West Virginia Expert Pain Management Panel Safe & Effective Management of Pain (SEMP) Guidelines 2025

Prior to starting opioid therapy and periodically during the continuation of therapy, clinicians should evaluate risks for opioid-related harms and discuss risks with patients. Certain risk factors, such as sleep-disordered breathing, renal and hepatic insufficiency, age, mental health comorbidities, and several others, are likely to increase susceptibility to opioid-related harms and should also be routinely monitored. ¹² There are several screening tools with good predictive value that have been developed specifically to screen for risk of opioid misuse in the context of chronic pain treatment. Although more in-depth research on evidence may be needed ¹³, these tools may be useful in determining relative risk, in addition to the medical history.

1. Patients Being Considered for Opioid Therapy
   1. Opioid Risk Tool, OUD (ORT-OUD)* (Appendix 1.1)
   2. Drug Abuse Screening Test, DAST (Appendix 1.2)
   3. Diagnosis, Intractability, Risk, & Efficacy Score, DIRE (Appendix 1.3)
2. Patients Already Receiving Opioid Therapy
   1. Current Opioid Misuse Measure, COMM (Appendix 1.4)
   2. Pain Medication Questionnaire, PMQ (Appendix 1.5)
   3. Prescription Drug Use Questionnaire, PDUQ (Appendix 1.6)

 _{*Can be utilized for both patients being considered and already receiving opioid therapy}

The use of a risk screening tool ultimately aims to assist in selecting the safest treatment options for each patient. The higher the risk of opioid-related harms for any individual patient, the less appropriate the use of controlled substances is because of their habit-forming or abuse tendencies, and an increased need for counseling and monitoring the respective patient for the given risk factors.

Pharmacogenomics (PGx) is the study of the role of genetics in drug response. In general, there can be genetic variability in multiple physiological systems of the human body (i.e., hepatic enzymes, drug receptors, drug transport genes, etc.), resulting in altered drug responses. Three of the most common hepatic cytochrome P450 (CYP450) enzymes that have shown distinct differences in genetic variability are 2C9, 2C19, and 2D6. 2C9 substrates include pain medications such as ibuprofen and celecoxib, while 2C19 substrates include diazepam, and 2D6 substrates include codeine, dextromethorphan, tramadol, duloxetine, venlafaxine, and tricyclic antidepressants. A chart illustrating the PGx metabolic differences within the population is available in Appendix 2.0. ¹⁴

When available and appropriate to the treatment regimen, genetic testing can help better predict an appropriate response to a medication such as codeine or tramadol. A CYP2D6 poor metabolizer may not receive adequate analgesia from codeine or tramadol. In contrast, an ultra-rapid metabolizer may experience unnecessary side effects (or even overdose) because of having more of the active metabolites present. This scenario emphasizes the need to not only review a patient’s medication regimen for drug-drug interactions, but also drug-gene interactions if that information is available.

To best treat patients in pain with these types of medications, common pharmacogenetic tests can be performed on blood, saliva, or cheek swabs by multiple testing companies. Patients should be reminded of the special privacy protections for their personal genetic information under the Genetic Information & Nondiscrimination Act (GINA) of 2008. ¹⁵ Testing typically costs a few hundred dollars and may be covered by third-party payers. Pharmacogenetic medication dosage guidelines are available via the PharmGKB website at: www.pharmgkb.org.

In order to encourage and emphasize the importance of proper use of any pain medications, it is important to make sure that both the patient and the provider(s) have reviewed the realistic expectations of therapy (pain reduction and improved functional status). Establishing a “Patient and Provider Agreement” (also referred to as a patient contract) is an invaluable tool to ensure a mutual commitment from the patient and the provider(s) to achieve and maintain treatment goals, while also stating any reasons for agreement termination.

