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Narcotic treatment contracts and the state of the evidence

Opium derivatives—and later, synthetic opioids—have probably been used for millennia for the relief of pain. Given human biology, they’ve probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.

But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.

The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone—the narcotic in vicodin–in emergency center charts increased 170%. This is a big problem.

So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we’ve discussed at length. But absent from that discussion was the evidence.

Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that?
I can’t answer the first question, but the second was subjected to a systematic review published in the current issue of Annals of Internal Medicine. One of the primary findings of this review was that this question has not been well-studied. The few studies that are out there do not measure some of the most important end-points, such as abuse, dependence, overdose, and death. They also don’t focus on primary care offices, the setting in which these drugs are often prescribed. The limited data available point toward a reduction in narcotic misuse with the use of treatment contracts. They conclude:

Our systematic review reveals that weak evidence supports the use of opioid treatment agreements and urine drug testing to reduce opioid misuse, despite the theoretical benefits of these strategies. This lack of evidence may explain in part why they have not been widely adopted in primary care.

I’m not as optimistic as the authors that it is the lack of evidence driving practice here. Leaving that aside, they make some interesting points regarding plausibility, attitudes, and the use of evidence. With regard to narcotic treatment contracts and urine drug testing they write:

Even in the absence of strong evidence, several compelling reasons for physicians to consider implementing these strategies exist. First, primary care providers who use opioid treatment agreements report improved satisfaction, comfort, and sense of mastery in managing chronic pain. Second, management strategies that include treatment agreements have been associated with reductions in emergency department visits in observational studies. Third, cross-sectional studies and a case series have demonstrated that urine drug testing is a valuable tool to detect use of nonprescribed drugs and confirm adherence to prescribed medications beyond that identified by patient self-report or impression of the treating physician. Finally, implementing routine urine drug testing may improve the provider-patient relationship and clinic morale, as suggested in a letter to the editor.

This is a clearly written and subtle approach to the use of a plausible but not-yet-proved modality, and is a nice example of one way to approach the dark zones of data in science-based medicine. They give a rationale for pursuing further research (the importance and scale of the problem of narcotic misuse, and the dearth of good evidence for current practices). And they give some plausible reasons why we might continue to use this as-yet unproved modality. But they do not overplay the current state of research, or make hyperbolic conclusions.

Science-based medicine does not always give us clear guidelines to care, but often leaves us with more questions to answer. This is one way to approach a difficult problem with incomplete data.

References

Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, & Turner BJ (2010). Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of internal medicine, 152 (11), 712-20 PMID: 20513829

Posted in: Science and Medicine

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31 thoughts on “Narcotic treatment contracts and the state of the evidence

  1. Carl Graham says:

    I agree that opiates have a place on chronic pain management but the statement “…the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain…” could be a little misleading as it confuses the good evidence available for their use in acute pain with the far less impressive evidence for their use on chronic pain.

    Current Australian and European treatment guidelines do not support a claim of high opiate efficacy for the management of chronic pain. In fact the most common view is that there is a lack of evidence about their long-term safety and efficacy and these drugs are seen as a second line treatment option which should be used with caution.

    This view is supported by the outcomes of meta-analysis and Cochrane review.

    A 2006 Canadian meta-analysis concluded: “Weak and strong opioids outperformed placebo for pain and function in all types of CNCP. Other drugs produced better functional outcomes than opioids, whereas for pain relief they were outperformed only by strong opioids. Despite the relative shortness of the trials, more than one-third of the participants abandoned treatment.” http://www.cmaj.ca/cgi/content/full/174/11/1589

    A Cochrane review for the use of opiates in chronic pain found: “Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief.” http://www2.cochrane.org/reviews/en/ab006605.html

    …and that in chronic low-back pain: “Based on our results, the benefits of opioids in clinical practice for the long-term management of chronic LBP remain questionable.” http://www2.cochrane.org/reviews/en/ab004959.html

    Also, as you suggest, there is significant street value for these medications and they are frequently diverted. Our hospital conducted an audit of opiate prescriptions via external researchers and found 46% of the scripts provided for strong opiates were diverted to non-prescribed persons and/or uses.

