Talking with Patients about Opioid Risks and Safety

In an interview conducted prior to a presentation delivered at PAINWeek 2011, held Sept. 7-10, 2011, in Las Vegas, Nevada, Geralyn Datz, PhD, discussed practical strategies for using effective spoken and written communication to help patients prepare for chronic opioid therapy. Dr. Datz is a psychologist and pain specialist who directs the Pain Management Program at Forrest General Hospital in Hattiesburg, Mississippi.

What information do patients need to know about opioids?

It begins with open communication between the provider and patient. This should include education about risks and benefits, awareness of adverse effects and how to report them, and an elementary understanding of addiction and how it develops.

Patients also require instruction about risks of sharing or taking another person’s medicines while using opioids, potential interactions, and knowledge of how to properly stop opioid therapy, if desired. It is also important to educate patients about proper storage and disposal of opioids, as these are avenues by which opioids can be diverted. It is possible to achieve these goals fairly quickly and succinctly with patients.

What are some of the spoken communications strategies you recommend?

Shared decision making is one strategy that is useful with patients. This requires a dialogue with the patient about his or her preferences or concerns, and allows the patient to ask questions, while the prescriber also communicates recommendations.

Research with pain patients has suggested these pain patients want their pain legitimized, and that the strength of the patient—provider relationship predicts adherence. These are important pearls of wisdom for prescribers. For example, if you have a patient that feels you are being dismissive of his or her pain and experience, he or she will be less likely to follow your instructions. In the best case, this could result in nonadherence. In the worst case, this could result in accidental overdose or even death. Neither outcome is desirable.

How important is it for clinicians to supplement these discussions with printed patient education materials?

It is vital to include both spoken and written materials when educating patients. Most patients do not remember everything that is said during an office visit, no matter how important the information may be. Written materials should reinforce every vital point that a prescriber wants his or her patients to know. Patients need time to reflect on what they’ve been told and read about opioid medications, discuss options and concerns with family or trusted friends, and be invited to return with questions. Patient education materials should be written in a simple and straightforward style, at an 8th-grade reading level, and with as little jargon as possible.

This allows the patients to comprehend the information being conveyed, and not feel confused about their care and what is expected of them.

How can prescription opioid addiction, misuse, and diversion be curtailed?

That question is the focus of much debate. Some would say these are system-based problems, which require a multifaceted prevention approach that includes prescribers, manufacturers, prescription monitoring programs, insurance companies, and law enforcement. Education alone will not do it. Education needs to be paired with action, consequences, monitoring, and consistency. That said, there are heuristics and patient care processes that prescribers can employ to assist in reducing aberrant behavior and addiction risk in their patients. One is the “Universal Precautions” approach created by Douglas Gourlay and colleagues. This is a simple yet thorough guideline that basically walks the provider through 10 steps for evaluating, monitoring, and reassessing how effective opioid therapy is. Most health care professionals do not receive nearly enough education and training to adequately address issues of opioid addiction, misuse, and diversion.

What is the best source of (or tool for) information regarding how to manage side effects?

Side effects of opioid therapy are common and can range from mild to extremely unpleasant. Some side effects may not be tolerated at all, and lead to discontinuation of therapy or trial of another opioid. First and foremost, side effects should be reported and discussed with the prescribing provider. It can be dangerous to abruptly stop opioid therapy. Secondly, patients need to be aware that many side effects can be effectively managed, and give the provider a chance to do so. I also encourage patients to be active in their pain care and seek out information on their own. This may include talking to their pharmacists and using self-management resources. Pharmacists are an underutilized resource and have a wealth of information to share. Patients can also go online to look up information about opioid medications via the manufacturer’s website or credible online resources such as PainSafe.org.

What are your thoughts on treatment agreements and their effect on the patient-provider relationship?

A treatment agreement is one possible tool for enhancing patient-provider communication. Agreements put in writing what the expectations of the professional relationship are that surround chronic opioid therapy. Ideally, they cement what is already known and communicated verbally. There are good agreements, and there are poor agreements. A well-written agreement should include safety instructions and troubleshooting advice, which may prevent misunderstandings and/or accidental or intentional breaches of the relationship later on. For example, treatment agreements can describe what patients should do in case of a pain emergency, how to handle it if another provider gives them a pain prescription, and what to do if their medicine is lost or stolen. When patients know what to do, they may act less impulsively. This is safer and also less frustrating for both patients and providers. When used well, treatment agreements enhance the patient-provider relationship. If used improperly, however, they can definitely harm this relationship. It is important to know the difference.