Oklahoma Prescription Monitoring Program Pocket Book For Prescribers

A POCKET BOOK GUIDE FOR PRESCRIBERS

METHODS FOR SAFER PRESCRIBING IN TRIBAL COMMUNITIES IN OKLAHOMA

AUTHOR NOTE

This publication was made possible through a grant from the Center for State, Tribal, Local, Territorial Support grant, which is housed within the Center of Disease Control, to the Southern Plains Tribal Health Board under cooperative agreement NU38OT000265. The content of this document is the responsibility of the author and does not necessarily represent the official position of the CDC.

Correspondence concerning this publication should be addressed to Casey Ward-Freeman.

CONTENTS

1. Chronic Pain Management Guidelines

a. The Treatment Team

b. CDC’s Opioid Prescribing Guidelines Applied to Native Communities

c. Multidisciplinary Pain Management

i. Treatment Alternatives to Opioids for Native Patients

ii. Treating Patients in Recovery

2. Laws and Policies of Safer Opioid Prescribing for Non-palliative Care

Address

9705 S Broadway Ext, Suite 200, Oklahoma City, OK 73114 Email cward-freeman@spthb.org

a. Oklahoma State Laws and Policies

b. Indian Health Service Policies

3. Detecting Substance Use Disorders

4. Thank You

5. Resources

6. References

A POCKET BOOK GUIDE FOR PRESCRIBERS

1

Chronic Pain Management Guidelines

Section 1: Chronic Pain Management Guidelines

Please note that these guidelines should not replace the provider’s clinical judgment about the care of individual patients.

Chronic pain is any pain that lasts for over 3 months. The pain can persist, or it may come and go. Chronic pain often interferes with daily activities. It can lead to depression, anxiety, and trouble sleeping, which can make the pain worse.

Chronic pain is one of the most common reasons adults seek medical care in the United States, and American Indian/Alaska Native patients are 3 times more likely to experience chronic pain than non-Hispanic Whites (Dahlhamer et al., 2016; Ross et al., 2019). The treatment of chronic pain should be individualized, patient-centered, and focused on meeting functional goals.

THE TREATMENT TEAM

Chronic pain management is often complex and time consuming. It can be particularly challenging and stressful for clinicians

working without input from other clinicians, and treatment is more effective when the medical and behavioral health care professionals collaborate (Center for Substance Abuse Treatment, 2012).

A multidisciplinary team approach provides many perspectives and skills that can enhance outcomes and reduce the stress on individual providers. Although having all relevant providers work within the same system and under the same roof is ideal, a collaborative team often must be coordinated across a community. This combined effort requires the identification of a designated lead care coordinator and a good system of communication between team members and the patient.

A treatment team comprises a combination of two or more professionals according to the primary care provider’s discretion and the patient’s unique needs and may include any of the following:

+ Primary care provider

+ Addiction specialist

+ Pain clinician

+ Nurse

+ Pharmacist

+ Psychiatrist

+ Psychologist

+ Other behavioral health treatment specialists (e.g., peer support specialist, social worker, marriage and family therapist, counselor)

+ Physical or occupational therapists

Addiction specialists can make significant contributions to the management of chronic pain in patients who have Substance Use Disorders (SUDs). They can do the following:

+ Put safeguards in place to help patients take opioids appropriately.

+ Reinforce behavioral and self-care components of pain management.

+ Work with patients to reduce stress.

+ Assess patients’ recovery support systems.

+ Identify relapse.

CDC’S OPIOID PRESCRIBING GUIDELINES APPLIED TO NATIVE COMMUNITIES

The CDC has released guidelines for prescribing opioids safely. The full guidelines may be accessed through the Resources section of this pocketbook. A quick overview is provided below, with a few additional considerations for Native communities. Please note that cancer patients, sickle cell patients, and other palliative care patients are largely exempt from these guidelines.

Before prescribing opioids, providers should do the following:

+ Consider that patients may feel pain reflected through social and spiritual qualities. Native patients may feel that their pain cannot be adequately reflected in a number or fixed pain descriptor (Jimenez et al., 2011). Listen to the patient’s story. Practicing active listening during the patient’s story increases connection and aids with associating a number or descriptor.

+ Consider how mental health is impacting pain. Providers should give all patients baseline and intermittent depression and anxiety screenings. Mental health challenges can make painful conditions worse (de Heer et al., 2014; Murez, 2021).

