Informed consent and treatment plans for chronic opioid treatment The patient-specific treatment plan should be developed and reviewed regularly to ensure that both the clinician and patient agree on the goals of the therapy, treatment regimen, and options. Consider different treatment
● Reasons a drug may be changed or discontinued; treatment may be discontinued without agreement from the patient, such as violations of the treatment agreement. ● Education for patients stating that complete elimination of pain should not be expected. (HHS, 2019a) Chronic pain treatment agreements that outline the responsibilities of the patient and the provider are indicated for long- term treatment with opioids or other medications with the potential for substance abuse disorder. The U.S. Department of Health and Human Services, Division of Indian Health Services, recommends that treatment agreements include the following tenets: ● Treatment goals are defined in terms of pain management, restoration of function, and safety. ● The patient is responsible for safe medication use (i.e., not taking more than prescribed; understanding the dangers of using in combination with alcohol, cannabis, benzodiazepines, or other CNS depressants unless closely monitored by the prescriber). ● The patient will ensure secure storage and safe disposal. ● The patient will obtain opioids from only one clinician or practice. ● The patient will fill the opioids at only one pharmacy. ● The patient will agree to periodic drug testing (i.e., urine drug screening). ● The clinician is responsible for making themselves available or having a covering clinician available to care for unforeseen problems and to prescribe scheduled refills. (HHS, 2019a) Complete pain relief is often not achieved; a 30% reduction in pain is considered a good clinical response (Dowell et al., 2016). In a function-based treatment strategy for chronic pain, treatment efficacy is measured by the patient’s ability to achieve improved function rather than complete pain relief. These goals may include going to work, walking, achieving enhanced sleep, or improving social interactions. It may be beneficial to begin with more easily achievable goals and progress to more challenging ones after initial successes. This approach can be much more motivating than a plan resulting in early treatment failure (HHS, 2019b). precise motor control, heavy machinery, or chemical or biohazardous materials. Pregnant women also require an enhanced level of caution because chronic opioid use during pregnancy increases the risk of harm to the newborn, specifically neonatal opioid withdrawal syndrome. Further, these medications must be used cautiously in breastfeeding women because some opioids can be transferred to breast milk and may cause sedation or respiratory depression in the nursing infant. In elderly patients, clinicians should consider employing a lower starting dose, a slower titration period, and a longer dosing interval with more frequent monitoring. Patients with psychiatric disorders are at increased risk of adverse events associated with chronic opioid therapy. Untreated depression and other mental health disorders place patients at increased risk for misuse and abuse of opioid analgesics, including addiction and overdose. In addition, untreated depression may interfere with pain resolution. In cases where the opioid dosage increases, the prescriber should educate the patient on the risk of cognitive impairment that can negatively impact their ability to drive or perform other activities.
modalities, such as an interventional approach, a formal pain rehabilitation program, physical medicine, psychological and behavioral strategies, or medications (nonopioids and opioids), depending upon the physical and psychosocial issues related to the pain. Opioid therapy is not the appropriate first-line treatment for most patients with chronic pain. It should be reserved for intractable chronic pain not adequately managed with more conservative or interventional methods. Other nonopioid medications, treatment modalities, and nonpharmacological therapy should be tried first. Practitioners should document the effectiveness or failure of these medications before initiating opioid therapy (CDC, 2022a; Dowell et al., 2016). Suppose the prescriber determines that an opioid trial is an appropriate treatment option. In that case, the patient, caregiver(s), and family member(s) are informed of the risks and benefits of opioid analgesic therapy and the conditions under which the opioids are being prescribed. A trial implies that opioids are used for a short period (i.e., weeks or a couple of months), and continued use will be contingent upon demonstrated improvement in pain, physical function, and quality of life with no significant adverse reactions or aberrant behaviors (Kroenke et al., 2019). If the prescriber institutes long-term opioid therapy, a written informed consent and treatment agreement are recommended. The informed consent may address several issues, such as: ● Limited evidence of the benefit of opioids or other medications in managing chronic pain (except for cancer). ● Potential risks and benefits of opioid therapy. ● Potential short- and long-term side effects of opioid therapy. ● The likelihood that tolerance to and physical dependence on the medication will develop. ● Risk of drug interactions and oversedation. ● Risk of impaired motor skills. ● Risk of substance abuse disorder, overdose, and death. ● The clinician’s prescribing policies (e.g., number and frequency of refills, early refills, exceptions). Initiating opioid therapy for chronic noncancer pain When initiating opioid therapy for chronic pain, clinicians should start with immediate-release opioids and avoid extended- release formulations or long-acting opioids. Begin with the lowest effective dosage. Evaluate patients within one to four weeks of starting opioid therapy or dose escalation. Clinicians should evaluate patients every three months to assess the continued benefit and the development of any adverse effects once the opioid dose is stabilized. If the patient no longer benefits from the opioid therapy, the clinician should optimize the treatment regimen, including adding other treatment modalities or tapering off the opioid regimen (CDC, 2022b). Some patient populations and patients with certain conditions require closer monitoring and counseling before initiation and during chronic pain treatment. For example, patients receiving other central nervous system depressants, especially benzodiazepines, require special attention because of an increased risk of adverse events, including increased sedation, confusion, difficulty driving or performing other tasks requiring high concentration levels, respiratory depression, and overdose. It is also necessary to assess how the patient uses work equipment that requires
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