General Opiate/Opioid Information Sheet and Consent Form

 General Opiate/Opioid Information Sheet and Consent FormOpioids are derived either from opium, a natural chemical produced by the poppy plant, or are synthetically produced to have effects similar to opium derived products. Examples include: morphine, heroin, codeine, hydrocodone, oxycodone, methadone, etc.The primary medical indication for opiates is pain relief but they are also used to help in other medical conditions, most notably opioid use disorders (OUD). The benefits are to outweigh the risks for any prescribed medication. Pain management is an important and potentially critical medical matter. The benefits of agonist therapy (opioids) in the management of opioid use disorders can be life-saving as well. Primary/Most common side effects:ConstipationNausea/Itching/SweatingMild sedation or elationSleep apneaInteractions with alcohol and other prescribed or non-prescribed substances Rapid changes in dose, even if one has previously taken an opiate, can severely interfere with breathing, and overdoses can be fatal as some patients can simply stop breathing.Long-term complications include when used alone:Opioid use disorderIncreased sensitivity to painHormonal irregularitiesOther? (Stable chronic doses of opiates taken alone are NOT generally associated with any measurable change in one’s ability to think or act appropriately)Susceptibility to withdrawal/physical dependence/interactions with other substances Some important terms to understand: Opioid use Disorder: Current label used to connote compulsive and loss of control of the use of opiates. It also does sometimes apply in cases where a patient has only used their opioids as prescribed. An opioid use disorder may or may not include physical dependence. Physical Dependence: When associated with opioid use this means that anyone who takes opiates repeatedly may well need more opiates to have the same effect or might have withdrawal symptoms when the opiate is stopped or reduced . While a person with an opioid use disorder (OUD) will most often have some physical dependence, only two out of the seven historical criteria used for defining an opioid use disorder involve physical dependence. Many drugs cause physical dependence. But only a relatively few have properties that lend them to substance use disorders.When a patient has been diagnosed with anything more than a very mild opioid use disorder it implies that there have been chronic if not permanent changes to the brain. In the future through epigenetics or other means we might hopefully be able to correct the structural changes which occur as a result of long term opioid use in some patients. The susceptibility is clearly genetic arguably in large part. Other criteria we use to support the diagnosis of an opioid use disorder include impaired control over drug use, use longer than expected, compulsive use, continued use despite harm, and drug craving. Fortunately the vast majority of patients who take opiates will not develop permanent changes in their brain which warrants ongoing treatment. When opiates are taken regularly, even for a week or two, physical dependence can occur. (See below) This doesn’t mean one has an opioid use disorder.Patients who have had other substance use disorders, whether to tobacco, alcohol, and other substances are susceptible for a host of reasons to develop an opioid use disorder. As already stated this can occur even when the substance has been taken as prescribed and for relatively short periods of time. Substance use disorders are complex brain diseases. While there is a lot over overlap between different substance use disorders they all have unique attributes and often unique treatment strategies. Methadone or Buprenorphine – Making some comparisonsMethadone or buprenorphine are the most common opioids prescribed for opioid use disorders. For those with chronic pain they are often the safest and most effective opiates to prescribe to patients at risk. Patients and their families are often scared by methadone or buprenorphine because of the stigma associated with “addicts”. One spouse even confused methadone with methamphetamine, a powerful and often abused illegal stimulant! Please review my paper on the cultural influences related to opioid use disorders. It is available online at opas.us under handouts.We frequently prescribe methadone or buprenorphine for our patients with chronic pain for a number of reasons. Both methadone and buprenorphine are potent and long acting pain relievers.. They are more stabilizing for the brain than shorter acting opiates. As a result, while they both may cause significant physical dependence, they tend not to promote dysfunctional brains. Indeed, as already noted they are proven to be effective medical treatment for patients who have opioid use disorders. All opiates are a little bit different. Methadone is unique in several ways and it actually stimulates certain receptors in the spinal