  2. Peter Lipson says:

    Excellent points. I should perhaps have qualified the statement. Patients who present to a primary care practice often perceive opiates as being more effective for chronic pain (although that is purely anecdotal), and I think that is part of the problem.

    In my internal medicine practice, NSAIDs are often contraindicated. Also, “strong” vs “weak” opiates is a distinction that is unclear to me. I may have a patient with severe, inoperable spinal stenosis who is on a long acting opiate with a short acting opiate for breakthrough pain. Is the short-acting weak? Or is it per drug? Propoxephene often does only as well as placebo but hydrocodone and oxycodone are pretty strong opiates.

  3. vannin says:

    Unfortunately, there is a lack of longitudinal studies on opiod use, as one of the big questions with chronic pain is not whether it is effective when it is first given but whether tolerance develops over time and it ceases to provide effective pain relief while leaving the patient with lots of side effects. It even looks as if for some it may lead tp pain hypersensitivity.
    http://www.jpain.org/article/S1526-5900(05)00826-6/abstract

  4. A great topic: always helpful to get thinking ratioanlly, and looking at evidence, with the issue of opioids.

    Yet, I believe the set-up is wrong: the benefit of opioids in pain mgmt is contrasted with illegal, recreational use.

    Our actual clinical concern is: the trade-off between clinical benefit in the long-term, and the occurrence of unacceptable dependence in some portion of those patients; turning pain patients into opiate addiction patients.

    The fact that these pills are out there by the jillions, and are being sold on the street, is irrelevant to the question of how much dependence gets fostered inadvertently under normal clinical pain management use.

    The data and methods for answering these questions is distincly differnt from the data about how many pill abusers are out there, etc.

    The data and research stategies are more similar to the issue of addressing the cardiac harm of anti-cancer regimens, where some portion of cancer patients become heart patients.

    This is a fair run-down:
    Jette Højsted, Per Sjøgrena. Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain 11, 5, 490-518.

    I am going to put on my posychologist hat on, and make a suggestion: One guiding principle is that functioning is the outcome, not pain control. So, in place of the simple 1-10 VAS, practitioners should review the SF-36 withe their patients, throw around some “holistic / treating the whole patient” blather, then run through the SF-36 scales and ask: 1. how does pain impact [fill in the blank with subscales].”

    Then explain: “You know that pain meds carry a risk of addiction; we want to use pain meds as much as we can to get improvement on the pain scale, and to get improvement on these other scales – we want to minimize how much pain interferes with your functioning at work, around the house with chores, and so on.”

    “A way to know if you are getting addicted is if the meds begin to interfere with these other scales – you become less able to handle tasks around the house, you get worse at your job, and so on, because the meds are interfering. This happens in a small portion of people taking these drugs for chronic pain, maybe less than ten percent, but it does happen.

    “So, we will use this questionnaire as a guide to figure out if our plan to control pain is helping these other areas of your life, or is interfering.

    “If the pain meds start to interfere, we will consider changing things up: we might switch to another medication, we might revisit some behavioral strategies like exercise to fight deconditioning, we might consult with a pain psychologist, we might consider other pain management options such as TENS, and so on.

    “But we will figure out something to keep the risk of bad pain drug use from happening to you.”

    “So, on each visit, we will ask you to complete this 36-question form. OK?”

  5. Emma B says:

    Finally, implementing routine urine drug testing may improve the provider-patient relationship and clinic morale

    Speaking as someone who uses very small quantities of legitimately prescribed narcotics, I have real trouble agreeing with this.

    I have endometriosis — a “real”, biopsy-proven, medically-well-understood chronic pain condition. My endo isn’t especially severe, and most days I don’t even require ibuprofen. However, at certain points of my cycle, I need round-the-clock NSAIDs for several days at a time, and sometimes I have enough breakthrough pain to require narcotics on top of the NSAIDs. I use approximately two to three pills per cycle, so we’re not talking about the sort of daily usage that can result in physical dependence.

