Guidance for Assessment and Monitoring: Individuals using Opioid Medications

Background:

The ongoing opioid crisis in Alberta requires a coordinated approach from government, Alberta Health Services, regulated health professionals, and others.  Pharmacists are front line health providers working closely with individuals prescribed opiates, in particular those who have the potential for dependence, misuse, addiction and diversion.  Pharmacists are often the most accessible members of individuals’ healthcare team and play a vital role in their medication assessment and management. This includes many strategies including harm reduction. 

It is essential that pharmacists adequately assess and monitor individuals using opioid medications and work collaboratively within multidisciplinary teams to optimize health outcomes and minimize harm.

The Standards of Practice for Pharmacists and Pharmacy Technicians provide a framework for appropriate patient care however, due to the complexity of opioid use, additional guidance and interpretation of the Standards is required. 

Adherence to the following guidelines, based on the Standards, is an expectation of practice.
 


Guidance for Pharmacists and Pharmacy Technicians:

1. Pharmacists must establish and maintain a professional relationship with each individual using opioid medications.

2. 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.

3. Pharmacists must document details of the assessment in the patient record of care and develop a written treatment plan for individuals using long term opioid therapy1 or for those determined to be at high risk of misuse or addiction.

4. Pharmacists must collaborate with the prescriber and other healthcare professionals involved in the care of individuals using opioid medications.

5. Pharmacists and pharmacy technicians must monitor individuals for the signs of opioid misuse, diversion, or addiction and take appropriate action. 
 


Additional Interpretation:

1. Pharmacists must establish and maintain a professional relationship with each individual using opioid medications.

The pharmacist must:

  • identify the health priorities of the individual and work with them to set realistic expectations for pain management;
  • work to build and maintain rapport with individuals and avoid assumptions or stereotypes;
  • help individuals to understand that opioid medications are not a cure for their condition.  Let individuals know to expect a mild to moderate reduction in pain and increase in function; and
  • make individuals aware of the risks of opioids including tolerance, dependence, overdose, addiction and adverse effects such as sedation which can affect their quality of life.  Ensure that individuals fully understand the risks and benefits of using opioids.

2. Pharmacists must complete a thorough assessment of each individual who is prescribed opioid medications or sold an exempted codeine product:

  • every time a new prescription is filled or a codeine exempt product is sold;
  • every time a refill is dispensed; and
  • as required by the patient treatment plan.

A goal of assessment is to ensure that patients and prescribers consider all appropriate options before initiating opioid therapy and, for those patients that require opioids, that therapy is closely monitored. 

To complete an assessment, pharmacists must be familiar with accepted clinical guidelines2 and consider relevant factors including, but not limited to: 

Indication Effectiveness
  • Determine the type, cause and nature of the individual’s condition and whether an opioid is the appropriate choice.
  • Determine if the individual is opioid naïve (no opioid therapy within the last 180 days), if they have received opioids in the last 180 days and for what indication(s) or if they are on long-term opioid therapy.
  • Consider therapeutic interventions that may be appropriate for the type of pain being treated including:
    • non-pharmacological options such as lifestyle changes, dietary changes, physical therapy and cognitive behavioral therapy, etc.; and
    • other non-opioid pharmacological treatments with a lower addiction potential.
  • If the individual is opioid naïve, the initial total dose should be <50 Oral Morphine Equivalents (OME) per day and the duration of therapy should not exceed 1 week without reassessment.  If doses are increased, they should be titrated upwards and the individual should be monitored for pain control and/or function improvement.
  • For individuals using long-term opioid therapy, total doses should not typically exceed 90 OME/day and the individual should not receive more than a 30-day supply. 
  • If doses exceed accepted clinical guidelines, the pharmacist must ensure collaboration with the prescriber and any other involved healthcare providers.  Options to be considered include:
    • a gradual tapering to the lowest effective dose;
    • rotation to other opioids; and/or 
    • referral to another health care professional specializing in chronic pain management.
  • In circumstances, when it is determined that the dose or duration exceeds the accepted clinical guidelines, thorough documentation of the assessment, including a rationale, and an individualized monitoring plan must be created.
Safety Adherence
  • Use an appropriate tool(s)3 to screen the individual for potential misuse and/or addiction by assessing:
    • current and previous alcohol and drug use;
    • personal and family history of addiction;
    • history of mental illness; and
    • potential drug interactions, especially those that may increase sedation.
  • Canadian guidelines recommend against the use of opioids when the individual has an active substance abuse disorder or a history of substance abuse. The pharmacist must not dispense the medication under these circumstances without collaborating with the prescriber and ensuring the benefits outweigh the risks.
  • Patients with mental illness must be assessed for stability before dispensing opioids. This involves a pharmacist assessment and/or collaboration with the prescriber and other involved healthcare professionals.
  • Assess and monitor for potential and/or actual adverse drug events.
  • Is the patient willing and able to use/adhere to the therapy?
  • The pharmacist must review the Alberta Electronic Health Record (Netcare) or other independent source (e.g. triplicate prescription program, other community or hospital pharmacists) for history of drug therapy every time a prescription for an opioid medication is dispensed or an exempted codeine product is sold.  This review should include consideration of:
    • adherence to time intervals;
    • dispensing events at other pharmacies;
    • double doctoring; and
    • use of other medications that may affect opioid therapy.
  • If the pharmacist identifies any of the above issues, the pharmacist should collaborate with prescriber and determine a suitable course of action. 

