Step 3

Select and Prioritize Guideline Recommendations to Implement

“We realized that if we added up all the time our clinic spent with patients who were not being managed effectively and safely on chronic opioid therapy (e.g., front office fielding phone calls, MA’s calling patient back and “getting the story”, setting up contracts with patients, etc.) it was less than or equal to the amount of time it took us to systematically develop workflows and follow them.”

Once your system understands your areas to improve upon (Step 2) and specific goals (Step 3), your system should decide which CDC Guideline recommendations to pursue to address your needs and meet your goals. Each of the Guideline recommendations is provided below along with considerations for implementation based on the experiences of other systems and practices implementing these change.

Consider practice-level changes

In selecting which specific recommendations to pursue, your system may also need to concurrently consider which system- or practice-level changes are needed to facilitate adherence to the specific clinical recommendations. For example, these practice-level changes could include:

  • Establishing policies and standards for opioid prescribing and pain management: develop or revise policies to address your system’s goals and to ensure consistency in clinicians’ approaches. There are many examples of policies and standards (e.g., Parchman et al., 2017 ). Ensure you educate established patients on new policies and standards. As appropriate, consider the associated workflow changes needed to facilitate the new policies being implemented.
  • Developing a registry or use proactive population management: use existing infrastructure or even a simple approach like creating an electronic spreadsheet with a list of patients on long-term opioid therapy to facilitate population management.
  • Using an interdisciplinary, team-based approach: different care team members may be able to execute or support specific Guideline recommendations being implemented into the workflow.
  • Using information technology (IT), like electronic health record (EHR) functionalities: leverage your existing IT infrastructure, particularly the EHR, to facilitate adherence to the Guideline recommendations, such as shortcuts, templates, clinical decision support (CDS), and other functionalities.

In the following section, we provide examples of specific practice-level changes that may be useful for implementing the various Guideline recommendations. In the CDC’s Chronic Pain Care Involving Opioids: Coordinated Care Plan for Safer Practice more detail is provided on the practice-level changes, as well as an overview of the clinical approach to assessment, treatment and follow-up aligned with the CDC Guideline.

Determine which Guideline recommendations to implement

“I have taught my MA to do virtual UDT with my patients before I come in the room. They say, ‘If Dr. A were to do a UDT on you today, what would he find?’, I find my patients are much more honest than I thought; we are building trust with patients and saving my staff extra work and my patients extra money.”

Exhibit 3. provides each of the 12 CDC Guideline Recommendations along with considerations for implementation based on other systems’ and practices’ experiences, and the lessons they learned.

Exhibit 3. CDC Guideline Recommendations and Associated Considerations for Implementation

GUIDELINE RECOMMENDATIONS CONSIDERATIONS FOR IMPLEMENTATION
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Access can be a big issue; determine the non-pharmacologic therapies your practice already can access, and which ones can be accessed in the community. For example, while a practice may not have integrated behavioral health specialists, there are often community therapists and psychologists who can co-treat.

Consider focusing on chronic pain condition(s) that can benefit from a specific non-opioid or non-drug therapy and start there. For example, low back pain patients being referred to physical therapy or given exercise/stretches handout by clinicians.

Consider providing onsite chiropractic or acupuncture care.

2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Discuss with your clinicians how treatment goals are currently captured and established in collaboration with patients. For example, is there a specific place within the EHR to capture treatment goals and record each visit.

Use the PEG to assess pain and functional improvement, and teach clinicians on how to use the results with patients.

3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy. Several clinics used their treatment agreements<![if !supportFootnotes]>[1]<![endif]> to drive home the risk of taking opioids long-term.

Make sure patients understand components of the treatment agreement and what is necessary for them to continue getting their medication(s).

Patients sometimes self-taper once they learn the risks.

Establish a process to document clearly that this has been done. Either in agreement or in EHR. This is critical for risk management

4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. Develop a policy to improve consistency across clinicians.

Provide education or training to clinicians.

5. When opioids are started, started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day. Develop a policy on threshold dosages.

Incorporate a ‘hard stop’ in the e-prescribing system for clinicians to justify high dosages.

Use a ‘dashboard’ to show clinician’s current percentage or number of patients on high dosages; spur peer competition.

Consider “case reviews” with higher MED patients so providers are held accountable and also given implementation strategies by the team.

Consider a practice wide CME or training event detailing the guidelines with explanation and education.

6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed. Develop a policy for new opioid prescriptions for acute pain.

Align practice policy with state regulations on days’ supply limits (if applicable).

Consider doing risk assessment with patients asking for refills of opioid prescriptions that are acute.

7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and is continue opioids. Develop workflow to ensure patients are scheduled for a follow-up visit before leaving with new opioid prescription for long-term opioid therapy.

Establish a policy and train staff to refuse authorization of a 1st refill of a new opioid prescription until the patient has been in for a follow-up visit.

Develop a policy that new prescriptions for opioids will be written with no refills until after the patient has had a follow-up visit.

8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50MME/d), or concurrent benzodiazepine use, are present Develop a policy of prescribing naloxone for high-risk patients on long-term opioids.

Train clinicians and staff on use of naloxone.

Consider utilizing a pharmacist or medical assistant to train patients and their loved ones on when to use naloxone and how to use it.

9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. Develop a policy on the frequency of checking the PDMP.

Align the policy your state regulations for checking the PDMP.

Many practices have the MA print the PDMP and give it to the provider at each pain visit.

Medical assistant (MAs) or nurse (RN) checks PDMP (in delegable states).

10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs Determine the level of verification needed and feasible for your practice setting and implement an appropriate process; some clinics may choose higher levels of verification such as using temperature sensitive UDT or direct observation of urine sample collection.

Provide a quick link from the EHR for the specific UDT.

Consider having UDT to be random without the patient knowing ahead of time.

11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible. Use clinical decision support reminders to ensure clinicians avoid co-prescribing, whenever possible.

Facilitate clinicians checking the PDMP for prescriptions of benzodiazepines by integrating the PDMP into the EHR, as feasible.

Track and monitor co-prescribing and provide clinicians with feedback

Start taper plans on existing patients who are receiving benzodiazepines.

12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder. Identify available clinicians to prescribe MAT to refer your patients to.

Help clinicians in your practice to obtain buprenorphine waivers (see: https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management).

Provide training on diagnosing Opioid Use Disorder (OUD).

Behavioral health provides cognitive behavioral therapy (CBT) and/or pain group treatment.

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