Assess Opioid Use

Common prescription opioids [generic (brand) name]:

• Codeine (Tylenol with Codeine)
• Fentanyl (Duragesic)
• Hydrocodone (Hyslinga ER, Zyhodro ER)
• Hydrocodone + acetaminophen (Lorcet, Lortab, Norco, Vicodin)
• Hydromorphone (Dilaudid)
• Methadone
• Morphine (MS Contin)
• Oxycodone (OxyContin, Roxicodone)
• Oxycodone + acetaminophen (Endocet, Percocet)
• Oxymorphone (Opana, Opana ER)
• Tapentadol (Nucynta, Nucynta ER)
• Tramadol (Ultram)

Resources

• Opioid Information Sheet (UNC resource)

Calculate total daily dose (TDD), in morphine milligram equivalents (MME), factoring in scheduled and on-demand doses.

1. Determine total daily amount of each opioid patient is actually taking
2. Convert each to MMEs, using the appropriate conversion factor
3. Add totals together to get total daily dose (TDD) in MME

Resources

• Opioid Information Sheet (UNC resource) [recommended resource]
• Calculating Total Daily Dose of Opioids for Safer Dosage (CDC conversion chart)
• Opioid Conversion Table (AAFP Chronic Pain Management Toolkit resource)
• Opioid Equianalgesic Dosing (UNC Medical Center Guideline)

Determine how long the patient has been taking opioids (length of therapy), and if their use has been persistent or intermittent.

Clarify indication for use and goals of therapy, considering clinical, functional, and patient personal goals of therapy.

Resources

• Opioid Clinical Implementation Tools and Factsheets (CDC quick reference guide)
• CDC Guideline for Prescribing Opioids for Chronic Pain (CDC resource)

1. Assess level of pain control (should not be the sole assessment for effectiveness)
   • PEG Screening Tool: Pain average, interference with Enjoyment of life, and interference with General activity (PEG) Assessment Scale
2. Assess functional status/functional goals

1. Assess opioid-induced side effects.
2. Assess potential drug interactions and cumulative effects.
3. Consider offering patient a prescription for Naloxone, especially if risk factors for overdose are present. Ensure education on appropriate use is provided.

Resources

• Assessing Benefits and Harms of Opioid Therapy (CDC factsheet)
• Opioid Clinical Implementation Tools and Factsheets (CDC quick reference guide)
• Opioid Information Sheet (UNC resource)

Assessing a patient’s adherence to a prescribed medication regimen is always important. For opioids, screening for misuse, abuse, and non-use is also critical for evaluating the safety and effectiveness of the medication.

1. Assess patient/caregiver understanding of regimen(s)
2. Utilize assessment tools
   • Current Opioid Misuse Measure (COMM) Worksheet
   • Opioid Risk Tool (ORT)
3. Perform a pill count for all opioids the patient is taking
   • Pill Count Procedure (UNC resource)
4. Check your state’s Prescription Drug Monitoring Program (PDMP) at least every 3 months [e.g., NC Controlled Substance Reporting System (CSRS)]
5. Perform Urine Drug Screen (UDS) at least annually, if available
   • UNC Sample Urine Drug Screening Report (UNC resource)
   • Urine Drug Testing Factsheet (CDC handout)
   • Urine Drug Testing (AAFP resource)

At all follow-up visits:

1. Assess adherence to deprescribing regimen
   • Addressing Barriers to Opioid Tapering (UNC resource)
2. Assess symptoms/severity of pain
   • PEG Screening Tool
3. Assess for side effects/withdrawal symptoms
   • Clinical Opiate Withdrawal Scale (COWS)
   • Subjective Opiate Withdrawal Scale (SOWS)
   • Clinical Institute Narcotic Assessment (CINA)
   • Opioid Information Sheet (UNC resource)
   • Opioid Withdrawal: Care Instructions (Epic patient education resource)