CDC Recommendations

The developing brain may be more susceptible to addiction when exposed to opioid medications and non-medical use is more common among younger people. Those risks should be considered when prescribing to an adolescent.

Patients with mental health conditions are at increased risk for developing chronic pain; therefore, physicians should be cognizant of a patient’s psychological status and potential for substance use disorder. “Because psychological distress frequently interferes with improvement of pain and function in patients with chronic pain, using validated instruments such as the Generalized Anxiety Disorder (GAD)-7 and the Patient Health Questionnaire (PHQ)-9 or the PHQ-4 to assess for anxiety, post-traumatic stress disorder, and/or depression (205), might help prescribers improve overall pain treatment outcomes. Experts noted that prescribers should use additional caution and increased monitoring to lessen the increased risk for opioid use disorder among patients with mental health conditions (including depression, anxiety disorders, and PTSD), as well as increased risk for drug overdose among patients with depression.”

A patient-provider collaborative written opioid treatment plan should be established before opioid therapy and be reviewed and updated on a regular basis. Prescribers should tailor the treatment goals to the patient’s circumstances, cultural preferences, and characteristics and pathophysiology of the pain. The pathophysiologic basis of the pain can help establish a prognosis for future improvement (or worsening) in function and pain, and should influence the treatment goals. Non-opioid treatment modalities should be included in the treatment plan whenever possible to maximize the likelihood of achieving treatment goals. Patient responsibilities include properly obtaining, filling, and using prescriptions as directed, and adherence to the treatment plan. The treatment plan is usually combined with a consent form.

Prescribers should obtain and document information about the patient’s treatment and history.

Prescribers should document the treatment, interactions, and findings throughout their professional relationship with the patient. Providing thorough documentation throughout the treatment plan is essential for patient safety and prescriber protection.

The treatment plan and goals should explicitly include a plan to modify or discontinue opioid therapy when benefits do not outweigh the risks or when the patient fails to adhere to the agreed upon treatment plan.

Prescribers should evaluate benefits and harms with patient within 1 to 4 weeks of starting opioid therapy or at the time of dose escalation; then continue to evaluate the benefits and harms of therapy with the patient every 3 months or more frequently if needed. If the benefits do not outweigh the harms of continued opioid therapy, prescribers should optimize other therapies and work with the patients to taper opioids to lower dosages or to taper and discontinue opioids.

Prescribers should discuss with patients the known risks and realistic benefits of opioid therapy and patient and prescriber responsibilities for managing therapy, including any conditions for continuation of opioid treatment. This discussion should be documented using a written and signed informed consent form, which is often combined with the treatment plan.

The informed consent form typically includes information about the:

- Potential risks and benefits of controlled substance use, including the risk of misuse, dependence, addiction, overdose, and death
- Adverse effects of opioids
- Likelihood of tolerance and dependence developing
- Possible drug interactions and risk of over-sedation
- Limited evidence of the benefit of long-term opioid therapy
- Risk of impairment while operating motor vehicles or equipment or performing other tasks
- Prescriber’s policies and expectations
- Specific reasons for adapting or discontinuing opioid therapy

Informed consent should also include explaining to patients that they should not expect complete relief of their pain. Improved function is the main criterion for continuing opioid treatment.

Discuss with the patient the involvement of family and caregivers in their care and receive written permission from the patient to involve the family or caregivers. This is best done before starting to treat the patient, because it can be more difficult to obtain consent after an issue occurs.

Utah Code Section 58-37f-301(5) allows a person for whom a controlled substance is prescribed to designate a third party who will be notified when a controlled substance is prescribed to the person. Prescribers should discuss this designation with patients.