Chronic Pain Initiative Tool Kit: Primary Care Provider

A project of:

 Copyright NC Community Care Networks, Inc.

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 Copyright NC Community Care Networks, Inc.

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Introduction
Community Care of North Carolina (CCNC), in conjunction with non-profit organization Project Lazarus, is responding to some of the highest drug overdose death rates in the country through its Chronic Pain Initiative (CPI). In the past decade, there are increasing indicators that the misuse and abuse of prescription opioid analgesics by patients contributes to this epidemic. This Primary Care Physician Toolkit is one of three resource documents created through this collaboration to assist medical care providers throughout North Carolina in managing patients with chronic pain. Similar Toolkits have been created for CCNC Care Managers and hospital Emergency Departments. While the CPI is initially targeting Medicaid patients, the recommended tools and strategies are useful for any patient struggling with pain issues. Medical care providers are encouraged to adopt the practices and policies in this Toolkit for all patients, regardless of payment source. While doctors and nurses play a major role in treating chronic pain and preventing overdose deaths, the responsibility for action goes beyond the clinic. CCNC is working with Project Lazarus to engage the entire community in preventing overdoses. This public health model is centered on community coalitions tailored to each locality. The model uses data from state health surveillance systems to get a clearer understanding of the nature of the overdose problem and engages doctors and nurses in both prevention of opioid abuse and optimal treatment of chronic pain. This public health model has been proven to produce results in North Carolina, including both dramatic and sustained decreases in prescription opioid overdose, and improved access to appropriate opioid pain treatment.
The goals of the Chronic Pain Initiative are to reduce opioid-related overdoses, optimize treatment of chronic pain and manage substance abuse issues associated with opiod misuse. Many people who have problems with opioid use also have legitimate needs for adequate pain control. Education around safe prescribing and appropriate use of opioids in our health care system and communities will enhance pain control and prevent unnecessary injury and death for our citizens in North Carolina. Some notes on specific sections of this Toolkit:

Opioids in the Management of Chronic Pain: This five-page overview provides a concise review of chronic pain issues and regulations and outlines key tools for managing the care of patients with chronic pain patients. Assessment and Management Algorithms: These flowcharts summarize the optimal processes for assessing and managing chronic pain. Pain (opioid) Management Agreement: This agreement is helpful in clarifying patient guidelines and protecting the provider from prescribing to drug-seeking patients. CCNC recommends its use with patients for whom opioids are prescribed.

 Chronic Pain Progress Note: This form provides a convenient record of the pain visits and a helpful reminder of questions to ask regarding risk factors for opioid misuse. Medication Flowsheet: This flowsheet is intended to serve as a comprehensive record of a patients opioid medication history. By briefly checking this form, providers can quickly determine how many chronic pain medicines the patient has been prescribed, as well as trends in dosage. About Community Care CCNC is a community-based, public-private partnership that takes a population management approach to improving health care and containing costs for North Carolinas most vulnerable populations. Through its 14 local network partners, CCNC creates medical homes for Medicaid beneficiaries, individuals eligible for both Medicare and Medicaid, privately-insured employees and uninsured people in all 100 counties. About Project Lazarus Project Lazarus was established in 2006 in response to extremely high rates of unintentional drug poisoning deaths (overdoses) in Wilkes County, NC. Project Lazarus empowers communities to prevent drug overdoses and meet the needs of those living with chronic pain by harnessing public health data and connecting community groups to state and national resources.

Addiction Alert This article is written out of disappointing experiences with patients in recovery from their addiction who suffer relapse into drug dependency precipitated by analgesics prescribed by a physician, surgeon, or dentist. Scientific evidence is increasing to show that persons with addiction, at least the great majority, have an underlying neurobiological basis for this disease. Often this problem is due to a genetic variation whereby alcohol and other drugs are metabolized differently. This metabolic difference is predisposing for an individual so affected to become addicted. This metabolic difference causes the patient after one exposure to certain agents to crave repeated dosing. This phenomenon may lead to loss of control of such drug usage and to progress quickly into addictive behavior. At The Healing Place of Wake County, a residential recovery facility for homeless persons with addiction, clients spend 9 to 14 months in which they stop using alcohol and other drugs; learn how to live with sobriety; and re-establish themselves as sober, self-supporting members of the community. They work diligently with strong peer support to establish a lifestyle of recovery with total avoidance of alcohol and other drugs. They become actively affiliated with the recovery network in this community. They are taught in detail about their disease of addiction including the fact that they need to avoid even one alcoholic beverage or dose of narcotic. Their metabolic variable makes it advisable for them to avoid both such agents. They are repeatedly instructed on this precaution. Even so, with a subsequent scenario whereby these persons suffer pain after injury, surgery, or a dental procedure; they may be prescribed an analgesic. If such analgesic is in the narcotic family, these patients may experience an exacerbation of their problem with a precipitous recurrence of their dependency on their prior substance of choice. These clients are treated for a variety of medical problems in the clinics at The Healing Place, both at the mens facility and the womens facility. We carefully avoid both narcotics and benzodiazepines. With rare exception their pain can be managed with such agents as acetaminophen or ibuprofen. If they do have intense pain such that narcotics are needed to control the pain, it is advisable for them to return to the Detoxification Unit at either of these facilities for that pain medication to be managed so that a return to drug dependency does not recur. Please keep this last measure in mind for such patients. Realize that a few days in the Detox Unit is of no charge to these individuals and is much preferred over sliding back into a pattern of addiction. Obviously to avoid this pitfall, one needs to be knowledgeable about a history of addiction. The clients of The Healing Place are instructed to inform their prescribing professional of this addiction. Also, the professional is wise to make some inquiry of all patients regarding past history so as to avoid such prescription. We have seen Healing Place graduates have their devastating addiction exacerbated by relatively benign Vicodin prescribed following a minor dental or surgical procedure. This disease of addiction is life-long in its risk, and needs proper attention to avoid relapse. Robert H. Bilbro, MD, FACP

Community Care of Wake and Johnston Counties

Primary Care Physician Toolkit for Chronic Pain Patients Table of Contents
I. Local Wake and Johnston County Data II. Opioids in the Management of Chronic Pain: An Overview III. Assessment and Management Algorithms IV. Sample Practice Policy V. Medicaid Provider Portal VI. Controlled Substance Reporting System a. Information b. Application VII. Medicaid Pharmacy Lock-in Program VIII. Concurrent Substance Use Assessment Tools IX. Patient Treatment Records a. Treatment Agreement Samples (Pain Contract) b. Opioid Risk Tool c. Current Opioid Misuse Measure d. Chronic Pain Progress Note e. Medication Flowsheet f. Personal Care Plan g. Functional Ability Questionnaire (FAQ) X. Urine Drug Screening XI. Proper Prescription Writing XII. Patient Education Materials XIII. Resources a. Care Management for Medicaid Patients b. Primary Care, Behavioral Health, Pain Management, Dental Providers XIV. Law Enforcement Issues All copyrighted materials used by permission.

Goals
As a community, address the rapidly rising problem of uncoordinated and excessive use of prescription pain medications

Change systems of care and prescribing patterns to promote quality and safe care for patients with chronic pain
Avert unintended deaths and overutilization of the health care system

Poisoning Deaths: N.C., 1999-2009*

In 1999, the number of unintentional poisoning deaths was 279; in 2009, the number of deaths had increased to 1,036.
1,500 1,200

Number of Deaths

900

Unintentional Suicide Homicide Undetermined All Poisonings

600

*Provisional data.
0 Source: N.C. State Center for Health Statistics, 1999 2000 Vital Statistics-Deaths, 1999-2009 Analysis by the Injury Epidemiology and Surveillance Unit 2001 2002 2003 2004 2005 2006 2007 2008 2009

300

Year

Percent Change in Rates Between 1999 and 2009 Leading Causes of Injury Deaths: N.C. 1999 to 2009*
Firearm - Assault, -25.3%

Injury Mech/Intent

Unintentional Falls, +68.1%

Firearm - Self-Inflicted, +1.7%

Unintentional Poisoning, +212.7%

Motor Vehicle, -28.8%

-50

50

100

150

200

250

Percent Difference

*Provisional data.

Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epidemiology and Surveillance Unit

Wake and Johnston Counties

Between 2000 and 2009, Wake County had 357 deaths and Johnston County had 78 deaths due to unintentional poisoning. Only Mecklenburg County (424 deaths) had more deaths between 2000 and 2009 than Wake County

Primary Cause of Death Due to Unintentional Poisonings: N.C., 2008

Substance Non-opioid analgesics Anti-epileptic and sedativehypnotics Narcotics and hallucinogens Drugs acting on the autonomic nervous system Other /unspecified drugs X-Code X40 X41 X42 X43 X44 Number 7 33 726 0 175

X40, X46, X47, X48, X49 2% X45 6% X44 17%

X41 3%

Alcohol Organic solvents

Other gases Pesticides

X45 X46
X47 X48

57 2
9 1

Narcotics

Other/unspecified chemicals

X49

Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2008 Analysis by Injury Epidemiology and Surveillance Unit

X42 72%

Wake Co. Unintentional Poisonings Deaths Due to Licit Opioids or Narcotics

80 70 60 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 # of deaths due to drugs, medications, and biologic substances # of deaths due to licit opioids/narcotics *excludes opium/heroin

Johnston Co. Unintentional Poisonings Deaths Due to Licit Opioids or Narcotics

16 14 12 10 8 6 4 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 # of deaths due to drugs, medications, and biologic substances # of deaths due to licit opioids/narcotics *excludes opium/heroin

Causes of Unintentional Poisoning, NC DETECT:

January June, 2010* (ED Visits = 6, 828)
Other & Unspecified Substances 5% Gases/Vapors 11%

Poisonous Foodstuffs/Plants 16% Drugs 61%

Corrosives Drugs (over-the-counter, 3% Cleansing Agents prescription, and illicit drugs) 2% Alcohol 2% were mentioned in 61% of ED visits due to unintentional poisonings. *Provisional data: final diagnoses may take up to three months.

Source: NC DETECT, 2009 Analysis by Injury Epidemiology and Surveillance Unit

The Ten Most Frequently Cited Drugs in ED Visits Due to Unintentional Poisonings, NC DETECT : 2010*
600 570 553

Number of ED Visits

500 400 300 200 100 0

er Op io id s in es s s s alg es ics ss an ts Ag en ts Su bs tit ut e Ag en t ot ics ul an t az ep pn St im pr e m ic as cu la r M us cle An nz od i es /H y Ag en t s

284

258

251 201 167 163 161 136

Ot h

id e

rm on

An t

er Se da tiv

Be

io v

Sy st e Sm oo

CN S

at ic

Ar o

Ca rd

Ho

Drug Type

*Provisional data Jan-June: final diagnoses may take up to three months.

Ot h

Source: NC DETECT, 2009 Analysis by Injury Epidemiology and Surveillance Unit

th /S ke

le ta l

Wake and Johnston Counties Hospitalizations and Emergency Department Visits Due to Unintentional Poisonings
Hospitalizations (2008)
#
Johnston Wake CCWJC 81 237 318

ED Visits (2009)
#
203 752 955

Rate*
51.4 28.7 32.6

Rate*
119.4 83.3 89.2

NC

3752

39.6

9590

101.3

*All rates are age adjusted and per 100,000 residents

From Data to Action- YRBS

YRBS= Youth Risk Factor Surveillance System

Opioids in the Management of Chronic Pain

Community Care of Wake and Johnston Counties

Opioids in the Management of Chronic Pain: An Overview

Appropriate treatment of chronic pain may include both pharmacologic and non-pharmacologic modalities. The Board realizes that controlled substances, including opioid analgesics, may be an essential part of the treatment regimen. All prescribing of controlled substances must comply with applicable state and federal law. Guidelines for treatment include: (a) complete patient evaluation, (b) establishment of a treatment plan (contract), (c) informed consent, (d) periodic review, and (e) consultation with specialists in various treatment modalities as appropriate. Deviation from these guidelines will be considered on an individual basis for appropriateness. --NC Medical Board Position Statement

The issue of chronic pain is a complicated one, requiring a substantial amount of knowledge and skill for appropriate evaluation, assessment and management. Diagnostic expertise is required to rule out a variety of medical and psychiatric conditions including certain malignancies, neuromuscular pathology, somatization, and malingering. Effective management may require consultation within an interdisciplinary team of professionals. Patients may need any of a number of different classes of medication to manage their pain, including opioid analgesics. As outlined by the NC Medical Board above, the proper steps must be taken when dealing with the difficult issue of opioid use for chronic pain. This informational tool explores different issues in the management of chronic pain, especially in the use of opioids. Please review and implement these recommendations as appropriate to ensure the highest standard of safety and quality of care for your patients.

Evaluation of the Patient Presenting with Chronic Pain Opioids should not be prescribed without first performing a comprehensive assessment of the patient. The patient's history should document, among other things, an adequate trial of nonopioid therapy. The history should also be used to screen for psychosocial issues, i.e. history of depression or other psychopathology that may affect the perception of pain. A biopsychosocial assessment should be performed, which includes information not only about the history of the pain, but also about the patient's quality of life and ability to perform daily functions. This information can be used to assess progress in areas other than intensity of pain. The patient may be encouraged to find out that his or her function is improving, even when there does not seem to be any improvement in pain.

