Keywords

Introduction

A systems level approach to management of the patient on chronic opioid therapy (COT) at the office or clinic level is essentially a standardized approach to this special patient population. At the heart of this is the opioid treatment agreement which spells out the expectations of treatment for both the primary care provider and the patient. As managing chronic pain may be time consuming, it may not only make the physician’s life easier [1], but also is recommended by the CDC [2] and may be required by law depending on the state. The opioid treatment agreement comprises of many components. It essentially states treatment goals, risks, qualifications for obtaining prescription opioids, and explains the monitoring process.

Currently, there is no evidence that treatment agreements reduce overdose and death. In addition, there are varying physician views [1] on the usage of “pain contracts” or “pain agreements” from punitive and self-serving, to much needed and an improvement to chronic pain management workflow. Usage of the word “agreement” may make this treatment document more collaborative instead of punitive [2]. Explanations introducing the opioid treatment agreement can discuss the reasons that this agreement exists. Scripts can include the opioid epidemic, risks of opioid therapy, and that it is a universal policy for all patients on COT, much akin to using gloves and other forms of universal precautions (Table 9.1). Of course, the individual provider can use any combination he or she wishes or invent their own standardized script when introducing the need for the opioid treatment agreement.

Table 9.1 Example scripts to use when introducing an opioid treatment agreement
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Treatment agreements, and the office polices they contain, may improve provider satisfaction and confidence with opioid treatment management [3, 4]. Example office policies regarding COT [2, 5] that may be of benefit are listed in Table 9.2.

Table 9.2 Example office policies for the management of patients on chronic opioid therapy
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All office policies do not need to be included in the treatment agreement as they may not be pertinent to the actual chronic opioid treatment agreement whose chief purpose is to inform the patient standard requirements for refills, opioid risks, and measures to improve opioid safety. A separate chronic pain (or more specifically chronic opioid treatment) policy can address what is included in the treatment agreement along with other specifics concerning new patients on COT, frequency of checking PDMP databases and urine toxicology, standards for referrals, criteria for initiating a chronic opioid treatment agreement, definitions of and consequences for major and minor violations, etc. Of course, a clinic can simply adopt components of previously published guidelines as part of its chronic pain policy. One readily available example of a complete policy on chronic noncancer pain can be found at the University of Michigan Health System [6]. Essentially, the office policies on chronic opioid therapy will define chronic opioid therapy and dictate how a patient on chronic opioid therapy will be managed. The process of developing thorough guidelines for an entire healthcare system is beyond the scope of this book (which focuses more on the practice-based aspects of opioid management).

Lastly, there are various components crucial to constructing an opioid treatment agreement (Table 9.3). These were gleaned from readily available sample opioid treatment agreements listed in the CDC toolkit part C [2]. Main points are to discuss risks and unproven benefits of opioids, monitoring for safety, and refill requirements. Incorporating patient specific diagnosis, goals, and treatment plan will not only personalize the agreement, but help quantify treatment effectiveness (in terms of the patient’s functional and pain related goals). Remember to give the patient a copy of the opioid treatment agreement. Renew annually [2] or according to current recommendations.

Table 9.3 Main components of a chronic opioid treatment agreement
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Below are links to example opioid treatment agreements (Table 9.4). Some are written in layman’s terms and may be more appropriate for those with lower health literacy. The FDA uses more of a discussion format instead of a “contract” format written with input from plain language experts [7]. In general, when initiating an opioid treatment agreement, I will discuss each point with the patient in order to ensure comprehension and foster a collaborative relationship.

Table 9.4 Example opioid treatment agreements available on the world wide web
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Conclusions

Opioid treatment agreements and chronic pain policies currently have scant evidence (if any) concerning effectiveness in prevention of adverse events such as addiction, overdose, and death. However, it may make the management of deviant behavior (violations of the agreement), or adverse events (addiction, side effects, or overdose) a little more straightforward (and less stressful) when a protocol is already in place and the patient is aware of the protocol. Adopt and adapt various policies and work flows to make management of these complex patients a little easier.