Opioid treatment agreements delineate the basis for a therapeutic trial of opioid analgesics. Expectations and obligations of both the patient and the clinician are explained and put into writing. Boundaries are set for continued use of these medications while providing an opportunity for early identification and intervention of aberrant behaviors.
An agreement can be used as an educational document explaining the expectations of treatment, establishing the patient—practitioner relationship, and enhancing compliance. Elements of the agreement vary in content, but generally include:
■ Risks and benefits of treatment
■ Goals of treatment
■ Side effects of medications
■ Definitions of addiction, dependence, and tolerance
■ Rationale for changing or discontinuing medication
■ Expected patient behaviors
Examples of expected patient behaviors include the following: only take the prescriptions as directed, do not use alcohol or other sedating medications while taking opioids unless directed by your practitioner, receive opioid prescriptions only from the prescriber(s) listed, have the prescription filled only at one pharmacy, and do not request prescription refills early. Examples of opioid treatment agreements can be found at www.npweb.org or at the website for the American Academy of Pain Medicine (Exhibit 10.2).
It should be noted that the use of an opioid treatment agreement is one of several tools to monitor adherence. The act of signing the agreement is not a fail-safe preventative measure for subsequent prescription opioid abuse, and repeated review of the terms of the agreement is advisable.
When a patient deviates from the treatment agreement, the clinician must decide on an appropriate course of action. Although there is no clear-cut standard practice, several options may be considered based on the degree of departure and circumstances surrounding the incident. Options may include discharging the patient from the practice but continuing to treat the patient without opioid analgesics, continuing to treat the patient with greater vigilance, or referring the patient to a pain specialist or addictionologist. The decision must be based on a thorough assessment, with documentation of treatment rationale. The practitioner should not continue the same treatment without a thorough assessment, and documentation. If the decision is made to discharge the patient from the practice, a discussion with the patient as to the circumstances that led to this decision must take place. An addictions specialist or pain specialist should be included in the discussion of directions for opioid weaning, management of withdrawal side effects, and referral to an alternate provider, with accompanying documentation (D'Arcy & Bruckenthal, 2011).
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