Ten Key Concepts in Chronic Opioid Therapy (below)
A physician managing chronic pain is commonly in the position of referencing remote injury, and providing opioids in the context of analgesic tolerance, physical dependence, and risk from dose dependent toxicity. Compounding these issues are complex concepts relating to drug metabolism, drug-drug interactions, and compulsive medication overuse. In situations where risk-awareness differs from prescriber to patient, the provider can benefit from having a solid structure to authoritatively drive medication related decisions. The following concepts are critical for prescribers to consider when working with patients who receive opioid analgesics for chronic pain.
The shorthand version is the following: The physician has a responsibility to facilitate communications around risk. The physician is almost always going to understand the complexities of the medication risk better than the patient. The patient is more likely to focus on the pain. As dependence develops, a patient’s willingness to consider risk related information is shadowed by the consequences of decreasing or discontinuing therapy. At this stage, the patient’s decisional capacity may be considered impaired relating to issues of medication changes. Informed consent requires the patient to have the capacity to reasonably weigh risks. Even if they can work, balance a checkbook, and cook dinner, they may have sufficient bias towards continuation of therapy that renders them unable to weigh risks of that therapy. This is not a global impairment in decisional capacity, rather an isolated impairment in this narrow area. In the case of unreasonable risk, the physician has should exercise primary authority to make appropriate treatment decisions.
In a case where it is objectively ambiguous, as to whether the risks should be considered reasonable; a third party (i.e. a surrogate) could be assigned to weigh risks. It can also be argued the third party may have an incomplete capacity to weigh risk based on experience, or patient bias. However, family members appreciate providers that are candid about their concerns, and generally appreciate being asked to help. It also can help you learn about your patient.
In practicality, everything that makes you uncomfortable as a professional about treating your patient with opioids, you should be able to openly share with your patient. If it triggers a reasonable discussion, that’s good. Your concerns are on behalf of the patient, so the spirit of your concerns should be validated. You are within your rights and responsibilities to reflect openly on behalf of the patient’s best interest. If the conversation seems like it is driven by excess bias on the part of the patient (defensive, hostile, etc); consider bringing a family member into the conversation in a subsequent visit.
I frame it this way to the family member: “As someone who cares about your family member, you are invested in how things turn out. Five years from now, we don’t want to regret decisions we make today. We don’t want the pain medicines to interfere with your (sister/husband’s/etc.) health, like suffering an overdose, or needing higher and higher dosages over time. It’s my obligation to discuss the risks of the medications with your (sister/husband/etc.). I am also concerned that since changing therapy could put them in withdrawal or increased pain, they may not be as able to fully consider the risks of ongoing therapy, as much as you, a family member who cares about them. We all want to make the best decisions today, and avoid problems from the pain medication, in spite of the pain.”
Introducing risk conversations to a family member with the patient present reinforces your authority in the doctor-patient relationship. It generates an opening for risk, reason, and logic to play into the calculus of decision making. It places the patient’s autonomy to participate in decision as an element that must be balanced against independent concerns. Ultimately if you feel like you are the only one in the room that is making any sense, while there is non-trivial risk relating to their medication use, then the patient is not a good candidate for long term therapy. You might begin identifying alternatives that are minimally destabilizing to the patient, and transition the patient in that direction. It’s important that the patient and/or their surrogate are fully and reasonably capable of understanding the high level of risk associated with opioid analgesics, along with the alternatives to existing or proposed therapy. If you conclude the risk of therapy places the patient at an unreasonable risk for bad outcomes, then you may need to drive action around unilateral decisions. Use your authority, take appropriate actions, and keep your patient safe.
TEN KEY CONCEPTS TO REMEMBER WHEN TREATING CHRONIC PAIN WITH OPIOID ANALGESICS
- 1. INFORMED CONSENT: The legal and ethical obligation to inform patients of the benefits, potential risks, and alternatives to an existing or proposed therapy. Informed consent requires that the patient or their surrogate is competent to weigh risks relating a therapy or its alternatives.
- 2. SHARED DECISION MAKING: Conversations that take place with a patient and/or the patient’s surrogate, intended to weigh information related to risks, benefits, and alternatives to a medical decision. Documentation of shared decision making satisfies informed consent.
- 3. DECISIONAL CAPACITY: The extent to which a patient or their surrogate is reasonably capable of weighing risk related information pertaining to a specific therapy or proposed change in therapy.
- 4. AUTHORITY: The physician’s right or responsibility to exercise the full extent of their medical training, knowledge and experience to make appropriate decisions.
- 5. TREATMENT BIAS: A preferred treatment alternative specific to one’s circumstance or perspective.
- 6. RISK AVERSION BIAS: The prioritization of safety considerations above other considerations.
- 7. DEPENDENCE BIAS: The extent to which the inherent possibility of suffering related to withdrawal interferes with a reasonable consideration of treatment decisions, or weighing risk of those decisions.
- 8. UNREASONABLE RISK: Therapeutic decisions that reach beyond accepted professional standards, such that any reasonable person weighing the breadth of considerations would consider it unreasonable to proceed.
- 9. AUTONOMY: The patient’s preference, and rights, as it relates to therapeutic decisions.
- 10. SURROGATE: A person with intact decisional capacity, who is otherwise identified by the patient to participate in shared decision making on behalf of the patient.
CME ON THIS TOPIC HERE
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6 Key Communication Points For Physicians asking Patients to Sign a Pain Medication Agreement http://t.co/ODKMRzbzla
— Michael Schiesser MD (@manageaddiction) November 5, 2013
— Physicians Insurance (@PhysicianInsure) October 9, 2013