Provider’s Toolkit

“…There is no consistent, high quality, evidence that chronic opioid therapy is effective for the treatment of non-cancer pain.” – Dr. Camden Kneeland, Medical Director, Montana Center for Wellness and Pain Management and MMA Prescription Drug Abuse Reduction Faculty.

MANAGEMENT OF CHRONIC NON-CANCER PAIN

Risk Factors for Developing a Prescription Drug Abuse Problem

Many patients fear that they may become addicted to medications that are prescribed to them for legitimate medical conditions, such as painkillers after surgery.  These risk factors may be considered as potential lead-ins to prescription drug abuse:

  • Past or present addictions including alcohol
  • Pre-existing psychiatric conditions
  • Exposure to peer pressure or social environment where there is drug use
  • Easy access to prescription drugs, such as working in a health care setting
  • Lack of knowledge about prescription drugs
  • Multiple health problems and taking multiple medications

If you suspect your patient has a substance abuse issue, refer them here.

PATIENT EDUCATION OF CHRONIC NON-CANCER PAIN

Health Risks of Prescription Drug Abuse

  • Organ damage and failure
  • Tolerance to the medication
  • Psychological addiction and cravings
  • Withdrawal symptoms
  • Paranoia
  • Depression
  • Decreased cognitive function

Controlled Substance Risks Agreements

Risks – One Page Patient Form
Risks – Pain Agreement

Download all PDFs
Download Editable Files
Montana Prescription Drug Registry

Naloxone Rescue

Provider information on Naloxone in Montana

House Bill 333, the Help Save Lives from Overdose Act was passed by the Montana Legislature in 2017.  This bill authorized increased naloxone access by requiring Montana Department of Public Health and Human Services to provide a state-wide standing order for pharmacies to dispense naloxone prescriptions.

Learn More

What’s available?

Naloxone is available as an auto injector (Evzio), nasal inhaler (Narcan Nasal) and naloxone nasal spray atomizer kit.

Who should receive naloxone?

Theoretically anybody prescribed an opioid could receive naloxone rescue medication.  Those at risk of opioid overdose should receive naloxone including:

  • patients with poor or compromising medical condition such as
    • respiratory illness/infection, COPD, asthma, smoking, sleep apnea
    • renal dysfunction, hepatic impairment, cardiac illness or HIV/AIDS
    • known alcohol use
  • patients who are also being prescribed sedatives or benzodiazepines
  • patients prescribed methadone or buprenorphine, especially during dose titration or taper
  • patients with concurrent antidepressant prescription
  • high dose opioid prescriptions defined as ≥50 MEDD

Others that should be considered are those patients

  • with a history of substance use disorders or a history of overdose
  • with loss of opioid tolerance including patients:
    • who have recently been incarcerated
    • who have been engaged in an opioid abstinence program.

What education should be provided?

MT DPHHS has developed an OPIODS Overdose Recognition and Response Guide.

Discussion should include:

  • What is naloxone: Opioid reversal medication which may cause withdrawal
  • Recognizing an overdose–when to use naloxone: no response, slow or no breathing, pale or clammy skin, blue lips, fingernails or skin, slow erratic pulse, snoring or choking noise
  • How to use naloxone: instructions per dosage form dispensed
  • Call “911”
  • When to give a second dose: If the person has not started breathing in 2-3 minutes.  Remind the patient that naloxone only lasts 30-90 minutes, so calling “911” and being prepared to give a second dose if the person stops breathing again is important
  • When to get a refill: if used, product is damaged, lost, or expired
  • Overdose prevention: use medications only as prescribed, avoid mixing with other drugs or alcohol, tolerance decreases quickly if a patient has not taken opioids for a while, physical conditions that increase risk of overdose

Who are generally not good candidates for naloxone rescue kits?

Hospice and palliative care patients may not be candidates for naloxone but should be evaluated on a case by case basis.

SAMHSA provides information and training materials for providers interested in developing a medication-assisted treatment program.

The American Medical Association offers a free CME:
A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know 

The Office of Disease Prevention and Health Promotion has a free CME program:
Pathways to Safer Opioid Use

The Defense and Veterans Center for Integrative Pain Management offer a robust curriculum:
Joint Pain Education Program (JPEP)

Provider FAQs

The American Society of Addiction Medicine defines addiction as follows: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” Read Full Article Here

When other reasonable options have failed to provide adequate analgesia and an appropriate risk assessment has been performed.

Full history of addiction, substance abuse and a screening questionnaire, such as the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) – See Provider Toolkit

Physical therapy, diagnostic imaging, diagnostic injections, neuropathic pain medications (if neuropathic pain exists), anti-inflammatory medications, acetaminophen. Consider a formal neuropsychological evaluation for complex cases.

  • Controlled substance agreement should be reviewed and signed
  • Random Pill Counts and Random Urine Drug Testing
  • Review of the Prescription Drug Registry

When there is inadequate evidence to demonstrate compliance or improvement in functional abilities and/or quality of life;
The risks outweigh the benefits;
And/or a violation of the controlled substance agreement.