Opioid "Contracts" Dividing Doctors, Pain Patients

By Paul Gaita 05/09/18

The written agreements are causing a rift between patients who just want to continue treatment and doctors who have to set treatment guidelines.  

doctor and patient disagreeing over prescription.

The increased use of written agreements between medical professionals and chronic pain patients that details conditions under which opioid medication can be prescribed is causing considerable debate about whether such "contracts," as they are often described, are useful in reducing misuse of such medication, and can have a negative impact on the doctor-patient relationship.

Health care professionals who support the use of agreements say that they provide a clear outline of treatment guidelines, but patients have expressed concerns over feeling judged for their medication needs or being forced into signing the documents in order to continue treatment.

Both sides are also concerned that the "contracts" may not directly address the pain that prompted the need for opioid treatment, or what to do if a patient breaks the rules established in the agreement.

The documents, which are typically called opioid treatment agreements, outline conditions by which the doctor will prescribe pain medication; a template agreement from the American Academy of Pain Medicine states that these may include random urine drug tests and pill counts, and if violated, can result in discontinuation of prescriptions to that patient.

In some cases, patients also agree to obtain pain medication only from the doctor on the agreement, who may also require written permission to receive a prescription from another doctor.

"It is really meant to be used as a clear way to establish an understanding of [opioid] treatment guidelines and expectations of the patient and physician," said Dr. Kavita Sharma, a pain physician with Manhattan Pain & Sports Associates.

Though frequently called "opioid contracts" or "pain contracts," the agreements are not legally binding and cannot be used in a court of law.

As Healthline noted, the patient's signature serves as a means of indicating that the conversation about guidelines took place.

"A signed written agreement is essential to set the ground rules in a fair and unbiased way so each patient has a clear understanding of how they are expected to behave," said Dr. Mark Malone, medical director of the Texas-based Advanced Pain Care.

But patients have said that the requirement of a signed document in order to receive the same pain medication that, in some cases, they've obtained for years without any conditions makes them feel as if they are suspected of misuse by their doctor.

"I've never done anything wrong, but somehow, the contract made me feel like I already had several strikes against me," said Lynn Julian Crisci, who was injured in the 2013 Boston Marathon bombing.

As Healthline noted, other patients and medical professionals have said that the agreements felt "coercive," and undermined their sense of trust with their doctors.

"You're basically saying to a patient: 'You are in pain, and there's an indicated treatment for you. But I'm only going to give you that treatment if you sign this contract," said Dr. Peter Schwartz, an associate professor of medicine at Indiana University School of Medicine.

Crisci added that the requirements can often feel like patients such as herself are being unduly penalized for what has happened in the opioid crisis.

"There are people who become addicted to prescription drugs and have overdosed, and that is undeniably tragic," she said. "But the solution is not, 'Let's take everyone’s medication away and punish you all.' The solution should be addiction treatment, not punishing patients."

The agreement arrangement also raises a host of secondary issues with patients and doctors alike. If a patient breaks the rules of the agreement by testing positive for illicit drugs, how should their medication be restricted?

Studies have also indicated that the language used in the agreement can, on occasion, be too obtuse for some patients to fully understand what they're signing, while others have indicated that they offer little to no help at all in reducing misuse of opioids.

Dr. Britt Ehlert, an internist with Alliana Health in Minnesota, said that she has gotten a better response from patients by simply addressing the nature of their pain instead of the amount of medication.

"It is key to treat the patient with respect and to actually take very good care of them clinically," she said. "Over time, patients learn to trust you, and that becomes more important to them than the agreement you asked them to sign."

The fact that one approach does not address all issues when talking about chronic pain is ultimately at the heart of the debate over opioid treatment agreements.

"We have to confront the fact that we have people in pain who do not benefit from these medications or cannot comply with the requirements of these contracts," said Schwartz. "We have to find a new way to balance our responsibility to use these medications appropriately with our commitment to compassionately treat pain."

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Paul Gaita lives in Los Angeles. He has contributed to the Los Angeles Times, Variety, LA Weekly, Amazon.com and The Los Angeles Beat, among many other publications and websites.