University of Iowa

UIHC Pain Management Clinic

FPInfo: Resources to support patient care

Instructions on Managing Patients for Reduction of Chronic Opioids (Twelve Steps)

1.     Consider opioid reduction/cessation for patients on high dose opioids without clearly defensible reason. For those with rationale need we recommend the annual DEXA, serum testosterone levels (for males), vitamin D and TSH.

2.     If you don’t have sufficient time to do all this then give the patient 2 to 4 weeks of his scheduled medications, schedule the patient back to see YOU and, in the interim, complete the elements below (20 minutes).

3.     Create “Chronic Pain” onto EPIC Problem List

4.     Add smartphrase “.NARCONTRACT” into the Chronic Pain Overview window (we all have it as a smartphrase now).

5.     Go to far right hand column and click on “FYI”. If not visible then look below to “More Activities” and add FYI to your column.

6.     Within the FYI window click on “New Flag”.  In the “Flag type” pull down menu select “Opioid Plan in Place”. Add text if you want. Click on “Accept”.

7.     Using the “Epic” icon in the upper left hand corner go to the “Help/Web Links/Medical Record Forms/G-2e Opioid Medication Agreement” and make 2 copies of this document. Go over the highlights with the patient, tell him that it is our clinic policy to have all patients on chronic opioids sign the document irrespective of their pattern for use. Put the signed copy in our clinic team folders to be scanned into the EPIC Media section and give the unsigned copy to the patient.

8.     In Chart Review evaluate any of the following in order to populate the .NARCONTRACT smartphrase in your new Chronic Pain problem. If this information fails to clearly justify chronic opioid use then initiate taper/cessation management.

a.     1^st UIHC and 1^st DFM clinic visit relevant to pain diagnosis.

b.    Any physical therapy, ED or relevant sub-specialty visits.

c.     Most recent DFM clinic visits

9.     In Results Reviewed evaluate any relevant imaging studies. Is there a Drugs of Abuse-urine screen? If not, consider ordering one recalling that cannabinoids and synthetic opioids need to be ordered separately in addition to “Drugs of Abuse—urine”.  See urine drug screen protocol and orders

10.  To check the PMP profile, go to the PMP website (type "Iowa PMP" in a Google search).  On the left side is 'Requests' - click submit under this.  Enter the patient's name and DOB, and then submit. 

11.  Consider opioid taper/cessation for patients:

a.     Who do not have an indication that shows improved outcomes for chronic opioid use.

b.    Who violate the terms of their opioid agreement

c.     Who do not have specialty justification for chronic opioids (Pain Clinic, Orthopedics & Rehab, Neurosurgery, etc)

d.    Multiple opioid prescribers, frequent overlapping of narcotic prescriptions from multiple sources,  as noted  in the PMP review. The answer for this problem is not to taper opioids, but to sign an agreement whereby they use one prescriber and one pharmacy.  They may see several specialists and utilize whichever pharmacy is most convenient at the time.   THEN – if they violate the terms of the agreement a taper should be considered. 

12.  For opioid tapering - see guidelines posted on Med Hub or www.paintopics.org

Lee Kral, Pharm D

Mike Ernst, Pharm D

Rick Dobyns, MD

January 2011