|
OPAS |
|
Methadone Patient Syllabus |
|
Methadone use for pain |
|
|
|
J.
Kimber Rotchford MD MPH |
|
8/11/2008 |
1334
Lawrence Street
Port
Townsend, WA 98368
|
This syllabus is to
help patients or prospective patients to be more informed and to have
helpful references pertinent to methadone care through OPAS. Please let staff know if you have
unanswered questions. |
360.385.4843
Table of Contents
Introduction to Methadone Use in Chronic Pain
OPAS Opiate/Controlled
Substance Use Agreement & Consent Form
OPAS Opiate Use
Information Sheet and Consent
OPAS Agreement and
Consent for Group participation
Copy of letter
regarding acute pain care in patients who are taking methadone
Introduction
to Methadone Use in Chronic Pain
You will be receiving this handout as a result of requested help for a chronic painful condition that is either treated or might benefit from treatment by methadone, a potent opiate pain medication. Note: Being treated with methadone does not mean you are an addict or have and addiction to pain medications.
Many patients who are prescribed pain medications develop complications from their use. Not uncommonly, a complication includes addiction to, as well as dependence on, opiates. We are prepared to help prevent and address all complication of methadone use. To this end we have staff who have specialized in addiction medicine and are board certified by the American Society of Addiction Medicine.
The following are basic guidelines based on two broad categories of patients who might benefit from methadone. As in all areas of medicine the best care is individualized.
The first category of patients is made up of patients who have had limited counseling or formal support in dealing with their chronic non-cancerous pain, addictive disorders, or both. These patients often require intense interventions to stabilize their pain or chemical dependency. In addition to intensive counseling and often group therapy, they benefit from close medical supervision. Their care is often compromised by unrecognized or undertreated medical and psychiatric problems. They warrant frequent physician visits for at least three months and then monthly visits until well stabilized.
The second category of patients already have had fairly extensive pain management and are at low risk of complications from opiate administration. If they have had issues with addictions they have been treated and generally are referred to OPAS for simply a consultation in pain management. They most often are cared for in a primary care setting. Frequency of visits especially benefit from individualization.
All patients who are prescribed opiates through OPAS are asked to read and sign and our Opiate Use Information and Consent Sheet. It is in this packet of information and will contain answers to most of your questions about the safe use of methadone for chronic pain.
Further information about methadone for pain management and the treatment of opiate dependency are available online.
References online:
http://www.painmed.org/pdf/PainMedFAQ.pdf
http://www.csat.samhsa.gov/publications/brochure.aspx
OPAS
Opiate/Controlled Substance Use Agreement & Consent Form
Patient’s Name: __________________________________
Date:
____________________
DOB:
_________________________________
Name of Pharmacy: ____________________________________________
Current Controlled Substances:
________________________________________
Ability to read more
than 8th grade level:
Yes No
This is an agreement between you and
our medical staff. Its purpose is to
help provide you with the best of care while you are receiving opiates for pain
management or opiate dependency. No
changes to the agreement are to be made without your permission and that of a
staff physician (No other staff member of OPAS has the authority to make any
changes) Any discussion of or changes
to of this agreement are expected to be made at the time of an appointment. Revisions
to this agreement require a new one to be signed with the changes noted. Any time you do not follow your agreement we
reserve the right to stop treating and prescribing for you. If that occurs we will notify you in writing
and give you up to four weeks in order to find alternative care. We will share your records with any new
provider. We want you to receive the
best of medical care for your pain or chemical dependency problems. For this to happen we understand that we need
your help and honesty.
How is one to be honest about not
being able to adhere to this agreement if the relationship with OPAS physicians
is threatened by being honest? The
question is especially pertinent if one is dependent on us for his/her medical
care.
What’s more, if you’ve had previous problems with addiction or adhering
to doctors’ prescriptions it is likely that you may have problems keeping this
agreement. Fortunately, the answer is
simple. OPAS clinicians provide
specialized care and have no intention of stopping necessary care simply
because of failure to adhere to this agreement. Rather, what you can expect is
for our clinicians to intervene in a way that will make it more likely for you
to be able to adhere to this agreement and allow the relationship to
continue. We are, however, ethically
obliged to report illegal behavior such as diversion of medications to other
individuals. We have terminated care in
cases when after breaking the agreement a patient is unwilling to follow
through with recommendations to work at making the agreement work. If one can’t adhere to this agreement
something else needs to be done. Also,
there is scientific evidence that indicates that one is less likely to help a
patient with a chronic pain disorder, especially a patient with a chemical
dependency problem, if continuity of care is not encouraged. So there are many incentives for our staff to
work with you to assure proper ongoing medical care. The only other time we have terminated care
is when the patient’s behavior is so disruptive and/or threatening to staff or
other patients that it interferes with others getting the care they need. We hope this explanation is reassuring but
please speak with one of our physicians or other staff if you want further
clarification. Hopefully, even if you
are simply tempted or have an urge to not adhere to this agreement you will
feel comfortable talking about it with one of our clinicians. Although we are not always immediately
available we most often will get back to you within 24 hours when you have an
urgent need after hours.
