Luminosity Health and Wellness
Now Accepting New Patients
Pain Management Protocol Luminosity Health and Wellness.
Goal: To provide safe and effective care for patients experiencing pain by aligning our practice
with the standards set forth by CDC and state of Colorado.
Process: Evaluate patient’s history of pain and type of pain, potential for addiction, functional
status, psychosocial risks, medical co-morbidities, and ongoing response to treatment.
​
12-point pain model
​
1) Identify type of pain and source of pain. Review/obtain imaging or other studies
such as EMG to provide clear diagnosis of type of pain. Physical evaluation.
a. Acute vs Chronic Pain
i. Acute: tissue injury which resolves with healing
ii. Chronic: Initially pain generated by injury but lasting longer than 3
months or longer than expected healing time for the injury. In
chronic pain a shift occurs from acute injury and healing to abnormal
maladaptive pain. This occurs in the peripheral and central pain
pathways.
​
2) Psychosocial Risk Assessment
a. Abuse and trauma
b. Coping and social support
c. Smoking, alcohol abuse, substance abuse
3) Co-morbidity assessment
a. Depression and anxiety
b. Sleep impairment
c. Chronic respiratory disease
d. Neurologic disorders
e. cardiovascular disease
f. Metabolic disorders
4) Assessment of medication side effects including:
a. Psychological: Euphoria, depression, anxiety, thought disorders, addiction,
serotonin syndrome, etc.
b. Functional: sedation, respiratory depression, constipation, nausea, vomiting,
etc.
c. Physical ability to care for oneself and to work
d. Immunologic changes: puritis, skin reactions
e. Endocrine changes
​
Program Components:
1) Assessment: addiction, functional status, imaging, neuromuscular testing, etc.
2) Cognitive Behavioral Therapy and coping skills (Behavioral Health)
3) Progressive strengthening and functional restoration (in conjunction with Physical
Therapy and Health Works), Multi-Modalities.
4) Medication in compliance with CDC recommendations
a. Establish treatment goals for pain and function
b. Consider how therapy will be discontinued if benefits do not outweigh risks
c. Continue opioid therapy only if clinically meaningful improvement in pain
and function outweighs safety risks
d. non-pharmacologic therapy and non-opioid therapy are preferred for
chronic pain
e. When using opioid therapy, combine with non-pharmacologic therapy and
non-opioid therapy as appropriate.
f. Review with patient risk/benefit and side effects of medications.
5) Pain Management Contracts – including random drug screening, functional
assessment, participation in functional restoration through physical therapy and
exercise, multi-modality interventions, pill counts at every appointment, attendance and
participation in all aspects of pain management, etc.
6) Violations to not adhering to pain management contract
a. Patient will be safely tapered off medication and referred to appropriate
resources, or discharged from practice if indicated.
b. Patient will be encouraged to continue with our practice for non-pain
management care, Injection therapy, multi-modality approach.
Criteria for referral to alternative resources.
a. Scope of care is beyond CDC guidelines for pain management (hospice, palliative care, addiction medicine)
b. Patient is not improving with prescribed therapies
c. Patient is a candidate for spinal injections/blocks
d. Patient requires specialty services (neuro-surgical, neurology, ortho)
e. Patient requires assistive equipment, home health, alternative therapy.
​
Criteria for long term Primary Care Pain Management:
1) All diagnostic studies are filed in EMR which support diagnosis of pain and type of pain
2) Addiction Assessment
3) Functional Capacity Assessment
4) Co-Morbidity Assessment
5) UDS compliance
6) Full participation in Physical Therapy/Exercise program/alternative modalities with documentable
improvements in functional status, multi-modality approach, referrals, etc.
7) No missed appointments for therapy or medical management, initial evaluation will be
followed up at frequent intervals of no longer than every 1 month.
8) PDMP consistency
9) Pill count consistency
10) Signed Pain Contract
11) Quarterly review of adherence, addiction and functional status as well as medication
side effects
12) Participation in smoking cessation, alcohol abuse treatment, substance abuse treatment
as determined in treatment plan
​
Consequences of Non-Adherence to full treatment plan, including appointment attendance.
< >Patient placed on UDS protocol, Taper medication if indicated Re-evaluation with peer to peer Counseling patient on attendance and or UDS/Med compliance. Pt will be safely weaned off of all controlled substances. No further scripts for controlled substances will be written by our practice.Practice Prescribing Policy
​
Our prescribing policies are aligned with the CDC guidelines for prescribing opioid medications.
1) Utilize non-pharmacologic therapies first
2) Manage co-morbidities with non-opioid, non-benzodiazepine medications.
3) When treating acute pain will only use opioid medications if the acute benefit out
weighs the risk of utilizing opioid medication.
