Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain: an Educational Aid to Improve Care and Safety with Opioid Therapy 2010 Update
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Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy 2010 Update What is New in this Revised Guideline New data, including scientific evidence to support the 120mg MED dosing threshold Tools for calculating dosages of opioids during treatment and when tapering Validated screening tools for assessing substance abuse, mental health, and addiction Validated two-item scale for tracking function and pain Urine drug testing guidance and algorithm Information on access to mentoring and consultations (including reimbursement options) New patient education materials and resources Guidance on coordinating with emergency departments to reduce opioid abuse New clinical tools and resources to help streamline clinical care You can find this guideline and related tools at the Washington State Agency Medical Directors’ site at www.agencymeddirectors.wa.gov 1 Table of Contents Introduction ............................................. 1 Part II: Guidelines for optimizing 2010 Update ........................................................ 1 treatment when opioid doses are greater than 120mg MED/day .............. 12 How this guideline is organized ........................... 2 Assessing effects of opioid doses greater than Part I. Guidelines for initiating, 120mg MED/day ............................................... 12 transitioning, and maintaining oral How to discontinue opioids or reduce and opioids for chronic non-cancer pain .... 3 reassess at lower doses ................................... 12 Dosing threshold for pain consultation ................. 3 Referrals to pain centers ................................... 12 BEFORE you decide to prescribe opioids for Recognizing aberrant behaviors during opioid chronic pain ......................................................... 4 therapy .............................................................. 12 AFTER you decide with the patient to prescribe Reasons to discontinue opioids or refer for chronic opioid therapy ......................................... 5 addiction management ...................................... 12 Principles for safely prescribing chronic opioid Referrals for addiction management ................. 13 therapy ................................................................ 5 Screening and monitoring your patient ................ 6 Appendices ........................................... 15 Opioid Risk Tool (ORT) ................................... 6 Appendix A: Opioid dose calculations ............... 16 CAGE-AID ....................................................... 6 Appendix B: Screening Tools ............................ 18 PHQ-9 ............................................................. 6 Appendix C: Tools for Assessing Function and Tools for assessing function and pain ................. 6 pain ................................................................... 30 Assessing effects of chronic opioid therapy ......... 7 Appendix D: Urine Drug Testing for Monitoring Urine drug testing (UDT) ..................................... 8 Opioid Therapy ................................................. 31 Methods of testing ........................................... 8 Appendix E: Obtaining Consultative Assistance – Drugs or drug classes to test ........................... 9 for WA Public Payers Only ................................ 39 Interpreting results........................................... 9 Appendix F: Patient Education Resources ........ 41 Specialty consultation .......................................... 9 Appendix G: Sample Doctor-Patient Agreements Unrecognized diagnoses ................................. 9 for Chronic Opioid Use ...................................... 43 Psychological and addiction issues ................. 9 Appendix H: Additional Resources to Streamline Opioid management ...................................... 10 Clinical Care ..................................................... 46 Access to specialists and mentors .................... 10 Appendix I: Emergency department guidelines Tapering or discontinuing opioids ...................... 10 help coordinate care with primary care providers Recognizing and managing behavioral issues .......................................................................... 47 during opioid tapering ........................................ 11 References ............................................ 48 Acknowledgements .............................. 55 Figures and Tables Figure 1. Morphine Equivalent Dose Calculation ........................................................... 4 Figure 2. Graded Chronic Pain Scale .................. 7 Table 1. Guidance For Seeking Consultative Asistance ............................................................. 4 Table 2. Recommended frequency of UDT ......... 8 Table 3. Red flag results ...................................... 9 Table 4. Dosing Threshold for Selected Opioids .............................................................. 15 Table 5. MED for Selected Opioids ................... 16 Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP) released several recommendations for how health Introduction care providers can help. The recommendations This guideline was originally published in March include: 2007 as an educational pilot. Sponsored by the Use opioid medications for acute or chronic pain Washington State Agency Medical Directors’ Group 1 only after determining that alternative therapies (AMDG) , the original guideline and this updated do not deliver adequate pain relief. The lowest version were developed in collaboration with effective dose of opioids should be used. actively practicing providers with extensive experience in the evaluation and treatment of In addition to behavioral screening and use of patients with chronic pain. It is intended as a patient agreements, consider random, periodic, resource for primary care providers treating patients targeted urine testing for opioids and other drugs with chronic noncancer pain. It does not apply to the for any patient less than 65 years old with treatment of acute pain, cancer pain, or end-of-life noncancer pain who has been treated with (hospice) care. opioids for more than six weeks. If a patient’s dosage has increased to 120 mg Providers prescribing opioids know there is a MED per day or more without substantial delicate balance between the undertreatment and improvement in function and pain, seek a consult overtreatment of chronic non-cancer pain. This from a pain specialist. guideline provides information on the scope of the Do not prescribe long-acting or controlled- challenge, recommendations for prudent prescribing release opioids (e.g., OxyContin®, fentanyl and monitoring, advice on how to get consultative patches, and methadone) for acute pain. assistance, and resources for educating patients. The full report can be found at 2010 Update www.cdc.gov/HomeandRecreationalSafety/ In 2009, the AMDG surveyed medical providers in Poisoning/brief.htm . Washington State to assess the acceptability and usefulness of the guideline and to identify ways to Data collected in Washington state show: improve it (available at http://www.agencymeddirectors.wa.gov/Files/AG During 2004–2007, 1,668 WA residents had ReportFinal.pdf ). Results of the survey support the confirmed unintentional poisoning deaths due to 6 continued use of this guideline with the addition of prescription opioid related overdoses . Nearly clinical tools and improved information for half of these deaths were in the Medicaid accessing specialty consultations. population. Unintentional opioid-related overdose deaths Recent studies indicate a dramatic increase in increased 17-fold during 1995–2008. accidental deaths associated with the use of Hospitalizations for opioid-related overdoses prescription opioids and an increasing average daily increased 7-fold during 1995–2007. morphine equivalent dose (MED) of the most potent 1-3 Addiction treatment admissions, where opioids since 1999 . Between 1999–2006, people prescription opioids were the primary drug of aged 35–54 years had higher poisoning death rates abuse, increased from 1.1% to 7.4% between involving opioid analgesics than those in any other 2000 and 2009. age group4. Prescription opioid-related overdose deaths now exceed non-prescription opioid-related overdose In response to the increasing morbidity and mortality deaths7. associated with the increasing use of opioids, the 5 The death rate from unintentional poisoning Centers for Disease Control and Prevention has exceeded the death rate from motor vehicle crashes in 2006, and the gap continues to widen8. 1 The AMDG consists of the medical directors from these WA State Agencies: Corrections, Social and Health Services (Medicaid), Labor and Industries, and the Health Care Authority 1 Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP) The risks of opioid use are not exclusive to the adult population. According to the Healthy Youth Survey How this guideline is organized 2008 (available at The purpose of Part I of the dosing guideline is http://takeasdirected.doh.wa.gov), Washington to assist primary care providers in prescribing teens are using prescription opioid pain medicine to opioids for adults in a safe and effective get high. This includes: manner. 4% of 8th graders The purpose of Part II is to assist primary care 10 % of 10th graders (21% of these youth providers in treating patients whose morphine