Opioid Risk Evaluation Note For Chronic Pain
Based on VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain
1. Diagnoses responsible for chronic pain: _______________________________
Diagnosis confirmed by (check all that apply)
q physical examination ___________________
q appropriate imaging studies done (describe) ______________________
q other diagnostic studies (EMG, positive nerve block, epidural injection, etc.) _________
2. Justification for opioid trial
q This patient continues to have moderate to severe chronic pain and/or unsatisfactory functional outcomes in response to non-opioid pain management strategies.
Trials of the following strategies (titrated to target dose) have been completed (describe):
q Medications
q Nonsteroidal antiinflammatory drugs: __________
q Adjunctive analgesics (gabapentin, duloxetine, pregabalin, etc.): __________
q Muscle relaxants: _____
q Topical agents (lidocaine, capsaicin, etc.): _____
q Other medication: _____
q Relevant surgical procedures _____________
q Physical therapy/Physical modalities (heat, cold, exercises, TENS, chiropractic, etc.) _____________
q Interventions (epidural injection, facet block, etc.) _____________
q Biobehavioral (relaxation) or cognitive behavioral therapies
q Other___________________________________________
3. Opioid therapy trial should NOT be initiated if any of the following absolute contraindications are evident:
q Severe respiratory instability
q Acute psychiatric instability or uncontrolled suicide risk
q Diagnosed substance use disorder not in remission or under treatment
q True allergy to opioids
q Prior trials of specific opioids discontinued due to serious adverse effects.
q Potentially lethal drug-drug interaction
q (methadone only) QTc interval > 500 milliseconds
q Active diversion of controlled substances
4. Opioid therapy trial may be considered with caution, if any of the following relative contraindications are
evident. This list is NOT inclusive, and it is the provider's responsibility to assess other reasonable risk factors:
Psychosocial factors
q Suicide risk
q Unstable psychiatric disorder or personality disorder
q Social instability or other factor that may interfere with opioid adherence
q Suspected cognitive impairment that might interfere with safe use of medications
q Unwillingness or inability to comply with treatment plan
Drug and medication use history
q History of medication mis-management or nonadherence
q Evidence of recent illicit substance use, e.g., positive urine screen
q Substance abuse/dependence history or current substance use disorder under treatment
q No benefit from prior opioid trials for the same clinical problem
q Other:
Pertinent medical history
q Unresolved headache not responsive to other modalities
q Untreated sleep apnea (suspected or verified)
q Chronic pulmonary disease
q Cardiac condition (QTc interval 450-500 milliseconds) that makes methadone a risk
q Intestinal motility disorder (constipation, IBS, hx bowel obstruction, paralytic ileus)
q Respiratory depression in unmonitored setting
q Hepatic or renal insufficiency
q History of falls or gait instability
q No opioid contraindications are evident
Comments: ____________________
4. Select One of the Following:
o Initiation
o None of the above opioid contraindications apply. I believe the functional benefits outweigh specific risks of an opioid therapy trial for this patient. I have educated the patient regarding risks and expectations of opioid therapy, and the patient has signed an opioid treatment agreement after thorough discussion. The patient understands that a trial of opioid therapy will only be continued if there is evidence of functional benefit and no adverse effects. Comments (optional): _____________________________________
o One or more of the above contraindications apply and have been addressed. I believe the functional benefits outweigh risks of an opioid therapy trial for this patient, justified as follows: ______________________________________________________________ I have educated the patient regarding risks and expectations of opioid therapy, and the patient has signed an opioid treatment agreement after thorough discussion. The patient understands that a trial of opioid therapy will only be continued if there is evidence of functional benefit and no adverse effects.
o Patient is transferring a stable opioid regimen from an outside medical provider, whose assessment and justification for opioid therapy and treatment plan I have reviewed. Contingent on my further assessing opioid indications and risk factors specific to this patient, I am continuing the patient's opioid therapy. I have educated the patient regarding risks and expectations of opioid therapy, and the patient has signed an opioid treatment agreement after thorough discussion. The patient understands that a trial of opioid therapy will only be continued if there is evidence of functional benefit and manageable risk. Comments (optional): _____________________________________
o Continuation
o None of the above opioid contraindications apply. I assess functional benefits continue to outweigh risks of opioid therapy for this patient. I have educated the patient regarding risks and expectations of opioid therapy. The Opioid Treatment Agreement was reviewed. The patient understands that opioid therapy will only be continued if there is evidence of functional benefit and no adverse effects.
o One or more of the above contraindications apply and have been addressed. I believe the functional benefits outweigh risks for continuing opioid therapy trial for this patient, justified as follows: __________________________________________________________________ I have educated the patient regarding risks and expectations of opioid therapy. The Opioid Treatment Agreement was reviewed. The patient understands that opioid therapy will only be continued if there is evidence of functional benefit and manageable risk.
o Opioid Therapy Contraindicated
o One or more of the above contraindications apply. I believe the risks of opioid therapy outweigh the benefit for this patient. I have educated the patient regarding risks and will continue to manage the patient’s chronic pain and co-morbidities with comprehensive nonopioid pain treatment plan including referrals as indicated. Comments (optional): ____________________________
q Decision on Opioid Therapy Deferred:
Patient is attempting to transfer a stable opioid regimen from an outside medical provider, but insufficient medical data is available or I am unable to contact the previous prescriber. Situation has been discussed with patient who is aware that any decision on provision of opioid medications will be delayed pending satisfactory data collection regarding safety of opioid use. Comments (optional):
5. A baseline urine drug screen prior to initiation of opioid therapy.
Recent urine drug screen results: (pull in from labs)
(Link to CPRS order set for urine tox screens)
6. Treatment goals and additional comments:________________________________