    I’ve gotten some significant pushback from my doctor over the annual prescription renewal, despite having never abused my prescription in any way, and frankly, I resent it. I understand where she’s coming from as a provider, but I dislike being treated as a drug addict waiting to happen, when I have never given her any such indication. I’m frustrated that I’m being pushed toward treatments with major side effects, or which I have previously found to be ineffective, for purely legal reasons than medical ones — apparently it’s perfectly OK to take NSAIDs up to the border of thrombocytopenia, but add even very small doses of OMGnarcotics and maybe we should talk Lupron instead.

    If my doctor asked me not only to sign a contract, but spend an hour or more of my time and $50 or so per month for routine drug testing, it sure wouldn’t do much to improve my relationship with her — and I’d be just as angry if she imposed similar requirements for writing my NSAIDs. Contracts may or may not be successful in other ways, but I think it’s a big stretch to argue that they improve the “provider-patient relationship” by imposing significant burdens on half of that relationship for no additional benefits.

  6. Robin says:

    Do primary care physicians screen for mental illness when prescribing opiates? It’s a known risk factor for dependence (a good friend of mine with severe depression says, “heroin is better than anything in a psychiatrist’s arsenal”) and may be associated with mortality: http://www.ncbi.nlm.nih.gov/pubmed/20409446?tool=MedlinePlus

  7. colli037 says:

    Great discussion of an issue that is part of my daily life–I work in a university medical center “pain clinic”

    I agree that the issue of narcotic agreements has not been studied. Whether the treatment agreement is an “informed consent for treatment” is another question, as most of the agreements I have seen (including ours) also mention side effects and withdrawal effects of the medications.

    I have never had a patient refuse to sign an agreement, but it has been helpful when I need to discharge a patient from the clinic (they can’t say “you never told me” because they sign and get a copy of the agreement).

    The random urine screening tests are actually the best help. Not only do they give use drug levels for the meds we are prescribing, but also look at the illegal drugs. Several years ago our clinic started using a better test, and I found that 25% of my patients were scamming us. (either were not taking their medications, were abusing illegal drugs, or were taking medications from multiple physicians)

    Regarding costs–any potentially dangerous medication used long term has recommended lab tests–any medical disease like Hypertension of Diabetes has routine lab tests that are checked on a regular basis. Even NSAID’s if taken for prolonged times require a check of renal function and for anemia. So lab testing really needs to be viewed as monitoring chronic treatment. Its clearly not punitive, and necessary.

    Patients have to benefit from treatment otherwise treatment is futile. If a medication is not effectively controlling hypertension based on objective measurement of BP, we change medication or stop. If a pain medication is not controlling the patients pain based on a VAS score that is unchanged, or based on ability to perform their usual daily activities, we take them off that pain medication. This is a normal part of trying an opioid, although most physicians don’t discuss this with a patient.

  8. Emma B says:

    Regarding costs–any potentially dangerous medication used long term has recommended lab tests–any medical disease like Hypertension of Diabetes has routine lab tests that are checked on a regular basis.

    Yes, but those are covered by insurance, which I don’t think is the case for drug tests. The frequency is also an issue, because most chronic diseases only require very close monitoring in the early stages or when changing treatments.

    I get checked for NSAID side effects (I’ve skirted close to having platelet issues before), especially when we’ve been tinkering with different medications and schedules, but now it’s just a part of my annual visit unless I’m having other symptoms like bruising. Ditto with my hypothyroidism and asthma — initial stabilization, but now it’s annual or semi-annual monitoring unless there are specific problems.

    I don’t know exactly how pain medicine clinics work, because as I mentioned above, my absolute usage is very low. If you monitor patients closely in the initial stages and then decrease the visits and drug testing, that’s one thing. However, if you’re asking patients to make monthly visits (with monthly co-pays) and take monthly drug tests (paid out of pocket) for the entire duration of treatment, that’s a much more significant hassle to the patient than hypertension or diabetes.

