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Policies,Clinical,UW Health Clinical,Administrative,Legally Driven Care

Opiate Management for Chronic Non-Cancer Pain (1.2.3)

Opiate Management for Chronic Non-Cancer Pain (1.2.3) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.3


UW HEALTH CLINICAL POLICY 1
Policy Title: Opiate Management for Chronic Non-Cancer Pain
Policy Number: 1.2.3
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017

I. PURPOSE

The purpose of this policy is to establish a uniform and safe process for the evaluation, documentation,
monitoring, and oversight of chronic opioid therapy in patients with non-cancer pain. The exceptions to
this policy are patients being treated with opioids for cancer-related pain, terminally ill patients with a
prognosis of less than 6 months, and patients enrolled in a hospice program. In order to ensure the best
care for all patients at every point of access standards of care must be in place and consistently followed
across UW Health.

II. DEFINITIONS

A. Chronic Non-Cancer Pain: pain or discomfort that persists continuously or intermittently for longer than 3
months.

III. POLICY ELEMENTS

This policy applies to patients with chronic non-cancer pain who are prescribed chronic opioid therapy,
defined as lasting for 3 or more consecutive months, regardless of the total daily opioid dose. The only
exceptions to this policy are patients treated with opioids for cancer-related pain, terminally ill patients
with a prognosis of less than 6 months and patients enrolled in a hospice program.

All clinical staff involved in the care of patients on chronic opioid therapy will follow the procedures
outlined below.

Prior to the initiation of chronic opioid therapy all patients will have a thorough evaluation of the source
and nature of the pain.

All patients on or considered for chronic opioid therapy for 3 consecutive months or more will have a
documented treatment plan, periodic review and assessment of the plan, a signed controlled
substances medication agreement, periodic urine drug screening (UDS) and review and documentation
of the Wisconsin (or other state if appropriate) Prescription Drug Monitoring Program (PDMP).

When a surgeon or other specialty provider prescribes opioids to manage a patient’s pain and wish to
transition the patient back to a Primary Care Provider (PCP) for ongoing management they will review
the plan with the PCP prior to the transition.

IV. PROCEDURE

A. Documentation of Plan of Care and Problem List
Clear documentation in the patient’s problem list of Health Link by a UW Health provider is recommended to
allow other providers and staff to fully understand the plan of care.
Documentation to include:
i. Problem List
a. A diagnosis of chronic pain. Chronic Pain Syndrome [G89.4] or other Chronic Pain
b. The diagnosis/source of chronic pain
c. The information related to medications being prescribed:
1. Opioid medication name, strength and maximum quantity allowed per
prescription period
2. Date Controlled Substances Medication Agreement was signed
3. Name and location of designated pharmacy
4. Comments helpful to other care providers
5. Documentation of Wisconsin Prescription Drug Monitoring Program
(ePDMP) review (statement that review is complete, date of review,



