Module 4: Topic H

Learning Objectives

By the end of this topic, the student should be able to:

Summarize how to work with clients to set SMART goals.
Describe how to incorporate motivational interviewing to support goal establishment.
Describe how to partner with clients to ensure they are making informed decisions regarding their opioid use.
Describe community resources that clients can use in opioid-related decision-making.

Key Concepts

Goal setting within the recovery process often involves the SMART approach, which is an acronym that ensures goals are specific, measurable, action oriented, realistic, and time bound.
Goal setting is an important component of recovery and is best done collaboratively with the individual.
Using a person-centred approach is essential to ensure that individuals explore their own experiences openly to reach goals that are authentic, are tailored to their unique experience of addiction and recovery and encourage ownership and a feeling of responsibility.
The use of the general principals of motivational interviewing by the health and social service provider support goal establishment.
Obtaining informed consent is an important step in opioid therapy. Its definition as an informed decision to accept or refuse treatment makes it an important part of treatment agreements.
In-person or online patient education resources may need to be recommended if the client is seeking supplementary information during the opioid treatment decision-making process.

Goal Setting

Goal setting within the recovery process often involves the SMART approach, which is an acronym that ensures goals are Specific, Measurable, Action oriented, Realistic, and Time bound (Bovend'Eerdt et al., 2009).

Goal setting is an important component of recovery and is best done collaboratively with the individual. Using a person-centred approach is essential to ensure that individuals explore their own experiences openly to reach goals that are:

authentic,
are tailored to their unique experience of addiction and recovery, and
encourage ownership and a feeling of responsibility.

If a trusting relationship is absent, or the health and social service provider assumes a dominant role in goal setting, conflict can emerge, or goals may reflect the needs of the specific program (for example, be tailored to success rates) rather than what is best for the individual.

It is critical for the health and social service provider to show respect for and acceptance of the goals the individual establishes and to refrain from negotiating “higher” goals that may be unattainable and will reduce or threaten the process of self-efficacy.

Goal setting requires health and social service providers to be mindful of their own bias and values; they do not suggest goals that maybe beyond the capability of the client.

“Self-efficacy involves building up patients' belief in their ability to carry out or succeed with a specific task. This means providing a sense of optimism, often by setting a series of simple, attainable early goals toward recovery that will increase the substance-abusing patient's self-confidence when accomplished”
(Weaver et al., 1999, p. 922)

What Do SMART Goals Look Like?

Smart goals are short, clear, and identified by the person rather than by the provider. Each criterion (i.e., Specific, Measurable, Action oriented, Realistic, and Time bound) typically has only one to two small goals to support success (see examples below).

Respectful dialogue with the individual is important when establishing the SMART goals. The principles of motivational interviewing can be used as a guide is identifying goals as seen below.

Table 1: SMART Goal Examples
Component	Example
Specific	I will attend a weekly peer meeting as a form of support.
Measurable	I will keep a calendar of attendance. I will gain more self-confidence as a result of attending.
Action Oriented	I will make the necessary work and family arrangements to attendance regularly.
Realistic	If I feel sick or unwell, I will give myself permission to not attend.
Time Bound	I will attend weekly support meetings for the next six months at which time I will review with my [physician, counsellor, social worker, peer support, coach, etc.].

The health and social service provider can support goal establishment by keeping the general principals of motivational interviewing in mind (Center for Substance Abuse Treatment, 1999):

Express empathy through reflective listening.
Develop discrepancy between clients' goals or values and their current behaviour.
Avoid argument and direct confrontation.
Adjust to client resistance rather than opposing it directly.
Support self-efficacy and optimism.

Supporting Persons to Make Informed Decisions Related to Opioid Use

Person signing an informed consent form at the doctor's office.

nito100/iStock

Informed consent is defined as an informed decision to accept or refuse treatment and is an important component of the treatment process.

Informed consent is imperative, as it:

fosters treatment goals,
fulfills ethical and medical obligations, and
encourages ongoing treatment dialogue.

At a few transitional stages in opioid therapy, informed consent may need to be initiated or revisited. For example, informed consent could be obtained:

at the beginning of opioid therapy,
in the transition to a new prescriber, and
when opioid therapy transitions from an acute pain treatment to a chronic pain treatment.

It is critical that the person using opioids is free to make the decision regarding their treatment without internal or external coercion; thus, respecting and empowering the client will be key to informed decision-making.