+ Use nonjudgmental language when talking to patients. Some patients may worry about facing judgment for their pain (Duwe, 2019). Racial bias in pain management has been documented; Black patients are less likely than White patients to receive pain medication (Trawalter, 2020). This disparity is particularly pronounced when the patient has a subjective condition such as low back pain or migraines instead of an objective injury (e.g., compound fracture; Tamayo-Sarver et al., 2003). These disparities may exist because of false beliefs about Black people’s pain tolerance and due to racist bias that they are more likely to be drug seeking (Warraich, 2020). Native American patients may be experiencing the same disparities. As Duwe (2019) noted, Native chronic pain patients feel that stereotypes

about Native American stoicism can affect behavior. One patient said, “[Because of stereotypes,] I don’t look like I’m in pain. I look strong because I try to look strong. I don’t want to be looking all bent over and pitiful like I can’t, that I’m weak” (Duwe, 2019). A Native woman reflected on her pain by saying, “I think there’s kind of an expectation that we’re going to handle it and keep going” (Duwe, 2019). Using nonjudgmental language will help foster an open and trusting patient–provider relationship in which patients receive the best care possible.

+ Remember that nonpharmacologic and nonopioid therapies are preferred. If opioids are needed, combine their use with nonpharmacologic and nonopioid therapies (Dowell et al., 2016). Talk to the patient about their relationship with traditional healing and consider drug interactions.

+ Consider the benefits and risk of opioids for the patient. Discuss options for pain management with the patient and when appropriate, key family

members. Treatment decisions should be based on shared decision-making. Consider opioids only if the benefits for pain and function outweigh the risks to the patient (Dowell et al., 2016). The Opioid Risk Tool (Figure 1) is indicated in primary care settings to assess risks for opioid abuse among individuals prescribed opioids for chronic pain. The assessment takes less than 1 minute to administer. The tool is also listed in the Resources section of this pocketbook.

Opioid Risk Tool: A survey to assess risk of opioid abuse

Note. This questionnaire was developed to assess the risk of opioid addiction. “Predicting Aberrant Behaviors in Opioid-Treated Patients: Preliminary Validation of the Opioid Risk Tool,” by L. R. Webster and R. Webster, 2005, Pain Medicine Journal, 6(6), p. 432.

This tool should be administered to patients upon an initial visit prior to beginning opioid therapy for pain management. A score of 3 or lower indicates low risk

for future opioid abuse, a score of 4 to 7 indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse.

Mark each box that applies

Family history of substance abuse

Alcohol Illegal drugs

Rx drugs

Personal history of substance abuse

Alcohol Illegal drugs

Rx drugs

Age between 16-45 years

History of peradolescent sexual abuse

Psychological disease

ADD, OCD, bipolar, schizophrenia

Depression

Scoring totals

Establish treatment goals before starting opioids (e.g., realistic goals for pain and functions). Include realistic goals for pain and function and determine how the opioid therapy will be discontinued if the benefits do not outweigh the risks (Dowell et al., 2016). The chart in Figure 2 can be used to facilitate these conversations.

Functional Goals for Chronic Pain Treatment

Note. Adapted from “Functional Goals,” by American Association of Family Physicians, n.d., Chronic Pain Management Toolkit, Section 2, p. 16.

Functional Goals for Chronic Pain Treatment

Adapted from “Functional Goals,” by American Association of Family Physicians, n.d., Chronic Pain Management Toolkit, Section 2, p. 16.

What activities are limited due to pain?

LIMITED ACTION

walking exercise sleep

sexual activity work house work community responsibilities

family and friend relationships

self-care (bathing, dressing, eating)

cultural activities

caretaking other: _______________________

What activities are most important?

Write them here...

GOAL

Provider and patient can complete the action plan together:

TREATMENT PLAN

OPIOID SELECTION, DOSAGE, AND DURATION

(Dowell et al., 2016)

+ Immediate-release opioids are preferred to extendedrelease or long-acting opioids.

+ Prescribe the lowesteffective dosage.

+ Prescribe no greater quantity than needed. Three or fewer days is often sufficient; more than 7 days is rarely needed to manage acute pain.

+ Carefully reassess individual benefits and risks when considering increasing dosage to over 50 MME/day.

+ Avoid doses greater than 50 MME/day or carefully justify any decision to titrate the dosage to over 90 MME/day.

+ Prescribe naloxone for chronic pain patients and for patients at high risk of opioid overdose (see Figure 3).

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Note. Flyer available at https://www. spthb.org/resources/publications/.

