Lorraine Widdall, MS APRN BC
Interventional Spine and Pain Center
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Effective December 15, 2013
Emergency rule that temporarily adds
provisions under P.L. 185-2013 (SEA246)
regarding physicians prescribing opioids for
chronic pain.
Under Title 844 Medical Licensing Board of
Indiana
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Patients with chronic pain.
Chronic Pain is defined in this document as:
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
pathologic process that causes continuous or
intermittent pain over months or years.
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Patients with a terminal condition
Residents of a healthcare facility
Patients enrolled in a hospice program
Patients enrolled in an inpatient or outpatient
palliative care program of a hospital
Patient has been prescribed:
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2.
More than 60 opioid containing pills a
month; or
A morphine equivalent dose of more than 15
mg per day;
for more than 3 consecutive months
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Evaluation and Risk stratification
Education of the patient as to risks and
benefits of opioid therapy as well as
expectations related to prescription requests
and proper medication use
Continual monitoring and evaluation of
therapy
DOCUMENTATION
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Indiana legislature passed a law, in
compliance with a federal mandate for states,
requiring the Indiana Medical Licensing Board
to develop an emergency opioid prescribing
rule.
Proliferation of “pill mills”
Prescription drug abuse has become a bigger
problem than all other illicit street drugs
Pain has been treated as “5th Vital Sign”
The US comprises 4% of the world’s
population yet consumes 85% of the opioid
medication.
CDC
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Detox in Lake County Jail exploding from
prescription drugs (10:1 RX to heroin)
Sheriff has established the High Intensity
Drug Trafficking Task Force (Seized over
$7M in RX drugs in 2013, already over that
for 2014)
New trend: heroin cut with BZA
Wellbutrin and Gabapentin snorted together
mimic heroin.
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17th in US for RX drug deaths
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Porter county #1 in IN for heroin deaths
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In 2013, the OAG filed disciplinary complaints
against 15 physicians for overprescribing
pain medication; so far in 2014 they have
already surpassed that number
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Procedures
Physical therapy/Aquatic therapy
Lifestyle changes
NSAID
Adjuvant medications
Psychological counseling
Alternative treatments
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Epidural Steroid Injections
Joint injections
Steroid/Hyaluronate (Synvisc or Hyalgan)
Trigger Point Injections
Scar Neuroma Injections
Nerve Blocks (Chemical/Thermal)
Chemodenervation (Botox)
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Aquatic Therapy
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Land Based
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Home exercise program
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Weight loss
Smoking Cessation
Activity pacing
Back to work (work
hardening/conditioning/restrictions)
Exercise
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OTC ibuprofen and naproxen
Prescription
Mobic, Celebrex, Motrin, Diclofenac
Tylenol
Topical preparations
Pennsaid, Voltaren Gel, Flector patches
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Antidepressants: Nortriptyline, Amitriptyline,
Effexor, Cymbalta, Savella
Antiseizures: Gabapentin, Lyrica, Topamax,
Lamitcal, Tegretol, Gralise
Muscle Relaxants: Baclofen, Tizanadine,
Flexeril, Zanaflex, Robaxin, Skelaxin, (Exclude
Soma)
Sedative/Antianxiety: Valium, Xanax,
Klonopin
Topical: Lidoderm
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Evaluation is ALWAYS appropriate
Treat underlying issues that are closely
related to pain such as depression and sexual
abuse
Biofeedback
Relaxation/meditation
Imagery
Music therapy
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Acupuncture
Acupressure
Massage
Hypnosis
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Evaluation and risk stratification
History and physical
Obtain and review records from other
providers
Objective pain assessment tool
Risk for substance abuse tool (SOAPP)
Establish working diagnosis and tailor a
treatment plan
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Risks/benefits and expectations
Discuss alternative modalities to opioids
Simple and clear explanation to help patient
understand the key elements of their
treatment plan
Discuss with females ages 14-55 with
childbearing potential possible risks to the
fetus
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Review and sign a treatment agreement which
shall include at least the following:
1. Goals of treatment
2. Consent to drug testing*****(delayed
until 1/1/15 due to ACLU lawsuit filed 1/8)
3. Physician prescribing policies which must
include (at least) that the medication be taken
as prescribed and not shared with anyone
else.
4. A requirement that the patient inform the
physician about any other controlled
substances prescribed or taken.
5. Permission for random pill counts
6. Reasons that the opioid therapy may be
discontinued or changed by the physician.
*A copy of this agreement is to be retained in
the patient’s chart.
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Periodic scheduled face to face visits
Stable medication regime: at least every 4
months
Changed medication regime: at least every 2
months
During the visit, evaluate progress and
compliance and set clear expectations along
the way (such as participation in physical
therapy)
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INSPECT
At the outset of an opioid treatment plan
and at least annually thereafter.
Document in chart the consistency with
physician’s knowledge of patient’s controlled
substance history
Drug Testing
At the outset of opioid treatment plan and at
least annually thereafter.
Doesn’t specify serum, urine or saliva
Must include confirmatory test results
Inconsistencies or presence of illicits require
review of treatment plan.
Documentation of revised plan and discussion
with patient must be recorded in chart.
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When a patient’s opioid dose reaches a
morphine equivalent of 60 mg/day:
Face to face review of treatment plan
Consideration of referral to specialist
If continuing therapy, there must be a revised
assessment and plan for therapy
Documented assessment of increased risk for
adverse outcomes, including death.
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Short acting: Tylenol with codeine, Tramadol,
hydrocodone, oxycodone, hydromorphone,
Nucynta
Long acting: MS Contin, Fentanyl, Opana,
Oxycontin, (Zohydro)
Methadone
Demerol
Intrathecal opioid therapy
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THE HOLY TRINITY
Hydrocodone
Muscle Relaxant (Soma)
Benzodiazepine
Red flag for DEA
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PRN vs. Scheduled
Treat flares and return to baseline
It’s OK to say “no.”
Be aware of trends and fads (Adderall)
Stay informed and aware
www.opiophile.org
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Lake County Drug Task Force 219-755-3822
www.deadiversion.udsoj.gov
Scott Nowland (219) 681-7000 x128
www.cdc.gov
www.bitterpill.IN.gov (Indiana AG office)
www.supportprop.org (Physicians for
Responsible Opioid Prescribing)