Section 20-2-VII - Managing Patients Placed on Long-Term OpioidsA.Psychological EvaluationPatients who are placed on long-term opioids (3 months) should undergo a psycho-social evaluation, including formal psychological testing by a psychologist with a Ph.D. or a physician with the appropriate credentials, as well as consideration for a concomitant interdisciplinary rehabilitation treatment. It is preferable that these professionals have experience in diagnosing and treating chronic pain conditions and that patients thoroughly under-stand the need to pursue pain management techniques in addition to medication use in order to function with chronic pain.
B.Contraindications to Prescribing Opioids beyond Three Months1. Opioids should be discontinued if the patient did not meet the goals to improve pain and function - particularly the functional goals - that were formulated when opioids were initiated.2. Opioids should be discontinued if a psychological evaluation deems the patient a high-risk candidate for the use of controlled substances.3. Opioids should be discontinued if they have not reduced the patient's subjective pain complaints by 30%, at a minimum.4. Opioids should be discontinued if a patient cannot perform at least a sedentary level of work because of sedentary pain complaints. A patient may still be disabled from underlying significant objective physical abnormalities (i.e. severe neurologic deficit, loss of limb, severe structural orthopedic abnormalities, etc.). 5. Opioids should be discontinued if the patient cannot function secondary to side effects from the medication. 6. Opioids should be discontinued if the patient refuses non-interventional treatment options that might improve physical functioning and pain levels (i.e. physical therapy, cognitive behavioral therapy).7. Opioids should be discontinued if the patient shows significant nonorganic behaviors, such as strongly positive Waddell's signs.8. Opioids should be discontinued: a. when the patient receives prescriptions from more than one practitioner; orb. when the patient has inconsistent drug screens, absent extenuating circumstances. Prior to discontinuation of the opiate, a confirmation GCMS drug screen must be done on the sample to ensure that a false-positive or false-negative has not occurred.9. If there are extenuating circumstances which lead a clinician to believe an opioid should be continued despite one of the above contraindications, these must be clearly documented.C.Before Starting Chronic Opioid TherapyBefore starting opioid therapy for chronic pain, clinicians should:
1. review the patient's history of controlled substance prescriptions using the state Prescription Drug Monitoring Program and make the review part of the medical record;2. conduct urine drug testing;3. establish treatment goals with the patient, including specific goals for improvements in pain and function, as the goal of treatment is to improve both;4. discuss how opioid therapy will be discontinued when risks outweigh benefits, as opioid therapy should continue only if there is a clinically meaningful improvement in pain and function that outweighs the risks of this treatment; and,5. educate patients regarding the potential risks and benefits of use of chronic opioids.D.When Starting Chronic Opioid TherapyWhen initialing opioids for chronic pain, clinicians should:
1. prescribe immediate-release opioids rather than extended-release opioids;2. use the lowest effective dose;3. avoid prescribing opioid and benzodiazepines concurrently whenever possible;4. require an opioid contract with the patient that details the clinician's expectation that the patient will comply with the prescribed medication regimen. Opioids should be terminated if the contract is broken. Examples include but are not limited to: a. diversion of medication;b. noncompliance with drug dosing schedule; c. a drug screen that shows use of drugs outside of the prescribed treatment or evidence of noncompliant use of prescribed medications;d. a request for prescriptions outside of the defined time frame; ande. excessive dose escalation without physician approval.E.Continuing Chronic Opioid TherapyWhen continuing opioids for chronic pain more than three months, clinicians should:
1. conduct an ongoing review and clearly document: a. improvements in the patient's pain relief and functional status, as well as the patient's appropriate medication use and side effects, andb. the patient's clinical status, including physical examination. (i.e. range of motion, neurologic exam, spasm, etc.) on each visit. Use of cut and paste EMR records which result in identical histories and physical examinations on each visit shall not meet this criteria; 2. Clinicians shall conduct random drug screens at least two times a year. Monthly drug screens are not indicated as they are by definition not random. If more than two drug screens are done in one calendar year, the clinician must clearly document why additional testing was required;3. Clinicians shall review the patient's history on the Prescription Drug Monitoring Program whenever opiates are prescribed. The review (or the attempt to review the PMP if it cannot be accessed due to technical difficulties) should be documented or made part of the medical record.F.Escalating Opioid Dosage During Treatment1. Before escalating opioid dosing, the clinician shall review the effectiveness of opioid treatment. Some degree of tolerance can be anticipated, but opioid therapy should be discontinued if dose escalations fail to recapture previous pain relief or restore function.2. If the clinician escalates opioid dosing, the treatment goals of analgesic and especially functional improvement shall be specifically stated and clearly documented.20 Miss. Code. R. § 2-VII