The Opioid Crisis: A Multidisciplinary Perspective on Effective Management - Episode 16

Pain Contracts vs Agreements Between Clinicians and Patients

April 29, 2021

Charles Argoff, MD, leads a discussion on the use of pain contracts versus pain agreements between clinicians and patients to bring about desired outcomes.

Peter Salgo, MD: What about pain contracts? That is something that we heard a lot about for years. Do they work?

Charles Argoff, MD: First, I would not use the term “contract” unless my colleagues—I love the example that you gave, Joshua, about sitting down with the PDMP [prescription drug monitoring program] and talking to your patient. That is what the agreement is about. It is all about how to promote safety in prescribing for the patients’ betterment and safety. This is the way I think we can do this in the most safe and effective manner. It is more an agreement and not a contract. It is outlining those behaviors that would be problematic, and why they are problematic, and expectations. It is a shared understanding of what to expect, so I would not use the term contract. We use that and we remind our patients. We ask people to reaffirm these agreements every year so that our patients are reminded about the importance of this.

Joshua Lynch, DO, EMT-P, FAAEM, FACEP: We are getting away from the, I said it before, the “I got you!” mentality, and I would throw contracts under that header for sure. It is really important. Call it destigmatization, or just call it doing the right thing—we are making patients who use these drugs feel more normal. I think it all falls under the same kind of solution.

An example from the emergency department [ED] is that we do far fewer urine drug screens on overdoses that we know are opiate overdoses than we had in the past. Most patients who come in with an opiate overdose—they overdosed, they got naloxone, they came to the ED, they’re in naloxone-precipitated withdrawal, and in some cases, they are getting buprenorphine right away, which is awesome. Most of our opinions now reflect that doing the urine drug test to catch patients who are misusing cocaine too is of no clinical benefit at all. [Not doing the urine drug test] helps patients feel a bit normal. We are not going to change the treatment; we are still going to refer them, give them naloxone, hopefully get them on buprenorphine in the ED, and refer them to treatment.

I think it lines up with other things we do that may say, “We have one up on you. Here is a contract.” It is all in the delivery. We talked about this many times in regard to making the patient feel good. Do they feel better at home, seeing us via telemedicine? Great. Do they feel better sitting down and talking one-on-one about an agreement that we need to do for their safety? Great. Again, I think a lot of it is based on delivery and approach.

Peter Salgo, MD: That is what I was trying to get at. A contract is almost like, “OK, we made a deal—you broke your end of the deal. Somehow or other, it is your fault.” That always struck me as a bit off when you are trying to get patients to buy in to do this as a team.

Jeremy Adler, DMSc, PA-C, DFAAPA: I would echo Dr Argoff. I would move away from a contract-type relationship because it is not the case that, if they follow all the rules, they are guaranteed to get an opioid. That is not what the document is for; it is for guidance and an agreement. My MA [medical assistant] I work with tells our patients as she goes through process things like, “If you have lost medicine or stolen medicine, a police report is necessary.” That always is a point of discussion. She says, “If somebody is picked up with a bottle that has your name on it because it was stolen from you, who do the police think sold it to that person? You have to file this for your own protection.” The patients often say, “Oh, that makes a lot of sense.” It is a great way to provide a lot of education regarding opioids, safety measures like naloxone, urine drug monitoring—all the different things that we do, I think, can be summarized in these agreements. I think they are really important. It is not a “Got you!” We are not trying to establish a set of rules where, if you adhere to them, you are going to have an opioid, and if you do not follow the rules, you are not. It is not used in that manner.

Transcript edited for clarity.