Box 1. Items to Perform and Document in the Patient Record When Prescribing Opioid Therapy for Chronic Pain 23,64,78,86,131,144 1. Signed informed consent 2. Signed opioid treatment agreement(s) 3. Pain and medical history • C hief complaint • Treatments tried and patient response • Past laboratory, diagnostic, and imaging results • Comorbid conditions (e.g., medical, substance-use, psychiatric, mood, sleep) • Social history (e.g., employment, marital, family status, substance use) • Pregnancy status or intent, contraceptive use 4. Results of physical exam and new diagnostic and imaging tests • Review of systems • Pain intensity and level of functioning • One or more indications for opioid treatment • Objective disease/diagnostic markers 5. Results of opioid risk assessment prior to prescribing opioids • Clinical interview or any screening instruments • Personal history of SUD, mental health disorder • Family history of SUD, mental health disorder • Co-management or treatment referral for patients at risk for SUD • Treatment or referral for patients with active OUD • Treatment or referral for patients with undiagnosed depression, anxiety, other mental health disorders 6. Treatment goals for pain relief, function, quality of life 7. Treatments provided • With risk-benefit analysis after considering available nonpharmacologic and non-opioid • pharmacologic options • All medications prescribed (including the date, type, dose, and quantity) • All prescription orders for opioids and other controlled substances whether written or telephoned 8. Prescription of naloxone, if provided, and rationale 9. Results of ongoing monitoring toward pain management and functional goals SUD = substance-use disorder OUD = opioid-use disorder; PDMP = prescription drug-monitoring programs; UDT = urine drug testing
Opioid Treatment Agreements Opioid treatment agreements that spell out patient and HCP expectations and responsibilities are recommended by most opioid guidelines. 78,86 Consider including: 134 • Treatment goals in terms of pain management, restoration of function, and safety • Patient’s responsibility for safe medication use, such as agreement not to take more than prescribed, alter pills, or combine with alcohol, unauthorized prescriptions, or illicitly obtained drugs • Patient’s responsibility to obtain prescribed opioids from only one HCP or practice • Patient’s responsibility to fill prescriptions at only one pharmacy • Patient’s agreement to periodic UDT or other drug tests • Instructions for secure storage and safe
disposal of prescribed opioids • HCP’s prescribing policies, including handling of early refills and replacing lost or stolen medications • Reasons for which opioid therapy may be changed or discontinued, including violation of the treatment agreement • Statement that treatment may be discontinued without the patient’s agreement • HCPs availability policy, including responsibility to provide care for unforeseen problems and to prescribe scheduled refills • Education that the patient should not expect complete elimination of pain • The patient’s signature The forms for informed consent and treatment agreements may be combined into one document and adapted to the HCP’s needs and preferences. Examples of informed consent and treatment
agreement documents are available online from the New Hampshire Medical Society at https://www. nhms.org/opioid-prescribing-resources. Both forms can help facilitate discussions with the patient about ongoing risks and benefits and also provide structure in case difficult conversations become necessary regarding adherence to the treatment regimen. It is advisable to have a strategy to manage opioid misuse by the patient should it occur and to know and discuss with the patient indications for which opioid therapy may be discontinued. Managing Side Effects HCPs should expect, prevent, and take steps to manage opioid-related adverse effects. Common opioid side effects with suggested management strategies are listed in Table 7. 78
Table 7. Common Opioid Side Effects and Suggested Management Strategies
Side Effect
Management
Respiratory depression
Screen for sleep apnea Avoid sedatives, benzodiazepines, barbiturates, and alcohol
Constipation
Increase fiber and fluids; start prophylactic laxative treatment, particularly in older patients
Nausea or vomiting Hormonal deficiencies Sedation, mental clouding
Antiemetic therapy; symptoms tend to diminish
Screen symptomatic patients (fatigue, sexual dysfunction)
Counsel as to home, work and driving safety, and concomitant CNS-depressant risks; symptoms tend to diminish
Pruritis
Treatments largely anecdotal (may include reducing dose, changing medication)
Hyperalgesia
Reduce dose or change medication
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