Opioid Treatment Agreements Research Articles

The Legal Landscape for Opioid Treatment Agreements.

Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids' risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances in which the law permits flexibility for clinicians and health care institutions to adopt best practices. We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions' requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts' reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician-patient relationships and patient care within the bounds of relevant legal requirements and risks.

Influence of patient trust in provider and health literacy on receipt of guideline-concordant chronic opioid therapy in HIV care settings.

Persons with HIV (PWH) frequently receive opioids for pain. Health literacy and trust in provider may impact patient-provider communication, and thus receipt of guideline-concordant opioid monitoring. We analyzed baseline data of HIV-positive patients on chronic opioid therapy (COT) in a trial to improve guideline-concordant COT in HIV clinics. Retrospective cohort study. Two hospital-based safetynet HIV clinics in Boston and Atlanta. A cohort of patients who were ≥18 years, HIV-positive, had received ≥ 3 opioid prescriptions from a study site ≥21 days apart within a 6-month period during the prior year and had ≥1 visit at the HIV clinic in the prior 18 months. Adjusted logistic regression models examined whether health literacy and trust in provider (scale scored 11-55, higher indicates more trust) were associated with: (1) ≥ 2 urine drug tests (UDTs) and (2) presence of an opioid treatment agreement. Among 166 PWH, mean trust in provider was 47.4 (SD 6.6); 117 (70 percent) had adequate health literacy. Fifty patients (30 percent) had ≥ 2 UDTs and 20 (12 percent) had a treatment agreement. The adjusted odds ratio (aOR) for a one-point increase in trust in provider was 0.97 for having ≥ 2 UDTs (95 percent CI 0.92-1.02) and 1.03 for opioid treatment agreement (95 percent CI 0.95-1.12). The aOR for adequate health literacy was 0.89 for having ≥ 2 UDTs (95 percent CI 0.42-1.88) and 1.66 for an opioid treatment agreement (95 percent CI 0.52-5.31). Health literacy and trust in provider were not associated with chronic opioid therapy quality outcomes.

Clinician Perspectives on Opioid Treatment Agreements: A Qualitative Analysis of Focus Groups

Background Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians use them and if OTAs themselves modify clinician prescribing practices. Objective To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. Design We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. Participants 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. Approach Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. Key Results Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. Conclusion This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education.

Health disparities in ethnic and racial minority populations with pain and opioid use disorder.

Healthcare providers are not prepared to address health disparities among ethnic and racial minority populations with either persistent and chronic pain or substance use disorder (SUD). Recognizing biases from policies to provide pain management and treatment for SUD in our healthcare systems, from our individual state laws and federal guidelines, is necessary. Biases are embedded in the screening and treatment of patients with chronic pain through the use of screening tools, opioid treatment agreements, and prescription drug monitoring programs. Additionally, the punitive treatment of people of ethnic and racial minority populations who experience persistent and chronic pain, opioid use disorders, or other SUDs needs to be redirected to facilitate solutions rooted in equity.

Adherence to Opioid Patient Prescriber Agreements at a Safety Net Hospital.

Patient prescriber agreements, also known as opioid contracts or opioid treatment agreements, have been recommended as a strategy for mitigating non-medical opioid use (NMOU). The purpose of our study was to characterize the proportion of patients with PPAs, the rate of non-adherence, and clinical predictors for PPA completion and non-adherence. This retrospective study covered consecutive cancer patients seen at a palliative care clinic at a safety net hospital between 1 September 2015 and 31 December 2019. We included patients 18 years or older with cancer diagnoses who received opioids. We collected patient characteristics at consultation and information regarding PPA. The primary purpose was to determine the frequency and predictors of patients with a PPA and non-adherence to PPAs. Descriptive statistics and multivariable logistic regression models were used for the analysis. The survey covered 905 patients having a mean age of 55 (range 18-93), of whom 474 (52%) were female, 423 (47%) were Hispanic, 603 (67%) were single, and 814 (90%) had advanced cancer. Of patients surveyed, 484 (54%) had a PPA, and 50 (10%) of these did not adhere to their PPA. In multivariable analysis, PPAs were associated with younger age (odds ratio [OR] 1.44; p = 0.02) and alcohol use (OR 1.72; p = 0.01). Non-adherence was associated with males (OR 3.66; p = 0.007), being single (OR 12.23; p = 0.003), tobacco (OR 3.34; p = 0.03) and alcohol use (OR 0.29; p = 0.02), contact with persons involved in criminal activity (OR 9.87; p < 0.001), use for non-malignant pain (OR 7.45; p = 0.006), and higher pain score (OR 1.2; p = 0.01). In summary, we found that PPA non-adherence occurred in a substantial minority of patients and was more likely in patients with known NMOU risk factors. These findings underscore the potential role of universal PPAs and systematic screening of NMOU risk factors to streamline care.

