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5—Patient Education And Treatment Agreements
exhibit 5-4 reliable Web sites With Information on substance Use Disorders
The specifics of patient education vary from patient to patient and over time. However, general content areas for patient education include information about:
• The patient’s condition and the nature of the patient’s chronic pain.
• Treatments available, including nonphar
• The risks and benefits of treatment options.
• How and when to take medications.
• How to keep medications safely away from children (out of reach or locked up).
• The patient’s responsibility for keeping track of medications and not losing them or giving them to others.
• Any medication interactions.
• Common side effects of medication, their expected duration, and ways to manage them (e.g., a high-fiber diet to manage constipation common to opioid use).
• Warnings and potential adverse events associated with medications and other treatments.
• Pros and cons of CAM.
• Risks to pregnant and lactating women.
• The degree of pain relief the patient can realistically expect from a treatment.
• How to use treatment apparatus (e.g., transcutaneous electrical nerve stimula tion machine).
• How best to use the Internet to find information and sources of support.
• Under what conditions the patient should immediately call the clinician or go to the emergency department.
• How to deal with episodes of acute pain (e.g., from surgery or trauma), as well as flareup pain.
Patients may benefit from referrals to psychol ogists for assistance in basic coping skills and to physical therapists and other professionals (Naliboff, Wu, & Pham, 2006) for therapies that can be used in place of or in addition
to medication (e.g., meditation, relaxation, stretching, distraction).
Use of opioids requires additional educational efforts. To give informed consent, patients must understand the expected benefits as well as the uncertainties of chronic opioid therapy. Specifically, they must understand that excel lent analgesia can almost always be provided
by starting opioids; however, long-term studies are limited and often of poor quality. They
suggest that benefit diminishes with time; after 1½ years, about one-half of patients dropped out of opioid therapy because of side effects or the therapy’s loss of efficacy. Those continuing to take opioids had about 30 percent pain reduction (Kalso, Edwards, Moore, & McQuay, 2004).
Patients must also understand the risks of therapy, which include overdose (by patient, others, pets), constipation, sedation, and hor mone changes, and the hazards of combin ing opioids with sedating drugs or alcohol. Finally, they should understand that tolerance and physical dependence are expected conse
quences of extended therapy, that these condi tions do not necessarily indicate the presence of an addictive disorder, but that they do require that arrangements be made to prevent abrupt withdrawal when either the patient
or clinician is out of town or the clinician is otherwise unavailable. Policies of the clinician or program (e.g., requirements for urine drug testing, responses to lost or stolen prescription
reports, early refill requests) should be communicated in advance.
In addition, patients need to understand (VA/ DoD, 2010):
• The titration process, how soon the patient can expect maximum effective ness, and why taking medications exactly as prescribed is important to the titration process.
• The risks of discontinuing the medication abruptly (e.g., withdrawal symptoms).
• How medication will be safely discontinued (e.g., tapering, managing withdrawal symptoms).
• That drowsiness is a common side effect during titration and that patients should not try to drive or operate heavy machin ery until drowsiness is cleared.
• How to discuss pain therapy, analgesic needs, and recovery status with other health professionals (e.g., dentists, anes thesiologists). (See Exhibit 5-5.)
exhibit 5-5 Talking With patients Before surgery
Anesthesiologist: “I understand you are scheduled for knee-replacement surgery. Is there anything else you would like me to know about your health?”
Patient: “Yes, I was addicted to Vicodin many years ago. I still have chronic low back pain even though I had a laminectomy and fusion about 5 years ago. The pain following surgery was terrible. I do not want to go through that again. Doctor, I do not want to suffer. ”
Anesthesiologist: “I see. Please tell me more. I want to make sure that I have all the informa tion so that your surgeon and I can develop a pain management plan to address your concerns.”
Patient: “I take buprenorphine. It works very well for me.”
