Opioid Pain Contracts Can Damage Patient Trust, Bioethics Panel Says

A group of physicians and experts on pain policy have published an article arguing that while opioid treatment contracts between patients and their physicians can be useful, they can be harmful for the patient-physician relationship unless presented in the right way, American Medical News reported Dec. 27.

Doctors use the agreements — also known as “pain contracts” — to warn patients not to give away or sell their prescription pills. According to American Medical News, other physicians treating patients for pain have undergone “high-profile prosecutions,” and the contracts are seen as a way to protect physicians from liability. 

Myra Christopher, who co-authored the article in the November 2010 issue of American Journal of Bioethics, said that the contracts can be helpful in letting patients with histories of substance abuse or mental health issues make an informed decision about using opioids, and create an effective plan for care.

“It is not that any of us disagree with the notion that agreements can, in fact, be very helpful in certain circumstances,” Christopher said. “But, what is becoming common practice in many pain specialty clinics is using a preprinted, standardized form that says, ’If we’re going to treat or prescribe controlled substances to you, these are the conditions under which we’ll do so — and sign this document, and if you fail to do so, then we’ll fire you from our practice.’ “

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the number of Americans using opioid pain relievers non-medically grew from 11 million in 2002 to 12.5 million in 2009. All but seven percent of those surveyed by SAMHSA reported getting the drugs from a friend, family member, or dealer, not from their doctor.

Opioid misuse was responsible for 306,000 emergency room visits nationally in 2008 — twice the number in 2004, according to the Centers for Disease Control and Prevention (CDC). The agency also reported that opioids were implicated in 14,000 fatal overdoses in 2006, three times the number reported in 1999. 

Written contracts are consistent with “fundamental ethical principles,” said Perry G. Fine, MD, president of the American Academy of Pain Medicine, as long as their purpose is to support patient health and patients are not forced to sign them.

The American Academy of Pain Medicine, the American Pain Society and the Federation of State Medical Boards have endorsed the use of pain contracts with patients.

The problem, according to Will Rowe, CEO of the American Pain Foundation, is how the agreement is framed for the patient.

“Just think about how it’s presented — unless you sign this, you won’t get your medications,” he said. “That, to me, is crossing the line. … It’s basically a document that says, ’You do this, or I’ve gotcha.’ That’s basically interfering with what should be a trusting relationship between the patient and the practitioner.”