Review
Opioid Contracts in Chronic Nonmalignant Pain Management: Objectives and Uncertainties

https://doi.org/10.1016/j.amjmed.2005.09.019Get rights and content

Abstract

In this article, we review the principal objectives and ideal elements of opioid contracts, as articulated by proponents of the practice. We examine the limited empirical evidence for the effectiveness of opioid contracts in achieving their intended objectives and identify areas of uncertainty and of ethical concern regarding their implementation. We argue that the challenge in deciding about implementing opioid contracts in clinical practice relates to the multiplicity of potential objectives they might serve, to a lack of empirical evidence regarding their effectiveness, and to ethical concerns over their implementation. Specialty and primary care clinicians contemplating the use of opioid contracts in treating patients with chronic nonmalignant pain need to be sensitive to these considerations, and further debate and research is necessary to establish the proper objectives, elements, effectiveness, and ethical justifications of opioid contracts in clinical practice.

Section snippets

Adherence

The primary goal of opioid contracts is to promote patient adherence to opioid therapy.2, 3, 4 Adherence in opioid therapy is defined as the “self-administration of medications in prescribed amounts and at prescribed intervals,” and “includes obtaining a drug from a single prescriber and avoiding the use of other licit or illicit abusable drugs other than those approved by this single prescriber.”4 This definition of adherence in chronic opioid therapy reflects the problematic aspects of opioid

Opioid contracts: What’s the harm?

We lack both consensus on critical conceptual issues concerning the proper composition and goals of opioid contracts and empirical evidence of their effectiveness in achieving these goals. More conceptual and empirical work is needed to resolve these issues. In the meantime one might ask, “What’s the harm?” One might argue that the reasons for using opioid contracts are sufficiently compelling to justify employing these interventions despite the uncertainties about their use.

We believe that a

Why are opiate contracts so popular?

Opiate contracts are likely to remain widely used. It may be that clinicians who treat pain with opioids in this country inherit opiophobic values that are part of our history and culture. They cannot help but be inundated with the undeniable reality of drug abuse, addiction, and diversion, and the far-reaching social sequelae of these phenomena. In this climate, clinicians who prescribe opioids confront real risks of unwittingly facilitating opioid abuse and diversion and incurring sanctioning

What is a doctor to do?

The lack of empirical evidence supporting their use does not necessarily mean that opioid contracts are not effective or should not be used in clinical practice. What it does mean, however, is that clinicians should pause and critically reflect on why they are utilizing contracts and the contract’s specific content before adopting the practice. The model contracts: (1) emphasize that opiates are part of a comprehensive pain treatment program; (2) stress physician’s responsibility to work with

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    Dr. Arnold was supported by the Project on Death in America Faculty Scholars Program, the Greenwall Foundation, Ladies Hospital Aid Society of Western Pennsylvania, the International Union Against Cancer (UICC), Yamagiwa-Yoshida Memorial International Cancer Study Grant Fellowship, and the LAS Trust Foundation.

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