Community Care of Wake and Johnston Counties When performing labs, consider the use of a urine drug screen or other tests to identify the presence of illegal drugs, unreported prescribed medication (indicating that the patient may be seeing more than one provider), or unreported alcohol use. Management Issues A holistic plan for managing chronic pain should address five major elements: personal goals, improving sleep, increasing physical activity, managing stress, and decreasing pain. [ICSI] The Personal Care Plan for Chronic Pain created by ICSI is a good tool to help address these issues. When considering pharmacological treatment for chronic pain, the physician should consider non-opioid medications as appropriate. If the pain is determined to be neuropathic in origin, classes such as tri-cyclic antidepressants (e.g. amytriptyline), other anti-depressants (e.g. venlafaxine, bupropion), anticonvulsants (e.g. gabapentin) or corticosteroids may be effective. Other classes of drugs to consider for the treatment of certain subtypes of chronic pain include muscle relaxants, anti-spasmodics, anxiolytics, and drugs for insomnia. [ICSI]

Cognitive Behavioral Strategies to Assist Pain Management Ask the patient to take an active role in the management of his/her pain. Research shows that patients who take an active role in their treatment experience less pain-related disability. Let the patient know that you believe that the pain is real and is not in his/her head. Let the patient know that the focus of your work together will be the management of his/her pain. ICSI Patient Focus Group feedback included patient concerns that their provider did not believe them/their child when they reported pain. Tell the patient that chronic pain is a complicated problem and for successful rehabilitation, a team of health care providers is needed. Chronic pain can affect sleep, mood, levels of strength and fitness, ability to work, family members, and many other aspects of a person's life. Treatment often includes components of stress management, physical exercise, relaxation therapy and more to help them regain function and improve the quality of their lives. Avoid telling patients to "let pain be their guide" whether it is stopping activity because of pain or taking medications or rest in response to pain. Prescribe time-contingent pain medications, not pain medications "as needed." Timecontingent medications allow a disruption in the associations between pain behavior and pain medication. The powerfully reinforcing properties of pain medicines are then not contingent upon high levels of pain and pain behavior. Schedule return visits on a regular schedule and dont let the appointments be driven by increasing levels of pain. Physicians are powerful reinforcers, too. Reinforce wellness behaviors such as increased activity or participation in an exercise program. Enlist the family and other supports to reinforce gains made towards improved functioning, too.

Community Care of Wake and Johnston Counties Have the patient involved in an exercise program or structured physical therapy. Assist the patient in returning to work. Do this in a step-wise fashion that is not dependent on level of pain. Fear of movement or fear of pain due to movement is a significant concern for many chronic pain patients. Inactivity or avoidance of movement leads to physical deconditioning and disability. Try not to rely on sedative or hypnotic medications to treat the fear many chronic patients show of activity or fear of increased pain. When chronic pain patients expose themselves to the activities that they fear, which simply means when they do the things they have been afraid of and avoiding, significant reductions are observed in fear, anxiety, and even pain level. If patients' fears are excessive, relaxation strategies may be helpful or referral for more formal and intensive cognitive-behavioral therapy may be necessary.
--ICSI Assessment and Management of Chronic Pain

The Use of a Pain Contract/Treatment Agreement Opioids are not benign drugs. Every effort should be made to emphasize the importance of the patient's responsibilities to manage his or her pain safely. A pain contract, or treatment agreement, addresses these issues, while proposing strict rules and penalties if the patient does not abide by these rules. This written agreement may include: Goals of therapy--Partial relief and improvement in physical, emotional, and/or social functioning The requirement for a single provider or treatment team The limitation on dose and number of prescribed medications and the proscription against changing dosage without permission; discuss the use of "pill counts" A prohibition on use with alcohol, other sedating medications, or illegal medications without discussing with provider Agreement not to drive or operate heavy machinery until medication-related drowsiness is cleared Responsibility to keep medication safe and secure Prohibition of selling, lending, sharing, or giving any medication to others Limitation on refills: only by appointment, in person, and no extra refills for running out early Compliance with all components of overall treatment plan (including consultation and referrals) The role of urine drug screening, alcohol testing Acknowledgement of adverse effects and safety issues such as the risk of dependence and addictive behaviors The option of sharing information with family members and other providers, as necessary Need for periodic re-evaluation of treatment Consequences of non-adherence
--VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain

Community Care of Wake and Johnston Counties Contraindications to Initiation of Opioid Therapy Certain elements of the assessment should raise warning flags concerning the initiation of opioid therapy. Care must be taken when any of the following risk factors are present: Acute psychiatric instability or high suicide risk History of intolerance, serious adverse effects, or lack of efficacy of opioid therapy Meets DSM-IV criteria for current substance use disorder Inability to manage opioid therapy responsibly (e.g., cognitively impaired) Unwillingness or inability to comply with treatment plan Unwillingness to adjust at-risk activities resulting in serious re-injury Social instability Patient with sleep apnea not on CPAP Elderly patient COPD patients
--VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain

The Importance of Follow-Up During the titration phase, a lack of response despite increasing doses of opioids may indicate that the patient has non-opioid responsive pain and opioids should be discontinued. During the management phase, the opioid dose may continue to increase gradually if the patient becomes tolerant to the medication. If the physician becomes uncomfortable with the level of opioids required to manage the patient's pain, he or she is encouraged to refer the patient to any physician who has more expertise in chronic pain management. Consultation should also be requested when the patient's pain and functional status have not improved substantially after three months of opioid therapy. Patients taking opioids for chronic pain need to be periodically reassessed every 1-6 months. The frequency of follow-up will vary according to the patient characteristics, comorbidities, status of pain control, and type and dose of opioids used. The follow-up visit should be used to assess the patient's progress, not only in pain control, but also quality of life and functional status. Consistent administration of questionnaires such as the Functional Ability Questionnaire created by ICSI can document any progress in these categories. This information can also be used to make concrete plans and goals with the patient. During follow-up, the physician should also assess and document adherence to the medication. Consider using random pill counts or urine drug screens to assess adherence. Also, use this time to assess patients for behaviors that are predictive of addiction or misuse. Patients with behaviors characteristic of compulsive drug use should be referred to a substance use disorder specialist. If the patient appears to have significant problems with depression, anxiety or irritability, consider a psychiatric consultation.

Community Care of Wake and Johnston Counties Addressing Misuse Physicians should be equipped to deal with patients who are found to be misusing opioid medication. Possible responses might include: Education and discussion along with restatement of the written agreement Review of the written opioid prescribing agreement Recommending or insisting on consultation with a pain and/or addiction specialist Discussion with others involved in the patient's care Administration of medications under supervision or with the assistance of others Change of medication or amount dispensed More frequent clinic contacts Instituting regular or random urine toxicology screens as a condition for prescription renewal
--VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain

Mental Health Co-Management Chronic pain conditions result from a complex interaction between biological, psychological and social variables. Biology plays a part in the etiology of pain, but the perception of pain is shaped by psychosocial contexts. Therefore, mental health co-management should be considered for optimal improvement in the patients functional status and psychological health. These approaches focus on the emotional, cognitive and behavioral aspects of chronic pain. General agreement exists that psychological interventions may be the important adjuvant therapies in the medical management of chronic pain. [Adams et al.] These interventions, when combined with the comprehensive management plan outlined above, should improve the health of patients with chronic pain and decrease the likelihood of opioid misuse. Prepared by Caleb Pineo, MPH Candidate, UNC-Chapel Hill School of Public Health References: North Carolina Medical Board. Policy for the Use of Controlled Substances for the Treatment of Pain. Available at http://www.ncmedboard.org/Clients/NCBOM/ Public/NewsandForum/mgmt.htm. Last accessed January 24, 2007. Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI), Second Edition; 2007 Mar. Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of opioid therapy for chronic pain. Washington (DC): Veterans Health Administration, Department of Defense; 2003 Mar. Adams N, Poole H, Richardson C. Psychological approaches to chronic pain management: part 1. J Clin Nurs. 2006 Mar; 15(3): 290-300.

Assessment and Management Algorithms

Suggested PCP Clinical Management Flow for Chronic Pain Initiative

Patient Identifies Pain as Chief Complaint

Medicaid patient

Yes

No

Nurse/Admin Access Provider Portal Determine Medications, Visit History, Presence of CPI Indicator and Pain Agreement F MD Assessment of patient Determine etiology of pain per Assessment Algorithm (e.g. Neurological, Musculoskeletal, Dental)

Need for immediate, acute, on-site treatment (e.g. acute trauma)

Yes Treat immediate, acute pain as appropriate

No

Review Portal information, if Medicaid Review CSRS, if appropriate Determine if patient is a Chronic Pain Initiative* patient

Yes Treat according to practice policy Utilize Pain Agreements, Routine UDS, treatment record tools When possible, try to change to non-narcotic pain management per Management Algorithms

No Treat pain per Management Algorithms, avoiding narcotics if possible

Assess for possible present or history of co-morbid mental health, dependence, addiction issues Give Chronic Pain patient handout(s) Refer to CPI case management, if available Refer to MH, Pain, Substance Abuse Provider as applicable

*Multiple ED or office visits for chronic pain complaints or different acute pain complaints Multiple narcotic prescriptions dispensed per CSRS or provider portal

Assessment Algorithm

Patient has chronic pain

Critical first step: assessment History and physical Key questions Pain and functional assessment tools

Is there a correctable medical, neurological or surgical cause of pain?

yes

Specialty referral/consult

no Other assessment Work and disability issues Psychological and spiritual assessment Contributing factors and barriers Screen for depression and substance abuse

Determine biological mechanisms of pain*

* Pain types and contributing factors are not mutually exclusive. Patients frequently do have more than one type of pain, as well as overlapping contributing factors.

Neuropathic pain Peripheral (e.g., complex regional pain syndrome, HIV sensory neuropathy, metabolic disorders, phantom limb pain) Central (e.g., Parkinson's disease, MS, myelopathies, post-stroke pain)

Muscle pain Fibromyalgia syndrome Myofascial pain syndrome Trauma

Inflammatory pain Inflammatory arthropathies (rheumatoid arthritis) Infection Postoperative pain Tissue injury

Mechanical/ compressive pain Low back pain Neck pain Musculoskeletal pain shoulders/elbow, etc. Visceral pain

To management algorithm see next page

Modified from ICSI Assessment Algorithm, available at: http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/musculo-skeletal/ pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of_14400.html

Management Algorithm
General management: develop plan of care and set goals using the biopsychosocial model

Physical rehabilitation and psychosocial management with functional goals

Pharmacologic management

Behavior management

Physical rehabilitation

Level I treatment: neuropathic pain

Level I treatment: muscle pain Meds to consider: Tricyclic antidepressants (for short term pain and insomnia) Cyclobenzaprine (fibromyalgia) Duloxetine (fibromyalgia) Opioids rarely needed

Level I treatment: inflammatory pain Pharmacotherapy not within scope of this guideline. Consider referral to a specialist.

Level I treatment: mechanical/compressive pain Meds to consider: NSAIDs (short term) Noradrenergic and noradrenergic/serotoninergic antidepressants for pain Muscle relaxants Opioids rarely needed

See neuropathic pain management algorithm (next page)

Primary care to measure goals and review plan of care

Goals met? Function Comfort Barriers

no

Has enough been tried with Level I treatment?

yes

Level II treatment: interdisciplinary team referral, plus a pain medicine specialist or pain medicine specialty clinic

yes Self-management plan of care

no Return to General Management

Outcome assessment

Modified from ICSI Management Algorithm, available at: http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/musculo-skeletal/ pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of_14400.html

Management AlgorithmNeuropathic Pain

Neuropathic Pain

Disease specific measures

Symptom management

Local or regional treatment

Systemic treatment

Tighter glucose control in diabetes Use of disease-modifying agents in MS Surgery, chemotherapy, or radiation therapy for nerve decompression Infection control (e.g. in HIV infection, herpes zoster, Lyme disease) Drug Therapy Anticonvulsants Tricyclic antidepressants Mexiletene HCl Clonazepam Corticosteriods Dextromethorphan Opioids Behavioral Therapy Biofeedback Hypnosis Guided imagery Other relaxation techniques Cognitive-behavioral therapy

Topical agents Capsaicin Lidocaine patches Anesthetic creams

Regional anesthetics Sympathetic blocks Epidural/intrathecal blocks Selective nerve root blocks Epidural/intrathecal pumps

Stimulation-based therapy TENS Acupuncture Spinal stimulation Massage

Physical rehabilitation measures Splinting Assistive devices Range-of-motion exercises Ergonomic methods

Ablative procedures Phenol/alcohol nerve ablation Cordotomy/rhizotomy

Source: Belgrade, MJ. Following the clues to neuropathic pain. PostGraduate Medicine, 106(6), November 1999.

Department Policy Name: Patient Care-Chronic Pain Management Department Policy #: PC 8-4 Approval Date: 8/10/05 CEO Signature:

Policy Revision History Revision Date:

Revision #: 4/29/11

Revision Description: patient re-evaluation time was changed to every three months instead of every six months

I. PURPOSE WHSI recognizes that principles of quality medical practice dictate that patients have access to appropriate and effective pain relief. The appropriate application of up-to-date knowledge and treatment modalities can serve to improve the quality of life for those patients who suffer from pain as well as reduce the morbidity and costs associated with untreated or inappropriately treated pain. For the purposes of this policy, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments. The diagnosis and treatment of pain is integral to the practice of medicine. WHSI encourages providers view pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness. All providers should become knowledgeable about assessing patients pain and effective methods of pain treatment, as well as statutory requirements for prescribing controlled substances. Accordingly, this policy have been developed to clarify WHSIs position on pain control, particularly as related to the use of controlled substances, to alleviate provider uncertainty and to encourage better pain management. II. POLICY A. WHSI providers will make available care, treatment and medication(s) for patients with chronic pain based on national guidelines and North Carolina Medical Board Position Statements. B. WHSI will incorporate safeguards into its practices to minimize the potential for the abuse and diversion of controlled substances. C. WHSI, Inc. will assess all patients for pain upon the initial assessment. WHSI will ask all patients if they are experiencing pain. Age appropriate charts will be utilized pre each sites set procedures. Patients self report of pain will be charted, upon initial assessment and with each subsequent visit. D. WHSI medical staff (nurses and providers) will make an appropriate assessment of the patients pain, by including information about the following: history (onset), intensity, location, duration, frequency, quality of, associated factors, aggravating or alleviating factors associated with the pain. Nurses or Providers will be responsible for collecting this information and documenting any pertinent physical exam findings. E. WHSI will take information about comfort measures, analgesics and appropriate referrals for chronic pain management available. F. WHSI will have the PCP enter into a Pain Management Contract (see attachment) with patients on any recurring controlled narcotic pain medications managed within our practice. A copy of this form will be in the patients chart.

