By Dr. A. Carbonell
For all patients on controlled substances the following needs to be done: (this includes tramadol, Tylenol 3, Lyrica)
1. Face to Face visit every 3 months (this cannot be done via virtual visit, must be in person)
2. Contract signed ONCE (does not need to be redone) – iMed Consent
a. Tools=> Programs => iMed Consent. Once in the program select Pain management => Consents – Basic => Consent for Long Term Opioid therapy for pain
3. UDS every year, sooner if you think it is needed
4. State PDMP with every new prescription
a. New Note Titled “State Prescription Drug Monitoring Program” – run the patient through E-FORCSE and summarize the results in the note. This must be done every time a new Rx is written (monthly for opiates, q3 months for tramadol/Lyrica/Tylenol III
5. STORM assessment once per year
a. In CPRS go to tools => Reach => STORM patient review of opioid risk and once you look up the patient there is a link under their name to generate the chart note which will open a PDF that you can then copy
b. Note is called Opioid Risk Provider Review Database
c. If the storm assessment shows anything other than Low/Low for opiates (in terms of risk) they must either go to pain clinic to try to be tapered off or at least an E-consult for pain clinic for recommendations how to taper or adjust therapy
6. Up to date Naloxone Kit – the STORM tool will tell you if it is up to date (yearly for opiates, not needed for tramadol/Tylenol III/Lyrica)
CONTROLLED SUBSTANCE INCLUDED IN THE ABOVE
• All opioids (Opioid order: The Rx must say Non-Acute Chronic Pain)
• Tramadol, Tylenol with codeine and Lyrica – note they must have the face to face every 3 months just like opiates
CONTROLLED SUBSTANCES WITH EXCEPTIONS
• Testosterone – the exception is that these patients can be seen every 6 months instead of every 3 months for a face to face visit and they need a PSA and DRE at that time – Testosterone can be renewed at 6-month intervals therefore the PDMP only has to be written with every new renewal every 6 months.
• All Benzodiazepines – Face to face every 6 months instead of 3 however they do need the PDMP with every refill and UDS once per year
• Lyrica – Needs PDMP at the START and once per year. You DO need a face to face every 3 months if used for pain.
• Fioricet – this can be prescribed without PDMP for migraines but max 5 pills/month to avoid rebound headaches, can be legally prescribed for the year
The STORM tool is not all inclusive and the following are other red flags to look out for when renewing opioids:
***Risk Factors for Opioid Misuse***
-Illegal Drug use or prescription drug misuse (UDS positive or admitted use)
-History of substance abuse disorder or overdose
-Uncontrolled MH conditions – depression/anxiety
-Sleep disordered breathing (uncontrolled OSA) – ok to continue if they are compliant with CPAP
-Concurrent Benzo use – Black box warning against opiates + Benzos – must try to taper one off
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