• Items to include in a Patient & Provider(s) Agreement (Appendix 3.0)
• Patient & Provider(s) Agreement Examples
  1. American Association for Pain Management, AAPM (Appendix 3.1)
  2. Pain.Edu, typical (Appendix 3.2)
  3. Pain.Edu, low-literacy (Appendix 3.3)
  4. Veterans Affairs, VA (Appendix 3.4)

Pain should be thoroughly evaluated before prescribing medications or other treatments. Successful treatment of chronic pain involves a long-term process of monitoring and adjusting treatment, as necessary. A patient’s functional status, including activities of daily living, is often severely affected by pain. Inadequate treatment can considerably affect a patient’s quality of life or cause them to display drug-seeking behaviors when they are only seeking relief from chronic pain.

Any S.M.A.R.T. Goals (Specific, Measurable, Attainable, Realistic, and Timely) have a foundation around being able to be measurable in accordance with time. Thus, when setting appropriate pain management goals with patients, a timely plan of action is required to achieve and maintain a reduction in pain. With the acute management of pain, it is recommended to develop an end-of-therapy goal for any pain management medication based on the expected time frame of the healing process. Pain may become chronic in some cases; however, for the management of acute pain syndromes (i.e., fractures, etc.), there should be an end-of-therapy goal for pharmacological management to prevent any unnecessary long-term issues (i.e., adverse effects, dependency, etc.) whenever possible. In chronic pain management, these goals may be more difficult since the resolution of the syndrome, or the elimination of pain, is not expected to occur.

Psychological distress commonly interferes with the improvement of pain and function; therefore, performing a psychological evaluation may help clinicians improve overall pain treatment. For example, depression and stress are significant risk factors for worsening pain, and both can change with alterations in life circumstances. Using appropriate tools allows for objective quantification of benefits with opioids, i.e., improvement in perceived disability, pain-related worry, mood, and pain reduction. In some settings, when a patient has co-morbid mental health conditions, medication may be optimized to treat both pain and mental health disorders, such as depression, and certain medications used in mental health disorders (such as benzodiazepines) should be avoided so as not to exacerbate adverse effects of their analgesic therapy. ¹² When treating both conditions, careful documentation should be noted during the evaluation process.

Currently, the PHQ-2 depression screening instrument (Appendix 5.1) is a commonly suggested screening tool for depression, which is followed up with the PHQ-9 depression screen (Appendix 5.2). The purpose of the PHQ-2 is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression as a “first step” approach. Patients who screen positive should be further evaluated with the PHQ-9 to determine whether they meet criteria for a depressive disorder. Another useful depression screening is the Beck Depression Inventory, which is provided in Appendix 5.3.

Healthcare professionals play a major role in educating patients, and that education is very important for the topic of proper medication storage and disposal. It is essential to educate patients to store medications in a secure location, out of the reach and sight of children and pets, and to put medicines away after each use. Even simple measures, such as ensuring the safety cap is locked, can help prevent accidents. Patients need to be educated that if an accidental ingestion does occur, one should contact the Poison Center (1-800-222-1222) immediately or dial 911 if a person is exhibiting signs of an overdose or having a seizure.

Remind patients to store their medications in a cool, dry area. Since heat and humidity can alter medications, a bathroom is not a suitable location to store medications. Patients should be encouraged to use lockable storage, such as a safe, cabinet, or drawer, when applicable. Patients should also be reminded to take only the number of doses needed when leaving home or traveling. Overall, there is a need to emphasize inaccessibility for anyone besides the intended patient.The FDA recommends that most prescription medications be returned through a DEA-sponsored Take-Back Program, a DEA-Authorized collector (https://www.deadiversion.usdoj.gov/pubdispsearch) or throwing away in household trash by removing medications from the original container and mixing with an undesirable substance (i.e., coffee grounds, dirt, etc.) in a sealable container or bag. For a small number of medications, the FDA recommends immediate removal from the home by flushing them down the toilet or sink (Appendix 6.0). To dispose of a drug patch, carefully remove it by the edges and avoid touching the used medicine pad; then fold the patch in half, sticky sides together.