If there is a change in the
controlled substances you are taking, other than dosage changes, please sign a
new agreement. We recommend that all
psycho-active medicines be prescribed by one clinician. For your safety we require that you use the pharmacy you named above and obtain
all of your medications through it. If
it changes please inform us.
OPAS policy is to make refills only at the time of your regular
appointment. A regular appointment will most likely be required at least once every
four weeks. It is your
responsibility to assure that you have enough medications until your next
scheduled appointment. At first we will
not be able to honor your requests for extra medications for trips out of town,
etc. Later, based upon your history of
compliance and your medical stability we are able to make exceptions. If at all possible these discussions are to
be made at the time of a regular appointment.
Your written prescription and your drugs are like money.
If you lose either we will not replace them until your next scheduled
visit. Please call and speak
immediately with one of our clinicians so that they might help you manage any
withdrawal symptoms. Please take extreme
caution in protecting your medicines from loss or theft. You understand
that OPAS physicians will not replace
stolen or lost prescriptions. You understand that OPAS does not provide
emergency services and that medication refills do not constitute emergencies.
If you are a woman be sure to inform our physicians of
any possibilities of being or becoming pregnant in order to be more fully
informed of therapy options.
You agree by signing this agreement
that OPAS physicians are the only
practitioners prescribing controlled substances for you. Any prescribing clinician that you see as a
patient you agree to inform of this agreement and that you are taking an opiate
for pain management or opiate dependency.
If, in an emergency, you receive any medications from any other
clinician for any reason you must inform us as soon as possible. This includes hormones, birth control pills,
allergy medications, etc. You agree to
inform our physician about all other medicines and treatments that you are
receiving. Please ask other
providers to send records to confirm prescriptions of any controlled
substance. If we don’t have
confirmation it may impact what refills we are able to provide.
Illicit drugs are not allowed. The possible exception is Marihuana. If you are using a cannabinoid product
(Marihuana) for pain management this needs to be negotiated with our physicians
and generally requires medical marijuana authorization. Hence, you agree to ABSTAIN from using any
inappropriate pain medication (including
alcohol) or other non-prescribed drugs and to continue an effective pain
management or opiate dependency program while working with OPAS.
The OPAS staff has been instructed to
be courteous and show you respect.
Please treat them likewise. It is
important to us that you understand the proper use of your medications. In order to help you better we might ask you
to discuss what we told you at your last visit.
Some people find taking notes helpful.
Education is an important component of pain management and chemical
dependency. The best teachers, however,
are unable to help students who don’t listen attentively.
We reserve the right to ask you to give us a urine specimen or
other sample while you are at our office or obtain one that day. It is necessary that the specimen is collected
by an assistant properly trained. The sample
will be tested for controlled or addictive substances. You may refuse to do this. Unwillingness to
submit to a breadth, blood, or urine test will be interpreted as a strong
indicator that you have been using mood-altering chemicals or drinking alcohol
and that an immediate change in your treatment regimen is indicated.
You are not permitted to share any of the medications that we prescribe
with anyone else. As stated above this represents illegal
behavior and must be reported to authorities.
We also routinely require pill counts as a way to help document that
patients are taking their medications as prescribed.
We may require that you participate in active exercises or other forms of
therapy. We may ask that you demonstrate these to us
to be sure you have been instructed properly in their use. We may ask that you keep records of when and
how many exercises you do. We also require full access to medical
records or discussion with other practitioners/counselors that you are
currently seeing or have seen in the past.
Effective pain management or
chemical dependency treatment most often requires collaboration and a team
effort! By signing this agreement you
also give us permission to seek corroborating information from any individual
living in your immediate household.
Less secrets one has when using a
substance that is addictive the safer one is. Likewise, we will be
corresponding with your other health care providers but given the sensitivity
of some issues we will make professional decisions about what information
should be released. We will only
release information to professionals who you have indicated are part of your
health care team i.e.: other physicians, dentists, pharmacists, local emergency
rooms, counselors, ministers). We also
have a letter directed to other prescribing health care providers. We recommend that you read it, keep a copy of
it on hand, and provide a copy to all prescribing practitioners you see. We plan to send them a copy as well.
