Opioid Contracts and Random Drug Testing for People with Chronic Pain — Think Twice

Abstract

The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment.

Opiate Written Behavioral Agreements: A Case for Abandonment

“…WBAs are thought to provide a tool for managing what has become an epidemic of harms related to misuse of prescription drugs (Collen 2009). The number of deaths from unintentional drug overdoses has been rising steadily for the past two decades, and it has become the second leading cause of accidental deaths in the United States.…”

“…Generally, patients are asked to sign WBAs that are drafted by the physician or physician's practice without the opportunity to negotiate any of the terms, and they are only given the option to sign or reject them. Although WBAs are explicitly designed to allow physicians to exit the relationship, they do not provide a proportional outlet for patients, since patients are in need of medical services that can only be obtained from a limited number of physicians who provide pain management (Collen 2009 445, 449 [1965]) defines an unconscionable agreement as one with "an absence of meaningful choice on the part of one of the parties together with contract terms which are unreasonably favorable to the other party" ( §96(B)(2)(b)). Due to the asymmetrical relationship between patients and physicians, Collen (2009) argues that patients, who are in a vulnerable position and desperate for help, are thereby placed in a much "weaker position" for bargaining.…”

“…Although WBAs are explicitly designed to allow physicians to exit the relationship, they do not provide a proportional outlet for patients, since patients are in need of medical services that can only be obtained from a limited number of physicians who provide pain management (Collen 2009 445, 449 [1965]) defines an unconscionable agreement as one with "an absence of meaningful choice on the part of one of the parties together with contract terms which are unreasonably favorable to the other party" ( §96(B)(2)(b)). Due to the asymmetrical relationship between patients and physicians, Collen (2009) argues that patients, who are in a vulnerable position and desperate for help, are thereby placed in a much "weaker position" for bargaining. Furthermore, WBAs could be considered unconscionable because they are written at a level that it is not fully understood by the patient, and signed by patients under a kind of duress: under the influence of opiates or pain in the first place (Collen 2009;Prince 2010).…”

“…Due to the asymmetrical relationship between patients and physicians, Collen (2009) argues that patients, who are in a vulnerable position and desperate for help, are thereby placed in a much "weaker position" for bargaining. Furthermore, WBAs could be considered unconscionable because they are written at a level that it is not fully understood by the patient, and signed by patients under a kind of duress: under the influence of opiates or pain in the first place (Collen 2009;Prince 2010). Roskos and coauthors (2007) found that opiate WBAs "presented information at much too high a reading grade level, and with formatting characteristics that probably would make these documents difficult for the average patient to understand" (757).…”

Pain Care Management in the Emergency Department: A Retrospective Study to Examine One Program's Effectiveness

“…6 Some contracts stipulate random drug testing, but these have been criticized for being unenforceable, creating stigma, and destroying patient trust. 6,7 Patient care plans 8,9 and behavioral health interventions 10 for frequent ED abusers have also been tried with variable results and unclear effects.…”