Some guidelines strongly endorse the use of a formal written agreement
between the patient and physician at the start of opioid therapy. In the
ideal, the goal of this document is to inform the patient, define expectations,
clarify the consequences of problematic drug-related behavior, and document
informed consent. These agreements are often called “contracts,”
although they have no force of law.
These goals are laudable, but may be balanced by some negatives associated
with the use of “contracts.” Specifically, written agreements
may enhance the stigma associated with opioid drugs. They potentially
could contribute to assessment difficulties as the patient withholds or
skews information in an effort to meet expectations. If they make demands
(like no driving) that are inconsistent with the literature and would
compromise function if accepted, they could undermine the goals of therapy
or encourage the patient to lie. They could give a false sense of security,
and thereby reduce therapeutic vigilance. It is even possible that they
could implicitly hold a clinician to a certain level of clinical performance
and could be used adversely in a medicolegal dispute.
Given these potential negatives, and the lack of consensus about the role
of this approach, each clinician must decide whether the use of an agreement
is appropriate and likely to be beneficial. If the decision is made to
use such a document, it should be carefully crafted. In a survey that
identified the most common elements used by 39 university-affiliated pain
management centers, the following items were included by more than two-thirds
of these specialists:
- Avoid improper use of controlled substances (includes over-dosing,
seeking medication elsewhere, selling medication, stopping medication
abruptly)
- Terms of disciplinary termination (abusing medication, missed appointments,
violating contract, inappropriate behavior)
- Limitations for replacing medication or changing prescriptions
- Inform physician of relevant information (ie, side effects, other
medications, changes in condition)
- Submit to random drug screens
- Terms regarding appointments (missed appointment follow-up, appearing
without appointment)
- Instruction that there will be no early refills and no replacement
of lost prescription without police report documenting loss
- Limits on drug refills (phone allowances, only in person, call in
advance, normal office hours)
- Side-effects education (including withdrawal)
- Terms of nondisciplinary termination (e.g., no improvement, pregnancy,
tolerance, toxicity)
References
Fishman SM, Kreis PG. The opioid contract. Clin J Pain 2002; 18: S70-S75
Fishman SM, Bandman T, Edwards A, et al. The opioid contract in the management
of patients on chronic opioid therapies. J Pain Symptom Manage 1999;18:27-37
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