Assessing individuals using opioid medications: what you need to know
As you prepare to implement the Guidance for Assessment and Monitoring: Individuals using Opioid Medications which comes into effect October 1, 2017, it’s important to review and develop your pharmacy’s process for assessing patients. To do this, you’ll need to be familiar with the expectations for assessment outlined in the guidance document:
Pharmacists must complete a thorough assessment of each individual who is prescribed opioid medications or sold an exempted codeine product.
This assessment must include a review of the Electronic Health Record (Netcare) every time a prescription for an opioid medication is dispensed or sold.
For general information on assessment, you can refer to the ACP Standards of Practice for Pharmacists and Pharmacy Technicians. Standards 3, 4, 5 & 6 provide pharmacists with the expectations of an assessment and what to do if a drug related problem is identified.
Many pharmacists use the ACP Chat Check and Chart tool to frame their assessment processes. The ‘check’ portion of the tool involves four questions to assess whether a prescription is indicated, effective, safe, and if the patient is adherent to therapy. The opioid guidance document provides additional interpretation for each of these four questions within the context of opioid therapy.
Tip: A good first step is to familiarize yourself with the additional interpretation for each of the ‘check’ questions and discuss among team members how to best incorporate these additional elements into your practice.
As with any assessment, start with indication and determine why this individual was prescribed an opioid. Determine if the condition is acute or chronic and if they have used an opioid in the last 180 days or are they opioid naïve. For some indications, an opioid may not be optimal therapy. Consider if non-opioid medications and/or non-drug measures may be more effective and collaborate with the prescriber if required.
The 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain recommend that patients who are opioid naïve do not receive more than 50 oral morphine equivalents (OME) daily. Similarly, patients with chronic pain should not routinely take more than 90 OME daily. Remember, if your patient is prescribed doses outside of this range, it does not mean the pharmacist should automatically refuse to fill. Rather, this presents an opportunity for collaboration with the prescriber. To help the pharmacist assess pain control, there are tools available such as the Brief Pain Inventory and PEG inventory. Consider implementing these or similar tools into practice to help simplify and standardize your process.
Tip: Many pharmacies already use a standardized worksheet as the basis for assessment and documentation of injections. Consider adopting a similar process using tools specific to opioid therapy. These documents can be used in their current state or modified as required to fit the needs of your pharmacy.
Potential for misuse is an especially important safety consideration that must be assessed for each individual using opioid medications. Tools like the CAGE assessment and the Opioid Risk Tool can aid pharmacists in an assessment of the risk of addiction.
Opioid therapy presents pharmacy professionals with additional challenges due to the complex nature of pain management and the interplay with addiction and misuse. Because of this, pharmacists must evaluate information on Netcare or an alternative source every time an opioid medication is dispensed or an exempted codeine product is sold. This requirement aligns with the direction the College of Physicians and Surgeons of Alberta provides to physicians in Prescribing: Drugs With Potential For Misuse Or Diversion.
Many pharmacies already review Netcare regularly in this way with little disruption to workflow. For other pharmacies, a first step may be to consider current workflow and determine where it would be most effective to incorporate a check of Netcare.
If the patient information is not available on Netcare, other resources include other pharmacies and the triplicate program. Pharmacists can contact the TPP at 1-800-561-3899 ext. 4939 or TPPInfo@cpsa.ab.ca.
Tip: If you have pharmacy assistants or technicians in your pharmacy, you may find it helpful to ensure they have Netcare access to facilitate pharmacists’ review.
Patient assessment is already a well-established, integral part of your pharmacy practice. The opioid guidance document is simply intended to provide direction and additional considerations to help optimize this process for patients using opioid medications. Pharmacy teams should take time over the next few weeks to examine how they currently assess these individuals and determine if any enhancements need to be made to their systems.
Once you’ve successfully assessed your patient, you’ll need to document this. Watch for tips on how to efficiently document in the next issue of the Link.