Issue link: https://viewer.e-digitaledition.com/i/976263
the patient 's medication a nd treatment goa ls frequently. The review process applies to a ll patients prescribed a controlled subst a nce for more t ha n 9 0 days a nd w i l l t a ke pla ce i n conjunction with patient education about the hea lth risks, diversion risks a nd the dependency risks of the medications they have been prescribed. W h i le ch ron ic opioid t herapy (COT) prov ides benef it to some patient s w it h severe pa i n, it ca r r ies sig n i f ica nt risks, including addiction, overdose a nd death. Sa fe opioid prescribing requires careful assessment of potentia l benef its a nd ha rms before initiating therapy, close monitoring a nd robust clinic systems to suppor t prescribers a nd patients. The Hutchinson Clinic has identif ied three sepa rate risk groups a nd implemented policies to address each group. The protocols include but a re not limited to a n initia l assessment and pain histor y (including K-TR ACS checks), a tool to assess t he risk of opioid misuse, screening for a lcohol a nd dr ug use, menta l hea lt h eva luation a nd depression screening, a nd a baseline function with pa in assessment. Before COT beg ins, both pa r ties sig n a patient-physicia n opioid therapy agreement, and the patient starts on a tria l period with clearly def ined goa ls a nd a documented time fra me. For clinicia ns, the workf low includes writing shor t-term prescriptions of 28 days or fewer with no more tha n three simulta neous prescriptions with concurrent dates to avoid excess supply, a nd scheduling follow-up visits. T reat ment s s t a r t w it h non- opioid pa i n m a n a gement approaches a nd non-opioid medications. W hen opioids a re indicated, prescriptions sta r t at the lowest possible effective dose a nd a re only used when the benef its exceed the risks. Providers will modif y or taper therapy as appropriate when risks exceed benef its. Once a patient reaches a predetermined dosage threshold, a n automatic consultation with a pa in specia list ta kes place. If the specia list ca n keep the patient under the threshold, the prima r y ca re physicia n ma nages the patient. If the patient needs to exceed t he t hreshold for optima l treatment , t he specia list ma na ges unti l t he patient ca n ret ur n to below threshold levels. The ongoing monitoring process includes a ssessment of events since the previous visit, medication adherence, pa in assessment a nd prog ress towa rd functiona l goa ls, periodic urine drug tests, a nd a review of test results. Doctors watch carefully for aberrant behaviors such as forg- ing prescriptions, stea ling or borrowing drugs, only showing up for medication appointments, using prescriptions before the renewa l date, and other misuses. Other common aberrant behaviors include doctor shopping, positive urine tests, a nd concurrent illicit dr ug or a lcohol use, as well as persistent over-sedation or euphoria, intoxication a nd deterioration of function at work a nd in the fa mily. Decreases in physica l or psycholog ica l functions, a n increase in accidents a nd fa lls, a nd noncomplia nce with the non-opioid pa in components of treatment a re a lso monitored. To complement the overa ll strateg y, a process for provid- i n g ref i l ls wa s si mu lt a neously rol led- out . T hat process provides patients a nd sta ff with stable expectations of ref ill prepa ration. The Hutchinson Clinic a lso insta l led a med sa fe a nd beca me a reg istered Dr ug Enforcement A gency site for medication disposa l. Additiona lly, a ll acute opioid prescriptions a re accompa nied by a disposa l bag that sa fely deactivates a ny unused por tion of the drug. Clinic-wide, it is ta king a mu ltifaceted approach to address not on ly the controlled substa nce dispensing but a lso disposa l. Opioid overdoses increased by 70 percent in the Midwest from July 2016 to September 2017, and the Centers for Disease Cont rol a nd P revention repor t s t hat 115 A mer ica ns d ie ever y day from overdoses involving opioid medications. By establishing appropriate functiona l a nd pa in-relief goa ls for treatment prior to prescribing, Hutchinson Clinic providers ca n ta rget increase in function as well as reduction of pa in. T he Hutchinson Clinic is a multispecialty clinic serving a quarter-million patients annually. For more information about its new pain management and controlled substance policy, please contact Chief O perations Of ficer Brian Voth or Chief Medical Infor mation Of ficer Verlin Jan zen , M D, at 620 - 669 -2500. ■ M D N E W S . C O M /// M D N E W S G R E AT E R K A N S A S ■ 2 018 2 1