  9. colli037 on being scammed:

    “25% of my patients were scamming us. (either were not taking their medications, were abusing illegal drugs, or were taking medications from multiple physicians)”

    I can see that selling their meds is a scam, and someone getting opioid prescriptions from multiple doctors is lying to you so I will call that a scam too.

    But since when is the use of illegal drugs a scam? People might resort to all sorts of scams to get illegal drugs (then again, they might just grow them in their back yards), but once they’ve got them, I’m not sure how using them is “a confidence game or other fraudulent scheme, esp. for making a quick profit.”

    According to the National Survey on Drug Use and Health, in 2007, “14.4 million Americans aged 12 or older used marijuana at least once in the month prior to being surveyed, which is similar to the 2006 rate.”

    http://www.drugabuse.gov/infofacts/marijuana.html

    That works out to about 6% of Americans over age 12 using marijuana in the past month — that is, by your definition, involved in a medical scam. (What if they don’t have doctors: are they scamming someone else? Their mechanics, maybe?)

    I don’t use marijuana myself, and having grown up in the seventies I am well-aware of its negative effects on heavy, long-term users. But similarly, I am well-aware that it’s widely used by people who have no idea that you think they’re swindling you every time they share a joint with a lover.

    Or is that not what you meant?

  10. Peter Lipson says:

    Allison, most of these agreements specifically prohibit concomitant use of illicits. This is not simply because they are illicit but because they can interact with the narcs, and the doc no longer has control over the management of the condition.

  11. James Fox says:

    If a person with significant intractable chronic pain becomes addicted to an opiate pain medication, but is otherwise more functional and their pain is controlled as a result of opiate treatment, I have difficulty seeing the problem. Some people will be in pain for the remainder of their lives after an injury or as a degenerative disease progresses. Why deny relief because of the identified side effect of addiction? That seems to be a small price to pay if the benefits (increased functioning and pain control) outweigh the risks. It should be noted that being in pain, such as significant lower back pain, is associated with a marked increase of patient suicides.

  12. Steve S says:

    Great Post Peter! Several Points;
    A lawyer has told me that pain or narcotic contracts are not really worth the paper they are printed on legally.
    Next, when I was in private practice in a small town I had three, what I thought were really disabled people come and see me for Dilaudid. They had records etc. When they started coming a little more earlier for med prescription, I finally said they need to come off the meds. They thanked me very much and agreed. Two weeks later our pharmacy in town was broken into, by a professional, and the schedule 2 safe opened and the narcs taken. I never saw these people again. But I was contacted by the KBI that these three, truely disabled, were caught selling the prescription narcs, Dilaudid among others, in West K.C. Hence I don’t trust them as far as I can throw a narcotic user, until they have proven by time that they are trust worthy.
    An finally I agree with one of the other comments that function should be the scale to measure success. The pain scale is a worthless 5th vital sign, it is not objective and I have had people tell me with smiles that there pain was a 10 or higher. It is a subjective scale not objective, like real BP, Pulse, respiratory rate and temp.

  13. Harriet Hall says:

    Re functionality and opioids: In case you missed it, I reviewed a biography of Halsted, the father of modern surgery, who functioned remarkably well despite taking cocaine and opiates for most of his life. http://www.sciencebasedmedicine.org/?p=4117 Not really pertinent to this discussion except that it counteracts some misconceptions about what drugs and addictions can do to people.

  14. Peter Lipson says:

    #JamesFox

    I don’t generally use the word “addiction” for someone who is being treated with chronic opiates, has developed a level of tolerance, but has no maladapative behaviors associated with the use.

  15. James Fox says:

    @Peter Lipson
    Regrettably, while I think your description is valid, many PCP’s are in great fear of being accused of supporting a patient’s addiction and/or setting themselves up for an investigation in these cases. Perhaps the written agreement in these situations will afford some cover if there’s an investigation. I would think many insurance companies would require some form of written agreement with chronic pain patients taking opiates.

    Also I’ve had many clients with addiction issues and chronic pain who are prescribed with Methadone for the pain. Do you see this as a helpful option?

  16. “Why deny relief because of the identified side effect of addiction? That seems to be a small price to pay if the benefits (increased functioning and pain control) outweigh the risks.”

