Safe Opioid Prescribing

Primary Care Controlled Medicines Safe Prescribing Guidelines

Click here for a printable version of these guidelines.

For NEW requests for ANY CONTROLLED MEDICINE [1] likely to be CHRONIC (>12 weeks) and all patients already on long-term Controlled Medicines:
- Get confirmed drug of abuse urine test + write in specific the medicine you are looking for (before the start and at least once a year thereafter)[2]
- Check CURES[3] patient activity report (repeat every 4 months) - it is now the law
- Review and sign a Controlled Medicines Agreement (sample) with the patient and upload to EMR (ICD for Agreement signed Z79.899, ICD for chronic pain G89.29)
- Agree on a place in the chart/EMR where chronic opioid updates are documented and include: agreement signed, dose and frequency taken, an interval for refills, Utox date, CURES check date, naloxone prescription written (if on opioids). Keep the information current.
- Screen for use/abuse of drugs, alcohol and other controlled medications (ex. CAGE-AID), depression with PHQ-9, anxiety with GAD. Any positives will require closer monitoring.
- Regular follow-ups in a clinic (at least every 3 months)
- Counsel the patient about safe storage (locked box) and safe disposal ( DontRushToFlush website for the location of disposal sites)
For Opioid prescribing specifically:
- If planning to initiate Chronic Opioid Treatment (COT) consider:
  - Contra-indication in active opioid, benzodiazepine or alcohol addiction.
  - No evidence for benefit of COT in chronic headaches, fibromyalgia, or chronic low back pain. Conflicting evidence for chronic musculoskeletal pain, neuropathy.
  - If prescribing to a woman of childbearing age, advise against pregnancy while on COT.
  - 90 day continuous use is highly predictive of years’ use, stop prescribing for post-op pain prior to 3 months, usually <1 month suffices.
  - Higher risk for aberrancy in pts <30 yo, better tissue healing in general.
  - Opioid Risk Tool is helpful in determining the safety of initiation, frequency of follow-up.
If on chronic Opioid therapy:
- Prescribe Naloxone[4] (maintain active prescription)
- Annual comprehensive pain visit to discuss the plan and goals of care with PMD
- If on >90 MEDD (CDC recommended cut-off)[5], consider tapering to a safer dose[6] or co-managing with Pain Clinic and order a sleep study to evaluate for sleep apnea.
- Check LFTs periodically if on high dose acetaminophen combos.

After-hours policy: No refills of any controlled medicines after hours. To limit weekend calls, consider writing 28-day prescriptions instead of 30, meds will be due the same day of the week always.

Coverage policy: In the event that a patient’s PCP is not available, a covering physician may prescribe a standard 1-month refill if the patient is due. No early refills through covering providers.

Aberrancy policy: If aberrancies (repeated early refill requests, lost rx, after-hours calls, etc), treat for addiction or refer to Addiction Medicine – Gateway: 1-800-488-9919. SAMHSA: 1-800-662-HELP (4357).

Do not discharge a patient from your practice without a plan in place.

Non-daily use/<30 MEDD policy: For patients taking less than daily or low-dose of meds, check CURES periodically (Q 4months) and in the Problem List, under the appropriate diagnosis, list details of agreed-upon medication(s), dose(s), quantity prescribed and refill interval(s).

CDC Guidelines for Prescribing Opioids for Chronic Pain

Medical Board of California’s Guidelines for Prescribing Controlled Substances for Pain

Higher Dosage, Higher Risk

Higher dosages of opioids are associated with a higher risk of overdose and death—even relatively low dosages (20-50 morphine milligram equivalents (MME) per day) increase risk. Higher dosages haven’t been shown to reduce pain over the long term. One randomized trial found no difference in pain or function between a more liberal opioid dose escalation strategy (with average final dosage 52 MME) and maintenance of current dosage (average final dosage 40 MME). Click here for information on how to determine the total daily dose of opioids.

[1] Controlled medicines: opioids, benzodiazepines, hypnotics, stimulants, and soma. A physician may opt not to prescribe chronic controlled medicines prior to obtaining a patient’s outside records.

[2]Call the lab prior to acting on a drug test that is negative for the prescribed drug to ensure they looked for it.

[3] CURES: Controlled Substance Utilization Review and Evaluation System.

[4] Naloxone Rx: Narcan Nasal Spray 4 mg/0.1mL, sig: if suspect overdose, call 911, spray naloxone in a nostril. Repeat after 3 minutes in another nostril if still unconscious. More info available at prescribetoprevent.com.

[5] For safe disposal sites in the Bay Area go to DontRushToFlush website

[6]For help designing a taper go to http://www.rxfiles.ca/rxfiles/uploads/documents/opioid-taper-template.pdf