Breaking the pain contract: A better controlled-substance agreement for patients on chronic opioid therapy

Abstract

"Pain contracts" for patients receiving long-term opioid therapy, though well-intentioned, often stigmatize the patient and erode trust between patient and physician. This article discusses how to improve these agreements to promote adherence, safety, trust, and shared decision-making.

Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids

“…Similarly, it is important to determine the classification of pain, whether nociceptive, neuropathic or both, in order to ensure that non-opioid pharmacological options for neuropathic pain have been fully explored. Among the considerations suggested when prescribing opioids is the use of an opioid treatment agreement [7,[30][31][32][33][34], which I will elaborate on further in the following section.…”

Contracting Compliance: A Discussion of the Ethical Implications of Behavioural Contracts in the Rehabilitation Setting

“…Particularly in the context of the opioid crisis, clinicians may be searching for strategies that can offer safeguards against dependency in the case of prescribing opioid therapy to manage chronic pain. Behavioural contracts have been employed as one of these (somewhat controversial) strategies, where the patient is notified that their doctor may discontinue prescription if certain terms of use are not followed [2,5,6]. Additionally, and not necessarily related to substance use disorders, worries about violence against healthcare providers, other patients and visitors can motivate the imposition of behavioural contracts [7].…”

“…Additionally, and not necessarily related to substance use disorders, worries about violence against healthcare providers, other patients and visitors can motivate the imposition of behavioural contracts [7]. Contracts may also be employed in an attempt to mitigate physician risk and safeguard against medical malpractice litigation (e.g., the risk of being sued for an unsafe discharge) [5].…”

“…In addition to the belief that contracts promote positive outcomes, they may also be appealing from an administrative perspective. Contracts are easily reproduced and there is a misperception that they require little training to implement; templates are available online and adaptable to various situations; clinicians can simply modify them to suit their needs [5,7]. Because of this, some contract advocates have suggested that they constitute a fiscally responsible way to standardize departmental practices [3].…”

How Should a Physician Respond to a Patient's Pain When New Opioid Prescribing Laws Limit Shared Decision Making?

“…However, it should be noted that Tobin et al question the language used in an analogous form, the patient-provider agreement (ie, "pain contracts" for patients receiving chronic opioid therapy), which seems to stigmatize the patient and thereby risk undermining patient-clinician trust. 24 Although the Opioid Start Talking form could facilitate shared decision making in some cases, it could threaten the therapeutic alliance in others. Framing the Opioid Start Talking form in terms of shared decision making about opioid management for pain care could help avoid distrust.…”