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Opioid Agreement or Patient-Centric Action Plan?

      To the Editor:
      As an academically educated, board certified pain management physician, my opinions surrounding use of opioid agreements differ from those recently stated by Arnold et al.
      • Arnold R.M.
      • Han P.K.
      • Seltzer D.
      Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties.
      Chronic disease states require a commitment from both physician and patient in order to actualize therapy and optimize outcomes. Arnold and colleagues are correct in stating that use of “opioid agreements” may lack empirical evidence, but “chronic disease action plans,” which model opioid agreements, have been widely utilized and studied in patient-centric chronic disease management and demonstrated significant advantages in improved patient care.
      • Williams D.M.
      Considerations in the long-term management of asthma in ambulatory patients.
      • Handley M.
      • MacGregor K.
      • Schillinger D.
      • Sharifi C.
      • Wong S.
      • Bondenheimer T.
      Using action plans to help primary care patients adopt healthy behaviors: a descriptive study.
      • Turnock A.C.
      • Walters E.H.
      • Walters J.A.
      • Wood-Baker R.
      Action plans for chronic obstructive pulmonary disease.
      Ellwood launched the concept of patient-centric care in1988 and has continued efforts to underscore the importance of collaborative patient-physician disease therapy.
      • Ellwood P.M.
      Shattuck lecture—outcomes management A technology of patient experience.
      In 2003, Johns Hopkins and American Healthways convened to further define the patient-physician relationship. One recommendation included use of verbal or written agreements to improve communication and treatment outcomes.
      American Healthways. Johns Hopkins University
      Defining the Patient-Physician Relationship for the 21st Century 3rd Annual Disease Management Outcomes Summit.
      An opioid agreement is a simple and reproducible tool designed to define the responsibilities of both the clinician and patient and provide the patient with detailed risks and benefits of the prescribed therapy. It offers the opportunity to document critical concerns, such as personal issues, safe medication storage and use, the role of adjuvant testing, therapeutic alternatives, expected outcomes, and the consequences of nonadherence.
      • Burchman S.L.
      • Pagel P.S.
      Implementation of a formal treatment agreement for outpatient management of chronic nonmalignant pain with opioid analgesics.
      I offer the following response in regard to the authors’ perceived ethical dilemma surrounding the use of opioid agreements, as stated “From an ethical standpoint, the discriminatory implementation of opioid contracts may potentially violate patient’s rights to fair and equal treatment.” Not all patients suffering with chronic pain are candidates for opioid therapy, but all chronic disease patients may benefit from a written treatment plan. Patients who do require opioid therapy, especially those with a prior history of abuse or addiction, are entitled to a comprehensive therapeutic management plan and are expected to adhere.
      • Resnick D.B.
      The patient’s duty to adhere to prescribed treatment: an ethical analysis.
      The authors seem to understand the essence of an opioid agreement, as stated “Apart from their function of securing informed consent, opioid contracts may serve to organize and provide rational order to the problem of treating chronic, nonmalignant pain.” Order and documentation are both essential components, especially within the current medico-legal environment. But the authors caution the reader “Clinicians should exercise caution when deciding if and how they use this potentially promising but clearly problematic intervention.” This statement is bold and unmerited and only serves to remind us of how far we still have to go in understanding the complexities of chronic pain management.
      Clinicians should definitely incorporate a written treatment agreement for all pain patients. To quote Dr. Donald Berwick, Clinical Professor of Pediatrics and Health Care Policy at Harvard Medical School, President and CEO of the Institute of Healthcare Improvement, and an early patient-centric care advocate, “Nothing about me, without me.”

      References

        • Arnold R.M.
        • Han P.K.
        • Seltzer D.
        Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties.
        Am J Med. 2006; 119: 292-296
        • Williams D.M.
        Considerations in the long-term management of asthma in ambulatory patients.
        Am J Health Syst Pharm. 2006; 63: S14-S21
        • Handley M.
        • MacGregor K.
        • Schillinger D.
        • Sharifi C.
        • Wong S.
        • Bondenheimer T.
        Using action plans to help primary care patients adopt healthy behaviors: a descriptive study.
        J Am Board Fam Med. 2006; 19: 224-331
        • Turnock A.C.
        • Walters E.H.
        • Walters J.A.
        • Wood-Baker R.
        Action plans for chronic obstructive pulmonary disease.
        Cochrane Database Syst Rev. 2005; 4 (CD005074)
        • Ellwood P.M.
        Shattuck lecture—outcomes management.
        Arch Pathol Lab Med. 1997; 121 (1988): 1137-1144
        • American Healthways. Johns Hopkins University
        Defining the Patient-Physician Relationship for the 21st Century.
        2003 (http://www.patient-physician.com/docs/PatientPhysician.pdf. Accessed June 9, 2006)
        • Burchman S.L.
        • Pagel P.S.
        Implementation of a formal treatment agreement for outpatient management of chronic nonmalignant pain with opioid analgesics.
        J Pain Symptom Manage. 1995; 10: 556-563
        • Resnick D.B.
        The patient’s duty to adhere to prescribed treatment: an ethical analysis.
        J Med Philos. 2005; 30: 167-188