1. The physician performs a detailed reevaluation of the patient’s history and a physical as soon as possible after the 90-day threshold is reached.
2. The patient completes an objective pain assessment tool.
3. The physician performs a risk of substance abuse assessment. The physician should consider the use of appropriate baseline urine drug testing if the risk assessment or other evidence indicates there may be issues with the use of other drugs or with compliance with prescribed treatment.
4. The physician tailors a diagnosis and treatment plan with functional goals at the initial 90-day threshold visit and every 60 to 90 days.
5. At each threshold visit:
•The physician again informs patient of the risks, benefits, and terms of continuation of opioid treatment. The physician uses the threshold visits to review alternative pain management options.
•The physician again counsels women on risks associated with opioid treatment and pregnancy.
•The physician again informs patients about the cognitive and performance effects of these prescriptions and warns them about the dangers to themselves and others in operating machinery, driving, and related activities while under treatment.
•The physician reviews the patient’s current prescription monitoring program record. One goal of this review is to avoid duplicative or conflicting treatments from other physicians.
6. The physician and patient establish a treatment agreement plan.
•The physician ensures the plan includes measurable goals for reduction of pain, reduction in opioid therapy concomitant with reduction or resolution of the pain, and improvement of function. The plan should address what circumstances would allow a patient to receive prescriptions from other physicians.
•The patient assigns the treatment agreement with an updated signature at least yearly.
•The physician incorporates the plan into the patient’s medical record.
7. The physician should discuss risks and warning signs of opioid dependence and addiction with chronic pain patients.
8. The physician discusses naloxone and its use to reverse overdoses. The physicians offer to prescribe naloxone to their patients after such discussions.
9. The
physician who is not a pain management specialist should not initiate treatment
plans that call for an excess of 100 milligrams of morphine equivalent opioids
per day without a documented consultation with a pain management specialist.
If a patient is currently receiving >100 mg morphine equivalent per
day, the physician institutes a plan to begin tapering the dose or advises the
patient to consult with a pain management specialist.
10. When clinically possible, physicians should select abuse-resistant and abuse-deterrent medications.
11. If high risk or low benefit warrants a discontinuation of opioid therapy, physicians prescribe non-opioid alternatives for continued pain management.