    If the addiction level could be predictable and manageable I would not have an issue with this statement. But I have a family member who was near death three times from overdoses of Oxycontin (combined with alcohol) that was originally prescribed for serious degenerative back pain. It seems the risks weren’t manageable or predictable.

    That said, I’m not against opiates for pain management, Emma B makes a compelling case that sometimes they can be used successfully. But the reality is once one doctor has stopped prescribing them to a particular patient due to concerns of addiction. That patient can easily go online to buy them (as my family member did). Who is responsible for follow-up or follow through care? The nature of addiction tell us that the addict may not seek care until the situation is dire (if at all).

    To often these cases are dismissed as “just individuals making bad choices” But I don’t feel that my family member really had a choice, it seemed how they were born.

    Thank you Dr. L. for taking this subject seriously.

  17. Peter Lipson says:

    I’m not a pain expert, but methadone can be abused just like any other opiate. The primary advantage is it’s extended half-life compared to other opiates. But tolerance develops just as it does with others, and it is associated with the same withdrawal syndrome.

  18. Steve S says:

    The problem is that not that most PCP are afraid, the problem is that most have been taken by the faction that want to use the prescription for means other than relieving pain. I am much more comfortable with patients I put on narcotics for pain that I know they have. The biggest problem is patients that come into the office that are already on pain meds from someone else or have dupped them into getting pain meds. I have a lot of sympathy for those in real pain. We simply don’t have an objective way of measuring pain to know if it is real. The pain scale is totally subjective and the addicts know the scale. Maybe that study that Peter talked about with increasing ADP might at last give a clue to how we can objectively measure pain. Most of us have been taken by con artists, that is problem. Don’t mix up uncaring for being suspicious of being taken again. When a doc goes into an area and he or she becomes know as giving out pain meds liberally, all the addicts and others will know it within a short time and beat a path to his or her door. I have seen this happen many times.

  19. My understanding is that addicts may feel “real pain” when they’re out of meds; they aren’t lying.

  20. Peter Lipson says:

    Withdrawal is very painful. And addiction is not as simple as “gimmie drugs, i wanna get high”. It is, for the addict, a physiologic need that alters rational behavior.

  21. Steve S says:

    I agree that withdrawal is painful and addiction is not as simple as gimmie drugs, I wanna get high. However, does that mean that we should prescibed narcotics to the addict to keep his disease going? To alleviate his pain of withdrawal? Does giving narcotics to addicts to alleviate their pain of withdrawal make it right? Yes Harriet is right, I have read that book about Halstead also. He was one of the most brilliant docs in history, but he had an addiction that led him to being absent, in some cases 1/2 the year from his profession and not helping his patients. Families of addicts also go through a type of a hell, even when their loved ones get the drugs legally, does that justify maintaining the addiction? Yes, narcotics are a blessing to those in pain, but it is a double edge sword that also cuts. We as physicians must be thoughtful, compassionate and pragmatic about our treatments and use these drugs, indeed any drug or treatment. I know I had a family member addicted to a drug. It caused hell. Just her getting the drug didn’t make the hell get better, no matter how much she needed it.

  22. Steve S says:

    Sorry another point I forgot. I have seen physicians, ER etc prescribe dilaudid for relative minor injuries or conditions. It is almost as if smashing your finger with a hammer justifies getting dilaudid for the pain. That is wrong! The medication should fit the level of pain. Again we do not have an objective way of gauging pain, it is all subjective. Out of this misuse of pain medication I have seen patients come in addicted to a narcotic that should not have been. Was that justified? These same patients do not want the addiction, they have told me that they wish they would have been treated with something else. Withdrawal from narcotics usually is not lethal, although the patient will tell you that they feel like they are dieing. In contrast alcohol does have a mortality rate associated with withdrawal. I think being compassionate should not mean trading one type of pain for another.

  23. colli037 says:

    The urine drug screens are covered by insurance (same as any other lab test for long term monitoring of treatment).

