Breaking the pain contract: A better controlled-substance agreement for patients on chronic opioid therapy

Daniel G. Tobin; Kristine Keough Forte; Summer Johnson McGee

doi:10.3949/ccjm.83a.15172

Article Figures & Data

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TABLE 1

Essential elements of shared decision-making

1 Define the problem
How is the pain affecting the patient’s quality of life and ability to function?

2 Present and discuss treatment options
Consider nonpharmacologic (eg, physical therapy), pharmacologic, and procedural options

3 Discuss benefits, risks, and costs
Consider efficacy, adverse effects, availability, monitoring needs, and other risks

4 Explore the patient’s values and preferences
Discuss ideas, concerns, and outcome expectations

5 Discuss the physician’s treatment recommendations
Base recommendations on medical knowledge and patient preferences

6 Discuss the patient’s ability to follow through on the treatment plan
Can the patient realistically adhere to appointments, tests, and referral plans?

7 Clarify understanding
Consider the patient’s health literacy and assess the patient’s understanding of options

8 Make or defer decision
Make a treatment plan or delay until additional input (eg, from family) can be gathered

9 Arrange follow-up
Create a plan to follow up and modify or continue the treatment decision

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TABLE 2

A checklist for chronic opioid therapy

Both the physician and the patient should initial each point.

Provider initials	Patient initials	Shared responsibilities
		1 We talked about how my pain affects me and how opioids may help me function. We agreed to work toward the following goals: (Table 1, elements 1, 4, and 8) Goal #1: Goal #2: Goal #3:
		2 We talked about other treatment choices. We decided together to use opioids, but my doctor also recommends starting or continuing the following: (Table 1, elements 2, 5, and 8) Physical therapy: Yes/No Talk therapy: Yes/No Exercise: Yes/No Counseling: Yes/No Massage, chiropractor treatment, acupuncture: Yes/No Other pain medications: Yes/No
		3 We talked about possible side effects and the risk of overdose. We also talked about what to do if this happens. (Table 1, element 3)
		4 We agreed to be honest with each other. We both have the same goal—to safely control my pain. (Table 1, element 4)
		5 We talked about the cost of my medication and which drugstore I will use. We also talked about other choices if they become too expensive. (Table 1, elements 3 and 6)
		6 We agreed that opioids can be dangerous, especially if used in the wrong way. For my safety, we agreed that my doctor needs to monitor my pain treatment. This may include: (Table 1, element 9) Pill counts, to be sure the number of pills used is correct Urine (“pee”) or blood tests, to be sure I am taking my medication correctly and no unsafe drugs are present Checking the state “prescription monitoring program” to be sure the drugstore is filling pain pills only when they are due and only from this doctor’s office.
		7 We agreed that I would take only the number and type of pills prescribed to me. We will work together to change them if they are not meeting our agreed-upon goals. (Table 1, elements 7 and 9)
		8 I will tell my doctor about all the pills I am taking and any new medication given to me by someone else. (Table 1, element 2)
		9 My doctor has the right name, address, and phone numbers for me. I will let my doctor know if they change. (Table 1, element 6)
		10 If I have a problem, or if my pain medication is not working, I will talk to my doctor before I do anything different with my pills. (Table 1, element 9)
		11 I agree to take my pills the way the doctor tells me. If I do not understand the directions, I will ask questions. (Table 1, element 7)
		12 My doctor explained that opioids are even more dangerous when they are mixed with other drugs or alcohol or used in the wrong way. For safety, I understand that I should not: (Table 1, elements 3, 5, and 6) Use illegal or recreational drugs, including marijuana Take medications not prescribed to me Drink more alcohol than my doctor thinks is safe for me Take extra pills or ask for early refills Get opioids from other doctors or the emergency room Give or sell my pills to someone else Drive a car until I know how the pills affect me.
		13 I understand that my pills are for me only. I will keep them in a safe place away from children and other people. I will also get rid of leftover pills only in the way my doctor or pharmacist teaches me. (Table 1, element 3)
		14 I will tell my doctor right away if I am pregnant. I know that my medications may need to change to keep me and my baby safe. (Table 1, elements 3 and 9)
		Physician responsibilities
		15 I will listen to my patient’s stories about living with pain. I will keep their personal goals in mind when recommending treatment. (Table 1, element 5) 16 I will keep learning about how to treat pain and recognize when opioids are causing more harm than good. (Table 1, element 5) 17 I will make sure my patient has the right phone numbers for my office and the hospital. (Table 1, element 9) 18 My office and I will be available to my patients when they need help. (Table 1, element 9) 19 I will make sure my patient knows my office rules about how and when to ask for refills. (Table 1, element 7) 20 I will teach my patients how to take their pills safely. I will have them show me to be sure they are doing it right. (Table 1, element 7) 21 If I believe opioids are no longer safe or helping my patient, I will carefully stop prescribing them and use other treatments. (Table 1, elements 5 and 9)