Opioids

The Opioid Epidemic

Education, Referrals, and Resources

The abuse of prescription drugs is a serious societal and public health problem in the United States and in Arizona:

  • Arizona’s Controlled Substances Prescription Monitoring Program indicates there are approximately 10 million Class II-IV prescriptions written and 524 million pills dispensed each year.
  • Prescription pain relievers account for more than half of the drugs dispensed in the state.
  • Overdose deaths from prescription analgesics increased more than four-fold from 1999 to 2010 in the U.S., with the Centers for Disease Control and Prevention (CDC) declaring it an epidemic.
  • Arizona ranked 6th highest in the nation in 2010 for drug overdose deaths and had the 5th highest opioid prescribing rate in the U.S. in 2011.

As the use of these habit-forming drugs grows, so too does the likelihood of adverse outcomes related to misuse and abuse. Relieving pain and reducing suffering must be done in a manner that limits the personal and societal harm from prescription drug misuse and abuse.

Mercy Care, Mercy Care Long Term Care, and Mercy Care Advantage are stepping up our efforts to assist you with being part of the solution to this nationwide epidemic. It is our goal to provide you with a “one stop resource” for information about:

  • changes in state and federal legislation
  • current opioid prescribing guidelines
  • guidelines for drug screening
  • the use of Narcan
  • resources for substance abuse treatment and pain management
  • information about neonatal abstinence syndrome
  • sample downloadable patient-provider agreement and risk assessment forms
  • links to CME and other reference materials you might find useful in your practice

We will continue our efforts to provide you with new information as we receive it to help stem this health issue:  

Appropriate Treatment of Pain

(also see Booklet, If At First You Don’t Prescribe)

Just as all infections are not the same, all pain is not created equal. You wouldn’t treat a UTI the same way you would treat pneumonia. Likewise, nerve pain is not treated the same way as musculoskeletal or other types of pain.

There is little or no evidence from high quality clinical trials to show that opioids work well for pain. In head-to-head comparisons, opioids are not as effective as non-opioid drugs for pain!

  • Studies show a combination of ibuprofen (Motrin, Advil, etc.) and Tylenol works BETTER for acute pain than opioids.
  • There are only two studies showing that a traditional opioid can provide good long term pain relief, and then only for about 5%-10% of people.
  • Opioid adverse events are common (nausea, constipation, etc.) and can be very severe. There is considerable evidence linking opioid use (especially high doses) to death, suicide, fracture, heart attacks, and hospital admission.
  • Recent published CDC data shows being on an opioid for only 4 to 5 days is predictive of still being on them a year later!

Things to Consider if You do Prescribe an Opioid

  • Establish a firm diagnosis to support the need for an opioid.
  • Review risk factors with your patient and obtain a signed patient-provider agreement (see downloadable forms for a sample).
  • Perform a urine drug screen prior to initiating treatment and as clinically indicated thereafter.
  • Check and document findings in the CSPMP prior to prescribing a controlled substance or any medication with potential for drug interaction or an additive effect when used with a controlled substance (Black Box warning for benzodiazepines).
  • Complete a risk assessment tool (see downloadable forms for samples) prior to initiating treatment.
  • Coordinate care with other providers and document this in the patient’s medical record.

 

Arizona Senate Bill 1283

  • Beginning January 1, 2017, a medical practitioner, before prescribing an opioid analgesic or benzodiazepine controlled substance listed in schedule II, III or IV for a patient, shall obtain a patient utilization report (i.e., check the CSPMP) regarding the patient for the preceding twelve months from the controlled substances prescription monitoring program's central database tracking system.  
  • The medical practitioner is not required to check the central database tracking system pursuant to this subsection if any of the following applies: PATIENT RECEIVING HOSPICE CARE, PATIENT BEING TREATED FOR CANCER OR CANCER-RELATED ILLNESS OR CONDITION, A MEDICAL PRACTITIONER WILL ADMINISTER THE CONTROLLED SUBSTANCE, THE PATIENT IS RECEIVED THE CONTROLLED SUBSTANCE WHILE AN INPATIENT OR IN RESIDENTIAL TREATMENT IN A HOSPITAL, NURSING CARE FACILITY, OR MENTAL HEALTH FACILITY, the medical practitioner is licensed pursuant to title 32, chapter 11 and is prescribing the controlled substance to the patient for no more than five days after oral surgery.

  Executive Order 2016-06 - Prescription Opioid: First Fill Limit

  • The directors of AHCCCS and the Arizona Department of Administration (ADOA) shall adopt any necessary policies and rules to limit the initial fill of any prescription opioid to no more than 7 days.
  • The directors of AHCCCS and ADOA shall adopt any necessary policies and rules to limit all initial and subsequent opioid prescriptions for minors (beginning as a minor, but following the member throughout their life) to no more than 7 days, except in the case of cancer, other chronic disease, or traumatic injury (AHCCCS list Exhibit 310-V-3- consists essentially of chemical and thermal burns, partial or complete amputations, and crush injuries).