    Regarding the Scamming comment I made–I was not talking about the occasional patient using marijuana for their pain. I’m talking about patients who are selling their oxycontin for cash (testing negative for their pain medication) and taking other drugs (cocaine, etc). These patients never complain or act surprised when they get caught.

    The problem with using illegal drugs at the same time as getting treatment for chronic pain are 1) This is in the treatment agreement the patient signs up front 2) They are illegal! this means the patient must commit a crime, and associate with other criminal to get their drugs. They are frequently placed in the situation of trading their prescription medications for other drugs.

    I’m not suggesting that marijuana is a problem for pain patients, just that it is still illegal even for medical use in the state I practice in.

    Addiction needs to be considered separately from tolerance with withdrawal symptoms (withdrawal symptoms are NOT a sign of addiction, only a sign of tolerance. Opioids are not the only medications that cause symptoms when stopped suddenly. Addiction is the behavior and misuse of the prescribed medication. Even former addicts can be treated with opioids in the right setting (takes a lot of work on everyones part, but there are clinics that do this reasonably well)

  24. colli037,

    Your words were, “The random urine screening tests are actually the best help. Not only do they give use drug levels for the meds we are prescribing, but also look at the illegal drugs. Several years ago our clinic started using a better test, and I found that 25% of my patients were scamming us. (either were not taking their medications, were abusing illegal drugs, or were taking medications from multiple physicians).”

    If the issue is that they’re selling their prescription drugs to buy cocaine, then the “abusing illegal drugs” part of your definition of “scamming us” can be dropped because it’s already covered by “not taking their medications.”

    If you don’t care if your patients use some marijuana in addition to their prescription medication, does that mean you excluded the marijuana users from the 25%?

    I’m guessing you left them in, because you had them sign a contract saying that they wouldn’t use illegal drugs, and breaking this contract defines “scam” – even though you have behaviour in the contract that you admit you don’t care about.

    My (pedantic) point is just that a more honest report of the numbers you got for “scammers” might be more along the lines of 22%, not 25%. Because some of the behaviour that the tox screen caught doesn’t actually show that they are abusing their prescriptions; it’s just illegal in itself. You might have reasons to include all illegal drugs as part of the contract, which is fine. But I’m wondering why you would describe behaviour you as a doctor do not care about as “scamming you.”

  25. [perseverating some more]

    Would the following be an appropriate rephrase?

    “I found that 25% of my patients were breaking their contracts. A full 22% were outright scamming me.”

    Or would I be missing something about the importance of the contract?

  26. Steve S says:

    There is a very interesting book that addresses the problem of addiction and chronic pain from a different perspective. I don’t know if you are aware of it. It is by R. Douglas Fields PhD Chief of the Section on Nervous System Development and Plasticity at the National Institute of Child Health and Human Development, part of NIH, and Adjunct Professor in Neuroscience and Cognitive Science Program at the University of Maryland. The book is called the Other Brain and it talks about the research of the influence that glia have on neurons in the brain. There are two chapters that have to do with the current discussion; Glia and Pain, A Blessing and a Curse and Glia and Addiction, A Neuron-Glia Dependence. I would recommend this book highly. New research is giving an idea of what can be done to treat chronic pain and addiction. Just FYI.

  27. trrll says:

    “I agree that withdrawal is painful and addiction is not as simple as gimmie drugs, I wanna get high. However, does that mean that we should prescibed narcotics to the addict to keep his disease going? To alleviate his pain of withdrawal? Does giving narcotics to addicts to alleviate their pain of withdrawal make it right? ”

    In fact, continuing to prescribe opiates to addicts is the basis of opiate maintenance, which remains the most successful treatment modality for opiate addiction. Being opiate dependent is not in itself a particularly serious medical problem, so long as one is able to obtain opiates legally. Opiates do not carry much risk of organ toxicity, and an opiate dependent person on a stable dose of an opiate does not experience either withdrawal or marked intoxication. On the other hand, a person who is seeking and taking illicit drugs is at very high risk of infection, overdose, and legal and financial complications. The long-term success rate of abstinence as a treatment for addiction is not high.

