Shared decision-making promotes mutual respect between patients and physicians, is achievable in primary care, and can improve health outcomes.27,28 One study found that physicians trained in joint decision-making for chronic opioid treatment for 2 hours were more likely to enter into treatment agreements and set mutually agreed functional goals with patients, and they felt safer. Competent and comfortable treatment of chronic pain.29 In addition, after learning about the risks, some patients may forego opioid treatment. Compared to previous primary care studies [4, 18, 19], our study sample was older [4, 19] with more medical comorbidity. The main indication of opioid use in our population has been musculoskeletal pain, which is consistent with other studies of opioid prescribing in primary care [4, 18, 19]. Comorbid anxiety and depression were significantly higher in previous studies with patients with PCN in primary care. In a study of 209 patients who received opioids for CNCP, 36% had depression and 21% of women and 9% of men had anxiety [18]. In a study of 48 patients who received opioids for the NCP, 54% had depression and 21% had anxiety [4]. However, these previous studies assessed lifelong depression through a file review, while we looked at current anxiety and depression with PHQ-9 and GAD-7 in CSA recruitment. We observed a prevalence of moderate to severe anxiety of 7.8% and moderate to moderate depression of 11.4%. Depression is a risk factor for non-adherence [28]. Patients with chronic comorbid pain, anxiety, and depression are more likely to continue using opioids [29] and develop opioid use disorder [30].

Clinical assessment tools such as the Opioid Risk Assessment Tool (ORT) are designed to assess the likelihood that a patient will exhibit deviant behaviour when prescribing opioids for the CNCP. However, screening tools such as ORT are not commonly used in clinical practice. The CDC`s guidelines on prescribing opioids for chronic pain suggest that clinicians should not overestimate the ability of these tools to exclude the risks of long-term opioid treatment [7]. There is a need to develop effective screening tools to stratify the risk of patients starting AUCs. Such tools could allow clinical practices to include patients at higher risk of opioid use disorder in counselling or in more frequent follow-up and surveillance, as opposed to a “one size fits all” strategy that can currently permeate clinical practice. Such language thwarts attempts at open communication and implies a pejorative attitude towards patients. Stigma can lead to undertreatment of pain, the doctor`s refusal to prescribe opioids, and the patient`s refusal to submit to the terms of a perceived unfair unilateral agreement. As a result, poorly drafted opioid agreements compromise the trust necessary for a physician-patient therapeutic relationship and can compromise optimal pain management.20-23 Regulatory societies and professional societies have been promoting or prescribing written pain management agreements for more than a decade to establish informed consent, improve adherence, and reduce risk. Unfortunately, the content of these agreements varies, their effectiveness is uncertain and some are stigmatizing or convincing, jeopardizing trust. In addition, many are written at reading levels that go beyond the comprehension of most patients.

However, we believe that a well-written agreement is still an important tool in the treatment of chronic pain. The model presents critical information that the patient and physician can discuss and (initially) confirm in writing. It is divided into three sections: shared responsibilities, patient responsibilities and medical responsibilities. Each contains an approximately equal number of elements; this is conscious and visually conveys the idea of an equal and shared responsibility towards the patient and the doctor. The patient, physician, or both must initialize each point to indicate their consent. For these reasons, we encourage physicians to adopt the term “Controlled Substances Agreement” or something similar. This label faithfully reflects the specificity of the treatment and means a partnership between the patient and the doctor. In addition, it allows the doctor to use the agreement when prescribing other controlled substances such as benzodiazepines and stimulants, which also carry a risk of addiction, abuse and side effects. Controlled substances agreements have four commonly identified objectives,34 which are reviewed below: Some doctors inadvertently stigmatize. Believing that they can determine which patients will abuse their prescriptions, they only use controlled substance agreements in this subgroup.

In fact, however, physicians are notoriously unable to predict which patients will abuse prescription opioids or experience side effects.25 Therefore, it is important to be transparent and consistent with monitoring practices for all patients on chronic opioid treatment.26 Interestingly, a 2014 survey found that most primary care physicians felt that controlled substance agreements were not increasing. opioid abuse. 41 In addition, those documents are associated with a greater sense of satisfaction and control on the part of doctors42 and, for some doctors, those reasons may be sufficient to justify their use. Many authors say that the main purpose of the Controlled Substances Agreement is to promote the use of the drug as prescribed, without derogation and only by a doctor.35-38 This objective seems reasonable. . . .