Initiating chronic opioid therapy: recommended steps

Express empathy, partner with your patientEmpathy signals that the provider has the patient’s best interests in mind
Expressing empathy does not commit the provider to prescribing opioid therapy
Optimize nonopioid therapyUtilize nonpharmacologic treatments, adequately dose nonopioid analgesics, and use disease-modifying therapy when appropriate, typically in combination
Frame the treatment plan as a therapeutic trialOpioids should only be continued:
 If safe and effective
 At the lowest effective dose, and
 As one component of a multimodal pain treatment plan
Target functional goalsTreatment goals should be based on functional improvement, not pain reduction
A useful mnemonic to help identify such goals is SMART: specific, measurable, action-oriented, realistic, and time-bound
Obtain informed consent, document thoroughlyCommunicate risks, potential benefits, and safe medication-taking practices, including safe storage and disposal of unused opioids
Document this conversation clearly in the medical record
Employ safe, rational pharmacotherapyConsider opioid potency, onset of action, and half-life when choosing a medication
Comorbid conditions and concurrent prescriptions should affect choice of formulation, dosage, and rapidity of titration
Methadone accumulates in adipose tissue and needs to be up-titrated slowly