Considerations before prescribing opioids for chronic use
| Question . | Considerations . | Resources . |
|---|---|---|
| Knowledge | ||
| Am I familiar with non-opioid pain management options? | Non-opioid treatment options are preferred first-line therapies for mild to moderate pain, including in malignancy, and can also be used concurrently with opioids. Options may include pharmacologic treatments (acetaminophen, nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, gabapentin, pregabalin, anti-depressants, topical agents), nonpharmacologic treatments (physical therapy, occupational therapy, tai chi, yoga, community social activities, and counseling), and interventional approaches (eg, nerve blocks). | CDC Guidelines for Chronic Opioid Prescribing,2 Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines,42 Management of Chronic Pain in Survivors of Adult Cancers: ASCO Guidelines43 |
| Am I familiar with opioid dosing, transitions, and complications? | Safe management of patients who use chronic opioid therapy requires a comprehensive understanding of opioid pharmacology, available agents, titration and transition strategies, and potential complications. | ESMO Clinical Practice Guidelines,42 American Pain Society Guidelines,28 ASCO Educational Review25 |
| Am I familiar with federal and state laws, national practice guidelines, and existing internal practice guidelines related to opioid prescribing? | Practices that engage in chronic opioid prescribing are encouraged to develop internal policies related to management based on national guidelines and federal and state laws. | National Conference of State Legislatures,44 state-specific Web sites, Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines,42 CDC Guidelines for Chronic Opioid Prescribing,2 Management of Chronic Pain in Survivors of Adult Cancers: ASCO Guidelines43 |
| Can I confidently recognize OUD? | OUD is a central nervous system–based medical condition diagnosed by DSM-5 criteria and managed with medication-assisted treatment and neurocognitive behavioral therapy. | DSM-5: Opioid Use Disorder45 |
| Infrastructure | ||
| Is my practice set up to accommodate chronic opioid prescribing? | Integrating chronic opioid prescribing into practice workflow may require reassessment of staffing volume and particular roles necessary to complete specific aspects of prescribing care, including downloading PDMP results for clinician review, distributing risk and symptom assessment forms, and reviewing CSAs. | CDC Guidelines for Chronic Opioid Prescribing2 |
| Have I developed internal policies for chronic opioid prescribing? | All practices that participate in chronic opioid prescribing are encouraged to develop internal policies based on federal, state, and societal guidelines and laws. Policies should address use of patient screening tools, frequency of screenings, referrals, CSA usage, UDS testing, pill counts, and management of suspected OUD. | CDC Guidelines for Chronic Opioid Prescribing,2 Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines42 |
| Do I have access to patient monitoring tools? | Clinicians with DEA numbers should be enrolled with their respective state PDMPs. They should also have risk scoring tools available for testing patients, as well as screening tools for depression, anxiety, and patient functionality. | PEG Functionality Assessment,46 depression screening (PHQ-9),47 anxiety screening (GAD-7),48 state- specific PDMP Web sites |
| Have I developed the necessary forms? | Practices that engage in chronic prescribing should consider developing and using handouts that describe the risks and benefits of opioid use, as well as CSAs. Other considerations may include documents describing the reasoning behind opioid prescribing changes and patient-friendly versions of facility opioid prescribing policies. | National Institute on Drug Abuse: Sample Patient Agreement Forms, 49 US Department of Health and Human Services Web site,50 CDC Guidelines for Chronic Opioid Prescribing2 |
| Are staff familiar with documentation requirements? | Staff with documentation privileges should be familiar with charting policies as they relate to opioid prescribing, including elements to include during office visits, phone call discussions, and management plans. | Internal policies |
| Referrals | ||
| Do I have a referral list for physical or occupational therapists? | Nonpharmacologic treatments such as physical therapy and occupational therapy play an important role in pain management. Clinicians are encouraged to use them as first-line therapy or conjunctively with opioids. | — |
| Do I have a referral list for pain management clinicians? | For complex pain syndromes, patients who require procedures, or complex chronic opioid prescribing concerns, hematologists should consider referring patients to pain management clinicians. | — |
| Do I have a referral list for palliative care clinicians? | For patients with malignancy or those facing life-threatening advanced illnesses, hematologists are encouraged to engage palliative care clinicians to assist with chronic pain management. | — |
| Do I have a referral list for addiction treatment clinicians? | Patients with suspected OUD require immediate assessment and referral to comprehensive treatment. Hematologists who engage in chronic opioid prescribing are encouraged to develop referral lists to addiction medicine physicians, addiction psychiatrists, buprenorphine-certified clinicians, and substance use disorder treatment programs. | SAMHSA National Helpline,51 SAMHSA Behavioral Health Treatment Services Locator52 |
| Question . | Considerations . | Resources . |
|---|---|---|
| Knowledge | ||
