Recommendations

Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent  discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug  take back programs to dispose of unused medication. It should also occur concurrently with the therapy  (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those  who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A  literature search was conducted dating back to the original 2010 recommendation to identify studies  comparing the effectiveness of different risk mitigation strategies for patients on or being considered for  LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements  (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The  study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective  database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT,  regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and  rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the  outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the  intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included  adverse events, pain management, and quality of life. Details of the actual intervention were vague and  did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low.  The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low  for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as  determined by an individual risk assessment.

Question: When should risk mitigation for LOT begin?
Answer: before the opioids are prescribed

Question: What should be done before the opioids are prescribed?
Answer: Risk mitigation for LOT should begin

Question: How should risk mitigation for LOT begin before the opioids are prescribed?
Answer: through an informed consent  discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug  take back programs to dispose of unused medication

Question: When should risk mitigation for LOT occur?
Answer: concurrently with the therapy  (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those  who develop an intravenous drug use disorder)

Question: What was the recommendation in the 2010 OT CPG?
Answer: use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT

Question: Is there any study looking at opioid treatment agreements  (OTAs)?
Answer: One identified study was a systematic review of 11 studies

Question: What kind of evidence is there to support the use of OTAs and UDT?
Answer: weak

Question: What is OTAs?
Answer: opioid treatment agreements