Physician use of opioid contracts varies with training

The use of opioid contracts—written contracts between physicians and patients concerning the prescription of opioid drugs for pain—appears to vary with the training level and specialty of the physician. Such contracts appear to be more likely to be used by residents and primary care specialists.

Opioid contracts, along with contracts on the use of other controlled substances, are already in wide use, with one study reporting that 42% of practitioners in a primary care setting use them, said Bryan Keith Touchet, M.D., assistant professor of psychiatry and medical director of the Psychiatry Clinic at the University of Oklahoma College of Medicine, Tulsa. But there has been scanty study of the factors that determine their use.

These contracts create an agreement between the patient and his or her physician that cover many aspects of opioid use. According to the American Academy of Pain Medicine and the American Pain Society, a written agreement between physicians and patients can be a way to inform a patient of the risks and benefits of opioid use, as well as the conditions under which opioids will be prescribed.

Although several versions of these contracts exist, most set out the terms of allowable opioid use by the patient, including spelling out requirements that the patient keep a record of his or her opioid use, obtaining prescriptions for opioid only from the doctor (who also signs the contract), filling the prescriptions at the same pharmacy when possible, and alerting the doctor to any side effects or problems. Some contracts stipulate that the drugs must be kept safeguarded by the patient, while others stress that the goal of pain management treatment is to eventually reduce the use of pain medication.

Opioid contracts lay out the consequences for the patient of any failure to follow the rules, said Touchet. The contract may state that the physician may stop providing prescriptions for opioid drugs or that he or she may dismiss a patient who refuses to comply with the contract, he explained.

Yet while contracts are in wide use, it is not known what determines whether a physician will use them. To evaluate this question, Touchet and his colleagues contacted all paid faculty, third- and fourth-year medical students, and residents at the University of Oklahoma College of Medicine and 196 completed an anonymous survey on the Internet. Of these, 122 indicated that they prescribed opioids.

The study found that residents were more likely to use opioid contracts than either students or faculty. "This finding seemed logical because residents are right in the middle of learning to use their skills," said Touchet.

Among faculty, primary care physicians were more likely to ask patients to sign a contract. "This was not terribly surprising. Primary care doctors are more likely to see patients about chronic pain," Touchet noted. They are also more likely to gravitate to the use of a contract because it might help them facilitate a working relationship with the patient, he added.

The physician's assessment of the rate of alcohol or drug abuse among his or her patients also had an effect, according to the study. Contract users are more likely to estimate such rates as higher than those who did not use contracts.

The use of opioids in pain management can be problematic for physicians, Touchet noted. "Doctors are caught between forces," he said. On the one hand, pain should be controlled and opioid drugs are effective pain relievers. On the other hand, physicians are worried about running afoul of regulatory agencies if opioid drugs they prescribe are misused or diverted.

"Some physicians feel the contracts protect them from liability. Whether or not that is true remains to be seen," Touchet said. There has been one legal case where the physician was found liable for not following the terms of the contract, he noted.

Touchet does not use contracts in his own practice except on occasion. When he does, he uses one that discusses controlled substances. "I don't generally prescribe opioids, but I do prescribe other controlled drug classes," he noted.

Further study is needed in this area, Touchet said. He and his colleagues are considering a broader study of the use of contracts, one that would examine patterns of use among physicians outside of an academic setting.

A sample opioid contract can be seen at www.rsds.org/3/clinical_guidelines/opioid_treatment_protocol.html .

THE AUTHOR is a writer based in New York.