| Am I familiar with non-opioid pain management options? | Non-opioid treatment options are preferred first-line therapies for mild to moderate pain, including in malignancy, and can also be used concurrently with opioids. Options may include pharmacologic treatments (acetaminophen, nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, gabapentin, pregabalin, anti-depressants, topical agents), nonpharmacologic treatments (physical therapy, occupational therapy, tai chi, yoga, community social activities, and counseling), and interventional approaches (eg, nerve blocks). | CDC Guidelines for Chronic Opioid Prescribing,2 Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines,42 Management of Chronic Pain in Survivors of Adult Cancers: ASCO Guidelines43 |
| Am I familiar with opioid dosing, transitions, and complications? | Safe management of patients who use chronic opioid therapy requires a comprehensive understanding of opioid pharmacology, available agents, titration and transition strategies, and potential complications. | ESMO Clinical Practice Guidelines,42 American Pain Society Guidelines,28 ASCO Educational Review25 |
| Am I familiar with federal and state laws, national practice guidelines, and existing internal practice guidelines related to opioid prescribing? | Practices that engage in chronic opioid prescribing are encouraged to develop internal policies related to management based on national guidelines and federal and state laws. | National Conference of State Legislatures,44 state-specific Web sites, Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines,42 CDC Guidelines for Chronic Opioid Prescribing,2 Management of Chronic Pain in Survivors of Adult Cancers: ASCO Guidelines43 |
| Can I confidently recognize OUD? | OUD is a central nervous system–based medical condition diagnosed by DSM-5 criteria and managed with medication-assisted treatment and neurocognitive behavioral therapy. | DSM-5: Opioid Use Disorder45 |
| Infrastructure | ||
| Is my practice set up to accommodate chronic opioid prescribing? | Integrating chronic opioid prescribing into practice workflow may require reassessment of staffing volume and particular roles necessary to complete specific aspects of prescribing care, including downloading PDMP results for clinician review, distributing risk and symptom assessment forms, and reviewing CSAs. | CDC Guidelines for Chronic Opioid Prescribing2 |
| Have I developed internal policies for chronic opioid prescribing? | All practices that participate in chronic opioid prescribing are encouraged to develop internal policies based on federal, state, and societal guidelines and laws. Policies should address use of patient screening tools, frequency of screenings, referrals, CSA usage, UDS testing, pill counts, and management of suspected OUD. | CDC Guidelines for Chronic Opioid Prescribing,2 Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines42 |
| Do I have access to patient monitoring tools? | Clinicians with DEA numbers should be enrolled with their respective state PDMPs. They should also have risk scoring tools available for testing patients, as well as screening tools for depression, anxiety, and patient functionality. | PEG Functionality Assessment,46 depression screening (PHQ-9),47 anxiety screening (GAD-7),48 state- specific PDMP Web sites |
| Have I developed the necessary forms? | Practices that engage in chronic prescribing should consider developing and using handouts that describe the risks and benefits of opioid use, as well as CSAs. Other considerations may include documents describing the reasoning behind opioid prescribing changes and patient-friendly versions of facility opioid prescribing policies. | National Institute on Drug Abuse: Sample Patient Agreement Forms, 49 US Department of Health and Human Services Web site,50 CDC Guidelines for Chronic Opioid Prescribing2 |
| Are staff familiar with documentation requirements? | Staff with documentation privileges should be familiar with charting policies as they relate to opioid prescribing, including elements to include during office visits, phone call discussions, and management plans. | Internal policies |
| Referrals | ||
| Do I have a referral list for physical or occupational therapists? | Nonpharmacologic treatments such as physical therapy and occupational therapy play an important role in pain management. Clinicians are encouraged to use them as first-line therapy or conjunctively with opioids. | — |
| Do I have a referral list for pain management clinicians? | For complex pain syndromes, patients who require procedures, or complex chronic opioid prescribing concerns, hematologists should consider referring patients to pain management clinicians. | — |
| Do I have a referral list for palliative care clinicians? | For patients with malignancy or those facing life-threatening advanced illnesses, hematologists are encouraged to engage palliative care clinicians to assist with chronic pain management. | — |
| Do I have a referral list for addiction treatment clinicians? | Patients with suspected OUD require immediate assessment and referral to comprehensive treatment. Hematologists who engage in chronic opioid prescribing are encouraged to develop referral lists to addiction medicine physicians, addiction psychiatrists, buprenorphine-certified clinicians, and substance use disorder treatment programs. | SAMHSA National Helpline,51 SAMHSA Behavioral Health Treatment Services Locator52 |
ASCO, American Society of Clinical Oncology; CDC, Centers for Disease Control and Prevention; COX-2, cyclooxygenase 2; DEA, Drug Enforcement Agency; GAD-7; Generalized Anxiety Disorder 7; ESMO, European Society for Medical Oncology; PHQ-9, Patient Health Questionnaire 9; SAMHSA, Substance Abuse and Mental Health Services Administration.