Checklist for prescribers

What to discuss with the patient when considering opioid treatment

• Explain that the evidence for the use of opioids as analgesics is best when used in the management of acute pain, over a period of hours from onset but tapering dose over days to a few weeks.
• Explain that opioids are poorly effective for long-term pain. For a small proportion of patients, opioids may be successfully used as part of a broader plan including non-medication treatments and self-management.
• Discuss the degree of pain relief that might be expected and understand that plan the aim is not complete pain relief but rather reducing pain sufficiently to engage in self management.
• Agree specific functional goals that might be achieved.
• Discuss the potential harms of opioid treatment including: -
  • Sedation
  • Nausea
  • Constipation
  • Effects on hormones
  • Effects on the immune system
  • Potential for the drugs to worsen pain
  • Potential for problematic drug use and addiction
• Discuss opioids and impairment of driving skills
• Discuss the opioid trial
• Discuss the circumstances in which opioid therapy will be stopped
• Discuss arrangements for review

Documentation

Clinical records should include:

• relevant clinical findings that support the decision to prescribe opioids
• agreed outcomes of opioid therapy
• the choice of drug, formulation, dose and duration of treatment
• the circumstances under which opioid therapy should be discontinued
• arrangements for follow up
• the information given to patients

Formal patient contracts have no legal validity. A written, structured agreement detailing agreement on outcomes of treatment, frequency of review, dose prescribed and circumstances in which opioid treatment may be stopped should be part of routine practice and can act as a helpful starting point when discussing progress of therapy.

Responsibility for Prescribing

Where practicable, the patient should receive prescriptions from a single prescriber and the drugs dispensed from a specified pharmacist. Documentation should be clear and accurate to support consistency of safe care if the patient needs a prescription from other than the usual prescriber.

Arrangement for Review

Where practicable, review of long term opioid therapy should be carried out by the initial prescriber until an agreed long term regimen has been established the patient should be reviewed within four weeks of initiation of opioid treatment. The frequency of review once the opioid regimen has been established will depend on the early effectiveness of treatment, the frequency of troublesome side effects, the timing of additional interventions to control pain (eg, surgery) and the presence of concerns in relation to problematic use of opioids. When a regimen is stable and the patient reports substantial relief of symptoms and where additional concerns do not dictate otherwise, opioid treatment should be reviewed at least six monthly.