work/Hobbies No Work/HobbiesAdapted: Stephen Passik
    23. 23. Risk Stratification Etiology Clear Unclear Psych No Hx Unstable Mood Addiction No Hx Active Addiction Medical No Comorbidities COPD, OSA Social Good Support Isolated/Chaos Activity Work/Hobbies No Work/HobbiesAdapted: Stephen Passik
    24. 24. Risk Stratification Etiology Clear Patients with no Unclear still risk can divert or abuse prescriptions Psych No Hx Unstable Mood Addiction No Hx Active Addiction Medical No Comorbidities COPD, OSA Social Good Support Isolated/Chaos Activity Work/Hobbies No Work/HobbiesAdapted: Stephen Passik
    25. 25. Risk Stratification Etiology Clear Patients with no Unclear still risk can divert or abuse prescriptions Psych No Hx Unstable Mood Addiction No Hx Active Addiction Medical No Comorbiditiesmany risksOSA Patients with COPD, still need care. Refer to a specialist. Social Good Support Isolated/Chaos Activity Work/Hobbies No Work/HobbiesAdapted: Stephen Passik
    26. 26. Opioid Risk Tool (ORT) Opioid Risk Tool Patient Form Name Date Mark each box that applies Female Male 1. Family history of substance abuse ! Alcohol [ ] [ ] ! Illegal drugs [ ] [ ] ! Prescription drugs [ ] [ ] 2. Personal history of substance abuse ! Alcohol [ ] [ ] ! Illegal drugs [ ] [ ] ! Prescription drugs [ ] [ ] 3. Age (mark box if 16-45 years) [ ] [ ] 4. History of preadolescent sexual abuse [ ] [ ] 5. Psychological disease ! Attention-deficit/ hyperactivity disorder, obsessive- compulsive disorder, bipolar disorder, schizophrenia [ ] [ ] ! Depression [ ] [ ]Webster, 2005. Recommended Tool by Interagency Guidelines. Copyright © Lynn R. Webster, MD. Used with permission.
    27. 27. Opioid Risk Tool Name Opioid Risk Tool (ORT) Physician Form With Item Values to Determine Risk Score Date Mark each box that applies Female Male 1. Family history of substance abuse ! Alcohol [ ] 1 [ ] 3 ! Illegal drugs [ ] 2 [ ] 3 ! Prescription drugs [ ] 4 [ ] 4 2. Personal history of substance abuse ! Alcohol [ ] 3 [ ] 3 ! Illegal drugs [ ] 4 [ ] 4 ! Prescription drugs [ ] 5 [ ] 5 3. Age (mark box if 16-45 years) [ ] 1 [ ] 1 4. History of preadolescent sexual abuse [ ] 3 [ ] 0 5. Psychological disease ! Attention-deficit/ hyperactivity disorder, obsessive- compulsive disorder, bipolar disorder, schizophrenia [ ] 2 [ ] 2 ! Depression [ ] 1 [ ] 1 Low (0-3) Moderate (4-7) High (≥8) Scoring totals [ ] [ ] OR Aberrant Behaviors: Low 0.08, Mod 0.57, High 14.3 Copyright © Lynn R. Webster, MD. Used with permission.Webster, 2005
    28. 28. Opioid Risk Tool Mark each box that applies Female Male 1. Family history of substance abuse ! Alcohol [ ] 1 [ ] 3 ! Illegal drugs [ ] 2 [ ] 3 ! Prescription drugs [ ] 4 [ ] 4 2. Personal history of substance abuse ! Alcohol [ ] 3 [ ] 3 ! Illegal drugs [ ] 4 [ ] 4 ! Prescription drugs [ ] 5 [ ] 5 3. Age (mark box if 16-45 years) [ ] 1 [ ] 1 4. History of preadolescent sexual abuse [ ] 3 [ ] 0 5. Psychological disease ! Attention-deficit/ hyperactivity disorder, obsessive- compulsive disorder, bipolar disorder, schizophrenia [ ] 2 [ ] 2 ! Depression [ ] 1 [ ] 1 Low (0-3) Moderate (4-7) High (≥8) Scoring totals [ ] [ ] OR Aberrant Behaviors: Low 0.08, Mod 0.57, High 14.3Webster, 2005
    29. 29. Opioid Risk Tool Mark each box that applies Female Male 1. Family history of substance abuse ! Alcohol [ ] 1 [ ] 3 ! Illegal drugs [ ] 2 [ ] 3 ! Prescription drugs [ ] 4 [ ] 4 2. Personal history of substance abuse ! Alcohol [ ] 3 [ ] 3 ! Illegal drugs [ ] 4 [ ] 4 ! Prescription drugs [ ] 5 [ ] 5 3. Age (mark box if 16-45 years) [ ] 1 [ ] 1 Pain Center Study: Might 4. History of preadolescent sexual abuse [ ] 3 [ ] 0 5. Psychological disease overestimate aberrant ! Attention-deficit/ hyperactivity behaviors disorder, obsessive- compulsive disorder, bipolar disorder, schizophrenia [ ] 2 [ ] 2 ! Depression [ ] 1 [ ] 1 Low (0-3) Moderate (4-7) High (≥8) Scoring totals [ ] [ ] OR Aberrant Behaviors: Low 0.08, Mod 0.57, High 14.3Webster, 2005
    30. 30. Depression ScreeningInteragency Guidelines Preferred: PHQ-9
    31. 31. Alcohol Screening CAGE adjusted to include drugs• Have you ever felt you ought to cut down on your drinking or drug use?• Have people annoyed you by criticizing your drinking or drug use?• Have you ever felt bad or guilty about your drinking or drug use?• Have you ever had a drink or used drugs first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?
