Opioid Monitoring in Primary Care

When the patient called the office to request her opioid medication refill, she was taken aback by the tone of the nurse who took her call. “If you don’t sign your updated opioid agreement, there will be no refill,” the nurse stated.

“Oh,” the patient replied. “I didn’t realize that was due.”

“We have a strict policy on opioids here. Everybody has to follow the rules.”

This fictional exchange is based on many anecdotes that my primary care patients have shared with me in recent months. The theme is always the same, “You’d better . . . or else . . ..” Somehow a safety initiative has transformed into one of enforcing the rules, a setup for unnecessary tension, and a far less than ideal experience for both care team and patient.

It’s difficult to face the fact that clinicians, to some degree, have been complicit in the current opioid crisis. In most cases, this was done during a time when limited understanding of opioid dependency coupled with recognition that pain was often ignored and undertreated, led to liberal prescribing patterns. Part of the response to a rising incidence of opioid use disorder, along with more judicious prescribing, has been to create more robust monitoring processes for patients who require chronic opioids for pain management.

In our practice, this involves every office touchpoint, from triage and scheduling, to clinical visit and checkout. Clinicians and staff need to convey that the purpose of this monitoring is keeping patients safe. Avoiding negative assumptions and maintaining self-awareness of personal bias or stigma are essential. If test irregularities or other issues arise, discussions must be approached with curiosity and concern, rather than with suspicion. When empathically positioned as an initiative which has the patients’ best interest as its central focus, opioid monitoring programs can strengthen the care team-patient relationship and minimize conflict.

Here are 4 phrases that may help build trust with patients who require opioid monitoring:

1. “We have an opioid prescribing agreement designed for your safety. We ask all patients who need opioid medicines to read and sign. Is there a convenient time to review it together?”

2. “I’d like to see you every three months to be sure your pain medicine is helping and discuss and possible side effects.”

3. “Your urine drug screen is overdue. Can I help you schedule the test at a time that works for you?”

4. “What’s your understanding of the urine drug screening test and why we ask you to complete one? Maybe I can explain it.”

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.