cord and brain that other opioids don’t. These are NMDA receptors and they may be important for some patients with chronic pain. Buprenorphine is unique in being arguably the safest while still being a potent opiate. Buprenorphine also tends to have less side effects than methadone and other opiates. Patients have unique brains and receptors so it isn’t surprising that there are variations in the responses to different opioids.Some Advantages of Methadone vs. Buprenorphine: Methadone is cheaper; more familiar to most clinicians; and perhaps is a more stabilizing drug for patients with certain mental health conditions. It has more research as to effectiveness; has no ceiling effect; it is more likely to be covered by third party payers; it is perhaps safer in patients with active liver disease; it is easier to mix and use with other opiates; and it can be swallowed and comes in liquid form. Methadone has received widespread publicity as a dangerous medication. A clinician prescribing it is best to be well trained or to have specialized support. That being said, methadone is not a “bad” drug. It actually has saved countless lives. Like most strong medications it needs to be properly prescribed and used only as directed. When prescribed appropriately and taken as directed serious complications are rare. Some Advantages of Buprenorphine vs. Methadone: Buprenorphine is much safer with significantly fewer deaths and complications associated with its use; it is a Class 3 narcotic so it can be more readily refilled and prescribed. In many patients it has less side effects and less interactions with other medications; it is less likely to aggravate or cause a substance use disorder; it tends to have less street value, and with some forms of pain such as fibromyalgia it appears more effective; it has a longer duration of action; withdrawal from it, while prolonged, appears to be less severe than with methadone; it is less likely to have been abused, and so less likely to trigger old dysfunctional patterns; and it can be legally prescribed for an opioid use disorder by any qualified physician. Methadone can generally only legally be prescribed for pain outside of a licensed Methadone clinic. Warnings: Mixing methadone or buprenorphine with alcohol or other sedatives is dangerous. There was a case in Florida where an 18 year old who took just one 10mg tablet of Methadone and one 1 mg tablet of Xanax (alprazolam) died. This individual probably had some genetic susceptibility. Nonetheless this unfortunate case highlights how dangerous these medications can be, especially if used by those unaccustomed or or when used in combination with alcohol or other medicines. Please inform any prescribing clinician that you are regularly using either methadone or buprenorphine. The following recommendations apply to driving:When not to drive or work around dangerous machinery or at heightIf there has been a recent dose escalationIf you feel drowsy (Lack of sleep also impairs one significantly)If you are in a great deal of painIf alcohol is takenIf you are frail or elderly, consider some special testing to assure safetyWe invite spouses and immediate family members to office visits to have their questions answered and express any concerns.Consent: I have read the above. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. I have been given options for pain management or treating my opioid use disorder. I am proceeding because my condition is serious or other treatments have not helped or are unlikely to help my pain or opioid use disorder. By having voluntarily signed this form, I give my consent for the treatment of my pain with opioid pain medicines whether it be for complex chronic pain or opioid addiction. I agree to keep my medications safe and locked, particularly if I’m traveling or there are people under 25 either visiting or in my household.Patient Signature: _______________________________ Date: ___________________Online references related to pain management and opioid use disorders:1. OPAS.US Please look under the tab Handouts for information on chronic complex pain and addiction, particularly opiate addiction. The manuals on buprenorphine and methadone are there.2. reviews the use of pain medications and indeed the pain foundation website is very helpful. 3. Dr. Rotchford belongs to the American Academy of Pain Management whose website contains a great deal of helpful information. HYPERLINK "; 4. Dr. Rotchford is board certified in Addiction Medicine through the American Society of Addiction Medicine. HYPERLINK "; 5. SAMSHA is the governmental agency most involved with informing the public about addictions. It provides extensive information online about methadone and buprenorphine.6. Cultural Influences with regard to Opioid Use Disorders - This link will take you to a paper written and submitted for publication in March/2017. HYPERLINK "; Revised 03/2017 ? 2016 OMS ................
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