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III. DEFINITIONS Acute Pain- Acute pain is the normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus and typically is associated with invasive procedures, trauma and disease. It is generally time-limited. Addiction- Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use, and continued use despite harm. Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and are not the same as addiction. Chronic Pain- Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathological process that causes continuous or intermittent pain over months or years. Pain- An unpleasant sensory and emotional experience associated with actual or potential tissue damage or describe in terms of such damage. Physical Dependence Physical Dependence is a state of adaptation that is manifested by drug classspecific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence, by itself, does not equate with addiction. Pseudoaddiction The iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction. The relief seeking behaviors resolve upon institution of effective analgesic therapy. Substance Abuse Substance is the use of any substance(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed. Tolerance - Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction.

IV. PROCEDURE WHSI recognizes that controlled substances including opioid analgesics may be essential in the treatment of acute pain due to trauma or surgery and chronic pain, whether due to cancer or non-cancer origins. WHSI will refer to current clinical practice guidelines in approaching cases involving management of pain. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and no-pharmacologic modalities according to the judgment of the provider. Pain should be assessed and treated promptly, and the quantity and frequency of doses should be adjusted according to the intensity, duration of the pain, and treatment outcomes. Providers should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not the same as addiction. The validity of the providers treatment of the patient must be based on available documentation, rather than solely on the quantity and duration of medication administration. The goal is to control the patients pain while effectively addressing other aspects of the patients functioning, including physical, psychological, social and work-related factors.

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A. Guidelines and Safeguards WHSI has adopted the following criteria and safeguards from the Federation of State Medical Boards and the Management of Chronic Non-Malignant Pain Position Statement from the NC Medical Board when evaluating the treatment of pain, including the use of controlled substances: 1. Evaluation of the Patient A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance. 2. Treatment Plan- The written treatment plan will state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the provider should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment. 3. Informed Consent and Agreement for Treatment The provider will discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient or with the patients surrogate or guardian if the patient is without medical decision-making capacity. The patient should receive prescriptions from one provider and one pharmacy. The prescribing provider will implement a Pain Management Contract with all patients taking controlled substances for chronic non-malignant pain outlining patient responsibilities, including but not limited to: a. urine/serum medication levels screening when requested; b. number and frequency of all prescription refills; and c. reason for which drug therapy may be discontinued (i.e.,violation of agreement) 4. Periodic Review- The provider should periodically review the course of pain treatment and any new information about the etiology of the pain or the patients state of health. Continuation or modification of controlled substances for pain management therapy depends on the providers evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patients decreased pain, increase level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patients response to treatment. If the patients is unsatisfactory, the provider should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. 5. Consultation The provider will refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. Special attention should be given to those patients with pain who are at risk for medications misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. 6. Medical Records- The provider should keep accurate and complete records to include: a. the medical history and physical examination,

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b. diagnostic, therapeutic and laboratory results, c. evaluations and consultations, d. treatment objectives, e. discussion of risks and benefits f. informed consent (including WHSI Pain Management Contract), g. treatments, h. medications (including date, type, dosage and quantity prescribed documented and regularly updated on the medication flowsheet), i. Instructions and agreements (Pain Management Contract) and j. periodic reviews. Records should remain current and be maintained in an accessible manner and readily available for review. 7. Compliance With Controlled Substances Laws and Regulations- To prescribe, dispense or administer controlled substances, the provider must be licensed in NC and comply with applicable federal and state regulations. Providers are referred to the Providers Manual of the U.S. Drug Enforcement Administration and the NC Medical Board website (www.ncmedboard.org) for specific rules governing controlled substances as well as applicable state regulations. 8. Patient will be seen by their WHSI provider at lest every three months, and more often if clinically indicated, for re-evaluation. These visits will include pain re-evaluation and writing prescriptions for treatment and stable therapy. Patients may also be seen more frequently if there are co-morbid conditions that require more visits. 9. Patients will call their provider no less than 3 business days prior to running out of current prescription, to obtain a month to month order. Each new written prescription will be picked up at the site. Signatures and pictures ids will be required for persons picking up prescriptions for controlled substances. 10. Only the patient and/or persons listed on the Patient Acknowledgement/Consent Form will be allowed to pick up written prescriptions for controlled substances. 11. Lost prescriptions will be rewritten only at the discretion of the treating provider. A copy of the new prescription will be kept in the chart for record of lost and misplaced prescriptions.

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FACTS ABOUT CONTROLLED SUBSTANCES

In 2008, more than 16 million controlled substance prescriptions were written and dispensed in our state. More than 5 million (5,297,074) individual patients were recorded as having been dispensed a prescription for a controlled substance. Number of prescriptions in the database is 35,376,972. Number of deaths from controlled substance accidental poisoning: January- December 2008: 798 January - June 2009: 443

QUESTIONS?
Contact the Drug Control Unit
(919) 733-1765 Johnny Womble Johnny.womble@dhhs.nc.gov William Bronson William.bronson@dhhs.nc.gov www.dhhs.state.nc.us/MHDDSAS/controlledsubstance/ www.sa4docs.org

CONTROLLED SUBSTANCES REPORTING SYSTEM

State of North Carolina - Beverly Eaves Perdue, Governor Department of Health and Human Services Lanier M. Cansler, Secretary Division of Mental Health, Developmental Disabilities and Substance Abuse Services www.ncdhhs.gov/mhddsas/ The Department of Health and Human Services does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. 10/09 - 2000 of this document were printed at $0.25 each. [First Printing]

NORTH CAROLINA DIVISION OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES

CONTROLLED SUBSTANCES REPORTING SYSTEM

WHAT IS THE CSRS?
Established by State law, the CSRS is a prescription reporting system that allows registered dispensers and practitioners to review a patients controlled substances prescription history on the web. It is intended to assist practitioners in monitoring patients by identifying and referring patients for specialized substance abuse treatment or specialized pain management.

DO

CSRS DOS & DONTS

Use as a resource for all patients being prescribed controlled substances. Discuss findings with patients. Leave room for human error in the system. Talk with other prescribers idenitified by the CSRS. Refer patients to substance abuse treatment or pain management specialists as appropriate.

INSTRUCTIONS FOR CSRS ACCESS

1 2 3 4 5 6
Read Instructions and Complete Access Application Sign Privacy Statement

HOW DOES THE SYSTEM WORK?

All prescriptions for controlled substances, schedule II through V, dispensed in North Carolina are reported into the CSRS database. Currently, pharmacies transmit the data twice monthly, on the 15th and 30th of each month. Starting January 1, 2010 pharmacies will transmit the data weekly. Prescribers and pharmacists register and are then granted a password to access the system online to look up a patients controlled substances prescription history. Information in the system dates back to July 2007. Prescribers may legally query the system for their patients only.

Photocopy Drivers License Notarize the Application Mail a hard copy to: NC CSRS 3008 Mail Service Center Raleigh, NC 27699-3008 Health Information Designs, Inc. will notify you by email when your request has been approved*

DONT

Use to screen out new patients.

WHAT CAN I DO WITH THE INFORMATION?

The practitioner should sit down with the patient and discuss the findings. He/she may suggest a referral to a substance abuse program or a pain specialist. Recent changes to the original legislation (August 2009) enable prescribers to call other prescribers identified on the CSRS. Behavioral health specialists need to continue to follow other applicable patient consent laws. Practitioners should not contact law enforcement unless the patient has forged a prescription.

Call the police unless other evidence of doctor shopping is present or a patient has forged a prescription. Release CSRS information to the police.

http://www.ncdhhs.gov/mhddsas/controlledsubstance/ csrsprofaccessandprivacy7-07.pdf (Application for prescriber access)

* If you do not receive an email from Health Information Designs, Inc. in 3

weeks please contact the Drug Control Unit at 919-733-1765

Dos and Donts for Prescribers and Dispensers Using the NC Controlled Substances Reporting System
DO Check the database prior to prescribing or dispensing a controlled substance. Discuss any findings of concern directly with your patients but dont give them a copy, have them contact us). Listen to your patients when they say the system is in error, and contact us to help verify if there are questions. Notify your patients that you use the system. Learn about SBIRT (Screening, Brief Intervention and Referral for Treatment) and use with your patients. Use behavioral contracts with patients where appropriate. Report forgeries to law enforcement. Inform us of non-reporting pharmacies.

DO NOT Use the CSRS to exclude potential patients prior to engaging them. Discharge patients without intervening and attempting to refer for substance abuse treatment or pain management. Have office people check the CSRS for you. Refer suspected Dr. Shoppers to police (you may call us) where your only source of data is the CSRS. Give information to law enforcement from the CSRS (except for forgeries). Believe information from the CSRS is the gospel truth. There can be errors. CSRS is a TOOL. CONTACT INFORMATION or QUESTIONS Call Bill Bronson or John Womble 919.733.1765 E-mail: NCControlSubstance.Reporting@dhhs.nc.gov

6/2010 NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Article 5E. North Carolina Controlled Substances Reporting System Act. 90-113.70. Short title. This Article shall be known and may be cited as the "North Carolina Controlled Substances Reporting System Act." (2005-276, s. 10.36(a).) 90-113.71. Legislative findings and purpose. (a) The General Assembly makes the following findings: (1) North Carolina is experiencing an epidemic of poisoning deaths from unintentional drug overdoses. (2) Since 1997, the number of deaths from unintentional drug overdoses has increased threefold, from 228 deaths in 1997 to 690 deaths in 2003. (3) The number of unintentional deaths from illicit drugs in North Carolina has decreased since 1992 while unintentional deaths from licit drugs, primarily prescriptions, have increased. (4) Licit drugs are now responsible for over half of the fatal unintentional poisonings in North Carolina. (5) Over half of the prescription drugs associated with unintentional deaths are narcotics (opioids). (6) Of these licit drugs, deaths from methadone, usually prescribed as an analgesic for severe pain, have increased sevenfold since 1997. (7) Methadone from opioid treatment program clinics is a negligible source of the methadone that has contributed to the dramatic increase in unintentional methadone-related deaths in North Carolina. (8) Review of the experience of the 19 states that have active controlled substances reporting systems clearly documents that implementation of these reporting systems do not create a "chilling" effect on prescribing. (9) Review of data from controlled substances reporting systems help: a. Support the legitimate medical use of controlled substances. b. Identify and prevent diversion of prescribed controlled substances. c. Reduce morbidity and mortality from unintentional drug overdoses. d. Reduce the costs associated with the misuse and abuse of controlled substances. e. Assist clinicians in identifying and referring for treatment patients misusing controlled substances. f. Reduce the cost for law enforcement of investigating cases of diversion and misuse. g. Inform the public, including health care professionals, of the use and abuse trends related to prescription drugs. (b) This Article is intended to improve the State's ability to identify controlled substance abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription drugs in an efficient and cost-effective manner that will not impede the appropriate medical utilization of licit controlled substances. (2005-276, s. 10.36(a).) 90-113.72. Definitions. The following definitions apply in this Article: (1) "Commission" means the Commission for Mental Health, Developmental Disabilities, and Substance Abuse Services established under Part 4 of Article 3 of Chapter 143B of the General Statutes. NC General Statutes - Chapter 90 Article 5E 1

(2) (3) (4)

(5)

"Controlled substance" means a controlled substance as defined in G.S. 90-87(5). "Department" means the Department of Health and Human Services. "Dispenser" means a person who delivers a Schedule II through V controlled substance to an ultimate user in North Carolina, but does not include any of the following: a. A licensed hospital or long-term care pharmacy that dispenses such substances for the purpose of inpatient administration. b. A person authorized to administer such a substance pursuant to Chapter 90 of the General Statutes. c. A wholesale distributor of a Schedule II through V controlled substance. "Ultimate user" means a person who has lawfully obtained, and who possesses, a Schedule II through V controlled substance for the person's own use, for the use of a member of the person's household, or for the use of an animal owned or controlled by the person or by a member of the person's household. (2005-276, s. 10.36(a).)

