LAS VEGAS—Treatment agreement documents are an expected and sometimes legally required part of managing chronic pain patients with opioid medications, but the extent to which patients understand the particulars of such agreements is questionable, according to clinical psychologist Ted W. Jones, PhD, of the Behavioral Medicine Institute in Knoxville, Tennessee.
Clinicians need to take steps to ensure that patients know the terms and conditions that will guide the opioid therapy they will receive, he said.
Treatment agreements typically include informed consent information—a review of the risks and benefits of opioid therapy—and outline the parameters of the provider-patient relationship and the circumstances under which opioid therapy will be withdrawn. In general, the emphasis on treatment agreements is on preparing and giving the documents to patients to sign and not whether patients actually comprehend the documents’ provisions, Dr. Jones said. A reason for that, he pointed out, is that it is time consuming for providers to review treatment agreements with patients. This raises doubts about the effectiveness of treatment agreements. He cited a systematic review published in 2010 in the Annals of Internal Medicine that concluded: “Relatively weak evidence supports the effectiveness of opioid treatment agreements and urine drug testing in reducing opioid misuse by patients with chronic pain.”
How patients are educated is key, Dr. Jones said to attendees. Ten years ago, his practice introduced group “medication classes” to address the issue of patient education. The course, led by a psychologist, reviews the terms of the provider-patient relationship and includes such instruction on how patients should take their pain medication and how the practice will monitor them. When patients are asked to sign a treatment agreement—which consists of 12 pages plus a one-page summary—they are scheduled for this 75-minute medication class, which they are expected to attend within the first three months of being prescribed opioids. If patients do not attend the class by then, opioids are tapered until they get to class.
The classes appear to reduce medication aberrant behavior, Dr. Jones said. They also make it easier for providers to deal with future aberrant behavior because they are sure patients were educated. Furthermore, the classes demonstrate to the patient population that providers are “going the extra mile” to have a “clean” pain practice and that the providers care about their patients and do not want unintended negative consequences, Dr. Jones said.