An Appraisal of Opioid Treatment Agreements for the Podiatric Physician.

Opioid treatment agreements are written agreements between physicians and patients that represent strategies enumerating the risks associated with opioid medications. These opioid treatment agreements set expectations and obligations, as well as identify responsibilities for both patient and prescriber for opioid therapy. Some critics assert that these agreements are cumbersome and degrade the patient once they enter into these agreements. A systemic literature search and review using the Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) tool was used to find citations describing opioid treatment agreements and their use. Then eligible and appropriate citations were dissected and analyzed. Using the available federal and state opioid prescribing policies, best practice guidelines as well as positive aspects of reviewed literature citations and avoiding bias, degrading, or macroaggression language, a non-cumbersome opioid treatment agreement specific to podiatric medicine was created. A balance argument for the use of opioid treatment agreements to avoid opioid use disorder that is grounded in clinical literature and commentaries are presented. A one-page sensible opioid treatment agreement specific to podiatric medicine, which is similar to more complex cumbersome ones that are found in the literature, and that may be used as part of any podiatric procedural or surgical inform consent, was created and is presented for review. The perception of defending opioid treatment agreements as documents of disclosure to assist patients in their autonomy was offered. Building on the systemic review findings and concept of using elements of disclosure, a model for an analgesic treatment as a one-page informational document to enhance podiatric physicians to create a specific individual analgesic treatment agreement mirroring the scope of podiatric practices that can be incorporated into procedural and surgical inform consent documents was offered.

Lessons Learned in Implementing a Chronic Opioid Therapy Management System.

Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization. Using iterative improvement lifecycles and systems engineering principles, we developed a risk-based workflow model for patients on chronic opioids. Two key safe opioid use process metrics-percent of patients with recent opioid treatment agreements and urine drug tests-were identified, and processes to improve these measures were designed, tested, and implemented. Focus groups were conducted after the conclusion of implementation, with barriers and lessons learned identified via thematic analysis. Initial surveys revealed a lack of knowledge regarding resources available to patients and prescribers in the primary care clinic. In addition, 18 clinicians (69%) reported largely "inheriting" (rather than initiating) their chronic opioid therapy patients. We tracked 68 patients over a 4-year period. Although process measures improved, full adherence was not achieved for the entire population. Barriers included team structure, the evolving opioid environment, and surveillance challenges, along with disruptions resulting from the 2019 novel coronavirus. Safe primary care opioid prescribing requires ongoing monitoring and management in a complex environment. The application of a risk-based approach is possible but requires adaptability and redundancies to be reliable.

Impact of a Vendor-Developed Opioid Clinical Decision Support Intervention on Adherence to Prescribing Guidelines, Opioid Prescribing, and Rates of Opioid-Related Encounters.

Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS. A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naïve patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements. The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged. A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.

‘First Do No Harm’: physician discretion, racial disparities and opioid treatment agreements

The increasing use of opioid treatment agreements (OTAs) has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on...

Opioid Treatment Agreements and Patient Accountability.

Opioid treatment agreements are written agreements between physicians and patients enumerating the risks associated with opioid medications along with the requirements that patients must meet to receive these medications on an ongoing basis. The choice to use such agreements goes beyond the standard informed consent process and has a distinctive symbolic significance. Specifically, it suggests that physicians regard it as important to hold their patients accountable for adhering to various protocols regarding the use of their opioid medications. After laying out a taxonomy of accountability relations between physicians and patients, I argue that opioid treatment agreements are justifiable for physicians to use in their provision of care only if they improve patient or public health outcomes, which has yet to be demonstrated.