4) For chronic pain, maximize non-opioid medications such as:
a. Tylenol/NSAIDS
b. Tricyclic anti-depressants
c. Gabapentin
d. Pregabalin
e. Etc.
5) Document clinically meaningful functional status at each appointment.
a. Annually complete comprehensive functional status assessment
c. Scores should improve by 30 % to be considered clinically significant
improvement in functional status.
6) Screen for addiction at every encounter for pain management
7) Review known risks of and realistic benefits of opioids at every appointment for pain
management.
b. The primary goal of our care is to restore function, not eliminate all pain
c. Fatal respiratory depression does occur
d. Potentially serious lifelong opioid use disorder leads to increase distress and
inability to fulfill major role obligations.
Common effects of opioids include
i. Constipation (prevention with increasing fluids, fiber and exercise)
ii. Dry mouth
iii. Nausea, vomiting
iv. Drowsiness
v. Confusion
vi. Tolerance
vii. Physical dependence
viii. Withdrawal symptoms
f. Driving or operating equipment while impaired is illegal
9) Prescribe lowest effective dose
10) After starting or increasing opioids re-evaluate in 1 to 4 weeks.
a. If benefit does not outweigh harm:
I. Optimize other therapies and work with patient to taper opioids to
lowest possible dose.
11) Plan strategies to mitigate risks of opioids.
12) Review MAPPs at initiation of opioid medication and at least every 1 months
13) Urine drug screen compliance and review.
14) Avoid prescribing opioids with benzodiazepines
15) Provide resources for opioid dependence disorder.
Practice
1. On a first new patient visit, no narcotics or other controlled substances will be
Prescribed.
2. Patients requiring chronic pain medications or long term-controlled substance therapy
must enter a written controlled substance contract and agree to use only one doctor or practice,
and only one pharmacy.
3. Urine drug screens may be requested at any time and are the financial responsibility of
the patient.
4. Chronic narcotic management requires individual visits to address the diagnosis and its
treatment independent of other medical problems. Usually this requires a dedicated
visit every 1 months or more often.
5. Patients found in violation of controlled substance contract will no longer be prescribed
narcotic medications and may be discharged from the practice.
UDS guidance
Patient review, each patient is unique in their diagnosis, situation and psychosocial consideration.
Ultimately up too the provider per their discretion, in alignment with Luminosity Health and Wellness.
Urine Drug Screens
< >No primary or no metabolite, or >1000 on primary with no metabolite with trending indicating shaving in cup or diversion. Consider Mouth swab for confirmation.
Counsel patient on proper use and indications of medication as they were prescribed.
Identify barriers to proper utilization
Warning of UDS protocol if continuation of Red Flag behavior.
Initiate UDS protocol for continued non-compliance.
7-day prescriptions for 3 weeks and weekly UDS.
<>Illicit drug use (one illicit drug identified in UDS)One illicit drug found in UDS.
Initiate UDS protocol to be completed for 3 weeks and clear and consistent UDS.
Consider referral to CBT.
7-day prescriptions for 3 weeks and weekly UDS.
Consider 25% reduction if patient has co-existing high-risk comorbidities or behavior health problems.
Referral for substance abuse.
<>Illicit Drug Use (more than 1 illicit drug identified)Consider
Mouth swab for confirmation.
Counsel patient on proper use and indications of medication as they were prescribed.
Identify barriers to proper utilization.
Initiate UDS protocol for non-compliance.
7-day prescriptions for 3 weeks and weekly.
UDS.25% reduction in prescribed therapy at provider discretion per risk profile.
Referral for substance abuse.
<>Illicit Drug Use (more than 2 illicit drugs identified)
Consider Mouth swab for confirmation.
Counsel patient on proper use and indications of medication as they were prescribed.
Identify barriers to proper utilization.
Initiate UDS protocol for non-compliance.
7-day prescriptions for 3 weeks and weekly.
UDS.25%-50% reduction in prescribed therapy at provider discretion per risk profile.
Referral for substance abuse
<>Benzodiazepine
New patient place patient on a taper protocol per CDC guidelines.
Established patient Consider UDS protocol per provider discretion.
Review board for Benzo indications and use with peer to peer.
UDS by # of drug screens.
< >Positive or negative UDS, Patients 1st UDS per protocol.
Continuation of protocol.
Consider 25% taper if patients UDS is still non-compliant.
Continuation of protocol.
Consider 25% taper if patients UDS remains non-compliant.
Re-evaluate patient and Consider 25% taper of medication.
Continuation of protocol.
Stop opioid therapy, counsel patient, explore alternative pain management, referral to specialty clinic (methadone clinic), Bring to board review peer to peer, If patient wishes to continue must complete at a minimum of 3 out of 3 consistent UDS before with established compliance and low risk behavior before considering continuation.