Currently, the PHQ-2 depression screening instrument (Appendix 5.1) is a commonly suggested screening tool for depression, which is followed up with the PHQ-9 depression screen (Appendix 5.2). The purpose of the PHQ-2 is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression as a “first step” approach. Patients who screen positive should be further evaluated with the PHQ-9 to determine whether they meet criteria for a depressive disorder. Another useful depression screening is the Beck Depression Inventory, which is provided in Appendix 5.3.

Naloxone ¹⁸ and Nalmefene ¹⁹ are opioid reversal agents utilized for acute opiate overdose and are available for use in the United States. Both agents reverse respiratory depression associated with opioid overdose. Both agents act as competitive opioid receptor antagonists, thereby reversing the respiratory depression induced by opioids. When compared to naloxone, nalmefene has a longer duration of action and a higher affinity for opioid receptors. ²⁰ Naloxone was approved in March 2023 as an over-the-counter medication and is accessible to all.²³ If cost is a limiting factor to obtaining over-the-counter naloxone, it can be prescribed by a healthcare provider or via standing order at any pharmacy in West Virginia and billed to insurance. Naloxone is available in multiple formulations including a 0.4mg/ml injection, 0.4mg/ml auto-injection, 4mg/10ml injection, 2mg/2ml injection, 5mg/0.5ml injection, 0.4mg/ml pre-filled syringe, 2mg/2ml intranasal solution, 3 mg/0.1 ml nasal spray, 4mg/0.1ml nasal spray, 8mg/0.1ml nasal spray, 10mg/0.1ml nasal spray, and 4mg/0.25ml nasal spray. Nalmefene is available in a 1 mg/ml injection, as well as a 2.7mg/0.1ml intranasal solution. 

Naltrexone is another opioid antagonist available in the United States, but it is not indicated for opioid overdose reversal. The long-acting injectable formulation is utilized for the treatment of opioid use disorder, and is contraindicated in patients with current physiologic opioid dependence or currently receiving opioid analgesics. To avoid precipitated withdrawal, an opioid-free washout period of 7-10 days is strongly recommended; and for patients taking longer-acting opioids, 14 days may be necessary. See drug label information for additional contraindications, warnings, and precautions.

• Patient/family/friend candidates for being prescribed take-home opioid antagonists (Appendix 7.1)
• SAMHSA Naloxone Administration Guidelines (Appendix 7.2)

In March of 2016, at the request of the governor, the 2016 legislature passed Senate Bill 431, available online at www.legis.state.wv.us, authorizing licensed pharmacists or pharmacy interns (working under the guidance of licensed pharmacists) to dispense an opioid antagonist without a prescription (West Virginia Code §16-46-1, et seq.). ²¹ A pharmacist or pharmacy intern who dispenses an opioid antagonist without a prescription shall report the dispensing in the PDMP and provide patient counseling (mandatory which the patient may not opt out) to the individual for whom the opioid antagonist is dispensed regarding, but not limited to:

• Proper administration;
• Importance of contacting emergency services (i.e., calling 911) as soon as practicable, either before or after administering the opioid antagonist;
• Risks associated with failure to contact emergency services following administration of an opioid antagonist;
• Providing educational materials on opioid-related overdose prevention and treatment, and opioid antagonist administration (materials developed by the WV Board of Pharmacy).

For more information: http://stopoverdose.org/index.htm

For substance use disorder (addiction) and especially if one was in a scenario where naloxone was administered (whether personally, family, or friend), sources of help and education include:

• 1-844-HELP-4-WV (1-844-495-7498)
• SAMHSA Helpline: 1-800-662-4357 (1-800-662-HELP)
• Veterans Crisis Line: 1-800-273-8255, Option 1
• Narcotics Anonymous (Personal): 818-700-0700
• Nar-Anon (Family/Friends): 1-800-477-6291
• WV Medical Professionals Health Program (Health Professionals): 304-933-1030