90-113.73. Requirements for controlled substances reporting system. (a) The Department shall establish and maintain a reporting system of prescriptions for all Schedule II through V controlled substances. Each dispenser shall submit the information in accordance with transmission methods and frequency established by rule by the Commission. The Department may issue a waiver to a dispenser that is unable to submit prescription information by electronic means. The waiver may permit the dispenser to submit prescription information by paper form or other means, provided all information required of electronically submitted data is submitted. The dispenser shall report the information required under this section on a monthly basis for the first 12 months of the Controlled Substances Reporting System's operation, and twice monthly thereafter, until January 2, 2010, at which time dispensers shall report no later than seven days after the prescription is dispensed in a format as determined annually by the Department based on the format used in the majority of the states operating a controlled substances reporting system. (b) The Commission shall adopt rules requiring dispensers to report the following information. The Commission may modify these requirements as necessary to carry out the purposes of this Article. The dispenser shall report: (1) The dispenser's DEA number. (2) The name of the patient for whom the controlled substance is being dispensed, and the patient's: a. Full address, including city, state, and zip code, b. Telephone number, and c. Date of birth. (3) The date the prescription was written. (4) The date the prescription was filled. (5) The prescription number. (6) Whether the prescription is new or a refill. (7) Metric quantity of the dispensed drug. (8) Estimated days of supply of dispensed drug, if provided to the dispenser. (9) National Drug Code of dispensed drug. (10) Prescriber's DEA number. (2005-276, s. 10.36(a); 2005-345, s. 17; 2009-438, s. 1.) 90-113.74. Confidentiality. NC General Statutes - Chapter 90 Article 5E 2

(a) Prescription information submitted to the Department is privileged and confidential, is not a public record pursuant to G.S. 132-1, is not subject to subpoena or discovery or any other use in civil proceedings, and except as otherwise provided below may only be used for investigative or evidentiary purposes related to violations of State or federal law and regulatory activities. Except as otherwise provided by this section, prescription information shall not be disclosed or disseminated to any person or entity by any person or entity authorized to review prescription information. (b) The Department may use prescription information data in the controlled substances reporting system only for purposes of implementing this Article in accordance with its provisions. (c) The Department shall release data in the controlled substances reporting system to the following persons only: (1) Persons authorized to prescribe or dispense controlled substances for the purpose of providing medical or pharmaceutical care for their patients. (2) An individual who requests the individual's own controlled substances reporting system information. (3) Special agents of the North Carolina State Bureau of Investigation who are assigned to the Diversion & Environmental Crimes Unit and whose primary duties involve the investigation of diversion and illegal use of prescription medication and who are engaged in a bona fide specific investigation related to enforcement of laws governing licit drugs. The SBI shall notify the Office of the Attorney General of North Carolina of each request for inspection of records maintained by the Department. (4) Primary monitoring authorities for other states pursuant to a specific ongoing investigation involving a designated person, if information concerns the dispensing of a Schedule II through V controlled substance to an ultimate user who resides in the other state or the dispensing of a Schedule II through V controlled substance prescribed by a licensed health care practitioner whose principal place of business is located in the other state. (5) To a court pursuant to a lawful court order in a criminal action. (6) The Division of Medical Assistance for purposes of administering the State Medical Assistance Plan. (7) Licensing boards with jurisdiction over health care disciplines pursuant to an ongoing investigation by the licensing board of a specific individual licensed by the board. (8) Any county medical examiner appointed by the Chief Medical Examiner pursuant to G.S. 130A-382 and the Chief Medical Examiner, for the purpose of investigating the death of an individual. (d) The Department may provide data to public or private entities for statistical, research, or educational purposes only after removing information that could be used to identify individual patients who received prescription medications from dispensers. (e) In the event that the Department finds patterns of prescribing medications that are unusual, the Department shall inform the Attorney General's Office of its findings. The Office of the Attorney General shall review the Department's findings to determine if the findings should be reported to the SBI for investigation of possible violations of State or federal law relating to controlled substances. (f) The Department shall purge from the controlled substances reporting system database all information more than six years old. (g) Nothing in this Article shall prohibit a person authorized to prescribe or dispense controlled substances pursuant to Article 1 of Chapter 90 of the General Statutes from disclosing or disseminating data regarding a particular patient obtained under subsection (c) of NC General Statutes - Chapter 90 Article 5E 3

this section to another person (i) authorized to prescribe or dispense controlled substances pursuant to Article 1 of Chapter 90 of the General Statutes and (ii) authorized to receive the same data from the Department under subsection (c) of this section. (h) Nothing in this Article shall prevent persons licensed or approved to practice medicine or perform medical acts, tasks, and functions pursuant to Article 1 of Chapter 90 of the General Statutes from retaining data received pursuant to subsection (c) of this section in a patient's confidential health care record. (2005-276, s. 10.36(a); 2009-438, s. 2.) 90-113.75. Civil penalties; other remedies; immunity from liability. (a) A person who intentionally, knowingly, or negligently releases, obtains, or attempts to obtain information from the system in violation of a provision of this section or a rule adopted pursuant to this section shall be assessed a civil penalty not to exceed five thousand dollars ($5,000) per violation. The clear proceeds of penalties assessed under this section shall be deposited to the Civil Penalty and Forfeiture Fund in accordance with Article 31A of Chapter 115C of the General Statutes. (b) In addition to any other remedies available at law, an individual whose prescription information has been disclosed in violation of this section may bring an action against any person or entity who has intentionally, knowingly, or negligently released confidential information or records concerning the individual for either or both of the following: (1) Nominal damages of one thousand dollars ($1,000). In order to recover damages under this subdivision, it shall not be necessary that the plaintiff suffered or was threatened with actual damages. (2) The amount of actual damages, if any, sustained by the individual. (c) A health care provider licensed, or an entity permitted under this Chapter that, in good faith, makes a report or transmits data required by this Article is immune from civil or criminal liability that might otherwise be incurred or imposed as a result of making the report or transmitting the data. (2005-276, s. 10.36(a).) 90-113.76. Commission for Mental Health, Developmental Disabilities, and Substance Abuse Services to adopt rules. The Commission for Mental Health, Developmental Disabilities, and Substance Abuse Services shall adopt rules necessary to implement this Article. (2005-276, s. 10.36(a).) 90-113.77. Reserved for future codification purposes. 90-113.78. Reserved for future codification purposes. 90-113.79. Reserved for future codification purposes.

NC General Statutes - Chapter 90 Article 5E

Instructions for completing the Prescriber / Dispenser Database Access Request:

1. Information on the form must be legible 2. Fill in all of the information requested, or the request may be denied 3. Your DEA # will be your user name 4. You should propose a password
Passwords must be at least 8 characters in length Passwords must NOT contain dictionary words or a name Passwords must contain at least one (1) capital letter and one (1) lowercase letter and one (1) number. For example: H82bYb07 Bob12345 rsmith07 Acceptable Not acceptable Not Acceptable

5. After completing the access request, have it notarized and mail the access request, the signed privacy statement and a copy of your current drivers license to: NC CSRS 3008 Mail Service Center Raleigh, North Carolina 27699-3008 6. Health Information Designs, Inc. will notify you by e-mail when your request has been approved.

Prescriber / Dispenser Database Access Instructions

July 2007

North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Controlled Substances Reporting System Mail Service Center 3008 Raleigh, NC 27699-3008 Phone: (919) 733-1765 Fax: (919) 508-0983 Prescriber / Dispenser Database Access
New
Name (First, MI, Last, Suffix (Jr., Sr., III))

Update

Terminate

Professional Title

State Board License Number

Facility Name

DEA Number (Hospital Residents add DEA extension #)

Facility Address

City, State, Zip Code

Area Code & Telephone Number

Area Code & Fax Number

Email Address

Proposed Password

Signature

Date

Subscribed and sworn to me, a notary public in and for the State of North Carolina, on this ________ day of _________________, ________. My commission expires on the ________ day of _________________, ________.

__________________________________________________ Notary Signature

Pursuant to N.C.G.S. 90-113.75 a person who intentionally, knowingly, or negligently releases, obtains, or attempts to obtain information from the system in violation of a provision of this section or a rule adopted pursuant to this section shall be assessed a civil penalty not to exceed five thousand dollars ($5,000) per violation.
Mail the following items to the Controlled Substances Reporting System: Notarized Database Access Form Signed Copy of Privacy Statement Copy of Current Drivers License

DEPARTMENT USE ONLY Date received Approved Disapproved Signature Date of Action

Prescriber / Dispenser Database Access July 2007

North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Controlled Substances Reporting System Mail Service Center 3008 Raleigh, NC 27699-3008 Phone: (919) 733-1765 Fax: (919) 508-0983

Privacy Statement
Statutory Authority: Article 5E, 90-113.70 the North Carolina Controlled Substances Reporting System Act, requires the Department of Health and Human Services to establish and maintain a controlled substances prescription reporting system of dispensed prescriptions for all Schedule IIV controlled substances. The purpose of this legislation is to improve the States ability to identify controlled substances abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription drugs in an efficient and cost effective manner that will not impede the appropriate medical utilization of licit controlled substances. Access to Information: NCGS 90-113.74. (c) (1) authorizes DHHS to release data from the Controlled Substances Reporting System to persons authorized to prescribe or dispense controlled substances for the purpose of providing medical or pharmaceutical care for their patients. NCGS 90-113.74. (c) (3) authorizes DHHS to release data from the Controlled Substances Reporting System to Special agents of the North Carolina State Bureau of Investigation who are assigned to the Diversion & Environmental Crimes Unit and whose primary duties involve the investigation of diversion and illegal use of prescription medication and who are engaged in a bona fide specific investigation related to enforcement of laws governing licit drugs. The SBI shall notify the Office of the Attorney General of North Carolina of each request for inspection of records. Unlawful Disclosure: Prescription information in the Controlled Substances Reporting System is privileged and confidential, is not a public record pursuant to G.S. 132-1, is not subject to subpoena or discovery or any other use in civil proceedings, and except as otherwise provided in Article 5E, may only be used for investigative or evidentiary purposes related to violations of State or federal law and regulatory activities. Except as otherwise provided in Article 5E, prescription information shall not be disclosed or disseminated to any person or entity by any person or entity authorized to review prescription information. As per 90-113.75., a person who intentionally, knowingly, or negligently releases, obtains, or attempts to obtain information from the system in violation of a provision of this section or a rule adopted pursuant to this section shall be assessed a civil penalty not to exceed five thousand dollars ($5,000) per violation. The clear proceeds of penalties assessed under this section shall be deposited to the Civil Penalty and Forfeiture Fund in accordance with Article 31A of Chapter 115C of the General Statutes. Account Agreement: By signing this agreement I understand that inappropriate access or disclosure of this information is a violation of North Carolina law. I hereby agree to follow the security and password policies of the NC Controlled Substances Reporting System. I agree that user account additions, deletions, and changes will be submitted in writing. I agree that I will not share my account information, login name, or password with anyone, even if they are authorized users of the program.

Signature: _______________________________________ Print Name: ______________________________________

Date: ____________________

Privacy Statement July 2007

An Information Service of the Division of Medical Assistance

North Carolina Medicaid Pharmacy Newsletter

Number 186

September 2010

In This Issue...
Implementation of a Recipient Management Lock-In Program Recipient Management Lock-in Program Emergency Fill Recipient Notifications Medicare and Medicaid Health Information Technology: Title IV of the American Recovery and Reinvestment Act Enrollment Fee Update: Reminders Procedures for Prescribing Synagis for RSV Season 2010/2011 Changes in Drug Rebate Manufacturers

Published by HP Enterprise Services, fiscal agent for the North Carolina Medicaid Program 1-800-688-6696 or 919-851-8888

September 2010

Implementation of a Recipient Management Lock-In Program

N.C. Medicaid will implement a recipient management lock-in program. The N.C. Administrative Code, 10A NCAC 22F.0704 and 10A NCAC 22F.0104, along with 42 CFR 431.54 and the Medicaid State Plan supports the States development of procedures for the control of recipient overutilization of Medicaid benefits, which includes implementing a recipient management lock-in program. Recipients identified for the lock-in program will be restricted to a single prescriber and pharmacy in order to obtain opioid analgesics, benzodiazepines, and certain anxiolytics covered through the Medicaid Outpatient Pharmacy Program. N.C. Medicaid recipients who meet one or more of the following criteria will be locked into one prescriber and one pharmacy for controlled substances categorized as opiates or benzodiazepines and certain anxiolytics for a period of one year: 1. Recipients who have at least ONE of the following a. b. 2. 3. Benzodiazepines and certain anxiolytics: more than six claims in two consecutive months Opiates: more than six claims in two consecutive months

Receiving prescriptions for opiates and/or benzodiazepines and certain anxiolytics from more than three prescribers in two consecutive months Referral from a provider, DMA or CCNC.

The process of identifying recipients for the program began in July. Recipients who meet the criteria will be notified by letter and asked to choose a prescriber and a pharmacy. The recipient must obtain all prescriptions for these medications from their lock-in prescriber and lock-in pharmacy in order for the claim to pay. Additionally, the prescribers NPI will be required on the pharmacy claim. Submitting the prescribers DEA will cause the claim to be denied. Claims submitted by a prescriber or filled at a pharmacy other than the one listed on the lock-in file will be denied. The recipient may not change their lock-in prescriber or pharmacy without authorization from DMA. Recipients who qualify for the program will be notified and locked in for one year after which time they will be removed from the program if they no longer meet the criteria. Recipients who continue to meet the criteria will be locked in for a subsequent year. Once released from the lock-in program, prescription claims will continue to be monitored. If it is determined that a recipient again meets the criteria, the recipient will be re-identified for the lock-in program. The N.C. Medicaid Program will reimburse an enrolled Medicaid pharmacy for a four-day supply of a prescription dispensed to a recipient locked into a different pharmacy and prescriber in response to an emergent situation. The recipient will be responsible for the appropriate copayment. Only one emergency occurrence will be reimbursed per lock-in period. Records of dispensing of emergency supply medications are subject to review by Program Integrity. Paid quantities for more than a four-day supply are subject to recoupment. Please refer to the DMA website at http://www.ncdhhs.gov/dma/pharmacy/ for updates.

September 2010

Recipient Management Lock-in Program Emergency Fill

The N.C. Medicaid Program will reimburse an enrolled Medicaid pharmacy for a 4-day supply of a prescription dispensed to a recipient locked into a different pharmacy and prescriber in response to an emergent situation. The emergency supply is limited to a 4-day supply. The provider will be paid for the drug cost only, and the recipient will be responsible for the appropriate copayment. A 3 in the Level of Service field (418-DI) should be used to indicate that the transaction is an emergency fill. Only one emergency occurrence will be reimbursed per lock-in period. Records of the dispensing of emergency supply medications are subject to review by DMA Program Integrity. Paid quantities for more than a 4-day supply are subject to recoupment.

