6. Regularly Reassess Treatment
Reassess: Monitor and Modify Treatment, Regularly
A new mantra: RE-EVALUATION not a REFILL!
In order to reassess, however, you have to set up the expectation that the patient WILL come back. It may seem obvious to you that patients who are maintained on chronic opioid therapy for their pain need to be periodically reassessed but it may not be obvious to your patients. This might be best summarized by reinforcing that a return visit by the patient is NOT for a REFILL, but for a RE-EVALUATION.
Moreover, you may both disagree on the definition of “periodically”…
The Indiana Emergency Medical Rules now make this quite clear, explicitly stating that patients on chronic opioid therapy must be see every 3-4 months for reassessment of pain, functionality and side effects of their therapy.
Re-assessing the primary measures of pain severity and functional level should be performed and documented at each routine visit, and must occur every 3-4 months. As with any chronic disease management plan, rationale for continuing or modifying treatment should be recorded in the medical record. Of course, if medication isn’t helping, it should be discontinued but often patients (and providers) fall into a pattern and fail to re-assess what they are doing, a sort of therapeutic inertia.
You have probably discovered by now that the pain scale asked of patients as they check into the clinic or the Emergency Department is not very discriminatory. It is certainly not enough to base a whole treatment regimen on. Asking patients questions regarding where they hurt and what makes the pain better or worse can go much further to understanding how they are doing. Additionally, asking them what they are able to do in terms of ADLs and other activities paints a much broader picture.
Assess the 5 A’s of Pain Medication.
Regularly assess the “Five A’s” of Pain Medicine: Analgesia, Activity, Adverse Effects, Aberrancy, and Affect
The big questions on a return visit are: is the pain medication working and is it leading to any adverse affects? With this information, we can decide whether and how to modify the patients treatment regimen.
We should assess:
- Analgesia: the patient’s pain severity as compared to previous pain levels
- Activity: the patient’s functional status, what they are able to do compared to previous assessments
- Adverse Effects: the negative effects of the medications on the patient. Are there any new complaints (such as constipation, fatigue, etc.) that may be medication-related
- Aberrant behavior: for patients prescribed opioids, the patient’s adherence to the prescribed regimen. Review their dosing patterns. Are they taking more than prescribed, sharing their medications with others, taking others’ prescription medications or other behaviors?
- Affect: the patient’s mental status, are there any signs of co-morbid mood disorders?
In addition, you should review what medicines they are taking and exactly how they are taking them so you can determine whether they are taking the correctly.
Review Diagnosis and Comobidity.
Just like everyone else, patient’s medical conditions, social situations and habits can change over time. Asking questions regarding their substance use, mood symptoms and other related questions is key to understanding what factors may be influencing their pain and functional status. By Indiana law, formal assessments (substance use screening, depression screening, etc.) should be performed and documented at least yearly but asking about these at each visit can help you better treat the patient more effectively and quickly should a new problem between arise between visits.
Re-evaluate, not just a refill. A better way to think about prescriptions.