DHS Issues Draft Opioid Prescribing Guidelines

By Mary Foarde and Laura Nelson

In an effort to combat the ongoing epidemic of opioid misuse and opioid-related morbidity and mortality, the Minnesota Department of Human Services (DHS) Opioid Prescribing Work Group (OPWG) recently issued Draft Opioid Prescribing Guidelines. The OPWG is an advisory body comprised of prescribers, pharmacists, health plan representatives, government officials, and consumer representatives convened to advance DHS' Opioid Prescribing Improvement Program.

The guidelines are designed to serve as a statewide opioid prescribing protocol for various pain scenarios, including acute, post-acute and chronic pain, and to provide a framework for the appropriate use of opioid analgesia within the larger context of pain management. They are intended for use by clinicians in primary care and specialty outpatient settings who manage pain. While it is difficult to predict how the guidelines will be applied, it is likely that they will be referenced as standard of care by licensing boards and plaintiff's attorneys. DHS will accept public comment on the draft guidelines until December 30, 2017. If you have concerns regarding the draft guidelines, we encourage you to submit comments to DHS.

The goals of the guidelines are to reduce the inappropriate use of opioid analgesia, limit the oversupply of prescription opioids in the community, reduce variation in opioid prescribing behavior, improve the safety and effectiveness of treatments for pain, and reduce the potential for harm from such treatments. The guidelines are framed around three key values:

  1. Prescribe the lowest effective dose and duration of opioids when used for acute pain. The guidelines recommend specific limits on the amount of opioids prescribed based on the circumstances and a general rule of prescribing no more opioids than are needed for initial tissue recovery following extensive surgical procedures or traumatic injury.
  2. Monitor the patient closely during the post-acute pain period. The guidelines recommend assessment and documentation of risk factors for chronic opioid abuse, specific limits on the cumulative dose of opioids, tapering consistent with expected tissue healing, and the development of a referral network for mental health, substance use disorder, pain education, and pain medicine.
  3. Avoid initiating chronic opioid therapy and carefully manage any patient who remains on an opioid. The guidelines recommend specific daily-dosage limits for long-term opioid use, strategies to lower risk when prescribing long-term opioid use, face-to-face visits at least every three months, and offering or arranging for evidence-based treatment for patients who develop an opioid use disorder.

The guidelines also contain specific recommendations by pain phase and discuss risk-mitigation strategies including co-prescribing naloxone to populations at high risk for opioid overdose, assessment for risk factors like depression, anxiety, substance abuse and fear avoidance, and non-opioid pain management alternatives. Additionally, they address indications for rapid and non-rapid taper of opioid use and special considerations for women of childbearing age to reduce instances of neonatal opiate withdrawal.

If you would like assistance reviewing the draft guidelines against your current opioid policies and procedures or support in preparing and submitting a comment to DHS, or for more information about the guidelines, please contact Mary Foarde, John Breviu, Laura Nelson or the Stinson Leonard Street contact with whom you regularly work.

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