Section 2: Laws and Policies of Safer Opioid Prescribing for Nonpalliative Care

Oklahoma State Laws and Policies

Tribal providers can take state laws and policies into consideration when assessing best-practice techniques and common prescribing practices throughout the state. Therefore, Oklahoma State Law states the following:

+ Naloxone can be prescribed to a patient at risk of opioid overdose. It can also be prescribed to their caregiver. A pharmacist can also dispense naloxone without a prescription. It is highly recommended to be prescribed alongside chronic opioid prescriptions.

+ Electronic prescribing should be utilized for all controlled substances in Schedules II–V (63 OK Stat § 63-2-309, 2020).

+ Prescribers (or their designated delegates) should check the patient’s PMP report before initially prescribing controlled medications. The PMP can help providers recognize substance use disorders and concerning behaviors or identify other prescription medications being taken. The PMP can help note the following concerns:

◦ early refills

◦ multiple providers

◦ multiple prescriptions

◦ forged or altered prescriptions

◦ an extended duration (i.e., over 7 days) opioid prescription for acute pain

◦ risky medication combinations (e.g., overlapping benzodiazepine and opioid prescriptions)

+ When the patient is using controlled medications long- term, prescribers should check the patient’s PMP report every 180 days. Checking the PMP more often than every 180 days is suggested (Oklahoma Prescription Monitoring Program, 2019).

+ For acute pain, prescribers should not issue an initial prescription for an opioid drug in a quantity exceeding a 7-day supply.

◦ After consultation, a second 7-day prescription may be issued if it is deemed necessary and appropriate. The second prescription can be issued on the same day under some circumstances (63 OK Stat § 63-2-309I, 2020).

◦ The prescription should be for the lowest effective dose of an immediate-release opioid drug and must state “acute pain” on the face of the prescription (63 OK Stat § 63-2-309I, 2020).

+ 63 OK Stat § 63-2-309I (2020) also stated that for chronic pain (i.e., 3 months or more of treatment), the prescriber should do the following:

◦ state “chronic pain” on the face of the prescription.

◦ review the course and effectiveness of treatment every 3 months

◦ evaluate the patient for signs of dependency before every prescription renewal and document the assessment.

◦ periodically make reasonable efforts, unless clinically contraindicated, to stop, decrease the dosage, or try other treatment modalities.

◦ monitor compliance with a patient–provider agreement. After 1 year of compliance with the patient–provider agreement, the physician may review the treatment plan and assess the patient at 6-month intervals. More information about Oklahoma state laws are listed in the Resources section.

Indian Health Service Policies

The Indian Health Service (IHS) has published policies covering opioid prescriptions, naloxone, and the PMP. The IHS (n.d.) stated that safe opioid prescribing “relies on the knowledge and skills of clinicians, complies with state and federal statues, and fulfills responsibilities to patients, communities, and licensing authorities”. Additionally, the IHS stated that health care providers should consider prescribing naloxone when a patient is at a high risk of opioid overdose or when the patient and/ or caregiver asks for it (IHS, n.d.). Below are specific guidelines for prescribers the IHS has released regarding the PMP (as stated in the Indian Health Manual).

+ Prescribers should register with their state’s PMP.

+ When accepting a new patient, clinicians should review the patient’s PMP report and should access PMP patient data prior to the appointment.

+ Health care providers should check the PMP before prescribing any Schedule II–V controlled medication.

+ PMP data should be reviewed when a patient is transitioning from acute to chronic opioid pain therapy and periodically during opioid therapy for chronic pain.

A Pocket Book Guide For Prescribers

3

Use Disorders

Detecting Substance

Section 3: Detecting Substance Use Disorders

Lessons From Trickster

“In many Tribal oral traditions Trickster is a scared, yet crafty being who manipulates and cheats others” (Tribal Opioid Response, 2020). Stories of Trickster are shared to teach important lessons about living in balance, respecting medicines, and remaining humble. Some describe Trickster as a coyote, whereas others say he is an old man or raven. Opioid misuse can be framed around Trickster. People can misuse medicines that were intended to heal. “We can imagine that there is a Trickster spirit guiding this transformation of medicine from a helpful healing tool to a harmful burden” (Tribal Opioid Response, 2020).

A provider may consider certain risk factors for addiction when treating patients who are experiencing chronic or acute pain. These risk factors can help inform treatment decisions and effectively address the patient’s pain. A few factors are associated with an increased risk of addiction:

+ family history: A person who has a family member who combats an addiction or who has a running family history of alcoholism or substance use disorders has an increased risk of developing an addiction in their own life (Center for Substance Abuse Treatment, 2012)

+ environmental factors: People who have experienced physical, emotional, or sexual abuse or trauma are more likely to develop substance use disorders. Others who have friends who use or those subjected to peer pressure may also be at a greater risk (SAMHSA, 2019).

+ preexisting mental health conditions: People with existing mental health conditions such as depression, PTSD, and ADHD are also more likely to develop substance use disorders as a way of coping with the emotions and anxieties these disorders can cause (SAMHSA, 2019).

As discussed previously, providers should work with chronic pain patients to evaluate the effectiveness and harm of the treatment plan. One step in the evaluation is assessing patients for substance use disorders or risky behaviors. The PMP and the chart in Figure 4 can help with the detection of substance use disorders.

Figure 4 (turn page)

Clinical tool for recognizing substance use disorders

Note. Adapted from “Screening and Assessment Tools Chart” by National Institute of Drug Abuse, n.d., Clinical Opiate Withdrawal Scale, Appendix 1.

Identifying these factors can help enhance patient safety and lead to better health outcomes. For providers who are concerned about a patient, the Resources section contains links to guidelines, tools, and organizations that can help inform their next steps. Remember, exercising compassion and avoiding stigmatizing language are critical.