Opioid treatment agreements in chronic non-malignant pain: The solution or the problem?

Opioid treatment agreements (OTAs) are routinely used in the primary care setting for patients initiating chronic opioid therapy for non-malignant pain despite limited empirical evidence supporting their use. In this commentary, we review the current practice guidelines in Ontario with regard to OTAs and evidence supporting their utilization in practice. We highlight the lack of high-quality evidence that OTAs lead to beneficial outcomes for patients or prescribing physicians and review the ethical quagmire they create in clinical practice. Physicians utilizing OTAs need to be aware of the limitations of OTAs and sensitive to their potential impact on the physician-patient relationship. Instead, we advocate for a return to a collaborative, patient-centered approach with physicians encouraged to involve patients in a shared decision-making process to set mutually agreeable goals for treatment with opioids, to obtain informed consent from patients, and to better tailor these agreements to reflect the interests of all parties involved. Further research and debate are required to improve the effectiveness and ethical justification for using OTAs in clinical practice.

Perceptions of prescription opioid medication within the context of cancer survivorship and the opioid epidemic.

Prescription opioid medication can be of great benefit for cancer patients and survivors who suffer from cancer-related pain throughout their cancer care trajectory. However, the current opioid epidemic has influenced how such medications are perceived. The purpose of this study was to explore the perceptions of opioid use and misuse in cancer survivorship within the context of the opioid epidemic. pt?>A qualitative study using a semi-structured interview was conducted with a purposive sample of health care professionals (n = 24), community-level stakeholders (n = 6), and cancer survivors (n = 25) using applied thematic analysis techniques. Crosscutting themes include (1) fear of addiction and living with poorly managed pain, (2) the importance of good patient/provider communication and the need for education around the use/handling/disposal of prescription opioid medication, (3) preference for nonopioid alternatives for pain management, (4) cancer survivors perceived to be low risk for developing opioid use disorder (include inconsistent screening), and (5) impact of policies aimed at curbing the opioid epidemic on cancer survivors. This study illustrates the intersecting and sometimes conflicting assumptions surrounding the use of opioids analgesics in the management of cancer pain among survivors embedded within the national discourse of the opioid epidemic. A system of integrated cancer care using psychosocial screening, opioid risk mitigation tools, opioid treatment agreements, and specialist expertise that cancer care providers can rely on to monitor POM use in conjunction with patient-centered communication to empower patients informed decision making in managing their cancer pain could address this critical gap in survivorship care.

Emergency Department Utilization Among People Living With HIV on Chronic Opioid Therapy.

Chronic pain among people with HIV (PWH) is a driving factor of emergency department (ED) utilization, and it is often treated with chronic opioid therapy (COT). We conducted a cross-sectional analysis of a prospective observational cohort of PWH on COT at 2 hospital-based clinics to determine whether COT-specific factors are associated with ED utilization among PWH. The primary outcome was an ED visit within 12 months after study enrollment. We used stepwise logistic regression including age, gender, opioid duration, hepatitis C, depression, prior ED visits, and Charlson comorbidity index. Of 153 study participants, n = 69 (45%) had an ED visit; 25% of ED visits were pain-related. High dose opioids, benzodiazepine co-prescribing, and lack of opioid treatment agreements were not associated with ED utilization, but prior ED visits (p = 0.002), depression (p = 0.001) and higher Charlson comorbidity score (p = 0.003) were associated with ED utilization. COT-specific factors were not associated with increased ED utilization among PWH.

Exploring Patient Perceptions of Opioid Treatment Agreements in a Community Health Center Environment.

