I think that autonomy is very important when we’re looking at issues of adherence. In this country for the most part, people with pain are treated not particularly well, in my opinion, and as a bioethicist, I really struggle with that. Treatment agreements, also oftentimes called opioid contracts or opioid agreements are very one way, very unidirectional. In order to have a shared decision-making model, patients need to know what they’re getting themselves into, what kind of decisions are being made. With adequate information they can make good decisions with the physician as to whether or not opioids, or any other treatment is going to be in his or her best interest.
To get optimum adherence, we need to do more than treatment agreements. We need to provide education. We need to do urine drug testing on a regular basis. With all of the hullabaloo about opioids these days, it’s amazing to me to see how few physicians are actually doing opioid drug testing. In my eyes, it is the lynchpin of adherence and one of the lynchpins of good pain medicine. I think that the physician is as responsible for promoting adherence as is the patient in being adherent. It’s a fact that physicians are not adherent. They’re not adherent to the treatment guidelines that are evidence-based. The rest of the world is laughing at our pain medicine system because we do not follow the evidence-based guidelines. Perhaps if we did, we’d be modeling good behavior for the patient and the patient would be more likely to adhere. I think the way that we can do better in the area of adherence is to take time and educate, educate, educate. We take our patients’ intelligence for granted. If we educate in terms that they can understand, they’re going to be happier and we’re going to get better results.