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DURING OPIOID THERAPY: ASSESS HARMS, FOLLOW-UP, AND DISCONTINUATION

(Dowell et al., 2016)

+ Evaluate benefits and harms within 1–4 weeks of starting opioid therapy. Continue to reevaluate the opioid therapy at least every 3 months. Evaluate patients with higher risk of opioid use disorder more often.

+ Urine drug testing is recommended when initiating opioid therapy and at least annually for all patients on long-term pain therapy.

When discussing urine drug testing, be empathetic and focus on patient safety. If a urine drug test is abnormal, before making a treatment decision, remember to consider what the patient is reporting and order confirmation testing. False positives with point-of-care urine drug screening can be common and must be confirmed with gas chromatography–mass spectrometry testing (Yu, 2015).

+ Continue therapy only if there is clinically meaningful improvement in pain and function that outweighs the risks to patient safety.

+ All patients should receive baseline and intermittent depression and anxiety screenings. Patients with pain and behavioral health comorbidities face challenges that can exacerbate painful conditions (de Heer et al., 2014; Murez, 2021).

+ When opioid therapy needs to discontinue, but no illicit drug use or abuse has been confirmed, taper the opioids slowly to minimize symptoms and signs of opioid withdrawal.

+ If illicit drug use or prescription abuse is confirmed, strongly consider a referral to an addiction or pain management specialist. Prescribing should be discontinued.

MULTIDISCIPLINARY PAIN MANAGEMENT Treatment Alternatives to Opioids for Native Patients

Native patients may experience and manage their pain differently than those in the dominant culture. Native patients have reported dissatisfaction with standard pain scales and questionnaires; pain often encompasses social and

“For Native patients...pain often encompasses social and spiritual qualities that cannot be reflected through a number on a pain scale.”

spiritual qualities that cannot be reflected through a number on a pain scale (Jimenez et al., 2011). Improving trust and communication is an important step in improving pain management for Native patients. Therefore, providers should consider nonopioid treatment paths when managing pain in Native patients (see Table 1). A few things to consider are listed in the sections below.

MEDICATIONS.

The goal is to limit adverse outcomes while ensuring patients have access to medication-based treatment that can enable a better quality of life and function. The choice of medication should be based on the pain diagnosis, the pain mechanisms, and any related comorbidities following a thorough history, physical exam, other relevant diagnostic procedures, and a risk–benefit assessment that demonstrates the benefits of a medication outweighs its risks (Dowell et al., 2016).

LIST OF NONOPIOID MEDICATIONS THAT CAN BE USED TO TREAT PAIN:

+ Acetaminophen

+ Anticonvulsants

+ Nonsteroidal antiinflammatory drugs

+ Topical agents

+ Tricyclic antidepressants

+ Serotonin–norepinephrine reuptake inhibitors

Note. This list is not all-inclusive or prescriptive.

NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT

Treatment approaches that incorporate psychological, social, and cultural interventions along with physical interventions are more effective for reducing longterm pain and disability compared with usual care or physical therapy alone (Dowell et al., 2016).

+ Restorative therapies: Practices implemented by physical therapists and occupational therapists (e.g.,

physiotherapy, therapeutic exercise, and other movement modalities), chiropractic care, and osteopathic manipulative therapies are valuable components of multidisciplinary, multimodal acute and chronic pain care (Dowell et al., 2016).

+ Interventional approaches: Interventional approaches including image-guided and

minimally invasive procedures are available as diagnostic and therapeutic treatment modalities for acute, acute on chronic, and chronic pain when clinically indicated. The various types of these procedures include trigger point injections, radiofrequency ablation, cryoneuroablation, neuromodulation (Mukund et al., 2019).

+ Behavioral health approaches: Psychological, cognitive, emotional, behavioral, and social aspects of pain can have significant effects on treatment outcomes.

+ Complementary and integrative health: Treatment modalities such as acupuncture, massage, movement therapies (e.g., yoga, tai chi), and spirituality should be considered when clinically indicated. (Jimenez et al., 2011)

+ Spiritual aspects: Spiritual aspects of care are an important part of Native American patients’ healing practices. Respectfully talk to the patient about their relationship to traditional healing (see Table 2). Be open and nonjudgmental. Cultural connections can bring peace and healing (Duwe, 2019).

TIPS FOR TALKING TO PATIENTS ABOUT THEIR USE OF TRADITIONAL HEALING TECHNIQUES

+ Use a patient-centered approach.

+ Ask permission to ask more about culture and beliefs.

+ Take cues from the patient on their comfort level.

+ Consult with others and maintain education.