Describe patient attitudes toward opioid treatment agreements (OTAs) and characterize perceptions of their impact on patient care, behavior, communication with prescribers, and engagement with the health care system. Qualitative descriptive study. Federally qualified health center with six clinic locations serving a rural population. Patients were prescribed long-term opioid therapy and were required to sign an OTA through an in-person office visit with a clinical pharmacist. Patients who signed an OTA were recruited to participate in semistructured, in-person, one-on-one interviews. Data were analyzed using immersion-crystallization methods. Among the 20 patients recruited, 50% were men; 70% were insured by the state's Medicaid program; and 85% were using opioids for hip, back, and/or neck pain. Four major themes arose from the interviews. First, individuals who use long-term opioids experience a wide variety of opioid-related fears and stigmas. Second, individuals articulated real or potential benefits from implementing OTAs. Third, opinions differed on whether OTAs affected behavior and reduced opioid misuse and diversion. Finally, individuals provided feedback on the health care system's OTA implementation process. Patients experienced a wide variety of opioid-related fears and stigmas, including how OTA requirements can perpetuate these issues. Despite these feelings, participants articulated real or potential positive outcomes from the use of OTAs, although they were mixed on whether these agreements translated to any behavior changes. If OTAs are to become standard practice, future research is needed to describe the diversity of patient perspectives and experiences with OTAs and to evaluate their effect on patient outcomes.

Prescribing Patterns and Use of Risk-Reduction Tools After Implementing an Opioid-Prescribing Protocol.

The literature on results from primary care-based opioid-prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted. Electronic medical record data were obtained for 2607 patients. Demographics, Patient Health Questionnaire-9 scores, body mass index, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid-prescribing protocol within a federally qualified health center. χ2 and t-tests were computed to estimate change in opioid prescribing, morphine-equivalent dose, comedication prescribing, and number and type of protocol elements utilized. The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre to postimplementation (P < .0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, P = .0006) and antidepressant (56.0% to 51.6%, P = .012) prescribing significantly decreased. Total opioid prescriptions and maximum morphine-equivalent doses were similar from pre to postimplementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines. Implementing a multi-faceted opioid-prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high-risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols.

Treatment of chronic noncancer pain in patients on opioid therapy in primary care: A retrospective cohort study

This study sought to characterize the real-world treatment of chronic noncancer pain (CNCP) in patients on opioid therapy in primary care. A retrospective cohort study from 2014-18 was conducted at a multidisciplinary primary care clinic in Chilliwack, British Columbia. Included were adults on daily opioid therapy for CNCP. Patients receiving palliative care or ≤1 visit were excluded. Outcomes of interest included use of opioid/nonopioid pharmacotherapy, number/frequency of visits and proportion of patients able to reduce/discontinue opioid therapy. Seventy patients (mean age 53 years, 53% male, 51% back pain) were included. Median follow-up was 6 visits over 12 months. Sixty-two patients (89%) reduced their opioid dose, 6 patients had no change and 2 patients required a dose increase. Mean opioid dose was reduced from 183 to 70 mg morphine equivalents daily. Twenty-four patients (34%) discontinued opioid therapy, 6 patients (9%) transitioned to opioid agonist therapy and 6 patients (9%) breached their opioid treatment agreement. Nonopioid pharmacotherapy included nonsteroidal anti-inflammatory drugs (64%), gabapentinoids (63%), tricyclic antidepressants (56%) and nabilone (51%). Over half of patients were no longer on opioid therapy by the end of the study. Most patients had a disorder (e.g., back pain) for which opioids are generally not recommended. Overall mean opioid dose was reduced from baseline by approximately 60% over 1 year. Lack of access to specialized pain treatments may have accounted for high nonopioid pharmacotherapy usage. This study demonstrates that treatment of CNCP and opioid tapering can successfully be achieved in a primary care setting. Can Pharm J (Ott) 2020;153:xx-xx.

CE: Implementing Guidelines for Treating Chronic Pain with Prescription Opioids.

Chronic pain, stemming primarily from musculoskeletal conditions and severe headaches, is a growing problem in the United States, affecting as many as 43% of adults. Opioids are frequently prescribed to manage chronic pain despite limited data on their long-term efficacy and the potential risks of long-term use. In 2017, more than 47,000 people died as a result of an opioid overdose involving illicit opioids (such as heroin), illicitly manufactured opioids, diverted opioids, prescription opioids, or some combination thereof. Although it's been more than three years since the nationwide opioid crisis prompted the Centers for Disease Control and Prevention (CDC) to release a guideline outlining safe practices for prescribing opioids to patients with chronic pain (unrelated to active cancer or palliative and end-of-life care), opioid misuse remains a significant concern. Historically, physicians have been tasked with the primary responsibility for implementing opioid safety measures, but nurses in the primary care setting are being increasingly relied on to incorporate these measures as part of their practice. In this article, we discuss the use of five tools outlined in the CDC guideline: prescription opioid treatment agreements, urine drug screening, prescription drug monitoring program databases, calculation of morphine milligram equivalents, and naloxone kits. Primary care nurses can use these tools to promote opioid safety among patients receiving opioid therapy for chronic pain.

