Sign on the dotted line: opioid agreements in patients with a history of substance misuse

Introduction The management of pain in palliative care patients with a history of substance misuse can be challenging. Patients may have a low pain threshold, feel ill at ease in unfamiliar clinical environments and consequently compliance can be poor. Doctors may feel ill at ease prescribing opioids due to fears of exacerbating the addiction or contributing to overdose. Following a regional audit of the management of this patients group, regional guidelines were developed recognising the importance of close working between disciplines and the use of opioid agreements. The development of opioid agreements with patients can improve compliance and quality of life. Aims A reflection on our experiences introducing verbal and written opioid agreements within the palliative care setting. Methods Opioid agreements were utilised with two patients with cancer pain and a coexistent history of substance misuse, in both inpatient and outpatient settings. Written and verbal contracts were used detailing expectations of the patient, role of healthcare physicians, and the plan of care. Results The staff observed improvement in compliance with medication, relationships with staff members and symptom control. The agreements facilitated communication between the hospice, primary care, community pharmacy, and the addiction team. Conclusion Introducing opioid contracts to this group of complex patients ▶ Set clear boundaries for the patient and staff involved in their care ▶ Improved compliance and consequently relationships between patients and staff ▶ Empowered patients to take responsibility for their own analgesic management ▶ Facilitated clear communication between the numerous healthcare professionals involved in the patients care. We feel that the use of opioid agreements with patients with a history of substance misuse has improved the patient experience.