+ Include culturally relevant questions in patient intake questionnaire.

+ Be nonjudgmental.

+ Allow plenty of time for discussion or storytelling.

+ Try to use the language that the patients uses.

+ Be open with the patient about the limited knowledge of traditional healing techniques.

+ Thank the patient for sharing their experiences.

TREATING PATIENTS IN RECOVERY

The provider may consider referring a patient in recovery to an addiction specialist for assistance with treatment. However, this may not always be feasible due to rural locations or provider shortages. When an addiction specialist is the prescriber of analgesics, medical responsibilities (e.g., prescribing of analgesics, physical therapy, orthotics) should be coordinated with the clinician responsible for other components of the pain treatment (Center for Substance Abuse Treatment, 2012). Goals for treating chronic pain in patients who are in recovery are as follows:

+ Include the patient in conversations around the treatment plan. Use language that focuses on health and safety. Avoid judgment and stigmatization. Motivational interviewing skills can be useful here. More information about motivational interviewing is listed in the Resources section.

+ Treat chronic, noncancer pain with nonopioid analgesics as determined by pathophysiology.

+ Recommend or prescribe nonpharmacological therapies (e.g., cognitive–behavioral therapy [CBT], exercises to decrease pain and improve function).

+ Treat comorbidities.

+ Initiate opioid therapy only if the potential benefits outweigh the risks and only for as long as is unequivocally beneficial to the patient. Educate patients on the risk of opioid dependence, overdose, and death as well as on the safe storage of medication.

+ Assess treatment outcomes.

In addition, use of the Oklahoma Prescription Monitoring Program (PMP) is advised when treating patients. The PMP is discussed in more detail in Section 2.

A POCKET BOOK GUIDE FOR PRESCRIBERS

Prescribing for Non-Palliative Care

Laws & Policies of Safer Opiod

Section 2: Laws and Policies of Safer Opioid Prescribing for Nonpalliative Care

Oklahoma State Laws and Policies

Tribal providers can take state laws and policies into consideration when assessing best-practice techniques and common prescribing practices throughout the state. Therefore, Oklahoma State Law states the following:

+ Naloxone can be prescribed to a patient at risk of opioid overdose. It can also be prescribed to their caregiver. A pharmacist can also dispense naloxone without a prescription. It is highly recommended to be prescribed alongside chronic opioid prescriptions.

+ Electronic prescribing should be utilized for all controlled substances in Schedules II–V (63 OK Stat § 63-2-309, 2020).

+ Prescribers (or their designated delegates) should check the

patient’s PMP report before initially prescribing controlled medications. The PMP can help providers recognize substance use disorders and concerning behaviors or identify other prescription medications being taken. The PMP can help note the following concerns:

◦ early refills

◦ multiple providers

◦ multiple prescriptions

◦ forged or altered prescriptions

◦ an extended duration (i.e., over 7 days) opioid prescription for acute pain

◦ risky medication combinations (e.g., overlapping benzodiazepine and opioid prescriptions)

+ When the patient is using controlled medications long-

term, prescribers should check the patient’s PMP report every 180 days. Checking the PMP more often than every 180 days is suggested (Oklahoma Prescription Monitoring Program, 2019).

+ For acute pain, prescribers should not issue an initial prescription for an opioid drug in a quantity exceeding a 7-day supply.

◦ After consultation, a second 7-day prescription may be issued if it is deemed necessary and appropriate. The second prescription can be issued on the same day under some circumstances (63 OK Stat § 63-2-309I, 2020).

◦ The prescription should be for the lowest effective dose of an immediate-release opioid drug and must state “acute pain” on the face of the prescription (63 OK Stat § 63-2-309I, 2020).

+ 63 OK Stat § 63-2-309I (2020) also stated that for chronic pain (i.e., 3 months or more of treatment), the prescriber should do the following:

◦ state “chronic pain” on the face of the prescription.

◦ review the course and effectiveness of treatment every 3 months

◦ evaluate the patient for signs of dependency before every prescription renewal and document the assessment.

◦ periodically make reasonable efforts, unless clinically contraindicated, to stop, decrease the dosage, or try other treatment modalities.

◦ monitor compliance with a patient–provider agreement. After 1 year of compliance with the patient–provider agreement, the physician may review the treatment plan and assess the patient at 6-month intervals. More information about Oklahoma state laws are listed in the Resources section.

