Practice Name Here: Initial Evaluation for Possible Opioid Therapy

HPI:

______is a XX y.o. ______who presents now for an initial evaluation of chronic pain, and possible treatment with opioid therapy.

Using the validated tool, the Brief Pain Inventory, the patient describes his pain in the following ways:

  1. Anatomic location of pain on the anterior surfaces of the body:
  1. Anatomic location of pain on the posterior surfaces of the body:
  1. Rating of the “WORST” pain patient has experienced over the 24 hour period leading up to this appointment (0=No pain – 10=Worst pain):
  1. Rating of the “LEAST” pain patient has experienced over the 24 hour period leading up to this appointment (0=No pain – 10=Worst pain):
  1. Rating of the patient’s “AVERAGE” pain (0=No pain – 10=Worst pain):
  1. Rating of the patient’s pain RIGHT NOW (0=No pain – 10=Worst pain):
  1. Rating of how much the patient’s pain has interfered with his General Activity in the last 24 hours (0=Does not interfere – 10=Completely interferes):
  1. Rating of how much the patient’s pain has interfered with his Mood in the last 24 hours (0=Does not interfere – 10=Completely interferes):
  1. Rating of how much the patient’s pain has interfered with his Walking Ability in the last 24 hours (0=Does not interfere – 10=Completely interferes):
  1. Rating of how much the patient’s pain has interfered with his Normal Work (both inside and outside the home) in the last 24 hours (0=Does not interfere – 10=Completely interferes):
  1. Rating of how much the patient’s pain has interfered with his Relations with other people in the last 24 hours (0=Does not interfere – 10=Completely interferes):
  1. Rating of how much the patient’s pain has interfered with his Sleep in the last 24 hours (0=Does not interfere – 10=Completely interferes):
  1. Rating of how much the patient’s pain has interfered with his Enjoyment of life in the last 24 hours (0=Does not interfere – 10=Completely interferes):

Summary of Past Treatments for Pain:

Pharmacotherapy

  1. Any prior Opioid therapy:
  2. Any prior NSAID therapy:
  3. Any prior Adjuvant therapy for neuropathic or centrally mediated pain:
  4. Specific agents used include:

Non-Pharmacologic Treatments

  1. Any prior physical therapy:
  2. Other specific non-pharmacologic therapies which patient has received include:
  3. Any current treatment with benzodiazepines:

In last 24 hours, Mr./Ms. ______reports that the above outlined Pain Treatments have led to a % reduction in his/her pain when compared to without treatment.

Social History - Relative to Risk of Longer Term Opioid Use :

Social support structure for patient:

Current Housing / Living environment:

Objective : Depression Screen / Opioid Risk Tool / PE

Depression Screening Summary (PHQ-2 +/- PHQ-9):

(For the PHQ-2 the true positive rate (TPR)=62%, and the true negative rate(TNR)=95% for any depressive disorder.)

When asked today during our examination, the patient provided the following responses to depression screening

0=Not at all

1=Several days

2=More than Half the Days

3=Nearly Every Day

Over the last 2 weeks, how often have you been bothered by any of the following problems?

  1. Little interest of pleasure in doing things 0 1 2 3
  1. Feeling down, depressed or hopeless 0 1 2 3

Score from Questions 1 and 2:

IF the Total Score from questions 1 &2 = 0-2, this is considered normal or a “negative” screen for depression, and no additional questions were asked.

IF the Total Score from questions 1 &2 = 3-6, the patient was asked the following additional questions:

Over the last 2 weeks, how often have you been bothered by any of the following problems?

0=Not at all

1=Several days

2=More than Half the Days

3=Nearly Every Day

1 / Little interest or pleasure in doing things0 1 2 3
2 / Feeling down, depressed, or hopeless 0 1 2 3
3 / Trouble falling or staying asleep, or sleeping too much0 1 2 3
4 / Feeling tired or having little energy0 1 2 3
5 / Poor appetite or overeating0 1 2 3
6 / Feeling bad about yourself — or that you are a failure or have let yourself or your family down0 1 2 3
7 / Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3
8 / Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
0 1 2 3
9 / Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3
A11 – PHQ9 total score /

Total Score from Questions 1-9: ______

Risk Assessment for Possible Misuse / Abuse of Chronic Opioids

Opioid Risk Tool (Webster LR, Webster RM. Pain Med. 2005)

Mark Each Box That Applies / Score if Female / Score if Male
1. Family History of Substance Abuse /
  • Alcohol
  • Illegal Drugs
  • Prescription Drugs
/ 1
2
4 / 3
3
4
2. Personal History of Substance Abuse /
  • Alcohol
  • Illegal Drugs
  • Prescription Drugs
/ 3
4
5 / 3
4
5
3. Age (Mark Box if 16-45 years) / 1 / 1
4. History of Preadolescent Sexual Abuse / 3 / 0
5. Psychological Disease /
  • Attention-Deficit/Hyperactivity Disorder; Obsessive Compulsive Disorder; Bipolar Disorder; Schizophrenia
  • Depression
/ 2
1 / 2
1

Total Score ______Risk Category______

Low Risk 0-3

Moderate Risk 4-7

High Risk >7

Physical Exam:

Vital Signs: Temp:_____ BP: ____/____ P: ______R: ______

General:

HEENT:

Neck:

Cardiovascular:

Lungs / Chest:

Abdomen:

Extremities:

Genitourinary:

Rectal:

Back

Skin:

Musculoskeletal:

Neurological:

Assessment/ Plan :

Based on a review of the patient's Brief Pain Inventory, treatment history and the personal and social history of Mr./Mrs. ______, my assessment and plan is as follows:

1. Chronic Opioid Therapy is/is not appropriate for Mr./Ms. ______

2. Other treatment considerations should include:

3. The NC Controlled Substance Monitoring System was/was not reviewed and there was no evidence that the patient has been receiving controlled substances in an inappropriate manner.

NC Controlled Substance Reporting System Login Page

4. The Practice Pain Management Agreement was/was notreviewed with the patient today and the patient did/did not sign and voice understanding of the pain management agreement provisions and comprehends the potential adverse effects of opioid treatment described in the document.

5. A Urine Drug Screen was/was not performed today.

6. Goals of Treatment:

I did/did not review realistic and observable goals of opioid therapy today. Specific goals for which were set today include the following (see addendum for sample goals):

A. Physical Goals:

B.Functional Goals:

C.Social Goals:

Additional evaluation for the patient's pain includes:

Patient education regarding limitations of chronic opioid therapy, safe storage/disposal, not sharing, and motor vehicle safety were discussed.

The patient understands that opioid medications are being prescribed on a trial basis. Progress on the above goals as well as adverse effects will be reviewed at follow up visits and used to determine whether ongoing treatment is indicated.

Further opioid education was provided using the pain education handout our practice uses.

RTC in ____ weeks

Addendum:

©Community Care of North Carolina, Inc.
2300 Rexwoods Dr., Ste. 200 Raleigh, NC 27607
(919) 745-2350|