Opioid Contracts in Primary Care

Bill H. McCarberg, MD

Disclosures

November 16, 2009

Question

How can patient-physician contracts help the primary care doctor adhere to state opioid policy?

Response from Bill H. McCarberg, MD
Assistant Clinical Professor, Department of Family Practice, University of California San Diego School of Medicine; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, California

Opioid agreements are commonly used in pain specialty practices yet are less practical in the primary care setting. A recent study showed that 24%-42% of primary care provides use agreements in long-term opioid management.[1] The use of opioid agreements is endorsed by the Federation of State Medical Boards and is written into code in most state pain management policies. Agreements that are so widely used by pain specialists and endorsed by oversight organizations should be prevalent in primary care but are not.

There are many reasons why opioid agreements are not used more often in primary care. Many specialists have organizational support unusual in primary care. Before seeing the specialist, forms and questionnaires are mailed to patients. Patients must return the forms to attend the specialty appointment. Staff assembles the information and has it ready for the initial comprehensive visit, which can last 30-60 minutes. No such support systems exist in primary care. Patients present with a variety of complaints including pain, all requiring attention in a 15-minute visit. Filling out an opioid agreement in addition to all the other requirements takes low priority.

It is recommended that the agreement be discussed at initiation of opioid therapy. In clinical practice, opioids are usually started for acute painful conditions not expected to be long-lasting. With workup, treatment, referral, and continuing care, the patient is maintained on opioids and the discussion never occurs. The patient may also return from specialty care already on opioids or join the practice already taking an opioid. Discussing an agreement after a specialist started therapy or another trusted provider initiated treatment does not feel compassionate or caring.

Despite using multiple drugs for thousands of medical problems, primary care does not use an agreement for any of these therapies. Many of these treatments are much more dangerous than opioids; consider anti-arrhythmics, digoxin, and nonsteroidal anti-inflammatories as examples. Possible side effects are typically mentioned but there is no signed agreement describing patient responsibilities.

Relationships in primary care are built on trust and longitudinal exposure of the entire family over years of treatment. Consider this background of advocacy and examples of the language used in opioid agreements[2]:

  • I will NOT ask the doctor for extra refills if I lose or misplace mine;

  • I will NOT ask the doctor for extra refills if I use up my supply before my next appointment;

  • If I fail to comply with these requirements, the doctor will no longer order pain medicine for me;

  • If I fail to comply with these requirements, the doctor may send me to drug abuse treatment; and

  • If I fail to comply with these requirements, the doctor may stop giving me medical care.

This language feels accusatorial, mistrustful, and confrontational; attitudes not comfortable in primary care.

How do you interpret failure to adhere to an opioid agreement? Is this the "one strike and you are out" philosophy mentioned by many pain professionals? Knowing a patient and their family for years stimulates thoughts that perhaps the behavior is a misunderstanding by the patient or inadequate or inappropriate treatment of the pain. Maybe the aberrant behavior is the responsibility of primary care. With better assessment, patient education and optimal pain management, the behavior would improve. We are not pain experts and uncertainty leads to giving in to excuses not tolerated by pain experts. Now the primary care provider is not adhering to the opioid agreement and incurring new practice risks.

Despite all the reasons to not use opioid agreements listed above, primary care is warming to the new procedure. We all use new treatments as diseases are better understood with improved science. Procedures learned in medical school and mastered in residency must be constantly updated. Part of normal medical care includes staying current with medical practice. Promoted by the Federation of State Medical Boards and state pain policy, opioid agreements are the new treatment paradigm; new medical knowledge recommends this updated practice. Not only does an opioid agreement clearly outline what is understood about using opioids, it also announces the understanding to providers who cover during absences. Without a clear understanding, written somewhere in the medical record, providers filling in for you have to guess what is the correct refill interval. An agreement makes the refill decision easy for you and the covering doctor.

Rather than a punitive, accusing document, the agreement can simply outline the pain problem, the medicine, dosage, number of pills, refill interval, and how much time is needed for refills to be done. Other language can be added, adapted, written in later and adjusted according to the patient. Informed consent language could be added to include risks, benefits, and alternatives to opioid therapy. Once this practice behavior becomes standard, it is not difficult or uncomfortable. It is just another part of practice like adding a microalbumin to the diabetic screening labs or doing a monofilament examination.

Opioid agreements feel foreign, mistrustful, and insensitive. The agreements take extra time in the expanding workload and shrinking workday. We could just refer all these difficult pain patients to the specialists and let them handle the problem. But we do not refer because we know this is our responsibility. When statins were discovered, the treatment of cholesterol became more time-consuming. Adjusting therapy and taking liver function became part of our day. We did not refer all these patients. It is our responsibility to give the best possible care to the large number of patients with hypercholesterolemia. The extra work is accepted by all of us because we are primary care providers.

The same is true of pain treatment with opioids. Our patients benefit from opioid therapy and the right treatment includes opioid agreements. Although time-consuming and uncomfortable, primary care should include these agreements and we can add this needed option to our treatment plans.

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