Prescription drug monitoring programs (PDMPs), also known as Controlled Substance Monitoring Programs (CSMPs), must be fully utilized to reach their potential in controlling prescription drug abuse and diversion. All 50 states have some form of an operating PDMP; however, prescribers and dispensers are subject to different reporting requirements per state law. Based on data from national surveys and information, the best practices for any state in utilizing a PDMP ¹²:

• PDMP data should be reviewed before every initial opioid prescription for acute, subacute or chronic pain
• At a minimum, during long-term opioid therapy, PDMP data should be reviewed before an initial opioid prescription and then at least every 3 months or more frequent monitoring whenever practical should be considered.
• Clinicians should review PDMP data specifically for prescription opioids and other controlled medications patients have received from additional prescribers to determine whether a patient is receiving total opioid dosages or combinations (e.g., opioids combined with benzodiazepines) that put the patient at risk for overdose.
• PDMP-generated risk scores have not been validated against clinical outcomes such as overdose and should not take the place of clinical judgment.
• Clinicians should not dismiss patients from their practice based solely on PDMP information, as other physicians may be working at the same practice or providing coverage during a physician’s absence. Doing so can adversely affect patient safety and could result in missed opportunities to provide potentially lifesaving information (e.g., about risks of prescription opioids and overdose prevention) and interventions (e.g., safer prescriptions, nonopioid pain treatment, and effective treatment for substance use disorders.
• Consider the total MME/day for concurrent opioid prescriptions to help assess the patient’s overdose risk. In the context of medications for opioid use disorder (MOUD), buprenorphine should not be counted in the total MME/day in calculations because of its partial agonist properties at opioid receptors that confer a ceiling effect on respiratory depression.  However, in the context of pain management, buprenorphine can require calculations of MME (see Morphine Milligram Equivalents MMEs Special Considerations: Methadone and Buprenorphine for Pain Management Handout for additional information). If a patient is found to be receiving total daily dosages of opioids that put them at risk for overdose, discuss safety concerns with the patient, consider, in collaboration with the patient, whether or not the benefits of tapering outweigh the risks of tapering, and offer naloxone.
• Discuss safety concerns with other clinicians who are prescribing controlled substances for the patient. Ideally, clinicians should first discuss concerns with the patient and inform them that they plan to coordinate care with their other clinicians to improve the patient’s safety.
• Screen for substance use and discuss concerns with the patient in a nonjudgmental manner.
• When diverting (sharing or selling prescription opioids and not taking them) might be likely, consider toxicology testing to assist in determining whether prescription opioids can be discontinued without causing withdrawal. A negative toxicology test for prescribed opioids might indicate the patient is not taking prescribed opioids. However, clinicians should consider other reasons for this test result (e.g., false-negative results or misinterpretation of results).

West Virginia code regarding the mandatory use of the PDMP is provided in Appendix 8.0 and is available online at www.legis.state.wv.us. In summary, all licensees who dispense Schedule II, III, and IV controlled substances to residents of WV must provide the dispensing information to the WV Board of Pharmacy (BOP) at least every 24 hours. All licensed prescribers must check the PDMP at the initiation of opioid therapy and at a minimum of every year thereafter. A physician working in a licensed pain management clinic must check the PDMP at the initiation of the controlled substance therapy and at a minimum of every 90 days thereafter. ²² 

The West Virginia Controlled Substance Monitoring Program (CSMP) is available at: www.csapp.wv.gov/Account/Login.aspx

Urine drug screening/testing is important in the monitoring of compliance with prescribed medications and detecting the use of illicit substances. All healthcare professionals need the most up-to-date and comprehensive medication information (i.e., prescription medications, over-the-counter medications, herbals, supplements, illicit substances, etc.) to improve a patient’s longevity and quality of life. The timing of the urine drug screening/testing needs to be in line with the results available before or at the point of treatment decisions.