Recipient Notifications
Medicaid and N.C. Health Choice recipients are notified of benefit and coverage changes through monthly mailings. Copies of the notifications are available on DMAs website at http://www.ncdhhs.gov/dma/pub/consumerlibrary.htm. The notification that was mailed to recipients in August 2010 outlined a number of changes to the N.C. Medicaid Program and to the N.C. Health Choice Program. Medical Services Medicaid recipients were notified of the following changes to the N.C. Medicaid Program for medical services: Limitations to refills for lost prescriptions Implementation of a recipient management lock-in program for prescription drugs Changes to N.C. Medicaid Preferred Drug List Coverage of prescription vitamins and mineral products For more information about these changes, providers may refer to the August 2010 Medicaid Bulletin (http://www.ncdhhs.gov/dma/bulletin/0810bulletin.htm).

NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE PHARMACY LOCK-IN REFERRAL FORM

This form is used for referring North Carolina Medicaid recipients with possible medication over utilization to the Recipient Management Lock-in Program to evaluate the need for possible lock-in to one prescriber and one pharmacy. Please fax this form along with any supporting documentation to 919-715-1255. For questions regarding the use of this form, call 919-855-4300. Please note this completed form contains Protected Health Information (PHI) and should be handled in accordance with HIPAA regulations.

Referral Information Referral Source: [] Medicaid Provider [] CCNC Network Employee Referral Name: ___________________ Referral Phone : ___________________ Date of Referral: __________________ Please include contact information for appeals support.

Recipient Information Recipient Name: ________________________________________________ Recipient Medicaid ID: ________________________________________________ Recipient DOB: ________________________________________________

Reason for Referral [] Multiple Prescribers [] Multiple prescriptions for narcotics [] Multiple prescriptions for benzodiazepines [] Other Description of referral reason: ____________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Attachments: yes no Number of pages: _______

SBIRT SCREENING TOOLS

Recommended Substance Abuse Screening Tools for Primary Care Settings in NC
There are a number of substance abuse screening instruments that have been validated in diverse patient populations. These include, but are not limited to the AUDIT, AUDIT-C, MAST, DAST, CRAFFT, CAGE, CAGE-AID, ASSIST, TWEAK, and TACE. Different tools are appropriate for different settings and patient populations. To facilitate communication and collaboration between primary care practices and between primary care and specialty behavioral health, two instruments with wide applicability have been chosen and recommended to primary care practices in NC. These tools are the AUDIT-C (with one additional drug use question) and the CAGE-AID. The AUDIT-C has been successfully implemented throughout the VA healthcare system. The CAGE-AID is widely used and is included on many electronic medical record systems. It is recommended that screening begin with a prescreen.

Prescreen Questions
Do you drink alcohol? Have you ever experimented with drugs, including prescription drugs? If yes to either question, proceed with screen.

AUDIT-C plus drug question

The AUDIT-C consists of the first 3 questions of the 10 item AUDIT (Alcohol Use Disorders Identification Test). The AUDIT-C , which can be self-administered or be part of an interview, identifies harmful alcohol use and has cross-cultural validity. The AUDIT-C is scored on a scale of 0-12 points. A score of 4 points or more for men and a score of 3 points or more for women are considered positive for alcohol misuse. Using these cutoff points in family medicine settings, sensitivity is .86 and specificity is .89 for men with .73 sensitivity and .91 specificity for women. The VA system requires follow-up counseling/brief intervention for scores of 5 or more. (See scoring rubric on back of this sheet.) Q#1: How often did you have a drink containing alcohol in the past year? Q#2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? Q#3: How often did you have six or more drinks on one occasion in the past year? In North Carolina, particularly in primary care settings that serve an indigent population, drug use (both illicit and prescription drug misuse) also needs identification. This additional question is as follows: Q#4: Do you ever use illicit drugs or take prescription drugs other than how they were prescribed?

CAGE-AID
The CAGE-AID is a 4 item instrument based on the CAGE screening tool that has been adapted to also screen for drug use. It is widely used in primary care, particularly Emergency Departments. One or more yes answers constitute a positive screen. Sensitivity and specificity are .79 and .77 for 1 or more positive answer and .70 and .85 for 2 or more positive answers. In regard to drug use, including illegal drugs and the use of prescription drugs other than prescribed: Q#1: Have you ever felt that you ought to Cut down on your drinking or drug use? Q#2.: Have people Annoyed you by criticizing your drinking or drug use? Q#3: Have you ever felt bad or Guilty about your drinking or drug use? Q#4: Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?

Governors Institute on Substance Abuse www.governorsinstitute.org Get informed. Get involved.

SBIRT SCREENING TOOLS

CAGE-AID Overview
The CAGE-AID is a conjoint questionnaire where the focus of each item of the CAGE questionnaire was expanded from alcohol alone to include alcohol and other drugs. Clinical Utility Potential advantage is to screen for alcohol and drug problems conjointly rather than separately. Scoring Regard one or more positive responses to the CAGE-AID as a positive screen.

What is the AUDIT-C?

The AUDIT-C is a 3 question screen that can help identify patients with alcohol misuse. The AUDIT-C is scored on a scale of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered positive for alcohol misuse; in women, a score of 3 points or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her health and safety. The VA's performance measure requires brief counseling for alcohol use for any patient who scores 5 points or more on the AUDIT-C. The AUDIT-C questions are: Q#1: How often did you have a drink containing alcohol in the past year? Never (0 points)* Monthly or less (1 point) Two to four times a month (2 points) Two to three times per week (3 points) Four or more times a week (4 points) Q#2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? 0 drinks (0 points)* 1 or 2 (0 points) 3 or 4 (1 point) 5 or 6 (2 points) 7 to 9 (3 points) 10 or more (4 points) Q#3: How often did you have six or more drinks on one occasion in the past year? Never (0 points) Less than monthly (1 point) Monthly (2 points) Weekly (3 points) Daily or almost daily (4 points) * If patients are screened by interview, and AUDIT-C question #1 is answered "never", scores of 0 can be validly imputed for questions 2-3.6 If the AUDIT-C is administered on paper or online without a skip pattern (for non drinkers to skip questions #2-3), a "0 drinks" option is typically added to question #2.7 NOTE: A yes to the drug use question that accompanies the AUDIT C constitutes a positive screen

Governors Institute on Substance Abuse www.governorsinstitute.org Get informed. Get involved.

AUDIT- C
Lea las preguntas tal como estn escritas. Registre las respuestas cuidadosamente. Empiece el cuestionario AUDIT diciendo Ahora voy a hacerle algunas preguntas sobre su consumo de bebidas alcohlicas durante el ltimo ao. Explique qu entiende por bebidas alcohlicas utilizando ejemplos tpicos como cerveza, vino, vodka, etc. Codifique las respuestas en trminos de consumo (bebidas estndar). Marque la cifra de la respuesta adecuada en el recuadro de la derecha. 1. Con qu frecuencia consumi alguna bebida alcohlica? Nunca (0 puntos) Una o menos veces al mes (1 punto) De 2 a 4 veces al mes (2 puntos) De 2 a 3 veces a la semana (3 puntos) 4 o ms veces a la semana (4 puntos) 2. En el ltimo ao, Cuntas bebidas alcohlicas suele tomar en un da de consumo normal? Nunca 0* 1 2 (0 puntos) 3 4 (1 punto) 5 6 (2 puntos) 7, 8, 9 (3 puntos) 10 ms (4 puntos) 3. Con qu frecuencia toma 6 o ms bebidas alcohlicas en una sola ocasin? Nunca (0 puntos) Menos de una vez al mes (1 punto) Mensualmente (2 puntos) Semanalmente (3 puntos) A diario o casi a diario (4 puntos) 4. Ha usado drogas o tomado medicamentos de una manera diferente a la prescrita? S _____ NO _____ Registre la puntuacin total aqu _____________ Si la puntuacin total es mayor que el punto de corte recomendado, consulte el Manual de Usuario.

El AUDIT-C es una evaluacin de 3 preguntas la cual nos ayuda a identificar pacientes que abusan del alcohol. El puntuaje del AUDIT-C se basa en una escala de 0-12 puntos (puntajes de 0 reflejan ningn uso de alcohol en el ltimo ao). En los hombres, un puntaje de 4 puntos ms es considerado positivo en el abuso del alcohol; en las mujeres, un puntaje de 3 puntos ms es considerado positivo en el abuso de alcohol. Generalmente, cuanto ms alto sea el puntaje en el AUDIT-C, ms alta es la probabilidad de que el consumo de alcohol del paciente est afectando su salud y seguridad. La medida de rendimiento del VA requiere consejera breve sobre el uso del alcohol para cualquier paciente cuyo puntaje sea de 5 ms puntos en el AUDIT-C.

*Si los pacientes son evaluados mediante una entrevista, y la respuesta a la pregunta #1 del AUDIT-C es nunca, puede colocar puntajes de 0 en las preguntas 2-3. Si el AUDIT-C es administrado por escrito o por la red (internet) sin saltarse preguntas (para que los que no beben, salten las preguntas #2-3), una opcin de 0 bebidas es usualmente aadida a la pregunta #2. AVISO: Un S a la pregunta sobre el uso de drogas que acompaa el AUDIT-C constituye una evaluacin positiva.

Cuestionario CAGE-AID adaptado para incluir drogas

Fecha: ____/_____/_____ 1. Alguna vez ha sentido que debera disminuir o reducir su uso de alcohol y/o drogas? Alcohol: S _____ NO _____ Drogas: S _____ NO _____ 2. Se ha sentido alguna vez molesto por las crticas de la gente acerca de su uso de alcohol y/o drogas? Alcohol: S _____ NO _____ Drogas: S _____ NO _____ 3. Alguna vez se ha sentido culpable o mal debido a su uso de alcohol y/o drogas? Alcohol: S _____ NO _____ Drogas: S _____ NO _____ 4. Alguna vez ha necesitado alcohol y/o drogas temprano en la maana para estabilizar sus nervios o ayudarlo con la resaca)? Alcohol: S _____ NO _____ Drogas: S _____ NO _____

Tabulacin Puntuacin: Total de respuestas SI: __________ Determinacin positiva = Puntuacin de 1 o ms.

Patient Treatment Records:

1. Treatment Agreement (Pain Contract) 2. Opioid Risk Tool 3. Current Opioid Misuse Measure 4. Chronic Pain Progress Note 5. Medication Flowsheet 6. Personal Care Plan 7. Functional Ability Questionnaire (FAQ)

Opioid Agreement
I understand that Dr. _____________________________ is prescribing opioid medication to help me manage chronic pain that has not responded to other treatments. The goal of this medication is to lead to partial relief from pain, so that my physical, emotional, and social function will improve. If my activity level or general function gets worse, the opioid may be stopped or changed to something else. The risks, side effects and benefits of opioid treatment have been explained to me and I agree to the following instructions. Failure to follow these instructions will result in stopping the medication. 1. I will participate in any other treatments recommended by my provider. I will be ready to decrease or stop the opioid medication when other effective treatments become available. 2. I will take my medications exactly as prescribed and will not change the medication schedule or dosage without advance approval from my provider. I will provide my medication for pill counts at the providers request. I will not request early refills. 3. I will keep regular appointments at the clinic. 4. All opioid and other controlled drugs for pain must be prescribed only by Dr. ______________________. 5. I will inform the clinic within one business day if I am hospitalized for any reason, or if I have another condition that requires the prescription of a controlled drug (like narcotics, tranquilizers, barbiturates, or stimulants). 6. I will choose one pharmacy where all of my prescriptions will be filled. Pharmacy Name: Phone Number: Fax Number: Address: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

7. I understand that lost or stolen prescriptions will not be replaced, so I will keep my prescription and medication in a safe place. I will not under any circumstances sell, lend, or give my medication to others. 8. I agree to avoid all illegal and recreational drugs (including alcohol) and will provide urine or blood specimens at the doctor's request to monitor my compliance. 9. I agree to follow my doctors recommendations regarding the operation of motor vehicles or heavy machinery while taking this medication. 10. Refills will be made only during regular office hours, which are _______________________. Refills will not be made at night, on weekends or during holidays. I am responsible for keeping track of my remaining medication, so that I can call for refills in advance. This way, I will not run out of medication. 11. I have / have not received my prescription for Naloxone and the appropriate training for its use. Patient Name (print): ________________________ Patient Signature: ___________________________ Provider Signature: _________________________ Witness (optional): _________________________ Date: ________________________ Date: ________________________ Date: ________________________

Source: Adapted from ICSI Assessment and Management of Chronic Pain, Second Edition, March 2007 Distribution: White - Medical Record, Yellow Patient Please Note: Physician is to fax a copy of agreement to the Care Manager

Sample Pain Management Contract Patient Name ________________________ Physician Name _______________ Medical Record Number ______________________