    32. 32. Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
    33. 33. Informed Consent• Risks/Benefits• Alternatives• Risks of non-treatment
    34. 34. Informed Consent Consent improves consideration of risks and alternatives.• Risks/Benefits• Alternatives Consent can be used as a• Risks of non-treatment treatment barrier to
    35. 35. Informed Consent• Provider Bias can show up in Risks/Benefits how consent is performed.• Alternatives• Risks of non-treatment
    36. 36. Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
    37. 37. Treatment Plan• Improve Function
    38. 38. Treatment Plan Get back to work. (Biomedical)• Improve Function
    39. 39. Treatment Plan Get back to work. (Biomedical)• Improve Function Mood, Sleep. Patient-centered: Physical, Social, (Biopsychosocial)
    40. 40. How would we know that this is working for you without using the word ‘pain’?Mark Sullivan, University of Washington
    41. 41. Starting Opioids• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
    42. 42. Starting Opioids ?• Complete the database (5Ws and H)• Screen various risks for opioids• Informed Consent• Treatment Plan
    43. 43. Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
    44. 44. The 5 A’s • Analgesia • Adverse Reactions • ADLs Improved • Aberrant Behaviors • AssessmentStephen Passik
    45. 45. Chronic Pain Opioid FollowupCurrent Analgesic Regimen: _____________________________________________________________________________________________________________ Analgesia Improved ADLs What was your average pain over the past Physical Functioning week? Family Relationships Social Relationships What was your worst pain in the past week? Mood What percentage of your pain has been re- Sleep patterns lieved during the past week? Overall Function Is the amount of pain relief you are now get- ting enough to make a real difference in your life? Adverse Reactions Aberrant Behaviors Nausea Purposeful Over-sedation Vomiting Negative mood change Constipation Appears intoxicated Itching Increasingly unkempt or impaired Mental Cloudiness Involvement in car or other accidents Sweating Requests for frequent early renewals Fatigue Increasing dose without authorization Drowsiness Reports lost/stolen prescriptions Prescriptions from other doctors Changes route of administration Uses medications in response to situa- tional stressors Insists on certain medications by name Contact with street drug culture Abusing alcohol or illicit drugs Hoarding (Stockpiling) of medication Arrested by police or Victim of abuseAssessment:Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient. Continue Same Dose Titrate Dose Discontinue/Taper Change Medications
    46. 46. ADLs (Function)Surprisingly ReproducibleValidated across culture 8-10/10 6-7/10 General Activities 5/10 Relationships Relationships Walking Walking 3-4/10 Work Work Work Sleep Sleep Sleep Enjoyment Enjoyment Enjoyment Enjoyment Overall Mood Overall Mood Overall Mood Overall Mood
    47. 47. Pain Interference
    48. 48. Adverse Reactions• Nausea/Vomiting• Constipation• Itching• Mental Cloudiness• Sweating• Fatigue• Drowsiness
    49. 49. Adverse Reactions• Nausea/Vomiting• Constipation “The hand that writes the prescription should write for something for constipation.”• Itching• Mental Cloudiness• Sweating• Fatigue• Drowsiness
    50. 50. Chronic Pain Opioid FollowupCurrent Analgesic Regimen: _____________________________________________________________________________________________________________ Analgesia Improved ADLs What was your average pain over the past Physical Functioning week? Family Relationships Social Relationships What was your worst pain in the past week? Mood What percentage of your pain has been re- Sleep patterns lieved during the past week? Overall Function Having a standard group of Is the amount of pain relief you are now get- ting enough to make a real difference in your life? Adverse Reactions aberrant behaviors can aid a Aberrant Behaviors Nausea Vomiting team approach to monitoring Purposeful Over-sedation Negative mood change Constipation Appears intoxicated Itching Increasingly unkempt or impaired Mental Cloudiness Involvement in car or other accidents Sweating Requests for frequent early renewals Fatigue Increasing dose without authorization Drowsiness Reports lost/stolen prescriptions Prescriptions from other doctors Changes route of administration Uses medications in response to situa- tional stressors Insists on certain medications by name Contact with street drug culture Abusing alcohol or illicit drugs Hoarding (Stockpiling) of medication Arrested by police or Victim of abuseAssessment:Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient. Continue Same Dose Titrate Dose Discontinue/Taper Change Medications