• Alternative Drug Screening Methods (Appendix 9.1)
• Urine Drug Screening vs. Testing (Appendix 9.2)
• Frequency of Screening/Testing (Appendix 9.3)
• Urine Toxicology Detection Periods (Appendix 9.4)
• Urine Drug Cross-reactants (Appendix 9.5)
• Urine Drug Results (Appendix 9.6)

Consequences of Unintended Urine Drug Screening/Testing Results

It is important to note that urine drug tests do not provide information on how much or what doses of opioids were taken. If there are unintended urine drug screening or testing results, a careful reassessment of the treatment plan must be completed. A patient’s failure to adhere to the patient and provider agreement is not necessarily proof of abuse or diversion because it may be a result of inadequate pain relief, confusion regarding the prescription(s), a language barrier, or economic concerns. If uncertainty exists regarding the nature of the unintended result, the provider(s) may consider arranging for an in-person meeting in order to have a non-judgmental conversation to clarify the patient’s actions and concerns. If abuse or diversion is confirmed, treatment can continue with alternative therapies and consultation with a substance use disorder (addiction) specialist or psychiatrist and/or referral to a substance use disorder treatment program and/or law enforcement (if concern for the safety of others exists) should be considered.

Randomized and/or scheduled Pill Counts are one way of attempting to improve proper medication adherence and prevent and/or detect medication diversion. Any patient who refuses to provide their medication for a random or scheduled pill count can be considered for discontinuation of that particular or any controlled substance or non-scheduled medication(s) while continuing treatment with alternative therapies. It is recommended to schedule any appointment-based pill counts (and the appointment itself) within a minimum of 3 to 5 days of when the current prescription will run out of supply or refills.

• Process [One staff person will be assigned to ²³]
  1. Bring the patient to a private area of the clinic
  2. Ensure that a staff person is present to witness this procedure
  3. Request that the patient submit their medication to be counted and/or examined
  4. Receive the medication from the patient
  5. Count the medication on a clean flat surface using sterile gloves or equipment.
  6. Examine the color, shape and imprint of the tablet to ensure the medication is the same as prescribed. 
     1. If the medication is a capsule, the staff person shall examine the content of at least two capsules to ensure that the content has not been substituted. 
     2. If the color, shape, or imprint is questionable or the staff does not recognize the medication, the staff person shall verify the color, shape, and imprint of the tablet or capsule through a reputable pill identification resource or against the description on the prescription bottle, if available.
  7. Document the requested pill count, outcome, and witness’s name in the patient’s record.
  8. Advise the provider(s) of the outcome of the pill count.

Special Scenarios

Providers who are advised by their patient that the medication was lost, destroyed, or stolen shall: ²³

• Instruct the patient to better secure their medication in the future.
• (If lost in fire) Retain a copy of any fire report (reflecting that a fire occurred) to be placed in the patient’s medical record.
• (If stolen) Retain a copy of any law enforcement report (reflecting the theft) to be placed in the patient’s medical record.
• Replacement of lost or stolen medication is at the discretion of the provider and/or based upon the patient & provider(s) agreement.

Healthcare professionals have an ethical and legal obligation to both prevent prescription drugs from being diverted to nonmedical uses and to ensure patients receive safe and effective care involving healthcare professionals practicing in the usual course of their professional practice and treating a patient’s legitimate medical condition. The National Opioid Settlement expanded upon previous guidance from the US DEA about “Red Flags” to watch out for as healthcare professionals to ensure a comprehensive care plan is in place. It is essential to note that a Red Flag does not render the prescription illegitimate, but rather indicates a need for resolution of the Red Flag prior to the patient receiving the medication. ²⁴

• Patient
  1. Controlled Substance (CS) two occasions where refills too soon by >3 days
  2. Doctor Shopping
  3. Prescriber has >10 documented CS refusals within 6 months
  4. Three previous other CS from multiple prescribers with overlapping days within 30 days
  5. Distance between patient’s residence and pharmacy >50 miles
  6. Distance between patient’s residence and prescriber >100 miles
  7. Two previous CS refusals within 30 days
  8. Cash pay despite having prescription insurance coverage
  9. Three or more patients appear together for the same CS
  10. Slang term medication request
  11. Patient appears visibly altered, intoxicated, or incoherent.
• Prescriber
  1. Prescriber utilizes preprinted or stamped prescription pads
  2. Prescriber has no office within 50 miles of pharmacy
  3. Prescription written for controlled substance class II + Benzodiazepine + Carisoprodol
• Prescription
  1. Fails to meet legal requirements of a prescription
  2. Misspellings
  3. Atypical abbreviations
  4. Multiple colors of ink or handwritings