Diagnosis Requiring Medications: ___________________________

I agree to abide by the following guidelines for managing my prescription(s) for pain medications: I will only request and receive opioid (narcotic) pain medications for management of my pain from _______________________. I agree to inform any other provider (doctor, nurse practitioner, physicians assistant) participating in my care of this agreement. If another provider wishes to suggest changes in pain management, they can contact my primary provider during regular business hours, but no changes will be made without such contact. I will not request refills prior to the next regularly scheduled visit with my provider. I understand that if my medications are lost or stolen, they will not be refilled prior to the next refill date. If I use up my supply of medications before the date of the next refill, I understand that I will not receive extra medications. In this case I understand that I may suffer symptoms of withdrawal. I will inform my doctor in a timely manner if I have an increased need for pain medication or have difficulty taking the medication as prescribed. If I find that the current dose of pain medication is no longer adequate, I will discuss this situation with my doctor at a scheduled visit. I agree to follow my providers recommendations for other pain relieving therapies (physical t herapy, etc). I understand that if I do not make a reasonable attempt to adhere to other therapies my clinician may decide to discontinue prescribing opioids. I understand that in the event of an emergency where I am seen by another provider at a different facility and that provider prescribes pain medications, I agree to notify my provider immediately. I agree to use only the following pharmacy: ____________________________ located at _______________________, telephone number _____________________, for the filling of all my pain medication prescriptions. I will bring all unused pain medications to every office visit, including all current prescription vials. I will not sell or share any opioid pain medications. While this contract is in effect, I will not abuse alcohol or use illicit drugs. As a part of this program, I understand that urine drug screening may occur at enrollment, at future visits, and randomly. I may be required to come into the clinic within 24 hours notice to give a random urine specimen and present pill bottles for a pill count. I understand that my provider may verify whether or not I have a history of criminal drug convictions. I understand that my provider may use the North Carolina Controlled Substances Reporting System to verify that I am not receiving controlled substances from other providers. I agree to treat all clinic staff with respect and courtesy. If my behavior towards staff is inappropriate or disrespectful I understand that I may be discharged from the practice. If I violate the terms of this contract, I understand that my provider or Sample Clinic Opioid Oversight Board can decide that I will no longer be prescribed any opioid pain medications. If this occurs, I understand that I may continue with my current provider and not receive controlled substance medications from him/her or any other Sample provider, or I can decide to receive care elsewhere . If I change to another practice, I agree to allow my current provider to contact my new practice to transfer medical information including information about chronic pain treatment. Patient Signature _________________________ Date____________________________________ Witness _________________________________________

Opioid Risk Tool Male Family history (parents and siblings): Alcohol abuse Illegal drug use Prescription drug abuse Personal history: Alcohol abuse Illegal drug use Prescription drug abuse Mental health: Diagnosis of ADD, OCD, bipolar, schizophrenia Diagnosis of depression Other: Age 16-45 years History of pre-adolescent sexual abuse Total _____ (1) _____ (0) _____ _____ (1) _____ (3) _____ _____ (2) _____ (1) _____ (2) _____ (1) _____(3) _____(4) _____(5) _____ (3) _____ (4) _____ (5) _____(3) _____(3) _____(4) _____(1) _____(2) _____(4) Female

Scoring: 0-3 4-7 >= 8 low risk: 6% chance of developing problematic behaviors moderate risk: 28% chance of developing problematic behaviors high risk: >90% chance of developing problematic behaviors

Adapted from: Webster, LR and Webster, RM, Pain Med: 2005; 6:432-442

Current Opioid Misuse Measure (COMM)

The Current Opioid Misuse Measure (COMM) is a brief patient self-assessment to monitor chronic pain patients on opioid therapy. The COMM was developed with guidance from a group of pain and addiction experts and input from pain management clinicians in the field. Experts and providers identified six key issues to determine if patients already on long-term opioid treatment are exhibiting aberrant medication-related behaviors:

Signs and Symptoms of Intoxication Emotional Volatility Evidence of Poor Response to Medications
Addiction Healthcare Use Patterns Problematic Medication Behavior The COMM will help clinicians identify whether a patient, currently on long-term opioid therapy, may be exhibiting aberrant behaviors associated with misuse of opioid medications. In contrast, the Screener and Opioid Assessment for Patients with Pain (SOAPP) is intended to predict which patients, being considered for long-term opioid therapy, may exhibit aberrant medications behaviors in the future. Since the COMM examines concurrent misuse, it is ideal for helping clinicians monitor patients aberrant medication-related behaviors over the course of treatment. The COMM is: A quick and easy to administer patient-self assessment 17 items Simple to score Completed in less than 10 minutes Validated with a group of approximately 500 chronic pain patients on opioid therapy Ideal for documenting decisions about the level of monitoring planned for a particular patient or justifying referrals to specialty pain clinic. The COMM is for clinician use only. The tool is not meant for commercial distribution. The COMM is NOT a lie detector. Patients determined to misrepresent themselves will still do so. Other clinical information should be used with COMM scores to decide if and when modifications to particular patients treatment plan is needed. It is important to remember that all chronic pain patients deserve treatment of their pain. Providers who are not comfortable treating certain patients should refer those patients to a specialist.

2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The COMM was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

Scoring Instructions for the COMM

To score the COMM, simply add the rating of all the questions. A score of 9 or higher is considered a positive

As for any scale, the results depend on what cutoff score is chosen. A score that is sensitive in detecting patients who are abusing or misusing their opioid medication will necessarily include a number of patients that are not really abusing or misusing their medication. The COMM was intended to over-identify misuse, rather than to mislabel someone as responsible when they are not. This is why a low cut-off score was accepted. We believe that it is more important to identify patients who have only a possibility of misusing their medications than to fail to identify those who are actually abusing their medication. Thus, it is possible that the COMM will result in false positives patients identified as misusing their medication when they were not. The table below presents several statistics that describe how effective the COMM is at different cutoff values. These values suggest that the COMM is a sensitive test. This confirms that the COMM is better at identifying who is misusing their medication than identifying who is not misusing. Clinically, a score of 9 or higher will identify 77% of those who actually turn out to be at high risk. The Negative Predictive Values for a cutoff score of 9 is .95, which means that most people who have a negative COMM are likely not misusing their medication. Finally, the Positive likelihood ratio suggests that a positive COMM score (at a cutoff of 9) is nearly 3 times (3.48 times) as likely to come from someone who is actually misusing their medication (note that, of these statistics, the likelihood ratio is least affected by prevalence rates). All this implies that by using a cutoff score of 9 will ensure that the provider is least likely to miss someone who is really misusing their prescription opioids. However, one should remember that a low COMM score suggests the patient is really at low-risk, while a high COMM score will contain a larger percentage of false positives (about 34%), while at the same time retaining a large percentage of true positives. This could be improved, so that a positive score has a lower false positive rate, but only at the risk of missing more of those who actually do show aberrant behavior.

COMM Cutoff Score

Sensitivity

Specificity

Score 9 or above

0.77

0.66

Positive Predictive Value 0.66

Negative Positive Predictive Likelihood Value Ratio 0.95 3.48

Negative Likelihood Ratio 0.08

2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The COMM was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

COMM Please answer each question as honestly as possible. Keep in mind that we are only asking about the past 30 days. There are no right or wrong answers. If you are unsure about how to answer the question, please give the best answer you can.

Please answer the questions using the following scale: 1. In the past 30 days, how often have you had trouble with thinking clearly or had memory problems? 2. In the past 30 days, how often do people complain that you are not completing necessary tasks? (i.e., doing things that need to be done, such as going to class, work or appointments) 3. In the past 30 days, how often have you had to go to someone other than your prescribing physician to get sufficient pain relief from medications? (i.e., another doctor, the Emergency Room, friends, street sources) 4. In the past 30 days, how often have you taken your medications differently from how they are prescribed? 5. In the past 30 days, how often have you seriously thought about hurting yourself? 6. In the past 30 days, how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)? 7. In the past 30 days, how often have you been in an argument? 8. In the past 30 days, how often have you had trouble controlling your anger (e.g., road rage, screaming, etc.)? 9. In the past 30 days, how often have you needed to take pain medications belonging to someone else? 10. In the past 30 days, how often have you been worried about how youre handling your medications?

Never 0 O

Seldom 1 O

Sometimes 2 O

Often 3 O

Very Often 4 O

2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The COMM was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

Please answer the questions using the following scale: 11. In the past 30 days, how often have others been worried about how youre handling your medications? 12. In the past 30 days, how often have you had to make an emergency phone call or show up at the clinic without an appointment? 13. In the past 30 days, how often have you gotten angry with people? 14. In the past 30 days, how often have you had to take more of your medication than prescribed? 15. In the past 30 days, how often have you borrowed pain medication from someone else? 16. In the past 30 days, how often have you used your pain medicine for symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve stress)? 17. In the past 30 days, how often have you had to visit the Emergency Room?

Never 0 O

Seldom 1 O

Sometimes 2 O

Often 3 O

Very Often 4 O

2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The COMM was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

COMM

Responda a cada pregunta con la mayor sinceridad posible. Tenga en cuenta que las preguntas se refieren nicamente a los ltimos 30 das. No hay respuestas correctas ni incorrectas. Si no est seguro acerca de cmo responder a una pregunta, proporcione la mejor respuesta que pueda.
Responda las preguntas usando la siguiente escala:

Nunca

Rara Vez

A veces

A menudo

Muy a menudo

1. En los ltimos 30 das, con qu frecuencia ha tenido inconvenientes para pensar con claridad o ha tenido problemas de memoria 2. En los ltimos 30 das, con qu frecuencia alguien se ha quejado de que usted no cumple con sus responsabilidades (por ejemplo, cumplir con lo que debe hacer, como ir a clase, al trabajo o a una cita)? 3. En los ltimos 30 das, con qu frecuencia ha tenido que recurrir a otra persona (que no sea el mdico que le receta su medicacin) para lograr suficiente alivio del dolor con medicamentos (es decir, otro mdico, la sala de emergencias, amigos, en la calle)? 4. En los ltimos 30 das, con qu frecuencia ha tomado sus medicamentos de manera diferente de como se los recetaron? 5. En los ltimos 30 das, con qu frecuencia ha pensado seriamente en hacerse dao? 6. En los ltimos 30 das, con qu frecuencia ha pensado en los medicamentos para el dolor (si tena suficientes, en tomarlos, el horario de administracin de las dosis, etc.)? 7. En los ltimos 30 das, con qu frecuencia ha tenido una discusin? 8. En los ltimos 30 das, con qu frecuencia ha tenido inconvenientes para controlar la ira (p. ej., enojarse al conducir, gritar, etc.)? 9. En los ltimos 30 das, con qu frecuencia ha tenido que tomar medicamentos para el dolor que eran de otra persona? 10. En los ltimos 30 das, con qu frecuencia se ha preocupado por la manera en que maneja sus medicamentos?

0 O

1 O

2 O

3 O

4 O

2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The COMM was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

Please answer the questions using the following scale: 11. En los ltimos 30 das, con qu frecuencia otras personas se han preocupado por la manera en que maneja sus medicamentos? 12. En los ltimos 30 das, con qu frecuencia ha tenido que hacer una llamada telefnica de emergencia o acudir a la clnica sin cita? 13. En los ltimos 30 das, con qu frecuencia se ha enojado con otras personas? 14. En los ltimos 30 das, con qu frecuencia ha tenido que tomar una mayor cantidad de medicamento que la recetada? 15. En los ltimos 30 das, con qu frecuencia ha pedido prestados medicamentos para el dolor a otra persona? 16. En los ltimos 30 das, con qu frecuencia ha usado su medicacin para aliviar sntomas que no eran de dolor (p. ej., como ayuda para dormir, para mejorar el estado de nimo o para aliviar el estrs)? 17. En los ltimos 30 das, con qu frecuencia ha tenido que acudir a la sala de emergencias?

Never 0 O

Seldom 1 O

Sometimes 2 O

Often 3 O

Very Often 4 O

2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: PainEDU@inflexxion.com. The COMM was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

Northwest Community Care Network PROGRESS NOTE: CHRONIC PAIN MANAGEMENT Patient Name: _______________________ Date of Visit: _________________________ DOB: __________________________ Chart Number: ________________________
ANALGESIA Scale of 0-10 (0 = no pain; 10 = worst pain imaginable) rank: 1. What was your pain level on average during the past week? _____ 2. What was your pain level at its worst during the past week? _____ 3. Compare your average pain during the past week with the average pain you had before you were treated with your current pain relievers. What percentage of your pain has been relieved? _____ 4. Is the amount of pain relief you are now obtaining from your current pain relievers enough to make a real difference in your life? Yes _____ No _____ ADVERSE EVENTS Is patient able to tolerate current pain relievers? Yes _____ No _____ Is patient experiencing any side effects from current pain relievers? (i.e. constipation, itching, mental clouding, other) Yes _____ No _____ Detail: INTERIM HISTORY Employment: FAQ performed Screened for depression Care Plan reviewed/updated Urine drug screen performed Result: Continue regimen Changes made: ________________________________________ ________________________________________ ________________________________________ ________________________________________ Next visit: _______________________________ Requests frequent early renewals Increased dose without authorization Reports lost or stolen prescriptions Attempts to obtain prescriptions from other doctors Changes route of administration ASSESSMENT/PLAN Yes Yes Yes Yes Yes No No No No No ACTIVITIES OF DAILY LIVING Physician observation comparing usual functioning during the past month with usual functioning before being treated with current pain reliever(s): B = Better S = Same _____ _____ _____ _____ W = Worse

Physical functioning: Family relationships: Social relationships: Sleep patterns:

POTENTIALLY ABERRANT DRUGRELATED BEHAVIOR Using EtOH? Using illicit drugs? Yes Yes No No

Social Support:

Mental Health:

Physical Activity:

Social Activity:

Modified from: Expert Guide to Pain Management, edited by Bill McCarberg and Steven D. Passik. 2005, American College of Physicians.

Northwest Community Care Network Chronic Pain Medication Flowsheet Treatment Agreement in Place? _________________ Pharmacy Home: _____________________________ Date Medicine Naloxone Dose Instructions Refills Patient Name: ___________________ DOB: ________________________ Chart No: ___________________ Drug Testing Performed? Medicine CSRS* Count? Contacted?

