Posted By: Amanda Zimmerman, PA-C 
When providing patients with prescriptions of any type, it is best practice to also provide them with education on the medication’s use, storage, and risks. This is an extremely important aspect of prescribing opioids, as education has the potential to prevent opioid misuse and lessen the possibility of addiction development. The origins of the opioid epidemic are multifactorial, however, I strongly believe the lack of education surrounding chronic pain and opioid use on the part of providers and patients played a part. In fact, when the opioid epidemic really came to the forefront of healthcare and the media, I had some patients come to me and ask, “Am I taking an opioid?” They were typically patients who had come from a primary care provider who prescribed the opioid medication; by the time the patients made their way to me—a pain specialist—I had made the incorrect assumption that they already had been educated on their medication.
That said, it is wise to remember that education is not a “one-and-done” deal; it is something that should be ongoing during the entire course of care for your patients while they are on opioid therapy. It is also okay to repeat information. It is very likely that certain education points will need to be reiterated and revisited time and time again with the patient—and possibly their family—as you continue their care.
A strong educational plan for opioids includes the patient–prescriber agreement, the proper use of opioids, safeguarding measures, and monitoring for and managing adverse events (AEs). There is strength in numbers here: Friends and family of those prescribed opioids also should be educated on their safe use and AEs so that they can add to the safety efforts.
Patient–Prescriber Agreement
In terms of the patient–prescriber agreement (PPA), first and foremost, you want to be sure that the patient is able to read the document. You need to be sure that they are not just signing off on it without reading and understanding what is in it. This means the document should be in their preferred language and at an appropriate literacy level. Some patients cannot read and do not come forward with that information, so you want to make sure you are asking about that, as well as reading out the document for them—you do not necessarily need to read the entire PPA to them, but you want to hit the main points.
The PPA should include statements of your role in keeping the patient safe while opioids are being prescribed, as well as the patient’s role in keeping himself or herself safe while opioids are being prescribed. Emphasizing that this is a team effort with dual responsibilities is key here.
A strategy called the “teach-back method” can be useful—having the patients repeat your instructions to you in their own words so you can ensure that they understand the directives.
Proper Use of Opioids
Another key educational item to outline is that opioids should be taken only as prescribed. The patient should not crush, chew, or mutilate the tablet in any way. If it is a capsule medication, you need to check the prescribing information for the specific agent, as some capsules can be opened and sprinkled on food, but others cannot.
Proper use also includes not sharing opioids with anyone else, as well as not taking medication from anyone else, even if it is the same prescription. Many patients will offer opioid medications to their friends and family with complaints of pain in an effort to be helpful, but this is not safe and should not be encouraged. I have seen this happen quite regularly with my patients: One notable example is a patient who tested positive for methadone on routine screening—when not prescribed methadone. When questioned about it, she said her son—who is prescribed methadone for addiction management—gave it to her to help quell a cough. They both knew the medication was methadone, but the woman did not know it was an opioid, nor did she know how dangerous it was to take someone else’s opioid medication while currently taking her own. So, really, we cannot emphasize this education enough, and it needs to be revisited with patients on a regular basis.
Safeguarding Measures
Along with stressing that opioid medications are not to be shared, it is important to stress that they should be kept in a secure location. The prescription should be stored in a lockbox or safe so that no one else has access to it—this way there is less chance of a child accidentally ingesting the medication, as well as less chance for the medication to be stolen. Patients should be told not to tell others that they have an opioid prescription, nor should they tell others where it is stored. There are some scenarios in which patients should tell others that they have an opioid prescription—for example, close or trusted family members need to know their loved one is taking opioids to keep an eye out for signs of overdose. Deciding whom to tell can be tricky, but patients should be informed to use their best judgment when disclosing this information.
Monitoring
In the PPA is a section on required monitoring and follow-up visits. As a healthcare professional, you need to be monitoring your patients with urine drug screens, saliva swab screens, and pill counts. The frequency of follow-up and monitoring will vary based on patient factors, but personally I have my patients bring their opioid medication to every visit for a pill count so that I or my nurse can count and examine the pills to be sure that they are the appropriate medication. This measure helps you prevent or catch any medication diversion, and it also helps you understand exactly how much medication the patient is taking. You may find that some patients do not take as much of their medication as they are prescribed—this could give you the opportunity to discuss a dose reduction.
Adverse Events
While educating your patient about proper opioid use, it is important they understand the AEs and risks associated with this class of medication. Common AEs include pruritus and constipation; the most significant AE and risk is respiratory depression. Patients should be informed that there are management strategies for many of these AEs. For example, pruritus can be managed with diphenhydramine or a medication adjustment; constipation can be managed with lifestyle changes, over-the-counter laxatives, or prescription medications for opioid-induced constipation. Often, patients will not bring up AEs during visits—whether they are unaware that the symptom is due to their medication or because they are embarrassed by the symptoms. Educating your patient about AEs early on allows them to be aware of them and the need to take early intervention if one occurs. In addition, you should be asking about AEs at every visit.
Respiratory depression is the most serious AE associated with opioid use. In order to reduce your patient’s risk of respiratory depression, counsel them to abstain from alcohol and any concomitant sedating medications. Taking additional opioids or larger doses than prescribed also increases the risk for respiratory depression. It should be clearly stated to the patient that respiratory depression is life-threatening and they need to adhere to this guidance to prevent it from occurring.
Overdose can follow respiratory depression, and patients need to be educated on identifying and managing such situations. Signs that they and their family/friends should be aware of include pinpoint pupils, lack of consciousness, slowed/shallow breathing, or blue/ashen skin. Education on naloxone in case of respiratory depression and overdose is also key.
Naloxone Education
Education on naloxone should include what it is and why it is important (to reverse opioid overdose). It is important for everyone to have this on hand, even if they do not believe themselves to be at risk for an overdose. While taking opioid medication only as prescribed reduces the risk of an overdose, the possibility still exists. In fact, a vast majority of opioid overdoses are accidental, so this education should be provided to all patients, not just those with high-risk factors. Providing naloxone education does not mean you are singling out patients as being at high risk for overdose, but rather it is an important part of the treatment plan for everybody on chronic opioid therapy.
Patients should be told not to store their naloxone with their opioids—you want the naloxone to be easily accessed in case of an overdose. They also should carry the naloxone when traveling, just in case of an emergency. In contrast from safeguarding the opioid medication, patients should be told to share the location of naloxone with others, because in the event of an overdose, the patient will not be conscious and able to tell their family or friends where to find the naloxone and how to use it. If naloxone is used, patients and family/friends need to know to place the person in the recovery position and call 911 immediately—even if the person is revived following naloxone administration.
I know we do not have a lot of time with our patients, and this seems like a lot of information to convey, but patient education is a very important part of opioid management. We need to be sure that we are covering it thoroughly and consistently with all of our patients.
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