Develop a treatment plan which includes:
Objectives and criteria for measuring improvement in pain, functioning and other related issues such as insomnia, depression, and anxiety.
Additional therapies such as non-opioid medications or non-pharmacologic options being used. Consider using low-risk analgesics such as gabapentin for primary treatment as well as providing referrals for support groups and counseling.
Documentation of other evaluations, referrals or consultations in the medical record.
Implement a written informed consent and treatment agreement which outlines:
The risks, benefits, side effects, drug interactions as well as patient’s responsibility for safe usage, storage, and disposal of opioids.
The risk of opioid misuse, dependence, addiction, and overdose.
The limited evidence of the benefit of long-term opioid therapy.
Prescribing policies and expectations regarding the number and frequency of prescription refills, early refills and replacement of lost or stolen medications.
The patient’s agreement to obtain opioids from only one physician, practice, or pharmacy and consent to periodic drug testing.
The reasons for which therapy may be changed or discontinued, including failure to adhere to the policies in the treatment agreement.
Consider safer alternatives before initiating opioid therapy.
Initiate opioid therapy for a trial period (usually a maximum of 90 days) with a timeline for evaluating achievement of specific treatment goals.
Start opioid naive patients on the lowest possible dose and titrate as needed.
Consider starting with a short-acting opioid and switch to a long-acting or extended-release opioid if indicated.
Carefully evaluate the risks and benefits before continuing opioid therapy after the trial period
Regularly review, assess and document the results of the patient’s progress using:
The 5 A’s of chronic pain management (analgesia, activity, adverse effects, aberrant drug-taking behavior).
Assessment tools to measure pain and function such as the visual analog scale, the numeric scale, or the Pain, Enjoyment and General Activity (PEG) scale.
Conduct periodic drug testing to detect the use of non-prescribed drugs and determine adherence to the treatment plan. Discuss results with the patient and document them in the medical record.
Consider intermittent pill counting to reduce the risk of diversion.
Periodically review the PDMP to determine adherence to the treatment agreement.
Intervene if evidence or behaviors of misuse are found, such as:
The PDMP shows frequent early refills, opioids obtained from multiple physicians or pharmacies and multiple reports of lost or stolen prescriptions.
Drugs tests are positive for illicit or non-prescribed drugs.
Diversion or forgery of prescriptions, or the patient displays abusive or threatening behavior or shows signs of impairment.