If a patient needs a quantity greater than 30 tablets of pain medication due to trauma with multiple fractures, what options do we have?
If you feel there is medical justification for more than 30 tablets of a short-acting opioid for an episode of acute pain, it is recommended to provide two separate prescriptions. One prescription for the initial 30 tablets for the patient to fill and a subsequent prescription with justification for the pharmacy to submit for treatment authorization.
Are you requiring the doctor’s office or Health Center to fill out a Treatment Authorization Request (TAR) for these patients?
No, it is the dispensing pharmacy which is responsible for completing all TARs. Only the dispensing pharmacies are familiar with this process, the proper coding, and the electronic on-line platforms needed to do billing for medications and submitting prior authorization requests.
Treatment Authorization Requests (TARs) for medications is another term for Prior Authorization Request (PAR). The PHC formulary lists all formulary medications and criteria used to evaluate non-formulary requests; it is viewable on Epocrates and on the PHC website in two formats: PDF and our new interactive format (see http://www.partnershiphp.org/Pharmacy/Formularies.htm for both).
The dispensing pharmacy does need additional information from the prescriber who wants to prescribe a quantity higher than 30 tablets. The prescriber should write this info onto the prescription itself, and transmit the information when the prescription is sent to the pharmacy.
When is a quantity greater than 30 tablets of short acting opioid justified?
Justifications for short acting opioids for prolonged use:
• Terminal Conditions: Patients with terminal conditions causing pain, with less than a few months of life remaining.
• Active Cancer: Patients undergoing treatment for active cancer with pain caused by the cancer. If the cancer is in remission, the short acting opioid should not be prescribed.
• Acute Injury/Post-surgical Pain: Patients with post-surgical pain or an acute injury may require a temporary short acting opioid. For post-surgical and acute pain in the emergency department, ask colleagues to consider a single dose of 1000mg of IV acetaminophen, to avoid or reduce the need for opioids altogether. Like NSAIDS, IV acetaminophen inhibits cyclooxygenase-2 sufficiently to make it a helpful option for controlling acute post-op pain. In general, the increased pain from an acute injury (even if severe) passes quickly. It is almost always back to baseline in less than 3 weeks. The prescriber should set the patient expectation that the short acting opioid is temporary, and prescribe a limited amount of the opioid, if it is used at all.
• Medical Necessity: Justification for Medical Necessity will be evaluated on a case-by-case basis: If a short acting opioid beyond 30 unit doses is needed, the medical justification should be submitted with the prescription to the pharmacy. The dispensing pharmacy will complete the electronic prior authorization request, using this information.
Other justifications will also be evaluated for Medical necessity on a case-by-case basis. If a short acting opioid is needed, the medical justification should be submitted with the prescription to the pharmacy. The dispensing pharmacy will complete the electronic prior authorization request, using this information.
If the justification is not included with the prescription, the pharmacy should reach out to the prescriber (usually by phone or fax) to request the information. Providing the medical justification maximizes efficiencies and avoids extra work and time needed for both the medical office and pharmacy: including the justification on the prescription is the key.
Why is PHC doing this now?
The underlying motivation for this change is to improve patient safety with prescription opioid medications, for public health, moral, and regulatory reasons.
As you have probably heard, the CDC released a Guideline for Prescribing Opioids for Chronic Pain which reflect substantial changes from common current clinical practice. It notes that most chronic opioid use began with use of short acting opioids for acute pain, where the opioid was continued for too long. See our primary care blog post for a summary and some reflections.
Finally, if you have any concerns or questions as we implement this new policy together starting in June, please call us to discuss things. Thank you for your help and support.
What Information should be provided in the treatment plan when use of short-acting opioid may become chronic or need a longer duration of use?
Specific justification and patient diagnosis should be noted on the prescription. It is also important to put a date of discontinuance, indicating when you plan to discontinue the amount of opioids the patient is on.
Will a quantity limit be applied to a non-opiate naïve post-operative patient?
If the patient is currently on chronic extended release opioids, rather than short-acting opioids, they will be affected by the quantity limit. Partnership acknowledges that often times patients who are currently on opioids have developed a tolerance for the medication, and as such may need additional opioids. If you are concerned that a patient may require more opioids than the quantity limit allows. provide a prescription with justification prior to the surgery (on this prescription, be sure to provide the date of the surgery). The prior authorization process will be conducted as normal, and the patient will be able to pick up an increased quantity of opioids following surgery.