By signing below you are agreeing
that you have read the information in this agreement and that you understand
it. In addition your signature indicates
that your questions have been answered to your satisfaction. You promise to fulfill your part as a member
of a team that is trying to help you with your pain and or your chemical
dependency(ies). If you do not feel
that you can honor the commitments that are part of this agreement, you may
notify us now and or at any time. If
there are portions of this agreement you are unwilling to adhere to OPAS
clinicians will continue to see you for pain management and or chemical
dependency but controlled substances will not be prescribed.
Before signing this agreement please thoroughly
review our opiate or methadone information and consent form. By signing below
you acknowledge having read and consented accordingly.
Finally you understand that your express
consent is required to release any health care information relating to testing,
diagnosis, and/or treatment of psychiatric disorders/mental health, or drug
and/or alcohol use. If you have been tested, diagnosed, or treated for
psychiatric disorders/mental health, or drug and/or alcohol use, you are
specifically authorizing us to release such diagnosis to your pharmacy for the
purpose of ordering medication and to a laboratory for the purpose of ordering
laboratory analysis. Likewise the
release applies to any referring or prescribing clinician you are or have
seen. Likewise the release applies to
current household members or immediate family members.
Patient Signature:
_______________________________
Date: _______________
OPAS Opiate Use Information Sheet
and Consent
Narcotics technically refer to
drugs that cause one to get sleepy but more commonly and legally the term
applies to prescribed medications that are associated with addictive
behavior. Opiates are derived from the
poppy plant’s opium and are just one kind of narcotic. Opiates include: Morphine, Heroin, Codeine, Hydrocodone,
This paper is intended for the patients of OPAS & Dr. Rotchford who are taking opiates (prescription pain medications) long term to help manage their pain. In addition to our opiate use contract which spells out some the safety issues for using opiates long term, this paper will try to clear up some misconceptions about opiates and help us all communicate better.
In taking any medication the benefits are to outweigh the risks. Pain reduction is a very important medical matter. The benefits of using narcotics for pain management can be a very significant. Nonetheless, there are risks and side effects. Some of the primary immediate side effects of taking opiates include: constipation, cotton mouth, mild sedation, itching of skin, and nausea and/or vomiting. Some people actually become mildly stimulated when first starting narcotics. Most of the side effects do improve with continued use but we will be working closely with you to avoid as much as possible you having any side effects. There are also three other possible consequences of taking opiates that need to be discussed and clarified.
Addiction: Common language and usage of this word says that anyone who takes opiates repeatedly may well become addicted. When we speak of addiction in medicine, however, we have specific issues involved. These include behavior such as impaired control over drug use, compulsive use, continued use despite harm, and drug craving. Using standard medical term, the vast majority of patients who take opiates will not become addicted. Unfortunately, patients who have had addiction problems with other substances or who have been poorly managed with opiates often develop addictive problems on opiates. Addiction is a complicated term and inevitably we will be encouraging you to learn more about it in order to recognize it early on and to seek appropriate help for it.
Physical Dependence: Most anyone who is on significant doses of opiates for more than a couple of weeks, is likely to experience some withdrawal symptoms if the amount of opiate used is quickly reduced. This physical phenomenon of opiate use is not strictly speaking related to addiction. Although a person who is addicted to opiates may well experience physical dependence if taking opiates regularly, an opiate addict can also not experience physical dependence.
Tolerance: Some patients taking opiates experience a diminished effect of the drug over time. That is why some heroin addicts need higher and higher doses to experience the euphoria of opiates. Fortunately, most often in chronic pain patients we don’t observe tolerance and people will do just fine on the same amount of opiate for long periods of time. With ongoing care we always hope to see less amount of pain medication required.
Methadone or Methadone Use for Chronic Pain
We often prescribe methadone or methadone on a trial basis to patients who are in chronic pain. Patients and their families are often scared by methadone or the newer medicine methadone because they associate it with heroin use and addicts. One spouse even confused it with methamphetamine a powerful and very dangerous illegal stimulant. We prescribe methadone or methadone for our patients with chronic pain problems for a variety of reasons. First, methadone and methadone are potent and long acting. As a result, they allow patients to take their doses only two or three times a day. While they can cause significant physical dependency they tend to promote addiction much less than many other opiates because of their anticipated steady state level in the blood. All of the opiates are a little bit different despite the standard teaching that all opiates if taken in equivalent amounts help pain the same. Methadone actually blocks certain receptors in the spinal cord and brain that other narcotics don’t touch. They are called NMDA receptors and often they are important in patients with chronic pain. Some patients can’t tolerate methadone and it can be more constipating that some other opiates. If one is already taking another opiate it sometimes is tricky at first to find the right dose of Methadone. Many patients who are taking opiates do so because they help with anxiety and other troublesome emotions. All patients we care for will be encouraged to find ways besides medications to deal with anxiety and other uncomfortable feelings that contribute to pain.
