Table 2: Components of a Risk Mitigation Plan • Developing an opioid management plan • Providing patient education • Screening urine for drugs • Reviewing PDMP data • Counting pills • Scheduling more frequent monitoring visits Identifying Opioid Use Disorder How does a physician diagnose addiction in the setting of chronic pain? A simplified but practical way to assess for signs of an OUD is the 4Cs framework: Table 3: 4Cs Framework** • Impaired control over pain medication use • Compulsive use • Continued use despite harms (consequences) • Craving ** American Academy of Family Physicians. Opioid prescribing for chronic pain. Accessed Jan. 11, 2021. • Identify a patient ’s existing or former substance use disorder via clinical interview 4C’s and DSM 5, collateral interview, medical records, and screenings prior to prescribing opioids for pain management. • Re-evaluate opioid prescriptions after non-fatal overdoses and discuss risks of continued use. For patients who have a history of substance use disorder, initiating opioid therapy referral to an addiction specialist or reviewing AAFP’s OUD practice manual can be helpful. These are tools, not a decision. When a patient presents with unexpected results after a urine drug screen or medication count, this should trigger a change in a treatment plan, i.e., more frequent follow-up, additional testing etc., not the discontinuation of care. Patients are more likely to disclose OUD when they know that you can help them. With the U.S. Department of Health and Human Services announcing the waiver exemption on April 27, 2021, family physicians are in a unique position to not only diagnose but treat OUD when it occurs with limited barriers in place. Having a systematic approach can increase patient safety, improve patient compliance, and increase patient and physician satisfaction. Chronic Pain| Continued from page 25 Safe Prescribing and Monitoring Nearly 70 percent of drug overdose deaths in 2018 involved opioids, with two-thirds of overdose deaths involving a synthetic opioid (excluding methadone). In addition to the risk of overdose, patients prescribed opioids for chronic pain are at an increased risk for developing an opioid use disorder (OUD). Safer opioid prescribing by physicians and other clinicians is effective at reducing the risk of OUD. In the 2019 National Survey on Drug Use and Health, 1.4 million persons abused or were dependent on prescription opioid pain medication. As Deborah Dowell, MD, and colleagues reported in the CDC’s Weekly Morbidity and Mortality Report announcing the guideline for prescribing opioids for chronic pain: “For example, a recent study of patients aged 15–64 years receiving opioids for chronic non-cancer pain and followed for up to 13 years revealed that one in 550 patients died from an opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from an opioid-related overdose.” With new guidelines and increased scrutiny, physicians may be hesitant to provide appropriate pain management with opioid medications. Developing a structured protocol for monitoring and compliance in your clinic can set clear expectations for patients and reduce frustrations for staff and physicians. This includes, but is not limited to, written procedures on the frequency of urine drug screens, PMP searches (staff or physician accesses*), medication count protocol, review of an opioid management plan, collaborative information, and taper procedures. Before increasing medication dosages, determine if a functional evaluation has been completed and documented and if this improves function or if this is considered palliative. (In Washington, a PMP query must be completed before the first refill or renewal of an opioid prescription; at each transition phase; periodically based on the patient ’s risk level; and when providing episodic care to a patient who you know to be receiving opioids for chronic pain.) Darlene Petersen, MD, is the Medical Director at Rock Run Family Medicine in Roy, UT. Brian Hunsicker, director of external affairs for the Washington AFP, contributed to this article. UtahAFP.org | 26
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