Resources for Providers

Healthcare providers play a vital role by providing effective, well-managed medication and treatment for people living with chronic pain. Making sure that prescription drugs are available to people for whom they are necessary and appropriate is as important as preventing non-medical use and the potential progression from prescription drug therapy to illicit drug use. The goal of working with providers to manage pain therapy is not to reduce care for legitimate chronic pain patients, but to make sure these patients are safe and cared for as needed.

The following recommendations and resources provide information about opioid prescribing, the co-prescribing of naloxone, North Carolina continuing medical education (CME), and providing medication-assisted treatment.

Prescribing Opioids, Medication-Assisted Treatment

  • The Centers of Disease Control and Prevention released guidelines for prescribing opioids for chronic pain in March 2016. The North Carolina Medical Board (NCMB) has an official guidance document for the prescribing of controlled substances for pain treatment. The Medical Board has tentatively approved replacing the current statement and guidelines with the CDC recommendations.
  • NCMB has instituted a new CME requirement for licensees for controlled substances prescribing.
  • Trainings for licensees in controlled substances reporting have been organized by the Governor’s Institute, NCMB, North Carolina Board of Pharmacy, and the North Carolina Area Health Education Centers.

The Comprehensive Addiction and Recovery Act (CARA), passed in 2016, addresses several areas of overdose prevention, substance use disorder treatment, and opioid abuse prevention and intervention. Included in these provisions is the expansion of buprenorphine prescribing privileges to nurse practitioners and physician assistants. This bolsters a decision by the Obama Administration to increase the number of patients a practitioner can treat with buprenorphine from 100 to 275. More information about providing buprenorphine-assisted treatment, including Buprenorphine Waiver Management and Buprenorphine Training for Physicians, can be found through the Substance Abuse and Mental Health Services Administration (SAMHSA).

Co-Prescribing

The CDC recommends that providers consider prescribing naloxone to all patients on long-term opioid regimens and to anyone at risk of experiencing or being present at an opioid overdose. This is also endorsed by the American Medical Association. Find more information about naloxone co-prescribing through the CDC opioid prescribing guidelines or Prescribe to Prevent, an advocacy and education group.

Providing Care to People Who Inject Drugs

  • Use normalizing, destigmatizing language with patients seeking care for substance use disorders (including medication-assisted treatment) or harm reduction resources, including syringe exchange services.
  • Ask about frequency of sharing syringes and other injection equipment and discuss relevant risks and risk reduction strategies, regardless of pursuit of treatment.
  • Discuss health risks to people who inject drugs (including abscesses, endocarditis and sepsis, and bloodborne diseases like HIV and Hepatitis C), regardless of pursuit of treatment. 
  • If a patient is interested in treatment, ask questions about the use of harm reduction methods while pursuing treatment.
  • Acknowledge that you have received similar questions from other patients and that you are interested in providing such information and connections to care.
  • If a patient who injects drugs has limited access to syringe exchange services, consider prescribing syringes. Though some pharmacies sell syringes to the general public, it is up to pharmacists’ discretion and customers may face stigma and suspicion.

 Supporting Syringe Exchanges and Overdose Prevention Work

  • Encourage the pharmacies you work with to sell syringes, based on patient need.
  • Ask the pharmacies you work with whether they participate in the North Carolina naloxone standing order or a local health department naloxone standing order. Inquire about availability of naloxone, public demand, and available educational resources. Check pharmacy participation in the standing order at NaloxoneSaves.org.
  • Discuss how to identify and reverse an opioid overdose with patients receiving long-term opioid prescriptions, patients who use illicit opioids, and anyone who may experience or be present for an opioid overdose (including patients and their families). Discuss legal protections provided by the Good Samaritan Law and refer to patient education information at NaloxoneSaves.org.
  • Contact your local health department to find out whether they have a coalition and how to get involved. The majority of North Carolina health departments receive grant funding to prevent and respond to prescription drug overdose. With this funding, health departments support coalitions to address drug overdose in their communities, monitor local trends and implement community and medical response strategies.
  • Syringe exchanges respond to the health issues in the communities they serve. If a syringe exchange is operating in your area, ask staff if they are seeing any specific health issues among participants and what information or resources might be needed.
  • If your healthcare center is able, consider donating sterile syringes, biohazard containers, alcohol pads or safer sex supplies to syringe exchange programs. 

CDC Recommendations to Providers

  • Follow CDC opioid prescribing guidelines.
  • Screen patients for substance use disorder, including the misuse of prescription medications, suicide risk and depression. If needed, provide or link to mental health services, and connect people who inject drugs (PWID) or who show signs of opioid use disorders to medication-assisted treatment.
  • Test PWID for HIV and hepatitis and treat them if they are infected. Vaccinate patients for hepatitis A and B, if appropriate.
  • Prescribe sterile syringes to PWID, or refer them to syringe exchange programs (SEPs) or pharmacies that provide sterile syringes, where permitted by law.
  • Provide or refer PWID to HIV risk reduction counseling. Consider prescribing pre-exposure prophylaxis (PrEP) for PWID at very high HIV risk.
  • Prevent overdose deaths by providing naloxone or referring PWID to pharmacies or community-based programs that provide it, where permitted by law.

CDC Recommendations to State and Local Health Departments

  • Use data on HIV, hepatitis, substance use, and overdoses to determine where services are needed.
  • Work with law enforcement and local leaders to expand access to and understanding of SEPs, where permitted by law.
  • Provide HIV and hepatitis testing and prevention services for PWID.
  • Ensure treatment is available for overdoses, HIV, hepatitis, and substance use disorder, and inform first responders about available resources.
     

Healthcare providers are not obligated to report patient use of illicit drugs. Providers should not report knowledge of criminal activity to law enforcement unless the patient has an illness and/or injury specified in North Carolina General Statute 90-21.20. Find more information about Patient Injury Reporting in North Carolina here.

 

Resources

American Academy of Family Physicians Needle Exchange Program statement of support

CDC Vital Signs Syringe Services Programs for HIV Prevention factsheet

CDC Morbidity and Mortality Weekly Report (MMWR) Trends in HIV Diagnoses, Risk Behaviors, and Prevention Among Persons Who Inject Drugs — United States

CDC MMWR CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016

Centers for Medicare & Medicaid Services Partners in Integrity: What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs guide

Naloxonesaves.org

PrescribetoPrevent.org