Patient Centered Opioid Agreements 'Illuminate the Treatment Path'

LAS VEGAS—Opioids are complex medications; powerful in healing but also powerful in harm if misused. Opioids can mislead some users into harmful use and have diverse effects and side effects. Informed consent is critical to decision making, and clear goals permit assessment of treatment.

Those are the values of the universal use of the patient centered opioid agreement, along with the most important one: a “mutual agreed upon plan of care illuminates the treatment path.” That's the conclusion of Seddon R. Savage MD, MS, Medical Director of the Silver Hill Hospital Chronic Pain and Addiction Center; Director, Dartmouth Center on Addiction Recovery and Education; and Associate Professor of Anesthesiology, Dartmouth Medical School Adjunct Faculty, Dartmouth, New Hampshire, who provided an overview of the historical and public health context of opioid therapy, the role of the opioid agreement, and best practices in opioid therapy.

In his presentation at PAINWeek 2014, Dr. Savage reviewed “millennia of controversy” surrounding the use of opioid narcotics, from the “joy plant,” or Sumerian opium poppy, in 3000 BC, to date, with renewed interest in interdisciplinary pain care, evidence based healthcare reform, cost-effective care, and care of chronic illness.

Opioid therapy is more likely to be successful if the patient is engaged in treatment planning, understands the potential benefits and risks of treatment, and accepts the rationale for components of the care plan, which often is more structured than that with other medications.

“The use of a written opioid treatment agreement is becoming increasingly common and can serve as a helpful foundation for guiding clinical care when opioids are part of a pain treatment plan,” he said. “Informed consent for opioid therapy and an agreement on the plan of treatment are often integrated into a single document. However, their roles are actually quite different, so it is appropriate to consider each of them separately.”

Informed consent, for example, documents that potential benefits and risks of opioids for the patient have been considered by the physician and the patient and are acceptable to the patient. A clear understanding of the targeted benefits or goals of treatment as well as the particular risks for the individual can then inform the treatment plan.

A written plan of care that details the responsibilities of the patient and physician and the structural components of care assures the patient and the clinicians have a shared understanding of the plan. Together, these may serve as a basis for continuing or revising the care plan.

“The plan of care outlines a structure of care that supports safe and effective treatment,” Dr. Savage said. “Medication management usually includes the need for safe storage and disposal of unused medications, the importance of taking medications as prescribed with clear mechanisms for changing the dose or schedule specified, the indication of how requests for early renewals or reports of lost or stolen prescriptions will be addressed.”

Dr. Savage provided attendees with an “exit strategy” for opioid agreements (see Table).

Table. Exit Strategy

 Review clinical reasons for cessation
 Risks outweigh benefits
 Lack of improvement in condition
 No progress towards goals
 If addiction, mental health issues
 Refer for appropriate treatment
 Consider opioid agonist therapy for opioid addiction
 Taper opioids to avoid withdrawal
 Offer continued non-opioid pain treatment
 Engage in self care
 Multidimensional approach
 If diversion documented
 May not need taper
 Pain treatment may not be indicated


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