UW HEALTH CLINICAL POLICY 2
Policy Title: Opiate Management
Policy Number: 1.2.3

identification of any inconsistencies/warning signs). The PDMP must be
reviewed prior to ordering any controlled substance for a therapy longer
than 3 days.
6. Appropriate documentation supporting reason for prescribing any daily dose
equal to or over 90 morphine milligram equivalents (MMEs).
d. The Problem List will be updated whenever the information above changes. Problem
List and WI PDMP Website must be reviewed and edited at least once annually.
ii. Provider assessment of the following:
a. Pain using the Brief Pain Inventory (BPI) or PEG-3 tool - to be completed at least
annually
b. Functional status using the Physical Functional Ability Questionnaire (FAQ-5),
validated questions within the BPI or PEG-3 (e.g. work vs. unemployed; on
disability; self-care; mobility; household activities; social activity; support) – to be
completed at least annually)
c. Depression risk using the Patient Health Questionnaire (PHQ2) and Patient Health
Questionnaire 9 (PHQ9) – to be completed at least annually.
d. Opioid aberrant use behavior risk using the D.I.R.E. assessment tool - to be completed at
least once).
iii. Treatment Plan/Plan of care for the patient. (refer to UW Health Management of Non-Malignant
Chronic Pain in Primary Care – Adult – Ambulatory Clinical Practice Guideline) Examples include:
a. Functional goals for treatment
b. Exercise
c. Non-pharmacologic interventions
d. Pharmacologic therapy (non-opioid medications)
iv. Other:
a. Contingency plan for treatment outside of prescriber’s office
B. Medication List
i. The medication list will be updated with each change in medication therapy.
ii. Outdated or discontinued treatments will be deleted.
iii. Clinicians will consider prescribing naloxone to patients who are at risk for overdose, as determined
by the prescribing clinician, due to: a) therapy with higher daily dose of opioids (>50 morphine-
equivalents/day); b) history of overdose; c) concurrent use of opioids and benzodiazepines (or
other sedating medications); d) diagnosis of an alcohol/drug use disorder; e) risk for returning to a
high-dose use of opioids after a period of non-use (e.g., person with opioid addiction after
release/discharge from monitored settings where opioids were not used).
C. Controlled Substances Medication Agreement
i. Required for all patients receiving chronic opioid therapy for chronic non-cancer pain for three
consecutive months or more.
ii. The Controlled Substances Medication Agreement will be used to establish and document the
expectations/responsibilities of both the prescriber and the patient. The Controlled Substances
Medication Agreement includes informed consent to opioid therapy.
iii. The Controlled Substances Medication Agreement will be reviewed by the provider with patients
and signed by the patient, including opportunities for questions and answers, at least once every
3 years. This should be documented in the plan of care. With each update a new, signed copy of
the Controlled Substances Medication Agreement will be scanned into Health Link and the
Controlled Substances FYI will be updated.
iv. Controlled Substances Medication Agreement needs to be reassessed when a new or
emergent transition of care occurs or there is a change in the patient’s health status.
v. Procedure for managing violations of the Controlled Substances Medication Agreement
a. Minor infractions – examples include a loss of prescriptions, early refills, missed
appointments, or some abnormal urine drug screen testing results.
1. The prescribing provider will contact patient for assessment and discussion of
violation(s). This communication cannot be delegated to the clinical staff.
2. The prescribing provider reassess treatment plan, and progress and addresses
reason for violation(s).
3. The Controlled Substances Medication Agreement will be reviewed
and modified as needed. An updated, signed version of the Controlled



UW HEALTH CLINICAL POLICY 3
Policy Title: Opiate Management
Policy Number: 1.2.3

Substances Medication Agreement will be obtained.
4. The prescribing provider documents the new plan of care.
b. Major infractions – examples include doctor shopping, diversion, forged prescriptions,
repeated minor infractions, some abnormal urine drug screen testing results
1. The prescribing provider will contact the patient for assessment and
discussion of violation(s). This communication cannot be delegated to the
clinical staff.
2. Provider may follow the steps outlined above in V.a. or if deemed appropriate
terminate controlled substance therapy.
3. The Department of Patient Relations will be notified of the situation so that
psychosocial barriers can be assessed and addressed and/or the
Department of Patient Relations can provide support to the clinic
staff/providers related to challenging interactions, developing behavior
contracts, etc
4. The Department of Pharmacy will be contacted by the prescribing provider
for placement of the CSA (Controlled Substance Alert) flag in the medical
record. For placement of the CSA refer to UW Health clinical policy #3.2.2,
Use of the Controlled Substance Alert Within the Medical Record.
5. When controlled substance therapy is discontinued, patients will be allowed to
continue non-opioid treatment (all other general and specialty care not relating
to controlled substances prescribing) through UW Health unless there are
reasons sufficient for care termination, such as a clear violation of the law (e.g.,
forged prescription), evidence of diversion (police reports needed), or there has
been an irreparable breach in the provider-patient relationship. When
considering termination of all care, a No Further Service determination has to
be made in accordance with the UW Health clinical policy #1.2.6, No Further
Service. The Department of Patient Relations will be contacted for assistance
when care termination is considered.
c. If medication misuse (i.e. use for reasons other than for which prescription was
intended) or a substance use disorder is suspected, then steps for referral to addiction
specialist services should be initiated immediately. (Refer to UW Health Management
of Non-Malignant Chronic Pain in Primary Care – Adult – Ambulatory Clinical Practice
Guideline) Medication diversion is often difficult to differentiate from misuse or a
substance use disorder. Addiction specialist services may be considered to assist in
this ascertainment.
1. Alternative therapy and therapeutic taper will be considered if safe and
appropriate, until patient establishes addiction and a clear plan is in place to
modify the existing therapy.
2. Care of the patient should not be terminated unless there are reasons
sufficient for care termination. (See UW Health clinical policy #1.2.6, No
Further Service, section v.b.5.)
d. Communication with the patient’s other treating providers should be maintained
throughout this process to ensure that they are aware of the changed plan of care,
which should also be clearly documented in the patient’s medical record. Such
documentation should be easily found in the patient’s Problem List within the electronic
health record.
vi. A Controlled Substances Medication Agreement can be discontinued when a patient is no
longer being prescribed opioids. Documentation of reason for discontinuation and date will
be placed in the Controlled Substances FYI pertaining to the agreement and deactivation.
Provider is responsible for notifying the patient that the medication agreement has been
discontinued.
D. Urine Drug Screen (UDS)
i. All patients on chronic opioid therapy will have a urine drug screen at least once per year. The Pain
Management profile is the preferred urine drug screening test and should always be used in
suspicious situations.
ii. UDS should be performed more frequently if there are questions of abuse/misuse or diversion.
iii. Unexpected results should be submitted for confirmatory testing.