Substance Abuse Confidentiality Regulations – 42 CFR Part 2

  • Applies to any individual or entity that is federally assisted and holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment (most drug and alcohol treatment programs are federally assisted). For-profit programs and private practitioners are not subject to 42 CFR Part 2 unless required to comply by the state licensing or certification agency. HOWEVER, if the clinician uses a controlled substance for detoxification or maintenance treatment (e.g., buprenorphine, methadone) of a substance use disorder requires a federal DEA license, so becomes subject to this federal regulation.
  • The regulations restrict disclosure and use of alcohol and drug patient records maintained in connection with performance of any federally assisted alcohol and drug abuse program. This applies to any information that “would identify a patient as an alcohol or drug abuser…”
  • With limited exceptions, 42 CFR Part 2 requires patient consent for disclosure of PHI, even for the purposes of treatment, payment, or health care operations.

 

*Per ASAM

 

Controlled Substances Prescription Program registration

 

The Controlled Substances Prescription Program registration contains valuable information on how to register with the Arizona State Board of Pharmacy Controlled Substances Prescription Monitoring Program (CSPMP). Registration allows you to look up, view, and print controlled substance dispensing information on your specific patients. It also includes regulation requirements by the State of Arizona. Registration is a requirement for license renewal and use is required by SB 1283 (see above).

Morphine Equivalent Dose (MED) or Morphine Equivalent Daily Dose (MEDD)

What are MEDs/MEDDs?

  • MED stands for “morphine equivalent dose” or MEDD (morphine equivalent daily dose).
  • MEDs are a way of comparing potency of opioids against morphine as the standard.
  • MED=(mg x multiplier [given in CSPMP] x quantity prescribed) / # days’ supply
    • e.g., Tramadol 50 mg, # 120, 30 day supply: (50 x 0.1 x 120)/30=20 daily MED. Overdose risk doubles at 50-99 MEDs and increases 9-10 fold at 100 or more MEDs (as compared with doses of less than 20 MEDs).
  • Current CDC guidelines call for avoiding doses equal to or higher than 90 MEDDs. CMS is set to align with this recommendation on January 1, 2018.
  • Additional information is available from CMS regarding Calculating Total Daily Dose of Opioids for Safer Dosage

Prescribing Guidelines

What to do:

  • Think before you choose an opioid to treat your patients’ acute or chronic non-terminal pain. Research shows non-opioids are MORE effective (refer to our booklet: If at First You Don’t Prescribe  and CDC opioid prescribing guidelines, available online or as a downloadable app).
  • Educate yourself about evidence-based treatment of acute and chronic pain and use your role as your patients’ trusted advisor to offer the most appropriate treatment based on the cause of their pain.

 

 

What not to do:

  • Do not “fire”/abandon your patient. Some educational resources about strategies to help these patients are available in the links below (see Additional Resources). These patients may need your help more than ever.
  • Opioid withdrawal can present as acute pain or GI symptoms. These patients should be referred to a treatment or detox center, not treated with additional opioids.

 

To find Mercy Care Plan pain management providers, visit our online provider directory. Once you select your health plan you can search for “Pain Control” under Specialists.

You can also call Mercy Care Plan Member Services at 602-263-3000 or 1-800-624-3879 (TTY/TDD 711). They are available Monday through Friday from 7 a.m. to 6 p.m.

Key Drug Screening Reminders

  • Drug screening should be done prior to initiating treatment with opioids and periodically (2-4 x /year) and on a random basis thereafter. Findings should be addressed in the progress notes along with what actions took place based on the results.
  • Standing orders must be time limited since drug screening may potentially be tied to allegations of overpayment for services due to frequency, type of test, etc.
  • Testing should be tied to treatment and frequency of testing to the individual.
  • Drug screens answer which CLASS of drug is present, but not which DRUG.
  • The confirmation test identifies which particular DRUG caused the positive screening result.
  • Drug confirmation is important to differentiate false positives .
  • Where possible, use drug panels rather than individual drug tests to promote the most cost-effective care.

Provider Notifications

 

Mercy Care Plan and Mercy Maricopa have changed their prior authorization requirements as of 1/1/17 regarding the prescription of long-acting opioids.

  

Reference Material and Guides

 

 Tools for Risk Assessment

 

 Patient Patient-Provider Agreement Form

 

 Continuing Medical Education

 Opioid Prescribing CME Courses: Responding to the Public Emergency

 

Additional Resources