    The pain of withdrawal is not in itself a major concern. Opiate withdrawal is very unpleasant, but transient and not normally life threatening in adults, and the severity can be moderated by tapering off the opiate and using clonidine to moderate sympathetic overactivity. The real problem with addiction to opiates, as with most abused drugs, is craving, which recurs long after withdrawal is complete, frequently resulting in relapse into compulsive drug seeking.

  28. The Blind Watchmaker says:

    A few years ago, one of my patients reproduced my prescription pad on Word and did a reasonable job at faking my signature. He then began filling scripts for himself and also sold scripts to others. This is a nightmare for a doctor. One can see why many take such a defensive posture with patients when it comes to controlled substances.

    Recently, it has become permissible for us to prescribe controlled substances via an electronic prescription service such as Dr. First. The advantage to this is the prescriber can see what has been prescribed and when it was prescribed.

    Of course, this really only works if most doctors use such a system. Hopefully, we will get there soon.

  29. wertys says:

    Well done Dr Lipson on a very thorough discussion-starter. The use of opioids in chronic nonmalignant pain is actually a minefield for evidence-based practitioners, as inevitably the personal anecdotes begin colouring one’s interpretation of the evidence, such as it is. As a pain management specialist in a tertiary university hospital, we have not gone with formal opioid contracts for a number of reasons which may be helpful in this discussion.
    Firstly, the evidence in favour of long-term opioid treatment is less than compelling as monotherapy. One of the philosophies of comprehensive chronic pain management is that drugs, be they anticonvulsants, opioids or NSAIDs are never the whole answer to the problem. A contract risks focussing yourself and the patient’s attention on the medication and not the whole problem. Also, as you point out, while they increase the comfort of the practitioner, they do not measurably reduce scamming or improve outcomes.
    Secondly, a contract we feel is an abdication of the practitioner’s responsibility to have an empathic and honest relationship with his/her patient. We certainly have lengthy discussions regarding all the pros and cons of an opioid trial, and we always are firm about the need for measurable improvement in both pain intensity and daily function. We do not accept people remaining as couch potatoes with 5/10 pain instead of 7/10 pain. By having a formal contract, we feel that the interpersonal element of trust is made less important, since the first instinct of someone signing a contract is to look to the letter of it rather than the spirit.
    Thirdly, scammers operate in highly sophisticated and cynical ways, which tend to be either easy to spot if they’re no good at it, or impossible to spot without making every patient feel untrustworthy. This is a particular problem for primary care doctors that we don’t have so much in the pain clinic. Having clinic policies rather than requiring each doctor to make up his/her own mind at every consultation is probably the best solution. Diversion or illegal use of prescription opioids is a crime, and deserves to be treated as such. We don’t expect alcohol to be banned due to there being alcoholics, or gambling to be stopped because many people are unable to control their behaviour around it. Opioid contracts address none of these problems.

    As a tool for helping primary care doctors manage their own trepidation in conducting reasonable trials of opioid therapy, contracts can be useful if they are properly worded and constructed. That they have no legal basis is irrelevant other than as a record of conversation. In a tertiary pain management setting we believe they are not as effective as the hard work of developing an empathic and therapeutic relationship with a difficult patient.

  30. Chris says:

    (off topic note, kind of as a suggestion for a future article: While this is very interesting, being one of the population fraction that actually become very ill when prescribed those meds, I really don’t understand why anyone would actually want to take the stuff for “fun”. I have never ever taken more than a couple, before deciding that I was not in enough pain from the broken bone/back injury/dental procedure to warrant the nausea and subsequent head over toilet syndrome. The worst was when I was given one, I forget which one (vicoden?… they are never happy when I tell them of my very bad experience with percodan after having my wisdom teeth removed) when I was in labor to “take the edge off” since I was too dilated for an epidural… I was having contractions and wanted to vomit! Hate, hate, hate narcotic pain meds! What are options for us?)

  31. Chris says:

    (now I remember what made me sick to my stomach when I was in labor for my now 19 year old son, demerol… still it is a narcotic… I was given vicodin when my back went out… all nasty things)

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