This study provides new information on the use and perception of PPAs, which can serve as a guide for future research. In particular, understanding important content for patients will facilitate the development of a patient-centered AAE. We also describe trends that require further examination: the increasing pressure to use AAEs, described by general practitioners, particularly given the level of evidence of the effectiveness and use of AAEs in the ER. Although beyond the scope of this study, assessing the effectiveness of AAEs in preventing distraction and abuse should be a priority for future research before AAEs become standard practices. The results of this study should be interpreted with caution. Focus groups provide insight into participants` perceptions, attitudes and beliefs, but do not provide generalized quantitative results. Therefore, the attitudes and perceptions described in this report are not those of all patients or prescribers. On the other hand, these results provide information on the actual scenarios experienced by patients and prescribers. The American Medical Association (AMA) defines Informed Consent as “more than one patient to sign a written consent form. It is a process of communication between a patient and a doctor that leads the patient to take a particular medical intervention.¬†Prescribers reported misunderstandings about the importance of AAE in patients.

Some believe that patients misunderstood the AAE to mean that the prescriber agreed to prescribe drugs for opioids as long as the AAE was signed. This was confirmed by several patients who indicated that the signing of AAEs meant that they would have their pain treated. Many patients also reported that the prescriber was mostly responsible for the AAE. Both patients and prescribers questioned the legality of the AAE, while patients were more likely to think it was a “legal document” that they had to sign, while those subject to medical prescription were not sure of their legality. “It`s not a legal document,” said one general practitioner. Nevertheless, prescribers were likely to provide legal protection in the event of an infringement of the AAEs. One of them said, “(with a signed AAE), I cannot be blamed for being able to give up if I release a patient from the office.” Each of them refers to the same contractual document: an agreement signed between a prescriber and a patient that clearly defines the guidelines and responsibilities between these two parties with regard to the behaviours and expectations regarding the prescribing of opioid drugs. Compliance with the AAE is a time charge for both prescribers and patients. Several physicians indicated that it could take more than 10 minutes to explain an AAE and answer questions.

For a general practitioner, this valuable time could be spent discussing the patient`s health problems. This role could be transferred to a nurse or pharmacist. Many patients reported that a nurse explained the AAE to them. For patients, increasing the frequency of office visits and drug testing means more time and effort. Given the current state of evidence of the effectiveness of AAEs in reducing opioid abuse and diversion, consideration should be given to reducing some of the most distressing aspects of the AAE. [10.15] There was a dichotomy between patients and prescribers who participated in these focus groups. Most patients had signed an AAE in the ER or prior to the operation, while prescription participants used PPPs in private practice. This lack of compliance is probably due to the inclusion of patients who were not patients with chronic pain and perhaps to our recruitment method (the opt-in database). However, the goal of the focus groups was to study all the experiences and perceptions of PPA patients, not just those of patients with chronic pain.