FSMB Federation of State Medical Boards. Guidelines for the Chronic Use of Opioid Analgesics "In April 2015, the Federation of State Medical Boards (FSMB) Chair, J. Daniel Gifford, MD, FACP, appointed the Workgroup on FSMB’s Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain to review the current science for treating chronic pain with opioid analgesics and to revise the Model Policy as appropriate. To accomplish this charge, the workgroup conducted a thorough review and analysis of FSMB’s existing policy document and other state and federal policies on the prescribing of opioids in the treatment of pain, including the March 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. In updating its existing policy, the FSMB sought input from a diverse group of medical and policy stakeholders that ranged from experts in pain medicine and addiction to government officials and other thought leaders. Over the course of the last 12 months, the workgroup met on several occasions to examine and explore the key elements required to ensure FSMB’s policy document remains relevant and is sufficiently comprehensive to serve as a prescribing guideline and resource for state medical and osteopathic boards and clinicians."

Adopted as policy by the Federation of State Medical Boards April 2017

ASIPP American Society of the Interventional Pain Physicians’. Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines "Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s. In an attempt to control opioid abuse, numerous regulations and guidelines for responsible opioid prescribing have been developed by various organizations. However, the US opioid epidemic is continuing and drug dose deaths tripled during 1999 to 2015. Recent data show a continuing increase in deaths due to natural and semisynthetic opioids, a decline in methadone deaths, and an explosive increase in the rates of deaths involving other opioids, specifically heroin and illicit synthetic fentanyl. Contrary to scientific evidence of efficacy and negative recommendations, a significant proportion of physicians and patients (92%) believe that opioids reduce pain and a smaller proportion (57%) report better quality of life. In preparation of the current guidelines, we have focused on the means to reduce the abuse and diversion of opioids without jeopardizing access for those patients suffering from non-cancer pain who have an appropriate medical indication for opioid use."

Pain Physician 2017; 20:S3-S92 • ISSN 1533-3159

VA Department Of Veterans Affairs. VA/DoD Clinical Practice Guideline For Opioid Therapy For Chronic Pain "The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation."

VA/DoD Clinical Practice Guideline For Opioid Therapy For Chronic Pain Version 3.0 - 2017.

PPM Practical Pain Management Urine Drug Testing: What is Optimal Frequency and Duration? "How often and for how long to screen patients taking high-risk medications was a hotly debated question at this year's AAPM meeting. But the concensus appears to be that frequent screening early in the course of treatment is the best policy for uncovering medication-aberrant behavior (MAB). In one study, investigators at Boston PainCare, with affilications at Tufts School of Dental Medicine, Tufts School of Medicine, and Massachusetts General Hospital, looked at the rates of MAB using urine drug testing (UDT) data over a 12-month period. What they found was that 38% of the patients had at least 1 inconsistent UDT and 7.6% of all UDTs administered were inconsistent over the 12-month period. With this rate of inconsistent UDTs, 'monthly screening could take up to 13 months to identify an aberrancy, while semi-annual screeening could take up to 78 months,' noted the investigators."

Practical Pain Management

AAPM The American Academy of Pain Medicine. Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain "Over the last decade, opioid therapy has become a more acceptable treatment option for chronic pain of noncancer origin. The increase in opioid use between the years 1980 and 2000 was only 8–16%, however, by 2002, use had increased by over 222% [1–6]. Along with the increase in the utilization of opioids has come an increase in abuse and diversion of these controlled substances. The Drug Abuse Warning Network reports that emergency department (ED) admissions attributed to opioid use more than doubled between 2004 and 2009, with over 400,000 ED visits in the United States in 2009 attributed to opioid use. Approximately 80% of these ED visits involved polysubstance abuse [7,8]. While urine drug monitoring (UDM) is one of the few tools available to clinicians to monitor for abuse, misuse, and diversion of opioids, its use especially by primary care providers is surprisingly low. Previous literature has reported utilization rates of UDM for chronic opioid therapy (COT) patients ranging from 8% to 30% in primary care practices [9–11]. Anecdotally, reports by clinicians specializing in pain medicine suggest that their use of UDM is more routine. It has been postulated that low utilization of UDM by primary care may be partly due to a lack of understanding of results and how to interpret and act on them [12]. Also, there exists some risk of misinterpretation of UDM, which can bring harm to a compliant patient. This risk may give some primary care practitioners pause when determining whether to use UDM in their practice."

Pain Medicine 2012; 13: 886–896 Wiley Periodicals, Inc.

Pain Week Pain Week. Predicting Abnormal Urine Drug Testing in Patients on Chronic Opioid Therapy "This study was designed to assess how accurately clinicians can predict which patients on COT will have abnormal urine drug test results. The American Pain Society and the American Academy of Pain Medicine Guidelines for the Use of Chronic Opioid Therapy (COT) in Chronic Noncancer Pain state "In patients who are on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens. In patients on COT not at high risk and not known to have engaged in aberrant behaviors, clinicians should consider periodically obtaining urine drug screens" (Chou et al., 2009). Several retrospective studies demonstrated that physicians are often unable to accurately assess the likelihood of drug misuse, abuse or diversion in patients on COT. In a study investigating urine drug toxicology results in 122 patients receiving chronic opioids over a three year period, aberrant drug-related behaviors were discordant with urine toxicology. Twenty seven percent of patients with no behavioral issues had an illicit or non-prescribed controlled substance in their urine (Katz & Fanciullo, 2002). Michna (2007) reported on 470 patients where 45% were found to have an illicit drug, a non-prescribed controlled substance, or the absence of the prescribed medication. No clear predictors of abnormal drug screens were identified based on the variables of gender, pain site, type of opioid, opioid dose, number of opioids prescribed, or prescribing physician."

Pain Week

APS American Pain Society. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. "Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices."

The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130