INDIAN HEALTH SERVICE POLICIES

The Indian Health Service (IHS) has published policies covering opioid prescriptions, naloxone, and the PMP. The IHS (n.d.) stated that safe opioid prescribing “relies on the knowledge and skills of clinicians, complies with state and federal statues, and fulfills responsibilities to patients, communities, and licensing authorities”. Additionally, the IHS stated that health care providers should consider prescribing naloxone when a patient is at a high risk of opioid overdose or when the patient and/ or caregiver asks for it (IHS, n.d.). Below are specific guidelines for prescribers the IHS has released regarding the PMP (as stated in the Indian Health Manual).

+ Prescribers should register with their state’s PMP.

+ When accepting a new patient, clinicians should review the patient’s PMP report and should access PMP patient data prior to the appointment.

+ Health care providers should check the PMP before prescribing any Schedule II–V controlled medication.

+ PMP data should be reviewed when a patient is transitioning from acute to chronic opioid pain therapy and periodically during opioid therapy for chronic pain.

A POCKET BOOK GUIDE FOR PRESCRIBERS

3

Use Disorders

Detecting Substance

Section 3: Detecting Substance Use Disorders

Lessons From Trickster

“In many Tribal oral traditions Trickster is a scared, yet crafty being who manipulates and cheats others” (Tribal Opioid Response, 2020). Stories of Trickster are shared to teach important lessons about living in balance, respecting medicines, and remaining humble. Some describe Trickster as a coyote, whereas others say he is an old man or raven. Opioid misuse can be framed around Trickster. People can misuse medicines that were intended to heal. “We can imagine that there is a Trickster spirit guiding this transformation of medicine from a helpful healing tool to a harmful burden” (Tribal Opioid Response, 2020).

A provider may consider certain risk factors for addiction when treating patients who are experiencing chronic or acute pain. These risk factors can help inform treatment decisions and effectively address the patient’s

pain. A few factors are associated with an increased risk of addiction:

+ family history: A person who has a family member who combats an addiction or who has a running family history of alcoholism or substance use disorders has an increased risk of developing an addiction in their own life (Center for Substance Abuse Treatment, 2012)

+ environmental factors: People who have experienced physical, emotional, or sexual abuse or trauma are more likely to develop substance use disorders. Others who have friends who use or those subjected to peer pressure may also be at a greater risk (SAMHSA, 2019).

+ preexisting mental health conditions: People with existing mental health conditions such as depression, PTSD, and ADHD are also more likely to develop substance use disorders as a way of coping with the emotions and anxieties these disorders can cause (SAMHSA, 2019).

As discussed previously, providers should work with chronic pain patients to evaluate the

effectiveness and harm of the treatment plan. One step in the evaluation is assessing patients for substance use disorders or risky behaviors. The PMP and the chart in Figure 4 can help with the detection of substance use disorders.

Figure 4 (turn page)

Clinical tool for recognizing substance use disorders

Note. Adapted from “Screening and Assessment Tools Chart” by National Institute of Drug Abuse, n.d., Clinical Opiate Withdrawal Scale, Appendix 1.

Identifying these factors can help enhance patient safety and lead to better health outcomes. For providers who are concerned about a patient, the Resources section contains links to guidelines, tools, and organizations that can help inform their next steps. Remember, exercising compassion and avoiding stigmatizing language are critical.

Recognizing Substance Use Disorder

Please circle a number at the end of each question.

Question

Has the patient developed withdrawl symptoms, which can be relieved by tak ing more of the drug?

Has the patient had changes in their daily activity?

Find the sum of the numbers for each question. If the patient has a score of 15 or more, this is a time to have a fur ther conversation with the patient.

Has the patient recognized changes in their eating and/or sleeping habits?

Has the patient had “blackouts” or “ ashbacks” as a result of tak ing a prescription drug?

Does the patient ever feel bad or guilty about their drug use?

O ther areas of strength:

Suggestions for improvements:

A POCKET BOOK GUIDE FOR PRESCRIBERS

Thank You

Native Americans have a higher rate of death from opioid-related overdoses than the national average (Albuquerque Area Southwest Tribal Epidemiology Center, 2018). Although statistics and best practices are often presented with clinical

language, the opioid epidemic can feel deeply personal and challenging. Tribal communities are working to address the opioid epidemic, and safer prescribing guidelines are one tool they can use to do that. We thank you for your continued commitment to helping create healthy Native communities.