Some Advantages of Methadone vs Buprenorphine: It is cheaper; more familiar to most clinicians; perhaps more stabilizing in some psychiatric conditions, more research as to effectiveness; no ceiling effect; it is more likely to be covered by third party payers; perhaps safer in patients with active liver disease; it is easier to mix and use with other opiates especially at the time of acute injuries or surgical procedures; can be swallowed and comes in liquid form
Some Advantages of Buprenorphine vs Methadone: Methadone is much safer with significantly fewer deaths and complications associated with its use; it is a Class 3 narcotic so can be called in and doesn’t require a signed prescription; in many patients it has less side effects and less interactions with other medications; it is less likely to cause addiction and has less street value, in some forms of pain such as fibromyalgia it appears more effective; it has a longer duration of action; withdrawal from it appears less prolonged and severe than with methadone; it is less likely to have been abused by patients and so less likely to trigger addictive patterns; can be legally prescribed for opiate dependency by any qualified physician
Warnings: Mixing methadone or methadone with alcohol or other sedatives can be very dangerous. There was a case in Florida where an 18 year old who took only 10mg of Methadone and 1 mg of Xanax (Alprazolam) and died. Of course this individual probably had some genetic susceptibility but it nonetheless highlights how dangerous these medications can be especially if used in someone not use to them or when used in combination with other medicines. Please inform any physician you are seeing of your use of opiates. The following recommendations apply to driving:
• When not to drive or work around dangerous machinery or at height
– If there has been a recent dose escalation
– If you feel drowsy (Lack of sleep also impairs one significantly)
– If you are in a great deal of pain
– If alcohol is taken
– If you are frail or elderly, consider doing some special testing
If you have questions about opiate use we encourage you to let us know. We also invite spouses/immediate family members to office visits to have their questions answered.
Consent: I have read the above and I understand all of it. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. I have been given other options for my pain but am proceeding because my condition is serious or other treatments have not helped my pain. By having voluntarily signed this form, I give my consent for the treatment of my pain with opiate pain medicines. What’s more if I am being prescribed methadone for opiate replacement and or pain I give my consent. I have signed this document above after reading it in its entirety.
Patient Signature: _______________________________ Date: ___________________
There are many online references related to pain management and addiction:
http://www.painfoundation.org/page.asp?menu=1&item=3&file=documents/doc_033.htm reviews the use of pain medications and indeed the pain foundation website is very helpful. www.painfoundation.org
Dr. Rotchford belongs to the
Dr. Rotchford is certified in Addiction Medicine and an active member in the American Society of Addiction Medicine: www.asam.org
SAMSHA the
governmental agency that oversees chemical dependency treatment has extensive
information online about methadone and methadone: http://www.samhsa.gov/ Revised 8/2008
OPAS Agreement and Consent for Group
participation
It is important that you understand the kinds of
services you will be provided and the terms and conditions under which these services will be offered.
I, -------------------------------------------------------- , am requesting treatment from the staff of
)
OPAS.. As a condition of that treatment,
I acknowledge the
following items and agree to them. I understand the following: Please initial each item.
_____------ 1.
The Program: The outpatient chronic non-malignant pain treatment program
I am agreeing to participate in is part of an evidence-based educational approach
to chronic pain and/or chemical dependency. The content has been designed by
the staff of OPAS with reference to similar programs with effective
outcomes. The staff believes that the treatment
strategies employed provide a useful
intervention for chronic pain and/or chemical dependency. No specific outcome can, however, be guaranteed.
_____------ 2. Rules of Participation: Treatment
participation requires some basic ground rules. These conditions are essential for a successful treatment
experience. Violations of these rules may result in treatment
termination.
----------- I
agree to the
following:
a. It is necessary to arrive on
time for appointments. Upon each visit, I am to be prepared to leave a urine and/or breath alcohol
test if I’m being prescribed opiates or other controlled substances.
b.
