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Your colleagues offer guidance, suggestions on new opioid drug rules
e-Reports, Nov. 3, 2014
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Nearly 800 people attended the Indiana Attorney General’s 5th Annual Prescription Drug Abuse Symposium and that included physicians, law enforcement and other health care providers. With the focus on Indiana’s new Opioid Prescribing Rules now in effect, several of your colleagues shared how they are implementing the rules in their own offices and clinics.

All three quoted here are members of the Attorney General’s Prescription Drug Abuse Prevention Task Force. Each one invites you to email your questions.

Attorney General Greg Zoeller has committed to fighting the epidemic of drug abuse. Drug overdoses were blamed for 999 deaths in the state in 2012, a 57 percent increase in a decade. Zoeller noted Indiana has seen a decline of almost 11 percent in the amount of opioids prescribed since Dec. 15, 2013, when the emergency rules took effect.

Gregory Eigner, M.D., Fort Wayneemail him

Dr. Eigner

Dr. Eigner noted that screening for mental health issues, like depression and substance abuse, helps physicians manage chronic pain more safely and effectively.

He commented, “A number of surveys are available to assist you in collecting this information, such as PHQ-9 for depression and the Opioid Risk Tool for substance use/abuse.”

Dr. Eigner urged physicians to use INSPECT routinely and urine drug monitoring (UDM) periodically. “These tools augment patient safety and allow you to feel more secure when prescribing.”

Additionally, he suggested physicians consider asking office staff and nurses to help pull INSPECT reports and perform UDM as part of the office routine.

Overdose Chart

Amy LaHood, M.D., Indianapolisemail her
Dr. LaHoodDr. LaHood believes the MLB rules provide physicians guidance and standards of care for safer prescribing of chronic opioids. She noted that physicians in her practice find the rules helpful in providing safer care to a high-risk group of sometimes difficult patients.

“Once practices learn how to manage the changes in workflow, most providers feel more able to make informed decisions regarding whether a patient should be on opioids chronically,” she said.

In Dr. LaHood’s practice, physician satisfaction treating chronic pain has improved with implementation of the MLB rules. "Implementing these policies and educating our patients, staff and physicians have dramatically reduced the chaos we used to have with patients seeking pain meds," she explained.

Dr. LaHood’s office has pre-assembled patient packets in her office that include a pain inventory, assessment tools, a treatment agreement and a health questionnaire (PHCQ9) for depression. Nursing staff have patients fill out the paperwork prior to the physician evaluation to provide the physician necessary background information regarding opioid risk stratification.

Dr. LaHood recommended avoiding opioids in conditions where there is no evidence to support a benefit and exhausting non-opioid treatment modalities when treating chronic pain issues such as:

  • Chronic headache
  • Chronic low back pain
  • Chronic pelvic pain
  • Fibromyalgia
  • Functional bowel disorders

She also advised watching for comorbid risks with opioids. Patient mortality risk is more pronounced for patients with:

  • Benzodiazephine use
  • Illicit substance use/abuse
  • Alcohol overuse/abuse
  • Untreated mental health issues (depression, history of suicide attempt)
  • Chronic respiratory problems (asthma, COPD, OSA, CHF)

Palmer MacKie, M.D., Indianapolisemail him
Dr. MacKieSome physicians have described the new rules as a “wedge” between doctors and patients, but Dr. MacKie believes they help improve patients’ lives. “All this takes planning and preparation, but the smiles and sense of satisfaction you get are worth it.”

He supports the rules for reasons of patient safety; improved evaluation and education; reduced addiction and abuse; less morbidity and mortality.

“The risk of death increases at 50 mg.,” he explained. “Most overdoses occur with lower doses, and the risk rises as the dose of opioids rises.”

Dr. MacKie urges his patients to engage in activities that are meaningful and increase social interactions. As people do so, they rely less on opioids and opioid reliance diminishes.

“You see the patient for only 20-30 minutes a few times a year. What is their quality of life? Patients on strong opioids chronically often have lower quality of life and quality of life scores than those with chronic pain who never began chronic opioid therapy. Engage them. Teach them the benefits of living life with a purpose,” he said.

Find screening tools and other clinical resources here.

Read more about a study on physician use of INSPECT on the ISMA website.

Tips from the 5th Annual Prescription Drug Symposium
  1. Do your own evaluation.*
  2. Do risk stratification; assess mental health, including depression and substance abuse.*
  3. Set functional goals.*
  4. Utilize evidence-based treatments.
  5. Obtain informed consent, plus a signed treatment agreement. Discuss the risks and benefits of a treatment plan and explain that opioid therapy may be changed or discontinued.*
  6. Require periodic visits.*
  7. Remember the 5 A’s (activity, analgesia, affect, aberrancy, ADRs).
  8. Get an INSPECT report.*
  9. Do urine drug monitoring. However, know which test you are ordering and which drugs you are screening. Conduct confirmatory tests regardless of the result of the initial screening test.** Be sure to work with your toxicologist.*
  10. Re-evaluate your patient and the treatment plan when the MED enters the 60 mg./day range, inform of risk of OD and death and consider a consultation.*
  11. Always have an exit plan. Don’t begin a treatment that you are not prepared to stop.
*Requirement of the MLB prescribing rule
** The original published version of this statement, "Conduct a confirmative test for positives," was incorrect. 
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