Anesthesiologist: “Thank you for sharing this information. Knee surgery patients can feel a lot of pain afterward. Since we have 2 days before your surgery, we should be sure the doctor prescribing your buprenorphine knows that you are scheduled for surgery. She may want to change your buprenorphine dose. Also, we will consider using other pain medications or techniques to man age your pain. We’ll need to closely monitor you and assess your pain. We will also want to be sure that your support people are aware of the plan and are available to help you. May I contact your doctor and nurses?”
Patients also need to know about legal and regulatory issues (VA/DoD, 2010), including:
• The legal responsibilities of the clinician.
• That it is illegal to give away, trade, share, or sell prescription opioids.
• The potential effect of regulatory issues on occupation, lifestyle, and use (e.g., pilots, commercial drivers; Chou and colleagues  provide more information).
• The responsibility of the patient to report stolen medications both to the police and to the clinician.
methadone maintenance Therapy
Patients on methadone maintenance therapy (MMT) for opioid dependence need to under stand how pain treatment will affect their MMT and vice versa. Patients also need to understand that long-term use of opioids can bring tolerance, may cause them to become more sensitive to pain (to have opioid-induced hyperalgesia), and can cause the opioids to become ineffective over time. (Chapter 3 provides more information on opioid-induced hyperalgesia.)
In general, when patients receiving MMT have inadequate pain control, options include non-opioid therapies and dividing the daily methadone dose into three-times-a-day dosing. If a decision is made to increase the dose of methadone by the pain-treating clinician, it should be done only in concert with the MMT program. The patient must
be monitored for continued participation in an aggressive recovery program and for evi dence that the increased dose of methadone leads to demonstrable reductions in pain or improvements in function.
As with patient education, opioid treatment agreements (contracts) have had no random ized controlled trials that have specifically evaluated their effect on treatment outcomes. Such agreements are, however, recommended in clinical guidelines and are frequently used
in practice. Although written agreements spe cific to prescribed opioids are most frequently discussed, agreements can be used for other treatment modalities (e.g., exercise regimens).
Disagreement exists about the use of agreements when prescribing opioids (Heit, 2003). Some guidelines recommend opioid agreements only when the patient has or is at risk for an SUD. Others are concerned that “opioid contracts may diminish patient autonomy; autonomy and adherence may sometimes represent conflict ing values in chronic opioid therapy” (Arnold, Han, & Seltzer, 2006, p. 294).
These concerns can be mitigated somewhat by the way in which treatment agreements
are established. Patients can be informed that treatment agreements are mutually agreed-on plans and courses of action. Providing educa tion on options and involving the patient in planning and writing treatment agreements can preserve patient autonomy while establishing necessary guidelines. Arnold and colleagues (2006) suggest that, if a clinician chooses to use an opioid agreement, it should:
• Use neutral, nonconfrontational language.
• Be written so that the patient can under
• Emphasize opioids as a part of a com prehensive pain management plan that also includes physical therapy, counseling, and other medications for co-occurring disorders, as needed.
• Emphasize the clinician’s responsibility to work with the patient to alleviate his or her symptoms.
• Explain that the agreement protects the patient’s access to scheduled medications and protects the clinician’s license to prescribe them.
• Describe behaviors that are incompatible with chronic opioid therapy (e.g., getting prescriptions from other clinicians, losing medications).
• Describe the actions the clinician may take in response to these behaviors up to and including cessation of opioid prescribing.
As when treating all patients, the clinician
can assess the ability of the patient with or in recovery from an SUD to make an informed decision (Longo, Parren, Johnson, & Kinsey,
2000). If the clinician becomes aware of limi tations, he or she can (in addition to or instead of having a written agreement) involve the patient’s family in treatment, with the patient’s permission (Geppert, 2004).
