2. Patient selection and risk stratification
a. Prior to initiating COT for CNTP, or when accepting a patient in transfer on COT, or when it becomes clear that acute pain treatment is transitioning into COT of more persistent pain, documentation of pain history, pain treatment history, physical examination, appropriate testing, and a working hypothesis of the etiology of the pain and any co-occurring factors that may affect pain and pain treatment will provide a solid foundation for care. Evaluation-pain (limited to pain).pdf and EvaluationChronicPain-Initial(UMich).pdf
i. If opioid prescribing is transitioned to an addiction specialist, psychiatrist, other mental health-oriented professional or to a temporarily covering physician, working in collaboration with a PCP, pain specialist or other clinician who periodically examines the patient with respect to pain, omission of physical examination by the actual prescriber may be appropriate.
b. Querying the New Hampshire Prescription Monitoring Program database and review of relevant medical records can provide critical information on a patient’s use of opioids and other controlled substances. New Hampshire’s evolving Prescription Monitoring Program
c. Assessment of potential risk of opioid misuse either by clinical interview or using a validated risk screening tool can inform development of a plan for clinical care that appropriately accommodates identified risk. Opioid risk screening tools and articles
d. Urine toxicology screening provides objective information on substance use and can be a valuable source of information prior to initiation of long-term opioid therapy, when acute pain appears to be becoming chronic, or when accepting a patient in transfer who is already using opioids. Information on urine toxicology screening
e. Higher risk patients. Management of patients identified as at higher risk for opioid misuse demands more intensive and structured management to assure patient and public safety. Consultation with, referral to, and/or co-management with a mental health, addiction or pain specialist for higher risk patients is often appropriate.
Management of patients at higher risk
Substance abuse and mental health resources
f. Pregnancy. Women of childbearing potential need to understand the relative risks and benefits of COT during pregnancy and after delivery. Minimal or no use of COT for pain during pregnancy is usually advised, unless potential benefits clearly outweigh risks. If COT is used during pregnancy, it is important to anticipate and accommodate risks to the patient and newborn. NH high risk OB Centers and info on pain management in pregnancy