Conditions of treatment contolled substances require abstinence from all drug and alcohol use while a patient with
OPAS. The only exceptions are those medications
prescribed or authorized by a staff physician. If I am unable to make this
commitment, I will
discuss other treatment options with one of the staff physicians.
c. If I am receiving
opiate replacement or opiate pain therapy through OPAS the conditions of the
Opiate Agreement need to be respected as well.
I will discuss any drug or alcohol
use with the staff while in treatment.
d.
Treatment consists of individual and group sessions. Twenty-four hours’ notice will be given to reschedule individual appointments
if necessary. Group appointments cannot be
rescheduled, and attendance at them is extremely important and necessary for
ongoing medical management. Telephone notification will be
made for last-minute absence or lateness. If individual sessions
are missed at the time of group they can only be rescheduled during regular
OPAS office hours and extra fees not
covered by Medicare, DSHS, or other third parties may apply.
e. Treatment will be terminated if
I attempt to sell drugs or encourage inappropriate/non-prescribed drug use by
other patients.
f. I will not become involved
romantically or sexually with other patients.
g. I understand that it is not advisable to be
involved in any business transactions with other patients.
h. All matters discussed in group sessions and the identity of all group members are absolutely confidential and
will not be shared with non members.
i. All treatment is voluntary. When I decide to terminate treatment, I
will discuss this decision with the staff.
_____ 3. The Teaching Facility: Services are
provided by physicians, master’s-level
therapists, or other certified
addiction staff people. Our
medical director is a pain specialist and is board certified in Addiction
Medicine through the American Society of Addiction Medicine.
_____ 4. Consent to Videotape/Audiotape: To help ensure the high quality of services and training at the clinic, therapy sessions may be
audiotaped or videotaped for training purposes. The patient and, if
applicable, the patient’s family consent to observation, audiotaping, and videotaping for these purposes.
_____ 5. Confidentiality: Unless
part of the opiate agreement all information disclosed within these sessions is strictly confidential and may not be revealed to anyone outside the clinic staff without the written permission of the patient or the patient’s
family. The only exceptions are when
disclosure is required or permitted by
law. Those situations typically involve
substantial risk of physical harm to oneself or to others, or suspected abuse of children or the elderly.
---------- 6. Cooperation:
Accomplishing
treatment goals requires the cooperation and active
participation of patients and their families. Very rarely, lack of cooperation by a patient may
substantially interfere with OPAS’s ability
to effectively render services to the patient or
to others. Under such circumstances, OPAS may
discontinue services to the patient.
The patient certifies that he or
she has read, understood, and accepted
this Service
Agreement and Consent. This agreement and consent covers the length of time the patient is
involved in treatment activities with OPAS and Dr. Rotchford.
PATIENT
SIGNATURE DATE
Copy of letter regarding acute pain care in patients who are
taking methadone
Dear Health Care Provider,
All patients
cared for through OPAS and who receive opiates complete an opiate use
agreement. Let us know if you would
like to send you a copy of our agreement.
The language of the agreement is mostly standard. Since we are prepared to care for the disease
of chemical dependency as well as chronic pain, we are more likely to see
patients back and have more intense interventions for those struggling to
adhere to the agreement.
Confusion
sometimes occurs regarding the management of acute pain and or other
conditions. This is especially the case
when the use of controlled substances or other psycho-active medications are
indicated.
One question is
what constitutes a breach of the agreement?
May another provider prescribe opiates?
The answer is yes but it is contextual.
Patients who are on opiate management for chronic pain will experience
the same amount or even more pain than the average individual who injures them
self, has a surgical procedure, or who experiences an acute painful condition. When opiates are indicated for an acute
condition the following suggestion applies:
a. Prescribe a dosage that is 10-20%
higher than you'd prescribe an opiate naive patient.
b. Prescribe the dosage for 20% or so
longer than what is normally prescribed for the patient’s condition.
c. Prescribe the opiates on a time
contingent basis and not on a prn basis.
For example,
if one would typically prescribe 20 Vicodins following a painful
injury/procedure and the pain is expected to last 3 days then one might, in the
case of someone taking methadone chronically, prescribe 24 Vicodin in the
following manner: 2 QID for the first day, 2 TID the second day , One QID the third day,
One TID the fourth day and fifth day.
One can also complement the acute pain management with a non-steroidal.
Because our
patients can provide challenges with regard to pain management we are willing
to provide assistance for acute pain management. If we are to prescribe the opiates, however,
we need clear information regarding diagnosis and expected pain medication
needs for the typical patient with the acute condition.
Please don't hesitate to call the office
with questions. While we can't assure 24
hour coverage we do generally get back to messages within a 24 hour period.
Sincerely,
J. Kimber Rotchford, MD