*CSRSControlled Substances Reporting System

Assessment and Management of Chronic Pain Guideline Summary

Personal Care Plan for Chronic Pain

1. Set Personal Goals

Improve ICSI Functional Activity Score by _____ points by: Date ________ Return to specific activities, tasks, hobbies, sports by: Date ____________ 1. __________________________________________ 2. __________________________________________ 3. __________________________________________

Name: _______________________ Date: ____________________ Date of Birth: ______________ MR #: ___________________

Return to limited work /or normal work by: Date ________________ 2. Improve Sleep (Goal: ______ hours per night, Current: ____hours per night) Follow basic sleep plan 1. Eliminate caffeine and naps, relaxation before bed, go to bed at target bed time __________

Take night time medications 1. __________________________________________ 2. __________________________________________ 3. __________________________________________ 3. Increase Physical Activity

Attend Physical Therapy (days per week ________) Complete daily stretching (____ times per day, for ____minutes) Complete Aerobic exercise / Endurance exercise 1. Walking (____ times per day, for ____minutes) or Pedometer (_____ steps per day) 2. Treadmill, bike, rower, elliptical trainer (____ times per week, for ____ minutes) 3. Target heart rate goal with exercise _______ bpm

Strengthening 1. Elastic, hand weights, weight machines (____ minutes per day, ____ days per week) 4. Manage Stress - list main stressors ____________________________________________________ Formal interventions (counseling or classes, support group or therapy group) 1. ___________________________________________ Daily practice of relaxation techniques, meditation, yoga, creative / service activity 1. ___________________________________________ 2. ___________________________________________

Medications 1. ___________________________________________ 2. ___________________________________________ 5. Decrease Pain (Best pain level in past week: ____ / 10, Worst pain level in past week: ____ / 10) Non-medication treatments 1. Ice / Heat __________________________________ 2. __________________________________________ Medication 1. __________________________________________ 2. __________________________________________ 3. __________________________________________ 4. __________________________________________

Other treatments _________________________ Physician name: _________________________________ Date: ______________________ Created by Peter Marshall, MD as a member of the ICSI Chronic Pain guideline work group.

www.icsi.org Institute for Clinical Systems Improvement

Assessment and Management of Chronic Pain Second Edition/March 2007

Functional Ability Questionnaire

Name: ______________________ Date: _______________________ Date of Birth: ________________ MR #: _________________________

Instructions: Circle the number (1-4) in each of the groups that best summarizes your ability. Add the numbers and multiply by 5 for total score out of 100. ________ Self-care ability assessment 1. Require total care: for bathing, toilet, dressing, moving and eating 2. Require frequent assistance 3. Require occasional assistance 4. Independent with self-care ________ Family and social ability assessment 1. Unable to perform any: chores, hobbies, driving, sex or social activities 2. Able to perform some 3. Able to perform many 4. Able to perform all ________ Get-up-and-go ability assessment 1. Able to get up and walk with assistance, unable to climb stairs 2. Able to get up and walk independently, able to climb one flight of stairs 3. Able to walk short distances and climb more than one flight of stairs 4. Able to walk long distances and climb stairs without difficulty ________ Lifting ability assessment 1. Able to lift up to 10 lb. occasionally 2. Able to lift up to 20 lb. occasionally 3. Able to lift 20-50 lb. occasionally 4. Able to lift over 50 lb. occasionally ________ Work ability assessment 1. Unable to do any work 2. Able to work part-time and with physical limitations 3. Able to work part-time or with physical limitations 4. Able to perform normal work ________ Functional Ability Score

Created by Peter Marshall, MD as a member of the ICSI Chronic Pain guideline work group.

www.icsi.org Institute for Clinical Systems Improvement

2012

Urine Drug Screen Toolkit

Community Care of Wake and Johnston Counties
This is a tool that may be used to assist providers in prescribing medications safely when treating individuals with chronic pain.

TABLE OF CONTENTS
Introduction to the Urine Drug Screen Toolkit...3 I. Core Elements.......................................................................................................................... 4 Information for Staff ............................................................................................................. 5-6 Information for Patients ....................................................................................................... 7-8 II. Polices and Procedures ............................................................................................................ 9 a. b. c. III. a. b. i. ii. Preparing the office ............................................................................................................... 10 Routine Procedure ................................................................................................................. 10 Performing the Test ............................................................................................................... 10 Reading and Interpreting the Results ............................................................................. 12 Reading & Interpreting .......................................................................................................... 13 Special Consideration ............................................................................................................ 13 Abnormal Results: Negative for Prescribed Medication ....................................................... 13 Abnormal Result: Positive for an Unprescribed/Illicit Substance ......................................... 13

IV. Documenting Results...14 UDS Log.....15 V. Additional Resources....16

Introduction
This Urine Drug Screen Toolkit is a resource that may be used to assist medical care providers in treating and managing individuals with chronic pain. These are some recommendations and you are encouraged to adopt and utilize practices in this toolkit that you find helpful.

I. CORE ELEMENTS

Information for Staff

Who to Test Patients on chronic opiate regimen New patients already on narcotics Patients that you inherit Suspicious/ unusual behavior: Pseudo-addiction Patients with a history of addiction or currently in recovery When to Test Frequency: The decision on how often to collect samples is up to the practitioner and can vary depending on the individual patient. For example, take into account patient characteristics such as: o Patient behavior o Past positive tests o Indications of abuse or addiction Schedule: Research suggests it is best practice to collect samples on an unannounced basis. Two to three collections per year may be enough for pain patients who do not show signs of abnormal behavior First Visit At the beginning of the visit-before a prescription is written Before starting controlled substances Change in medication type or dosage Decline in patients level of functioning/mental status How to Test Lab or Rapid Urine Drug Screen Testing Routine, Monitored, or Observed a. When to complete a monitored or observed collection Tampering is suspected as evidenced by: temperature not WNL, observation of sample appears diluted, cloudy, or bubbly, or observations of patients behaviors and/or actions convey possible tampering. If the physician requests a monitored or observed collection How to Respond to Results If tampering is suspected, may want to consider offering the patient an option to retest. If you allow retesting it is encouraged to repeat the test on the same day the original is administered.

Common adulterants typically produce telltale signs of tampering: Drano, bleach and vinegar change the specimen's pH outside the normal range, goldenseal tea causes the specimen to turn brown, soap causes the specimen to become cloudy or bubble when shaken, table salt forces the samples relative density out of the normal range. If results are positive, for illicit substances or prescription medications that are not prescribed, it should be discussed in a non-judgmental, supportive way with the patient to see if there might be another cause of the positive result. Sometimes detecting an illicit substance can be used as a motivation to change.

A referral to addiction specialist should be considered and is strongly encouraged to rule in or out any substance abuse or dependency issues.

[Practice Letter head/logo]

Our practice is committed to delivering high quality and safe care to our patients.

A growing patient safety problem is unintended overdoses and deaths among patients using prescribed pain medications.

In response to this problem, patients who are receiving on-going prescriptions for pain medications may be asked to complete a Pain Management Agreement with their provider and provide a urine sample to check for medications in their system.

Information for Patients

Your doctor wants to make sure you are receiving safe and quality care. Under some circumstances you may be asked to provide a urine sample while you are receiving treatment. Q. How Can Testing My Urine Help My Doctor? A. Urine screens are used as a tool to help your doctor learn more information about the medications in your system. The information in your results can help the doctor detect dangerous drug interactions and protect you from any risk. The doctor uses your results to: Guide you in your treatment To assist you in receiving better treatment To help your doctor manage your prescription medications Monitor adherence of medications being prescribed To detect possible substance misuse Q. My doctor hasnt been testing me. What made him decide to test me now? A. Providing a sample for urine drug monitoring is not an indication that your doctor suspects anything or that you may be doing anything wrong. Your doctor may be doing randomized testing of many patients. What that means is that rather than having to decide who might best benefit from testing, he or she will pick patients for testing at random intervals. That way, no patient is ever singled out and no patient is accidentally skipped over. Q. Can I refuse to be tested? A. When a doctor chooses to use urine drug monitoring as a part of his or her treatments, it is usually an important part of how he or she makes important decisions regarding your care. It also indicates that the drugs prescribed as part of your medication regimen should be closely monitored. Refusing to be tested may make it impossible for your doctor to continue your treatment in a manner that he or she sees as effective and safe. As a patient you have the right to refuse testing, however, your doctor also has the right to decide how, if, and what kind of treatment he or she will provide. Please remember that your doctor is committed to your wellbeing and safety. Under Some Circumstances You May Be Asked To: Remove any unnecessary outer clothing (e.g., coat, jacket, hat, etc.) and to leave any purse, or other personal items you may have with the collector. To empty your pockets. To wash your hands prior to giving the urine sample. Wait to flush the toilet before giving your urine sample to the collector.
8

Different Types of Collections May Include Monitoring or Observed Collections. What is the Difference between a Monitored and an Observed Test? Monitored Test: The collector may stand outside the restroom and listen, but will not watch you. You may be asked to place one hand on the wall and/or stop urinating mid-stream. Observed Test: the collector may enter the restroom with you and will observe urine filter from your body directly into the collection cup. What about the Results of My Test? If your test is negative for any prescriptions that should be detected in your urine, positive for prescriptions you are not prescribed, or positive for illegal substances your doctor will discuss his or her concerns with you. Please direct any questions, comments, or concerns about testing with your doctor and not the individual collecting your urine sample.

II. POLICIES & PROCEDURES FOR IN-OFFICE TESTING

10

a. Preparing the Office Storage o Refer to package information and store as directed. o Do not use after expiration date on package. Materials Needed for Testing o Disposable Gloves o Liquid Soap One (1) plastic sealable bag * Note: liquid soap should be used as bar soap shavings can be hidden under fingernails and used to alter results of test. o Biohazard container or bags to dispose of used testing containers o Clock or stopwatch o Add bluing agent into toilet (optional) b. Routine Procedure for Preparing to Collect Urine Sample o Explain the basic collection procedures to the patient. o You may want to have patient remove any unnecessary outer clothing (e.g., coat, jacket, hat, etc.), empty pockets, and leave any purse, or other personal belongings with the collector. o Instruct and observe patient washing his/her hands. Collector should also wash hands at this time and follow with placing disposable gloves on hands. c. Perform the Test 1. Choose a collection cup and with patient present remove cup from the secured wrapper. (For quality control: check date to make sure not expired) 2. Direct patient to the restroom, give patient cup, and instruct patient to provide a sample to the minimal fill line labeled on the container and shown to the patient by the collector. (Note: Lid to container stays with collector) 3. Collector secures the lid on the collection cup and places container on a flat surface. 4. Read temperature to ensure it is within normal limits (90-100 degrees F) Chain of Custody: Both the collector and patient maintain visual contact of the specimen until results have been read and documented. 5. Read and document results of test within five minutes of sample being collected into cup. (Note: Refer to Instruction Booklet on how to read test results and ensure quality control). The Collection Process is now complete.
11

III. Reading and Interpreting the Results

12

a. Consult results reference guide provided with testing materials for interpretation. b. Special Considerations i. Abnormal Results: Negative for Prescribed Medication While absence of the prescribed drug could indicate diversion, there are other possible explanations: The patient may have run out of the medication before submitting a sample due to increasing the dose or frequency of administration. The patient is taking less than the prescribed amount of medication. In an attempt to cover up illicit drugs, the patient has tampered with his or her sample. If immunoassay testing that was not specific for a single drug was used, it will usually not detect semi-synthetic and synthetic opioids - i.e., buprenorphine, oxycodone, hydrocodone, hydromorphine, fetanyl, and methadone. In this case, confirmatory testing should be considered. ii. Abnormal Results: Positive for an Unprescribed/Illicit Substance Testing can be a good tool to screen for substance abuse, but a positive result does not mean the patient has an abuse or dependency problem and the following should be taken into consideration: False positives can occur due to cross-reactivity, where OTC and non-illicit drugs can look like illicit drugs and result in a positive. Recreational use

13

IV. DOCUMENTING RESULTS

14

ON-SITE UDS TESTING LOG

MEDICAID ID OR INITIALS/DOB = YES = YES DATE LOT# EXPECTED DID THIS RESULT CHANGE MANAGEMENT?

15

V. ADDITIONAL RESOURCES

16

17

Proper Prescription Writing

Northwest Community Care Network

Proper Prescription Writing to Prevent Diversion in Medical Practice

Writing prescriptions for controlled substances needs to be done with care. Here are some tips for reducing the chances that your script can be used by diverters. Write prescriptions like you write checks write out strength and quantity in both numbers and letters. For example, 10 mg <ten> and #15 <fifteen>. If no refills are required, circle zero and cross out the other refill numbers, and/or specify no refills. Do not pre-print your Drug Enforcement Agency (DEA) Registration number on prescription pads write the number in by hand. A prescription for an antibiotic or other routine medication can be rinsed or washed. Rinsing is when acetone (nail polish remover) or xylene is used to remove the writing from the body of a prescription. A diverter can then re-write it as a prescription for controlled substances, with signatures that appear to be legitimate. Handwriting your DEA number in also prevents lost/stolen prescription pads from being used. Gel ink pens are the most resistant to rinsing because the ink is more deeply imbedded in the fibers of the paper. Refillable ink fountain pens are also a good option. Ball point pens and regular ink pens are more prone to rinsing. Tamper resistant and permanent ink pens are available at office supply stores, including the UniBall 207. Consider keeping photocopies of prescriptions in patient files. If a pharmacy calls to question a prescription, you can verify the script by faxing a copy to them. Prescription pads with serial numbers make it more difficult for diverters to obtain controlled substances and prevent lost or stolen prescription pads from being used. Serialized prescription pads can be ordered from medical suppliers. A federal law was passed by the US congress in May, 2007 requiring the use of tamper resistant prescription pads for all Medicaid outpatient drugs. As of October 1, 2007, a prescription pad must contain at least one of the following characteristics. And on October 1, 2008, a prescription pad must contain all three of the characteristics. 1. One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form 2. One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber 3. One or more industry-recognized features designed to prevent the use of counterfeit prescription forms

Patient Education Materials

Chronic Pain
What is chronic pain?
There are 2 types of pain: acute and chronic. Acute pain doesn't last long and usually goes away as your body heals. Chronic pain lasts at least 6 months after your body has healed. Sometimes, when people have chronic pain they don't know what is causing it. Along with discomfort, chronic pain can cause low self-esteem, depression and anger, and it can interfere with your daily activities.