A POCKET BOOK GUIDE FOR PRESCRIBERS

5

Pocket Book Resources

Resources

CHRONIC PAIN MANAGEMENT

Centers for Disease Control (CDC) Chronic Pain Management Guidelines Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders from SAMHSA

CDC’s Pocket Guide: Tapering Opioids for Chronic Pain

Assessing the Benefits and Harms of Opioid Therapy [CDC]

Nonopioid Treatments for Chronic Pain [CDC]

Calculating Total Daily Dose of Opioids for Safer Dosage [CDC]

American Academy of Family Physicians

Chronic Pain Toolkit

IHS Safe OpioidPrescribing Policies

Centers for Disease Control (CDC) Safely and Effectively Managing Pain Without Opioids

Opioid Risk Tool

Understanding Motivational Interviewing [Motivational Interviewing Network of Trainers]

Spirit of Communication: A Culturally Adapted Motivational Interviewing Training for Southern Plains Tribal Health Board

PRESCRIPTION

MONITORING PROGRAM

Southern Plains Tribal Health Board’s PMP Toolkit

Chapter 32—State Prescription DrugMonitoring Programs from the Indian Health Manual

SUD DETECTION AND TREATMENT

Indian Country Substance Use Disorder ECHO Program

National Institute on Drug Abuse’s Screening and Assessment Tools Chart for Substance Use Disorders

Three Steps for Talking With Patients About Substance Use Disorder [American Medical Association]

OKLAHOMA STATE LAW

Prescription Limits and Rules for Opioid Drugs

Electronic Prescribing Statutes

A POCKET BOOK GUIDE FOR PRESCRIBERS

References

References

Albuquerque Area Southwest Tribal Epidemiology Center. (2018). The opioid crisis impact on Native communities.

Center for Substance Abuse Treatment (2012). Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US). (Treatment Improvement Protocol (TIP) Series, No. 54.)

de Heer, E. W., Gerrits, M. M. J. G., Beekman, A. T. F., Dekker, J., van Marwijk, H. W. J., de Waal, M. W. M., Spinhoven P., Penninx B.W., van der FeltzCornelis C.M. (2014). The association of depression and anxiety with pain: A study from NESDA. PLoS ONE, 9(10), e106907.

Dahlhamer J, Lucas J, Zelaya, C, Nahin, R., Mackey, S., DeBar, L., Kerns, R., Von Korff, M., Porter L., Helmick, C. (2016) Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States. MMWR Morb Mortal Wkly Rep 2018, 67:1001–1006.

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States. MMWR Recomm Rep, 65(RR-1), 1–49.

Duwe, E. A. G. (2019). Suffering like a broken toy: Social, psychological, and cultural impacts for urban American Indians with chronic pain. International Journal of Indigenous Health, 14(2), 150 –168. https://doi.org/10.32799/ ijih.v14i2.32967

Indian Health Service. (n.d.) Safe opioid prescribing.

Jimenez, N., Garroutte, E., Kundu, A., Morales, L., & Buchwald, D. (2011). A review of the experience, epidemiology, and management of pain among American Indian, Alaska Native, and Aboriginal Canadian peoples. The Journal of Pain, 12(5), 511–522.

Mukund, A., Bhardwaj, K., & Mohan, C., (2019). Basic interventional procedures: Practices essentials. Indian Journal of Radiology and Imaging

Murez, C. R. (2021). Chronic pain and mental health: The empowered patient’s guide. Practical Pain Management. Oklahoma Prescription Monitoring Program. (2019). Prescription monitoring program enhancements. Oklahoma Bureau of Narcotics and Dangerous Drug Control [PowerPoint presentation].

Ross, E., Huber, F., Kuhn, B., Lannon, E., Sturycz, C., Payne, M., Hellman, N., Toledo, T., Güereca, Y. Palit, S., Demuth, M., Shadlow, J. & Rhudy, J. (2019). Assessing chronic pain onset in Native Americans: Follow-up results from the Oklahoma Study of Native American Pain Risk (OK-SNAP). The Journal of Pain, 20(4), 533.

Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., & Baker, D. W. (2003). Racial and ethnic disparities in emergency department analgesic prescription. American Journal of Public Health, 93(12), 2067–2073.

Trawalter, S. (2020). Black Americans are systematically undertreated for pain: Why?

UVA Frank Batten School of Leadership and Public Policy.

Tribal Opioid Response. (2020). A trickster tale— Outsmarting opioids through education and action. Northwest Portland Area Indian Health Board.

Yu, H (2015). Pitfalls of point-of-care urinary drug screening for pain management. American Association for Clinic Chemistry.

Warraich, H. J. (2020). Racial disparities seen in how doctors treat pain, even among children. The Washington Post.

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