_______________________________ Developing a Safe Opioid Treatment Plant for Managing Chronic Pain
function • Appropriate trial of opioid therapy with or without adjunctive medication • Reassessment of patient levels of pain and functioning • Regular assessment with the 5 A’s (i.e., analgesia, activ- ity, adverse effects, aberrant behaviors, and affect) • Periodically review pain diagnosis and comorbid condi- tions, including substance use disorders • Documentation INFORMED CONSENT AND TREATMENT AGREEMENTS The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [4]. This agree- ment should address potential side effects, tolerance and/ or physical dependence, drug interactions, motor skill impairment, limited evidence of long-term benefit, misuse, dependence, addiction, and overdose. Informed consent documents should include information regarding the risk/ benefit profile for the drug(s) being prescribed. The prescribing policies should be clearly delineated, including the number/ frequency of refills, early refills, and procedures for lost or stolen medications. The treatment agreement also outlines joint prescriber and patient responsibilities. The patient agrees to using medica- tions safely, refraining from “doctor shopping,” and consenting to routine urine drug tests (UDTs). The prescriber’s responsibil- ity is to address unforeseen problems and prescribe scheduled refills. Reasons for opioid therapy change or discontinuation should be listed. Agreements can also include sections related to follow-up visits, monitoring, and safe storage and disposal of unused drugs. It is important to remember that treatment agreements are only one aspect of developing a safe opioid use plan. The evidence to support the use of such agreements to decrease the misuse of opioids is relatively weak, with little or no proof of improvements in adherence or patient care [6].
INTRODUCTION Nonpharmacologic therapy and non-opioid pharmacologic therapy are the preferred first-line therapies for chronic pain [1]. If opioids are used, they should be combined with non- pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient [1]. Opioid analgesics can be highly effective in relieving physical and psychological pain, but some patients are highly susceptible to opioid reward effects. A minority of patients may experience an initial response to opioid therapy of euphoria, stimulation, or intense well-being, and this response is associated with an increased risk for the development of opioid use disorder [2; 3]. Healthcare professionals should know best clinical practices in opioid prescribing, including the associated risks of opioids, approaches to the assessment of pain and function, and pain management modalities. According to the 2024 Federation of State Medical Boards (FSMB) guideline on opioid prescribing, the goals of pain treatment include “reasonably attainable improvement in pain to decrease suffering and to increase func- tionality and quality of life; improvement in pain-associated symptoms, such as sleep disturbance, depression, and anxiety; treating potentially reversible causes of pain; screening for side effects of treatment; and avoidance of unnecessary or excessive use of medications” [4]. Pharmacologic and nonpharmacologic approaches should be used on the basis of current knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with non-opioid pharmacologic or nonpharmacologic pain therapy without adequate pain relief are considered to be candidates for a trial of opioid therapy. However, patients with chronic pain should not be required to use or to fail other forms of pain therapy before initiating opioid therapy [4]. Not all individuals have equal access to alter- natives due to insurance, work, childcare, or transportation constraints. The treatment plan should always be individual- ized for the patient and begun as a trial for a defined period of time (usually no more than 30 days) before embarking on a definitive course of treatment [4]. All patients with pain have a level of risk that can only be roughly estimated initially and modified over time as more information is obtained. There are ten essential steps of opioid prescribing for chronic pain to help mitigate any potential problems [5]: • Diagnosis with an appropriate differential • Psychological assessment, including risk of substance use disorders • Informed consent • Treatment agreement • Pre- and post-treatment assessments of pain level and
CONSIDERATIONS FOR NON- ENGLISH- PROFICIENT PATIENTS
For patients who are not proficient in English, it is important that information regarding the risks associated with the use of opioids and available resources be provided in their native language, if possible. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. Interpreters can be a valu- able resource to help bridge the communication and cultural gap between patients and practitioners.
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MDNJ1525
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