Improving Family Medicine Residents’ Opioid Prescribing: A Nurse Practitioner-Led Model

Academic family medicine teaching centers face distinct challenges with opioid prescribing, including higher rates of opioid misuse in resident patient populations and lower levels of experience managing chronic noncancer pain. To improve opioid prescribing practices in an academic family practice, we introduced and evaluated a nurse practitioner-led collaborative care model. After implementation of the model, we found a reduction in the average dose of opioids prescribed, increased use of urine drug tests and opioid treatment agreements, and fewer prescribers per patient. The nurse practitioner-led model was successfully implemented in an academic family practice with improvements in opioid prescribing and monitoring practices.

Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers

ContextChronic pain, or pain lasting more than three months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT). ObjectiveOur objective was to explore palliative care providers' experiences with managing chronic pain in cancer survivors prescribed LTOT, specifically in ambulatory palliative care settings, and their strategies for overcoming challenges. MethodsWe recruited providers through leading national palliative care organizations who manage chronic pain in cancer survivors. Asked to consider only cancer survivors with chronic pain when responding, participants completed an online survey that included questions about use of opioid risk mitigation tools, confidence in addressing opioid misuse behaviors and discussing/recommending management approaches, and access to addiction treatment. ResultsOf 157 participants, most were physicians (83%) or nurse practitioners (15%). Most reported using opioid risk mitigation tools such as urine drug testing (71%), opioid treatment agreements (85%), and practitioner database monitoring programs (94%). Participants were confident (7–8/10) managing the most commonly encountered opioid misuse behaviors (missing appointments, marijuana use, and using more opioids than prescribed) and in their ability to recommend nonpharmacologic and nonopioid pharmacologic treatments for chronic pain (10/10). They were least confident prescribing naloxone or managing addiction (5/10); only 27% reported having training or systems in place to address addiction. Only 13% had a waiver to prescribe buprenorphine. ConclusionPalliative care providers are comfortable with many aspects of managing chronic pain in cancer survivors on LTOT, although challenges persist, including the lack of systems-based approaches and training in addiction treatment.

Chronic Opioid Therapy in People Living With Human Immunodeficiency Virus: Patients' Perspectives on Risks, Monitoring, and Guidelines.

Chronic opioid therapy (COT) is common in people living with human immunodeficiency virus (PLHIV), but is not well studied. We assessed opioid risk behaviors, perceptions of risk, opioid monitoring, and associated Current Opioid Misuse Measure (COMM) scores of PLHIV on COT. COT was defined as ≥3 opioid prescriptions ≥21 days apart in the past 6 months. Demographics, substance use, COMM score, and perceptions of and satisfaction with COT monitoring were assessed among PLHIV on COT from 2 HIV clinics. Among participants (N = 165) on COT, 66% were male and 72% were black, with a median age of 55 (standard deviation, 8) years. Alcohol and drug use disorders were present in 17% and 19%, respectively. In 43%, the COMM score, a measure of potential opioid misuse, was high. Thirty percent had an opioid treatment agreement, 66% a urine drug test (UDT), and 12% a pill count. Ninety percent acknowledged opioids' addictive potential. Median (interquartile range) satisfaction levels (1-10 [10 = highest]) were 10 (7-10) for opioid treatment agreements, 9.5 (6-10) for pill counts, and 10 (8-10) for UDT. No association was found between higher COMM score and receipt of or satisfaction with COT monitoring. Among PLHIV on COT, opioid misuse and awareness of the addictive potential of COT are common, yet COT monitoring practices were not guideline concordant. Patients who received monitoring practices reported high satisfaction. Patient attitudes suggest high acceptance of guideline concordant care for PLHIV on COT when it occurs.