Additionally, the Board of Pharmacy runs reports to identify abnormal prescribing. If a prescriber is among the top 5% in 4 of the 5 categories below, they are flagged as abnormal prescribers. The Board reviews the report and identifies prescribers who are prescribing abnormally, and these prescribers are then referred to their respective boards of medicine.

• Indicators for outliers:
  1. Number of CII opioids prescribed
  2. Average MME per prescription
  3. Total MME prescribed in the quarter
  4. Overlapping opioid and benzodiazepine prescriptions
  5. Total opioid patients

• Nociceptive Pain
  • General Description:
    • Pain arising from noxious stimuli affecting thermal, mechanical, or chemical receptors (nociceptors) in normal tissues.
  • General Examples:
    • Arthritis, mechanical lower back pain, post-operative pain, sports/exercise injury, etc.
  • Somatic Nociceptive Pain
    • Description: Outer organs, body walls, & limbs (bone/joints/muscle/skin) producing aching or throbbing, and is well localized.
    • Examples: Ankle sprain, incisional pain, etc.
  • Visceral Nociceptive Pain
    • Description: Internal organs; all thoraco-abdominal organs
    • Examples: Localized tumor or hollow viscus, IBS, myocardial infarction, etc.
• Neuropathic Pain
  • General Description:
    • Abnormal processing of sensory input by the Central Nervous System (CNS) and/or Peripheral Nervous System (PNS)
  • General Examples:
    • Neuropathic Lower back pain, etc.
  • Central Neuropathic Pain
    • Deafferentation
      • Injury to either the CNS or the PNS
      • Phantom pain (PNS) & burning pain below spinal cord injury/lesion (CNS)
    • Sympathetic
      • Dysregulation of the autonomic nervous system
      • Complex Regional Pain Syndromes (CRPS)
  • Peripheral Neuropathic Pain
    • Polyneuropathies
      • Pain is felt along the distribution of many peripheral nerves
      • Diabetic neuropathy, post-herpetic neuralgia, Guillain-Barre Syndrome pains, or alcohol-nutritional neuropathy
    • Mononeuropathies
      • Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the damaged nerve
      • Nerve root compression, nerve entrapment, trigeminal neuralgia
• Mixed Pain
  • General Description:
    • Combination of nociceptive and neuropathic pains
  • General Examples:
    • Fibromyalgia, headache, lower back pain, myofascial pain syndrome, or skeletal muscle pain, etc.

The following clinical pain management treatment algorithms intend to provide the best course of action for progression through escalating levels of pain management. These algorithms are intended to be used in conjunction with the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain. ¹² Not every single entity must be attempted to progress to the next level, as every patient is unique; however, attempts to reduce a patient’s pain and improve their daily function should follow the recommended treatment algorithm as closely as possible to provide the safest and most effective pain management for every patient. For instance, not every non-pharmacological treatment option must be attempted before progressing forward within each clinical treatment algorithm. However, a reasonable attempt should be made to try as many of the earliest treatment algorithm options as possible before progressing further. Whether considering or absolutely referring to a pain management specialist, the American Board of Anesthesiology (ABA), American Board of Pain Medicine (ABPM), or the American Board of Interventional Pain Physicians (ABIPP) have established and distinguished certifications.

• Non-Pharmacologic Treatment Options (Appendix 10.0)
  • Active & Passive Therapies
• Pharmacologic Treatment Options (Appendix 11.0)
  • Non-Opioids, Opioids, & Herbals and Supplements