The format, content, and time taken during this process will vary among clients depending on their capacity to understand, reasons for treatment, and previous experience with opioid therapy.

NOTE: Opioid addiction may hinder the ability to give informed consent. The client should not be intoxicated or suffering from acute withdrawal symptoms when consent is obtained.

What Does Informed Decision-Making Look Like?

Elements involved in informed decision-making (informed consent) include the following (Hall et al., 2012):

The patient’s diagnosis
The nature and purpose of the proposed treatment
The risks and benefits of the proposed treatment
Alternative treatments
The risks and benefits of the alternative treatments
The risks and benefits of not receiving a treatment
The support available

Community Resources

Clients may request or seek out supplementary resources when making decisions regarding their treatment or treatment of their loved one. Conducting an open dialogue about community resources that are freely available and accessible can help create a solid foundation to build upon during this process.

It could be recommended that the client seek additional in-person education and council.
A local community pharmacist (or the client’s pharmacist) could provide additional opioid education to the client, improving the client’s knowledge and confidence in their decision.
Encouraging and fostering inter-disciplinary relations in the decision-making process may also help with medical adherence and treatment outcomes.
The person using substances could seek peer support services as part of the decision-making process.

Take a moment to browse some existing online resources that could be recommended:

Stop and Think

Now that you have reviewed this content, try this:

Propose a SMART goal for improving the health outcome of a client

Consider client-centered, collaborative ways this could be achieved.

References

American Medical Association. Informed consent. (n.d.). https://www.ama-assn.org/delivering-care/ethics/informed-consent Bovend'Eerdt, T., Botell, R., & Wade, D. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: A practical guide. Clinical Rehabilitation, 23(4), 352–361. https://doi.org/10.1177/0269215508101741

Carter, A., & Hall, W. (2008). Informed consent to opioid agonist maintenance treatment: recommended ethical guidelines. International Journal of Drug Policy, 19(1), 79–89.

Center for Substance Abuse Treatment. (1999). Motivational interviewing as a counseling style. In Enhancing motivation for change in substance abuse treatment (Treatment Improvement Protocol Series, No. 35) (Chapter 3). U.S. Substance Abuse and Mental Health Services Administration. https://www.ncbi.nlm.nih.gov/books/NBK64964/

Cheatle, M. D., & Savage, S. R. (2012). Informed consent in opioid therapy: A potential obligation and opportunity. Journal of Pain and Symptom Management, 44(1), 105–116.

Chisholm-Burns, M. A., Kim Lee, J., Spivey, C. A., Slack, M., Herrier, R. N., Hall-Lipsy, E., Graff Zivin, J., Abraham, I., Palmer, J., Martin, J. R., Kramer, S. S., & Wunz, T. (2010). US pharmacists’ effect as team members on patient care: Systematic review and meta-analysis. Medical Care, 48(10), 923–933.

Giannitrapani, K. F., Fereydooni, S., Azarfar, A., Silveira, M. J., Glassman, P. A., Midboe, A. M., Bohnert, A. B. S., Zenoni, M. A., Kerns, R. D., Pearlman, R. A., Asch, S. M., Becker, W. C., & Lorenz, K. A. (2020). Signature informed consent for long-term opioid therapy in patients with cancer: perspectives of patients and providers. Journal of Pain and Symptom Management, 59(1), 49–57.

Hall, D. E., Prochazka, A. V., & Fink, A. S. (2012). Informed consent for clinical treatment. CMAJ, 184(5), 533–540.

Jacobson, P. L., & Mann, J. D. (2004). The valid informed consent-treatment contract in chronic non-cancer pain: Its role in reducing barriers to effective pain management. Comprehensive Therapy, 30(2), 101–104.

Laudet, A. B. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33(3), 243–256. https://doi.org/10.1016/j.jsat.2007.04.014

Ontario College of Pharmacists. (n.d.). Opioids. https://www.ocpinfo.com/practice_resource/opioids/

Swenson, C. N., & Poffenberger N. Development of a collaborative practice for management of chronic nonmalignant pain.

Weaver, M. F., Jarvis, M., & Schnoll, S. H. (1999). Role of the primary care physician in problems of substance abuse. Archives Internal Medicine, 159(9), 913–924. https://doi.org/10.1001/archinte.159.9.913

Module 4: Trusting, Compassionate, Therapeutic Relationships – Topic H Support persons to make informed decisions and set goals related to opioid use.