ATLANTA – Treating chronic pain poses unique challenges in this age of abuse and litigation, but using contracts can help improve the chances that patients get the relief they need from opioid therapy – safely and without legal ramifications, according to Dr. Allan Gibofsky.

Before you get to the point of discussing a contract, however, it is important to assess a patient’s risk for problematic medication use and substance abuse. Several validated measures exist for this purpose (although none are in widespread use), and other methods can also be used to help predict potential problems, said Dr. Gibofsky, professor of medicine and public health at Weill Cornell Medical College and an attending rheumatologist at the Hospital for Special Surgery, New York.

For example, prior history of problematic use, requests for increased dosage, a preference for a specific route of administration, patient focus on opioids during a visit, multiple calls from the patient regarding prescriptions, prescription "loss" or "theft," and obtaining the same prescription from multiple sources are all signs of trouble, he noted.

Other factors that might be useful to consider in evaluating whether a patient should be treated or referred to an addiction specialist or pain management specialist include family history, psychiatric pathology, current status of substance abuse in others’ eyes, a history of physical or sexual abuse, an environment that includes others who meet some of these risk criteria, a chaotic home environment, and a family history of major psychiatric pathology.

A determination should be made as to whether the patient should be treated or referred to a pain management or addiction specialist for care, Dr. Gibofsky said, suggesting that if the choice is to treat, then the patient should be categorized into a low or high perceived-risk category, and therapy should be structured from that perspective.

"That will help your ability to monitor the patient and help a patient who may have some vulnerability maintain control," he said.

A contract should be considered as a way for the physicians and patients to achieve those goals.

It is reasonable – though sometimes challenging – to request all medical records and to contact all other health care providers to obtain prescribing and other histories, as well as to suggest, or even require, that a patient receive a consultation with a specialist if there is concern about abuse or potential risk of abuse.

The contract can also spell out what is expected of both the patient and the provider, and it can provide for penalties on both sides for violations. For example, a contract can require that a patient be seen on a certain schedule, and it can state that only small amounts of medication will be given, that toxicology screens must be performed, and that prescriptions won’t be refilled without a verifiable reason, he explained.

A contract could also require that concomitant nonpharmacologic modalities – that could limit the required dosing of pain medications – be used, and that others, such as a spouse or significant other, be allowed to contact you regarding the patient’s compliance, he said.

Such contracts are recommended by many pain management specialists, and they have been widely adopted, but they remain controversial. While they can be educational and can provide clarification of roles, patients may perceive them as stigmatizing and punitive. They can limit flexibility and – ironically – can increase liability for providers who don’t live up to their own responsibilities as specified in the contract.

However, they can also provide a good framework from which to provide safe and effective pain management.

In patients whose drug use has become aberrant, the contract can allow for appropriate intervention or interruption of care. Depending on the factors driving the behavior, it may be appropriate to refer the patient for consultation with a specialist, or to confront the patient and terminate care; aberrant behaviors can be driven by a number of factors, including addiction or plain criminal behavior.

If therapy is continued, consider the patient to be in a reassessment stage. Restructuring of therapy, coordination with other providers, reinitiation of a contract, and/or more frequent visits may be appropriate.

"Patients with behaviors out of control or that cannot be brought quickly under control are patients who should not be treated," Dr. Gibofsky said, adding that enabling patients is placing them in harm’s way, and that is not only placing yourself in harm’s way, it is also "not engaging in the best practice of our profession."

Patients who can’t accept the structure of treatment also should not be treated, he said, adding that "the issues surrounding long-term opioid therapy are significant, and offer great promise, but also great risk."

With appropriate risk assessment and management, pain can, however, be managed effectively, he concluded.

Dr. Gibofsky reported that he had no financial conflicts of interest relevant to this presentation.

Consider a Contract in Chronic Pain Patients on Opioids