    51. 51. Chronic Pain Opioid FollowupCurrent Analgesic Regimen: _____________________________________________________________________________________________________________ Analgesia Improved ADLs What was your average pain over the past Physical Functioning week? Family Relationships Social Relationships What was your worst pain in the past week? Mood What percentage of your pain has been re- Sleep patterns lieved during the past week? Overall Function Is the amount of pain relief you are now get- ting enough to make a real difference in your life? Adverse Reactions Aberrant Behaviors Nausea Purposeful Over-sedation Vomiting Constipation It’s Not what Negative mood change Appears intoxicated you do but Itching Increasingly unkempt or impaired Mental Cloudiness Involvement in car or other accidents Sweating Requests for frequent early renewals what you Fatigue Increasing dose without authorization Drowsiness Reports lost/stolen prescriptions Prescriptions from other doctors document. Changes route of administration Uses medications in response to situa- tional stressors Insists on certain medications by name Contact with street drug culture Abusing alcohol or illicit drugs Hoarding (Stockpiling) of medication Arrested by police or Victim of abuseAssessment:Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient. Continue Same Dose Titrate Dose Discontinue/Taper Change Medications
    52. 52. Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
    53. 53. The Document• Contract or Agreement?• Universal or High-Risk?• Reading Level?
    54. 54. The Document I like 12 page contracts written at 15th grade level in• Contract or Agreement?10 point type.• Universal or High-Risk?• Reading Level I(if College-level OK?”. just say “Be Nice, are you really enabling care?)
    55. 55. NCFP Treatment Agreement • Preferred Brief/Simple over complete/legal. • Preferred low readability requirement • Reviewed Evidence about Treatment Agreements. • Preferred ‘Non-paternalistic’ tone.Sloane Winkes, Jonathan Ploudré, 2007
    56. 56. NCFP Treatment Agreement • Preferred Brief/Simple over complete/legal. • Preferred low readability requirement • Is this a barrier to care? No Reviewed Evidence about Treatment evidence of efficacy. No ‘Best Agreements. Practice’. Highly Variable. • Preferred ‘Non-paternalistic’ tone.Sloane Winkes, Jonathan Ploudré, 2007
    57. 57. You are being prescribed controlled or potentially addictive medications for thetreatment of pain or other health problems. These may include medications that can behabit-forming. It is our legal responsibility as health care providers, and our responsibilityto you, to do our best to assure that this medication is being used as safely as possibleand for the purpose for which it is intended.1. I will take my medications only as prescribed. I will not share them with or sell themto anyone else. I will not use recreational or illegal drugs.2. My doctor may verify this with periodic pharmacy checks, urine drug screens, and/ordiscussion with other health care providers.3. I will ask for refills only from my primary doctor and will use only one pharmacy.4. I will request refills only when due and realize that processing refill requests maytake 3 working days and may require an office visit.5. I will not seek pain medications from the ER or Urgent Care unless there is a new,acute problem that requires a small supply of medications until I can see my primarydoctor.6. I will avoid requesting pain medications outside of regular clinic hours.7. I realize that my doctor may not replace lost or stolen medications or prescriptions.8. I will treat North Cascade Family Physicians doctors, nurses and staff with courtesyand expect to be treated with courtesy in return. Failure to do so will result in dismissalfrom this clinic.9. The following behaviors, which may include an abnormal urine drug screen, abusivebehavior toward staff, selling medications or forging a prescription, in addition to abuse orviolation of this agreement and the medication(s) it applies to may result in dismissal fromNorth Cascade Family Physicians and you will receive no further controlledmedication(s).
    58. 58. How’d we do?• 1 page Document (not 10!) B+• 10th grade reading level (could be improved)• 1 minute 45 seconds to read.• MQAC: Add safeguarding. Other additions.