3. Pharmacists must document details of the assessment in the patient record of care and develop a written treatment plan for individuals using long term opioid therapy or those determined to be at high risk of misuse or addiction.

This treatment plan:

  • must identify the indication for the opioid;
  • must establish baseline data and identify parameters to monitor such as: pain and function, drug related problems, adherence and signs of misuse or addiction;
  • must specify appropriate timeframes for monitoring and follow up and identify who will conduct the reassessment;
  • must ensure that a documented record of care is created that includes a record of all collaborations, interventions and assessments performed by the pharmacist.  This record should be created in a way that is easily retrievable and is consistent among the pharmacy team members; and
  • should consider the use of a written two-way or three-way patient agreement to:
    • outline the responsibilities and expectations of the patient and the healthcare professionals involved;
    • acknowledge the mutual agreement and understanding of key elements involved in the provision of the opioid medication;
    • enhance collaboration with the prescriber (when using a three-way contract); and
    • prevent misunderstandings or conflict.

4. Pharmacists must collaborate with the prescriber and other healthcare professionals involved in the care of individuals using opioid medications whenever:

  • the prescribed medication choice, dose and/or regimen is outside accepted treatment guidelines or best practices; 
  • medication therapy problems are identified that cannot be treated within the practice of pharmacy; and/or
  • the individual exhibits signs of misuse, abuse or diversion including such as requests for early refills, evidence of the use of multiple physicians or pharmacies, or purchase of non-prescription opioids.

5. Pharmacists and pharmacy technicians must monitor individuals for the signs of opioid misuse, addiction, or diversion and take appropriate action.  Tolerance and dependence are well-known risks of opioid therapy and can happen to any individual using these medications.

  • When signs of possible misuse or addiction are identified the pharmacist should:
    • collaborate with other members of the individual’s healthcare team to determine an appropriate course of action;
    • provide education to the individual as necessary; and/or
    • refer the individual to appropriate addiction resources4 and/or other practitioners specializing in management of addictions.
  • Pharmacists and pharmacy technicians must work to prevent opioid diversion by: 
    • taking reasonable steps to determine if the prescription is authentic and has not been altered, forged, or stolen;
    • taking reasonable steps to verify the identity of the individual or their agent;
    • checking triplicate prescriptions against the Stolen or Missing Triplicate list5; and
    • ensuring safe use and storage by instructing individuals to:
      • store opioid medications in a location where they are not accessible to others.  When possible, opioid medications should be kept locked up to secure them from theft.
      • return unused medications to the pharmacy for safe disposal6

References and Additional Resources:

1. Legislation

2. Alberta College of Pharmacists Tools

3. Clinical Guidelines and Patient Assessment

4. Addiction and Substance Abuse


Footnotes

  1. Long term opioid therapy is defined as ongoing opioid therapy for treatment of chronic non-cancer pain (Chronic non-cancer pain includes any painful condition that persists for ≥3 months that is not associated with a diagnosis of cancer); 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain
  2. Refer to 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain;  http://nationalpaincentre.mcmaster.ca/guidelines.html 
  3. Opioid Risk tools; http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b02.html ; http://nationalpaincentre.mcmaster.ca/documents/cage_questionnaire.pdf
  4. For a list of addiction and mental health resources, refer to http://www.albertahealthservices.ca/amh/amh.aspx
  5. For the list of lost/stolen triplicates, refer to https://pharmacists.ab.ca/triplicate-prescription-program
  6. For information on pharmacist responsibilities for accepting and destroying opioid medications, refer to: 1) Standards for the Operation of Licensed Pharmacies; 5.14  2) https://pharmacists.ab.ca/how-do-i-apply-destruction-unusable-narcotics-and-other-controlled-substances

 

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Last updated: June 2017


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