VCU Internal Medicine Training Program
Chronic Pain Management

To all Resident primary care clinic providers (faculty and residents)—

We have established a new protocol for our chronic narcotic management plan. The protocol is outlined below. Note that it includes the following:

• Requirement to renew all contracts—starting March 3, 2008
• Ability to prescribe serial narcotic prescriptions (detailed instructions
  below)
• Requirement to enter ALL narcotic prescriptions into CERNER - to be printed on watermark paper now available on script printer in ACC workroom (ac02x279h2)
• New systematic monitoring of this patient population in clinic

Please read the attached handouts carefully and the step-by-step instructions outlined below by Andrew Poklepovic for writing serial narcotic prescriptions. Handouts include - new protocol (SOP), institutional contract, new opioid medication tracking sheet.

This protocol goes into effect on March 3rd, 2008. Any questions should be directed to or

Thank you to the clinic leadership team and clinic task force for making this happen!

—Stephanie Call

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Step by step process for initial narcotic prescriptions

• Go to easyscript and using the search field, select the narcotic you want.
• Adjust the Sig and Dosing schedule as you would for any other Rx.
• Change the Rx duration to 28 days (must free type "28 days" — it is not a default selection).
• Ensure that you have the correct number of pills- these are automatically calculated based on the dosing schedule and the Rx duration- If you want more or less you need to manually adjust.
• Ensure that you have selected the proper printer (ac02x279h2) using the hyperlink at the bottom of the script (as seen in the "How to Print in the ACC Clinic" attachment)
• Ensure that the "print DEA" checkbox has been printed.

Step by step process for narcotic prescriptions refills

• For the first refill, double click on the same narcotic you selected for the first script from the search field on the left hand side.
• This brings up a second Rx without altering the first one you made.
• Complete all fields as described above for the first script
• Click on the "Rx Date" field, this brings up a tab with an upside-down triangle next to the date.
• Click on this tab, bringing up the clickable calendar.
• Navigate through the calendar for 4 weeks from the date of the initial Rx. The stop date for the Rx will automatically be calculated.
• Under the "Comment" section, type "Do not fill before '___month, __day, __year' "
  By typing this into the comment field, it allows the comment to be viewed in the Rx list at the bottom of the screen, by holding the mouse cursor over the paperclip symbol.
• Repeat this same process for the second refill.

When the Rxs are printed, they will show the comment field with the "Do not fill..." portion of it.
The date that the script was printed is shown on the top right hand corner of the script, the date the Rx was ordered appears at the top left hand corner of the script. The Rx date and stop date fields that you filled out on the easyscript page do not appear, they are for Cerner and the medication profile.

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Pain Management Forms & Resources

• Tables for Urine Drug Test Interpretation
  • Interpretation of Screening Urine Drug Test (pdf)
  • Interpretation of Comprehensive Urine Drug Test (pdf)
  • Interpretation of Urine Drug Test Based on Opioid Prescribed (pdf)
• VCU School of Medicine Pain Education
• Standard Operating Procedure for Chronic Pain Patients (pdf)
• Patient Agreement for Controlled Substances Prescriptions (pdf)
• Pain Drug List For Urine Toxicology Screening (pdf)
• Pain Management Medication Flow sheet (pdf)
• Pain Management Referral Form (pdf)
• How to Print in the ACC Clinic (pdf)

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