OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

Opioid Contracts: The Ethical Prescription of Opioid

Pain Relievers to At-Risk Patients
Meladi Frankovich
Cultural, Legal, and Ethical Issues for the Health Sciences
Salt Lake Community College

OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

Introduction
Doctor Paulson entered the small room where his newest patient Marie was waiting. Her
chart said she was in regarding her chronic back and neck pain, and upon entering he could see a
clear look of discomfort on her face. Good morning Marie, Im Dr. Reggie Paulson. How are
you doing today?
Not well, Marie sighed. Im in so much pain I can barely walk. She went on to
describe her long history of neck and back surgeries, including multiple fusions for herniated
discs. Nothing seems to help the pain, and the hydrocodone Im taking now just isnt enough
she said tearfully. Ive had such a hard time getting help because I dont have insurance.
After further discussing her medical history, pain levels, and desired care plan, Dr. Paulson wrote
Marie a prescription for Percocet.
Several days later, Dr. Paulson received an angry phone call from Maries son, who had
found her prescription in her purse. He revealed that Marie had a long history of prescription
drug abuse, and had only recently come off probation for a DUI she received as a result of an
accident she caused while on her medication. He also revealed not only did Marie have very
good insurance which she avoided using to make it more difficult for new doctors to access her
complete medical history, but her phone records showed she had called multiple doctors offices
in the weeks leading up to her appointment with Dr. Paulson.

Thesis
Dr. Paulson is in a situation faced by nearly every doctor at one point or another in their
careers. While Maries behavior is strongly indicative of drug-seeking behavior, her history of
surgical attempts to relieve her back pain is not false. How is a doctor to know whether her pain

OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

is genuinely caused by her back issues, if its psychosomatic, if its withdrawal pain, or if its
simply an outright fabrication?
A possible solution or at least a possible deterrent to abusers is the use of opioid
contracts. Opioid contracts are a formal agreement between physician and patient, outlining
acceptable behaviors while receiving narcotic medication, proper usage, and conditions under
which a physician will continue prescribing said medications. While not legally binding, such
contracts can establish a history for at-risk patients such as former addicts and convicts, which
can be referenced later by other doctors, and used as part of the decision making process of
prescribing doctors.

Body
As a general rule, opioid contracts require a patient only receive prescriptions from one
doctor or clinic and only fill the prescriptions at one pharmacy, and stricter contracts may even
require periodic pill counts to ensure the patient is not taking more that the directed amount.
Contracts also clearly state that prescriptions will not be refilled early, even in the event of loss
or theft of the medication. Violation of the contract will usually result in the patient being
discharged from the physician or clinics care.
Opioid contracts are viewed by many as an impediment to the trust between patients and
physicians, particularly for historically disenfranchised groups such as ethnic minorities and
those living in poverty.1 However, the medical approach to opioid prescription inherently
involves some level of mistrust, as physicians often find the first question to come to mind is
whether the patient is being entirely truthful about their level of pain, or whether the pain even
exists at all. Usage of opioid contracts by default for all narcotic prescriptions can serve to ease

OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

patients concerns of profiling or targeting, while also allaying fears of the physician that they
may be enabling a patients drug addiction.
The medical indications of opioid prescriptions to at-risk patients are for long-term
treatment of chronic pain that is not eased by non-narcotic medication such as NSAIDs, in the
hopes of reducing pain severity and increasing the patients ability to function, while minimizing
unpleasant side effects and dependence. Opioid contracts serve to protect both the patient and
the physician by outlining a clear understanding of the expectations, risks, and limitations
surrounding the use of narcotic analgesics, and as such should be considered part of the process
of obtaining fully informed consent.
A patient that is unwilling to abide by the contract, or sign one at all, may very well be
one that is trying to obtain narcotics for recreational use, or is heavily addicted. If abuse is
suspected, either by the patient or by others that may be obtaining the drugs from the patient, a
physician cannot ethically continue offering the prescription as it places the abuser at great risk
of harm or even death. Alternative approaches at that point, including referral to an addiction
treatment facility or detox center, can both satisfy the ethical obligation of doctors to ensure
patients receive the treatment they need, and minimize the risk to the patient and liability to the
doctor.
The most at-risk patients, such as former addicts, mental health patients, and legal
convicts, stand to benefit the most from implementation of opioid contracts. These groups
statistically have the most difficulty obtaining opioid prescriptions, even if their chronic pain is
quite real and quite debilitating. Due to their histories, doctors are understandably hesitant to
prescribe narcotics for fear of assisting in the relapse of a recovered addict, creating a new
addict, or unintentionally contributing to the supply of drugs on the black market. Doctors may

OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

look into less effective methods to help these patients with their pain, but ironically, inadequate
pain management may actually increase the risk of relapse in recovered addicts2 or force such
patients to turn to more harmful or illegal means of treating their pain.
Opioid contracts can help mitigate the increased level of mistrust in at-risk patients, and
provides doctors an additional choice between unregulated prescription of pain medication or
simply refusing to prescribe them at all. This treatment option will benefit patients quality of
life by increasing productivity and improving social lives, particularly in the at-risk groups that
already face such struggles without the added burden of chronic pain. Additionally, it may ease
care by providing a structured environment of care and ease support and monitoring for at-risk
individuals. It can also prevent a desperate patient from turning to more dangerous means of
pain relief, such as heavy alcohol abuse or opiates obtained from drug dealers.
For new patients suspected of doctor shopping, an opioid contract may be contingent
on the results of a urinalysis, which would determine whether an individual is already taking
opioids and is attempting to obtain more. Urinalysis can also be used to determine whether a
patient is feigning pain in order to obtain medication for someone else or for resale, as well as
whether a patient may be abusing other substances that would severely interact with opioids. In
a five-year study of 330 opioid contracts (excluding cancer patients), 45 contracts were canceled
due to a positive toxicology report, abuse of the prescription drugs, or violation of contract
rules.3 In these cases, the contracts were effectively used to identify illicit or problematic
behavior in opioid patients.

OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

Conclusion
Opioid contracts can be an effective means to deter or identify potential drug abuse in
patients reporting chronic pain, and can provide a way for at-risk or historically untrustworthy
patients to have a chance at treating their pain. Such contracts also provide an additional means
of monitoring patients and identifying signs of abuse or addiction, which can enable healthcare
providers to direct such patients to treatment facilities. Furthermore, by extending usage of
opioid contracts to all patients, the risk of racial or socioeconomic profiling is minimized.
Opioid contracts can be a valuable tool to physicians with concerns of how to most ethically
prescribe opioids while ensuring their patients receive the care they need.

OPIOID CONTRACTS: THE ETHICAL PRESCRIPTION OF OPIOID PAIN RELIEVERS TO ATRISK PATIENTS

1. Buchman, D. & Ho, A. (2013, September 7). What's trust got to do with it? Revisiting
opioid contracts. Retrieved from http://jme.bmj.com/content/40/10/673.full?
sid=ba09b667-173d-4f6b-82a5-c61f33a2f062
2. Prater, C., Zylstra, R., & Mikller, K. (2002). Successful Pain Management for the
Recovering Addicted Patient. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC315480/
3. Hariharan, J., Lamb, G., & Neuner, J. (2007, January 5). Long-Term Opioid Contract Use
for Chronic Pain Management in Primary Care Practice. A Five Year Experience.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829426/