Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ 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. The treatment plan should always be individualized for the patient and begun as an “initial therapeutic trial” before embarking on a definitive course of treatment [113]. including the number/frequency of refills, early refills, and procedures for lost or stolen medications [113]. The American Society of Interventional Pain Physicians asserts that a robust agreement, which is followed by all parties, is essential prior to initiating and maintaining opioid therapy, as such agreements reduce overuse, misuse, abuse, and diversion.
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 [113]: • Diagnosis with an appropriate differential • Psychologic assessment, including risk of substance use disorders • Informed consent • Treatment agreement • Pre- and post-treatment assessments of pain level and 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, activity, adverse effects, aberrant behaviors, and affect) • Periodically review pain diagnosis and comorbid conditions, including substance use disorders • Documentation
(https://painphysicianjournal.com/current/pdf?article= NDIwMg%3D%3D&journal=103. Last accessed August 15, 2023.) Level of Evidence : III (Evidence obtained from at least one relevant, high-quality nonrandomized trial or observational study with multiple moderate- or low- quality observational studies) The treatment agreement also outlines joint prescriber and patient responsibilities [113]. The patient agrees to using medications safely, refrain- ing from “doctor shopping,” and consenting to routine urine drug tests (UDTs). The prescriber’s responsibility is to address unforeseen problems and prescribe scheduled refills. Reasons for opioid therapy change or discontinuation should be listed [113]. Agreements can also include sections related to follow-up visits, monitoring, and safe storage and
disposal of unused drugs. Considerations for Non- English-Proficient Patients
For patients who are not proficient in English, it is important that information regarding the risks asso- ciated with the use of opioids and available resources be provided in their native language, if possible. When there is an obvious disconnect in the com- munication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. Inter- preters can be a valuable resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than pas- sive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers who ulti-
INFORMED CONSENT AND TREATMENT AGREEMENTS
The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [113]. This agreement 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 docu- ments should include information regarding the risk/benefit profile for the drug(s) being prescribed. The prescribing policies should be clearly delineated,
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MDMS1526
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