    59. 59. I am being prescribed "controlled medications". These may relieve pain but could causeoverdose or become habit forming. It is my doctors duty to make sure thesemedications are being used as safely as possible and as intended.• I will ask for refills only from my primary doctor. I will use only one pharmacy.• I will take my medications only as prescribed.• I will not share them or sell them to anyone. I will safeguard prescriptions.• I will not abuse alcohol, recreational or illegal drugs.• My doctor may check on me by calling pharmacies or doing drug tests. My doctor may discuss my medications with my other providers. Other providers may also report violations back to my personal doctor. My doctor could even contact the authorities if illegal activities are suspected.• My refills may take 3 working days and might require an office visit. I will not request refills after hours.• I will not seek pain medications from the ER or Urgent Care unless there is a new, acute problem. Then I will only get a small supply until I can see my primary doctor.• My doctor may not replace lost or stolen prescriptions. My doctor may not refill medications early if I run out.• I may be dismissed from the clinic or have my medications stopped if there is a major problem. Major problems include abnormal drug test results, abusive behavior toward staff, selling medications or forging a prescription.
    60. 60. Updated Agreement• 8th grade reading level• 1 minute 15 seconds to read.• We need consensus before we change it.
    61. 61. Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
    62. 62. Urine Toxicology ~⅓ Addicts missed if you only look at aberrant behavior. Self-report of illicit drug use is unreliable. Limited evidence shows could reduce aberrant behaviors.
    63. 63. Urine Toxicology Increases Cost. If not careful, can be easy to mis-interpret. Can still be tricked — limits to ‘hard science’, sooner or later it comes back to trust.
    64. 64. Google: Employee Drug Testing Ace 12 panel The i-Cup
    65. 65. Point of Care Utox• The ‘iCup’ costs ~$9.• Photocopyable results.• Tests: illicit (cocaine, THC, amphetamine, Meth, PCP) other prescription misuse (benzo, barbituates, tri-cyclics) and opiates (opiates, Methadone, Oxycodone, Propoxyphene.• Most drugs detected in last 1-3 days.• Temperature Strip, Checks 3 Adulterants.
    66. 66. If only it were that simple…
    67. 67. Point of Care Limits• Low Sensitivity and Specificity (needs confirmation in high risk situations)• Cross Reactions cause false positives• False Negatives due to higher thresholds.
    68. 68. How to Collect? • AAFP Article 2010: Take off outer clothing, show what’s in your pockets, wash hands under supervision, place bluing agent in toilet and turn off water supply to the testing site. • Mayo Clinic Proceedings: If adulteration is suspected or results fall outside these ranges, another specimen should be collected under direct, observed supervisionGoogle: “AAFP Urine Drug Screening”, “Mayo Proceedings Urine Drug”
    69. 69. How to Collect?• AAFP ArticleEven with precautions, these 2010: Take off outer clothing, show what’s in your pockets, wash hands under supervision, still be bluing agent if test can place evaded. Easily in you use Google. toilet and turn off water supply to the testing site.• Mayo Clinic Proceedings: If adulteration is suspected or results fall outside these ranges, another specimen should be collected under direct, observed supervision
    70. 70. How to Collect?• What’s your pre-test probability?
    71. 71. False Positives • Amphetamines: Buproprion, Propranolol, Trazadone … • Barbituates: Phenytoin • Benzos: Sertraline, … • LSD: Amitriptyline, Doxepin, Reglan, Sertraline, Verapamil, … • PCP: Dextromethorphan, … • Propoxyphene: Methadone, Doxylamine, …Google: “Mayo Proceedings Urine Drug” for complete list
    72. 72. False Positives• Amphetamines: Buproprion, Propranolol, Trazadone …• Barbituates: Phenytoin• Benzos: Sertraline, …• LSD: Amitriptyline, Doxepin, Reglan, If you’re not careful with confirmation, false positives Sertraline, Verapamil, … can disrupt therapy and trust.• PCP: Dextromethorphan, …• Propoxyphene: Methadone, Doxylamine, …
    73. 73. False Negatives• Compliance Caveat: Many opiates are not well detected with routine urine tox. Fentanyl, meperidine,Hydrocodone, methadone, oxycodone, buprenorphene, and tramadol.
    74. 74. Confirmation Tests• More expensive (~$40 each, may need to do several to clarify based on drug metabolism)
    75. 75. Just Skip Urine Tox?• Standard of care in Interagency Guidelines.• Standard of care in MQAC
    76. 76. NCFP UTox Policy? Goes Right Here…
    77. 77. Monitoring Opioids• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
    78. 78. Monitoring Opioids ?• Documentation Tool (5 A’s)• Treatment Agreement• Urine Toxicology
    79. 79. Consider the 2007 DEA Ruling on Sequential Prescribing.“Do Not Fill until __/__/__”Allows 90 day prescription of Schedule II Opioids. The Glam Shot
    80. 80. NCFP ToDo List• Create Initial Chronic Pain Template.• Include Screening Tools in Initial Template.• Update Treatement Agreement• Create a Utox process• Create capability to interpret abnormal Utox screens.
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