Treatment agreements vary considerably from practice to practice and from patient to patient. However, some common elements of agreements include the following (Fishman,
2007; Heit, 2003; Jacobson & Mann, 2004; VA/DoD, 2010; Ziegler, 2007):
• Timeframe of the agreement
• Goals of therapy
• Risks and benefits of chronic opioid
• Requirement for obtaining prescriptions from a single clinician and a named pharmacy
• Activities for pain management (e.g.,
• Risk and benefit statement, including lists of possible side effects
• Proscription against changing medication dosage without permission
• Schedule for regular medical visits for
evaluation of the agreed-on treatment
• Requirement of complete, honest self- report of pain relief, side effects, and function at each medical visit
• Limits on medication refills
• Limits on replacing lost medications or prescriptions
• Consent for random urine drug testing and other specified testing
• Required pill counts
• Consent for appropriate release of infor mation (e.g., from family members, other clinicians, counselors, substance abuse treatment programs)
• Participation in agreed-on SUD recovery activities (e.g., treatment, continuing care, mutual-help groups)
• Requirements of the clinician
• Participation in agreed-on psychiatric
• Possible consequences of not following the treatment agreement
A useful treatment agreement should be revised as the patient’s needs and circumstances change. An opioid agreement by American Academy
of Pain Management is online at http:// www.aapainmanage.org. Exhibit 5-6 presents another sample pain treatment agreement for a woman in recovery from an SUD.
exhibit 5-6 sample pain Treatment Agreement
Patient: Irene Simpson Doctor: Dr. Miller Date: 1-19-10
This treatment plan has been developed to manage neck pain and tension headaches. It is open to changes when both the doctor and I agree that the changes are in my best interest and are likely
to improve my pain management or overall health. A primary goal of the plan is to protect my recovery from addiction.
1. My daily medications:
gabapentin, 1,200 mg three times daily. duloxetine, 90 mg every morning. topiramate, 100 mg at bedtime.
2. At the first indication of a headache, I will take ibuprofen (600 mg).
3. If possible, I will lie down in a darkened room with an ice pack to my neck and shoulders for
15 to 20 minutes to give the medication time to work; if the headache is still present in 30 minutes, I will take acetaminophen (500 mg). Use of opioid medications can be considered if this plan is unsuccessful. However, under no circumstances will I seek these medications from other doctors, friends, or the Internet. Instead, I will discuss my cravings and sense that the plan is not working with Dr. Miller, Joan Small, and my sponsor.
4. I will see Dr. Wong weekly or as recommended for acupuncture treatments.
5. I will walk 15 to 30 minutes daily.
6. I will attend the pain management group with Joan weekly and see Joan for individual sessions as indicated.
7. I will obtain all prescriptions for headache or other pain and for addiction recovery from
Dr. Miller, and I will fill all prescriptions at the Main Street Pharmacy.
8. I will not visit other physicians or the emergency department without first talking to Dr. Miller or to the doctor who is covering for him.
9. I will attend my home group (Tuesday Night Women’s Group) weekly, plus two other weekly Narcotics Anonymous (NA) meetings of my choice; I will talk with my sponsor at least weekly and will call her when I feel despondent or have cravings to drink or take opioid pills.
10. My daily meditation will focus on removing myself from conflicts where I do not have a direct role to play. I will try to remind myself when “I don’t have a horse in this race” at work or at home.
Important Phone Numbers:
Dr. Miller’s Office ................................... 222-3800
Dr. Miller’s Answering Service ............... 222-9000
Main Street Pharmacy ............................380-2000
Joan Small’s Office ................................ 380-2132
NA Hotline ............................................. 234-0081
Abby (sponsor) .......................................382-9970
Sample Pain Treatment Agreement ©MediCom Worldwide, Inc., 101 Washington St., Morrisville, PA 19067. Ziegler, P. Treating Chronic Pain in the Shadow of Addiction. Monograph 2007. Available at: http://www.emergingsolutionsinpain.com/index.php?option=com_continued&view=dispfm&Itemid=280&course=42
• Patient education is necessary for informed consent, and it equips patients to take an active role in their pain management.
• Education must be tailored to the individual patient. More research is needed on tailor
ing education to patients who have CNCP.
• Clinicians should take time to educate their patients and make sure patients understand how to help themselves.
• People learn in different ways; clinicians should have a variety of learning materials at their disposal.
• Treatment agreements document the treatment plan and the responsibilities of the patient and the clinician.