UW HEALTH CLINICAL POLICY 4
Policy Title: Opiate Management
Policy Number: 1.2.3

E. Prescription Refills
i. All prescriptions if mailed, called, or faxed will be to ONE agreed upon pharmacy.
ii. If a prescription hardcopy needs to be mailed, it should be mailed directly to the pharmacy.
iii. All patients with a Controlled Substances Medication Agreement will sign a release designating
him/herself or an appointee to pick up prescriptions for controlled substances. Any individual
picking up prescriptions must present a photo ID.
F. Periodic Review and Assessment
i. ALL patients with non-cancer pain who are treated with chronic opioid therapy must be evaluated
by the opioid prescriber at least once a year, and must be assessed by a clinician outside of that
prescriber evaluation visit at least once a year to discuss chronic pain management. During the
reassessment the provider will document in the patient’s Problem List:
a. Provider assessment of the following:
1. Pain using the Brief Pain Inventory (BPI) or the PEG-3 tool - to be completed at
least annually).
2. Functional status using the Physical Functioning Ability Questionnaire (FAQ-5),
validated questions within the BPI or PEG-3 (e.g., work vs. unemployed; on
disability; self-care; mobility; household activities; social activity; support) - to be
completed at least annually.
3. Depression risk using the Patient Health Questionnaire 2 (PHQ2) and Patient
Health Questionnaire 9 (PHQ9) - to be completed at least annually.
b. Confirm and update the medication list as needed.
c. Any changes to the Treatment Plan/Plan of care for the patient.
d. Any changes to the contingency plan for treatment outside of PCP-office.

V. FORMS

Controlled Substances Medication Agreement (Appendix A)
Tools and Support for Challenging Situations
Controlled Substance Alert Report Form

VI. COORDINATION

Author(s): Vice Chair, Clinical Care - DFM
Senior Management Sponsor: UW Health Chief Clinical Officer
Reviewers: Risk Management; UW Health Legal Department; Medical Director, Ambulatory Clinic
Operations; Medical Director, Pain Services
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several
entities. This policy applies to facilities and programs operated by the University of Wisconsin Hospital
and Clinics and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and
programs administered by the University of Wisconsin School of Medicine and Public Health. Each entity
is responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

UW Health Management of Non-Malignant Chronic Pain in Primary Care – Adult – Ambulatory Clinical
Practice Guideline



UW HEALTH CLINICAL POLICY 5
Policy Title: Opiate Management
Policy Number: 1.2.3

UW Health clinical policy #3.5.5, Pain Management
UW Health clinical policy #1.2.6, No Further Service
Pharmacy departmental policy #7.6, Documentation of Controlled Substances in UWHC Clinics
UW Health clinical policy #3.2.2, Use of the Controlled Substance Alert Within the Medical Record
UW Health Naloxone Rescue Kit for Opioid Overdose – Adult – Ambulatory [126] Delegation Protocol

IX. REVIEW DETAILS

Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020