24 9. Reduce the risk of opioid-based treatment It has become clear that the extensive, long-term use of opioids that are legitimately prescribed for pain management increases the risk of a patient becoming addicted and thereby developing a substance use disorder. A fundamental and widespread approach to the mitigation of this risk is to ensure that: (1) both the prescriber and the patient fully understand the consequences of taking the drug and (2) the physician and the patient have a clear and unequivocal understanding of the conditions under which the prescription will be continued. This strategy only relates to a situation where the physician and the patient have agreed that the use of opioids is the solution of choice, as opposed to finding an alternative approach to pain management. It is also assumed that the provisions for controlling the amount and duration of the prescription are consistent with the guidelines referenced in Play 2 above. In utilizing this strategy, the first step in reducing risk is to provide physicians and patients with the information they need. Literature, briefings to community groups and handouts in medical offices are all parts of an educational effort to ensure that every party is aware of the guidelines and constraints for using an opioid as a long-term medication. TheCaliforniaDepartmentofPublicHealth(CDPH)hasdeveloped“TheRisksAreReal,”astatewidecampaign designed to encourage patients to talk to their doctors about options for safe pain management and addiction treatment. A preview of the campaign outlining how coalitions can utilize its materials to amplify their community- based opioid overdose prevention programs is available through a recording, slides and campaign FAQs. Having achieved greater awareness of the risks and constraints, a number of organizations have promoted the concept of a written doctor-patient agreement that documents their mutual understanding of the issues involved in any long-term treatment program. There are numerous examples of policies that over the years have been expressed as such “contracts,”80 and models have been proposed by many professional organizations. They typically define circumstances in which the contract will be voided, such as failing a urine test.81 However, the concept of a doctor-patient “contract” has been seen by many as too legalistic an approach for something as personal and important as pain management. There have been cases of severe damage done to patients by the strict enforcement of contract terms.82 In general, the mere act of laying out this understanding between the physician and the patient is seen as a way of imposing a stigma on the patient that presumes a violation of the agreement.83 An updated means of documenting a doctor-patient understanding is proposed in an article in the Cleveland Clinic Journal of Medicine, which argues that the term “controlled substance agreement” is better and less obnoxious than “narcotic contract.” The authors further suggest that the agreement must: • engage the patient, emphasizing the shared, reciprocal obligations of physician and patient • address goals of treatment that are personalized and mutually agreed-upon and that incorporate the patient’s values and preferences • explain treatment options in a way that is understandable and informative for the patient84 Goals and Objectives The goal of this strategy is to ensure that physicians and patients fully understand the risks and obligations each has in undertaking opioid-based treatment, and to make clear the conditions for its continuation. The objective is to document this understanding, so it is clear to the patient. Theory of Change Patients are less likely to develop opioid use disorders if they receive sufficient education and agree to a clear, written understanding as the basis for and conditions of treatment using opioids. Examples Massachusetts law (Chapter 52) requires the physician and the patient to create a contract covering the use of opioids: “In the event that a practitioner recommends that an extended-release long-acting opioid be utilized during the course of long-term pain management, the practitioner shall enter into a written pain management treatment agreement with the patient that appropriately addresses the benefits as well as the risk factors for misuse of the prescribed substance under guidelines published by the department. Such an agreement shall be filed in the patient’s medical record or included in the patient’s electronic health record.”