Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
dosages or to taper and discontinue opioid [5]. (See Chronic Recommendation 10.2) CHRONIC PAIN RECOMMENDATION 5: INFORMED CONSENT Recommendation 5.1: Obtain Signed Informed Consent Form Prescribers should discuss with patients the known risks and realistic benefits of opioid therapy and patient and prescriber responsibilities for managing therapy, including any conditions for continuation of opioid treatment. This discussion should be documented using a written and signed informed consent form, which is often combined with the treatment plan. The informed consent form typically includes information about the: • Potential risks and benefits of controlled substance use, including the risk of misuse, dependence, addiction, overdose, and death • Adverse effects • Likelihood of tolerance and dependence developing • Possible drug interactions and risk of over-sedation • Limited evidence of the benefit of long-term opioid therapy • Risk of impairment while operating motor vehicles or equipment or performing other tasks • Prescriber’s policies and expectations • Specific reasons for adapting or discontinuing opioid therapy Informed consent should also include explaining to patients that they should not expect complete relief of their pain. Improved function is the main criterion for continuing opioid treatment. Recommendation 5.2: Educate Patient and Family/ Caregivers Educational material about the patient’s opioid treatment plan should be provided in written form and discussed in person with the patient and, when applicable, the patient’s family or caregivers. For patient education materials and resources on the risks of taking opioids and signs of an opioid overdose, visit www. opidemic.org. For information on safe storage and disposal, visit www. useonlyasdirected.org. For information on naloxone information, visit naloxone.utah.gov/.
Discuss with the patient the involvement of family and caregivers in their care and receive written permission from the patient to involve the family or caregivers. This is best done before starting to treat the patient, because it can be more difficult to obtain consent after an issue occurs. Utah Code Section 58-37f-301(5) allows a person for whom a controlled substance is prescribed to designate a third party who will be notified when a controlled substance is prescribed to the person. Prescribers should discuss this designation with patients. Note: Consultation with others, in the absence of consent, must be done within the guidelines and constraints of HIPAA. INITIATING AND ADJUSTING OPIOID TREATMENT (6.1-6.7) CHRONIC PAIN RECOMMENDATION 6: OPIOID TREATMENT TRIAL Recommendation 6.1: Combine Therapies When opioid treatment is indicated, non-opioid analgesics, adjuvant analgesics, and non- pharmacologic therapies should be used in combination with opioid treatment as appropriate for the patient. Combination products with opioid and non-opioid analgesics may result in better pain relief than either drug alone, but the opioid dose is limited by the non-opioid. The use of adjunctive medications, as well as other therapies, such as physical therapy, exercise, stretching, and other alternative therapies, can reduce the dose of opioid needed for adequate pain relief; and consequently, improve a patient’s functionality. Recommendation 6.2: Initiate Short-term Treatment Trial Opioid medication should be initiated as a short-term trial to assess the effects of opioid treatment on pain intensity, function, and quality of life. The prescriber should clearly explain to the patient that initiation of opioid treatment is not a commitment to long- term opioid treatment and that treatment will be stopped if the trial is determined to be unsuccessful. The trial should be for a specific time period with pre-determined evaluation points as defined in the treatment plan measures. The decision to continue opioid medication treatment beyond the trial period should be based on the balance between benefits gained in function and quality of life, and adverse effects experienced. Criteria for cessation should be determined before treatment begins. When a new patient has already been receiving opioid therapy for a chronic condition, the same recommendations apply: assess the patient’s chronic pain, complete a comprehensive evaluation, screen for risk of substance use disorder, establish a treatment plan and informed consent, initiate treatment trial, mitigate risks, and consider a multi-disciplinary approach. The evaluation process may require more time than the initial appointment, so the prescriber must use their professional
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