How is chronic pain treated?

Treatment of chronic pain usually involves medicines and therapy. Medicines used for chronic pain include pain relievers, antidepressants and anticonvulsants. Different types of medicines help people with different types of pain. You usually use long-acting medicines for constant pain. Short-acting medicines treat pain that comes and goes. Several types of therapy can help ease your pain. Physical therapy (such as stretching and strengthening activities) and low-impact exercise (such as walking, swimming or biking) can help reduce the pain. However, exercising too much or not at all can hurt chronic pain patients. Occupational therapy teaches you how to pace yourself and how to do ordinary tasks differently so you won't hurt yourself. Behavioral therapy can reduce your pain through methods (such as meditation and yoga) that help you relax. It can also help decrease stress. Lifestyle changes are also an important part of treatment for chronic pain. Getting regular sleep at night and not taking daytime naps should help. Stopping smoking helps, too, because the nicotine in cigarettes can make some medicines less effective. Smokers also have more pain than nonsmokers. Many other treatments can also decrease pain. They can actually change the body's chemicals that produce pain. Almost anything we do to relax or get our minds off our problems may help control pain. It's important to add relaxing activities to your daily life, even if you are already taking medicine for pain. You might have to use stress reduction methods for several weeks before you notice a decrease in pain. Your doctor can give you tips about stress reduction and relaxation methods. Most pain treatments will not take away all of your pain. Instead, treatment should reduce how much pain you have and how often it occurs. Talk to your doctor to learn how to best control your pain.

What drugs can treat chronic pain?

Many medicines can decrease pain, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), narcotics and others. Each one may have side effects. Some side effects can be serious. It's important to listen to your family doctor carefully when he or she tells you how to use your pain medicine. If you have questions about side effects or about how much medicine to take, ask your doctor or your pharmacist.

Narcotics
Narcotics can be addictive, so your family doctor will be careful about prescribing them. For many people with severe chronic pain, these drugs are an important part of their therapy. If your doctor prescribes narcotics for your pain, be sure to carefully follow his or her directions. Tell your doctor if you are uncomfortable with the changes that may go along with taking these medicines, such as inability to concentrate or think clearly. Do not drive when taking these medicines. When you're taking narcotics, it's important to remember that there is a difference between "physical dependence" and "psychological addiction." Physical dependence on a medicine means that your body gets used to that medicine and needs it to work properly. When you don't have to take the pain medicine any longer, your doctor can help you slowly and safely decrease the amount of medicine until your body no longer "needs" it. Psychological addiction is the desire to use a drug whether or not it's needed to relieve pain. Using a narcotic this way can be dangerous and may not help your pain. If you have a psychological addiction to a narcotic, your doctor may give you another drug to help with your psychological problems. Or your doctor might recommend that you talk to a counselor. Your doctor might also change the medicine that you are addicted to by lowering the dose, changing to another drug or stopping the medicine altogether. Narcotic drugs often cause constipation (difficulty having bowel movements). If you are taking a narcotic medicine, it's important to drink at least 6 to 8 glasses of water every day. Try to eat 2 to 4 servings of fresh fruits and 3 to 5 servings of vegetables every day. Be sure to tell your doctor if constipation becomes a problem for you. He or she may suggest taking laxatives to treat or prevent it.

Other medicines
Many drugs that are used to treat other illnesses can also treat pain. For example, carbamazepine (one brand name: Tegretol) is a seizure medication that can treat some kinds of pain. Amitriptyline (one brand name: Elavil) is an antidepressant that can also help with chronic pain in many people. Your doctor may want you to try one of these medicines to help control your pain. It can take several weeks before these medicines begin to work well. Remember -- if you are taking any pain medicine, be sure to ask your doctor or pharmacist before you take any other medicine, either prescription or over-the-counter.

Source
Treatment of Nonmalignant Chronic Pain (American Family Physician March 1, 2000,
http://www.aafp.org/afp/20000301/1331.html) Reviewed/Updated: 07/05 Created: 9/00 This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more information on this subject, talk to your family doctor. Copyright 2000-2005 American Academy of Family Physicians Permission is granted to print and photocopy this material for nonprofit educational uses. Written permission is required for all other uses, including electronic uses. Home | Privacy Policy | Contact Us | About This Site | What's New

Community Care of Wake and Johnston Counties (CCWJC) Adult Care Management Referral Form Please fax completed form to (919) 510-9162 Date: ______________ Referral Source/Agency: ____________________________________ Patient Name: ___________________________________________ Male/Female (circle one) DOB: ______________________ Medicaid ID Number: ______________________________ Patient Phone Number: _________________Patient informed of referral? Yes/No (circle one) Physical Address: ________________________________________ County: _____________ Primary Language: English _____ Spanish _____ Other (specify): _____________________

Person Referring: ________________________________ (MD, RN, SW, Other) please circle Phone#: _____________________________ Fax #: _______________________________ Reason for Referral: Asthma (please specify): ___________________________________________________ Repetitive Use of ED Services/Multiple Hospitalizations: _________________________ CHF (please specify): ______________________________________________________ Diabetes (please specify): __________________________________________________ Social Concerns/Family Support (please specify): ______________________________ Mental Health Concerns: ___________________________________________________ Financial/Housing/Community Resource Needs: _______________________________ Transportation Needs: _____________________________________________________ Chronic/Complex Medical Condition(s) Requiring Care Management Chronic Pain Concerns (specify): ___________________________________________ Needs assistance in following plan of care for chronic illness (please specify): _____ _________________________________________________________________________ _________________________________________________________________________ For Care Managers Use Only: Date: ____________________ _____ Accepted into Care Management _____ Other Interventions: _____________________________________________ Revised 03.09.2011

Resource List

Primary Care Providers (Medicaid and Uninsured) - http://www.ccwjc.com/provider_lists.asp Behavioral Health and Opioid Treatment Providers - Johnston County Access Center 919-989-5500 - Wake County Access Center 919-250-3133 Pain Clinics (Medicare/Medicaid) - Carolina Pain Consultants-Rex Pain Clinic - Carolina Pain Consultants at Wakefield - Duke Health Raleigh Pain Center - Brier Creek Integrated Pain and Spine - Dr. Rachid Idrissi, Clayton - Dr. Phillip Martin, Smithfield - Wilson Medical Center, Pain Management *Carolina Back Institute *NC Comprehensive Headache Clinic *does not accept Medicaid Dentists (Medicaid and Uninsured) - http://www.ccwjc.com/provider_lists.asp

919-784-3402 919-784-3402 919-954-3584 919-596-3400 919-350-4225 919-934-8171 252.399.8118 919-847-8200 919-781-7423

Homeless Shelters Wake County:

The Healing Place - Raleigh 919-838-9800 Single males and female Interact- Family Violence undisclosed locations 919-828-7740 (Domestic violence survivors) Raleigh Rescue Mission 919-828-9014 40 beds for men, usual 4-6 month commitment Raleigh Rescue Mission 919-828-4980 (83) 67 beds for women and 16 emergency beds Salvation Army 919-834-6733 23 single women, women with children Helen Wright Center 919-833-1748 36 Single females over 18 S. Wilmington St. Center 919-857-9428 234 Single Males Wake Interfaith Hospitality 919-832-6024 Couples, Working Families, Single pregnant women Wake Family Entry New Horizons 919-836-9197 20 Families with children; offered by Pan Lutheran Ministries

Johnston County:
Smithfield Rescue Mission 919-934-9257 Harbor, INC. Domestic Violence 919-938-3566

Outpatient Resources for Patients Needing Drug and Alcohol Abuse and/or Dependence Treatment

Johnston County Mental Health, Substance Abuse, and Developmental Disability Resources www.johstonnc.com/mentalhealth Screening and referral Access Center (24/7):919-989-5500/ 877-815-8934 Crisis Response (24/7): 919:989-5500 Mobile Crisis (24/7): 1-877-626-1772 Wake County Mental Health, Substance Abuse, and Developmental Disability Resources http://www.wakegov.com/lme/ Access Center (24/7):919-250-3133 or 866-518-6784 Mobile Crisis (24/7): 1-877-626-1772 Alcoholics Anonymous Call for follow up: 919-783-8214 Narcotics Anonymous Call for follow up: 1-877-590-6262 Arbor Counseling 4010 Barrett Drive Suite 101 Raleigh Phone: 9191-788-8002 Carter Clinic 8360 Six Forks Road Suite 202 Raleigh Phone: 919-573-6520 Fellowship Health Resources Wake 4112 Blue Ridge Road Raleigh Phone 9191-573-6520 First Step Services LLC 211 Six Forks Road Suite 117 Building B Raleigh Phone: 9191-833-8899 Hotline 1: 9191-833-8899

United Community LLC 4921 Professional Court, 1st Floor Raleigh Phone: 919-878-1590 Holly Hill Hospital 3019 Falstaff Road Raleigh Phone: 919-250-7000 Hotline 1: 9191-250-7000 Hotline 2: 800-447-1800 Life Skills Counseling 721 Tucker Street Raleigh Phone: 919-833-8862 Methodist Home for Children Bridges Program 1041 Washington Street Raleigh Phone: 9191-778-3762 North Carolina Behavioral Health 33 West Davie Street Raleigh Phone: 9191-828-9007 Omega Independent Living Services 3029 Stoneybrook Drive Suite 105 Raleigh Phone: 919-250-2004 Raleigh Methadone Treatment Center ( RMTC) 5109 Oak Park Road Raleigh Phone: 9191-781-5507 Southlight: Call for a referral 919-787-6131 Wake County Larry B Zieverink Sr Alcoholism Treatment Center 300 Falstaff Road

Raleigh Phone: 919-250-1500 Hotline: 919:250-1500 Hotline: 919-250-3133 Healing Place Mens Facility 1251 Goode Street Raleigh 9191-838-9800 Womens Shelter 3304 Glen Royal Road Raleigh 919-865-2550

NORTH CAROLINA STATE BUREAU OF INVESTIGATION DIVERSION AND ENVIRONMENTAL CRIMES UNIT (DECU)

Special Agent Gray Fullwood Greensboro: 336-256-1364 Raleigh: 919-779-8153

UNIT RESPONSIBILITIES

The Diversion and Environmental Crimes Unit investigates diversion of drugs by licensed healthcare professionals and others involved in the healthcare registrant field. Large scale or multi-jurisdictional prescription fraud cases.

Suspicious deaths in healthcare facilities.

Violations of state and federal statutes and regulations including: Clean Water Act, or other violations involving pollution or hazardous substances.

WHAT IS DRUG DIVERSION?

Diverting legitimate prescription drugs for illegal purposes

100000

120000

140000

20000

40000

60000

80000

Alprazolam Hydrocodone
2004

Diazepam Demerol Morphine Hydrocodone Alprazolam

TOP FIVE MOST DIVERTED DRUGS IN NORTH CAROLINA

2005

Oxycodone Diazepam Methadone Hydrocodone Oxycodone

2006 2007

Alprazolam Clonazepam Methadone Hydrocodone Phentermine Alprazolam Oxycodone Morphine

QUESTIONS
Response

of Provider if they suspect/learn of prescription forgery?

Notify Law Enforcement /NCSBI-DECU Notify NCDHHS - John Womble, Program Consultant
NC Controlled Substance Reporting System 919-733-1765 ext 248

Notify NC Board of Pharmacy

QUESTIONS
Response

of Provider if they receive an tip that a patient is selling their prescriptions?

* Notify Law Enforcement /NCSBI-DECU * The police departments and Sheriffs Office may be more familiar with the names of dealers

QUESTIONS
Should

a provider call the police when a patient divulges dealer information?

Notify Law Enforcement /NCSBI-DECU Benefit Cleans up your facility and will stop drug seekers, etc. from using your facility as a source.

QUESTIONS
What

are a providers rights when questioned by the SBI?

Provider is the victim Right not to answer any questions Right to ask questions Could be subpoenaed to court by District Attorney

QUESTIONS

Specific Identification/Information/Documents the provider should request before releasing confidential information to the SBI?

Credentials should be shown by Agent NCSBI-DECU No Subpoena needed Other Law Enforcement Organization Subpoena (depending on Info) HIPAA Law Enforcement Exemption

QUESTIONS
Ways

a provider can protect themselves from prescription forgery?

REPORT ALL SUSPICIOUS PEOPLE No DEA number unless needed Tamper resistant prescription paper Duplicate prescriptions Treat prescription pad like a check book E-Scripts (not approved by DEA for CS)

USEFUL WEBSITES

National Association of Drug Diversion Investigators (www.naddi.org)

Rx Patrol (www.rxpatrol.org)

DEA (www.deadiversion.usdoj.gov)
Regional Counterdrug Training Academy (www.rcta.org)

CONTACT INFORMATION
North Carolina State Bureau of Investigation Diversion and Environmental Crimes Unit (336) 256-1364