T

he US Senate recently passed legislation designed to address the nation’s opioid addiction epidemic, and President Obama is expected to sign it into law. Among other things, the bill promotes the use of opioid contracts. These are written agreements between doctors and patients about the conditions for prescribing opioids long term for chronic pain.

This is great news. It could also harm patients.

Opioid contracts clarify for doctors and patients how to prescribe these dangerous medications. By doing so, they can formalize safer approaches to opioid prescribing. That’s why they are already required by law in New Hampshire and Massachusetts.

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Even the best medicine can sometimes cause harm. My patient, Cindy (I’ve used a different name to protect her privacy), is a perfect example of the risks of using opioid contracts.

When she was 17, Cindy was abducted and sexually assaulted in the basement of a Boston tenement. Gagged and bound to a post, Cindy could hear her family calling for her, but she could not respond.

She eventually escaped. But to deaden her memories of that horrific experience, she turned to alcohol and heroin. Years later, when Cindy relocated to rural New England, she brought with her HIV infection, a painful nerve condition, and hopes of a better, sober life.

As Cindy reliably took her HIV and pain medications, she got healthier. A bond developed between us. She brought photos of her family to the clinic, and once gave me a little silver dove. It was thanks, she said, for helping her find some measure of peace.

The doctor who prescribed Cindy’s opioid pain medications had her sign an opioid contract. It mandated that she keep regular appointments, avoid requests for extra prescriptions, submit to random drug testing, and promise not to sell her pills, among other conditions.

After a few months, Cindy broke the contract by taking black market pain and anxiety medications as part of a rare weekend-long relapse. Her doctor said she “violated” her opioid contract, and immediately ended her opioid prescription.

Ashamed and in pain, Cindy fell back on heroin. When I saw her next, there were healing puncture marks on her arms and tears in her eyes. She wanted to treat her pain without heroin, and asked me not to “abandon” her.

I referred Cindy to rehab, kept treating her HIV, and got her to see a pain medicine specialist. This doctor also had Cindy sign an opioid contract. Not long after, she violated it by failing a random drug test — not because it was positive for heroin but because it was negative for her pain medication. Cindy’s doctor suggested that she was selling her pills instead of taking them — which she denied — and cut off Cindy’s supply of pain pills.

The next step was predictable: Stressed and in pain, she returned to heroin. Days later, Cindy was dead of a heroin overdose.

I learned that she had died while I was in the middle of a busy clinic. Patients waited in their rooms while I stared at the wall, unable to breathe. I had lost patients before over the course of more than a decade treating people with HIV and other deadly infections. But this was different. This time, I knew we had let Cindy down.

Cindy’s addiction alone may have killed her. Yet the delicate balance we had struck between the management of pain and addiction collapsed as soon as she was forced to start signing opioid contracts. These one-size-fits-all forms converted complexity into simplicity: If Cindy showed signs of addiction, her prescription was stopped.

Opioid contracts can harm patients in other ways. I have seen doctors use them to dump addicted patients who can be challenging to care for. I have also seen the time-consuming, multifaceted care that patients with addiction need be replaced by quick enactment of a legal-sounding opioid contract.

When patients signal they are at high risk of drug addiction or overdose by signing — or violating — an opioid contract, physicians should recognize that they are managing a complex problem that needs complex solutions.

An opioid contract may be a good start, but it should be joined by a panoply of other helpful measures. For instance, the CDC’s new guidelines on safe opioid prescribing (which notably don’t mention contracts) suggest steps like prescribing smaller numbers of pills more frequently, intensifying mental health referrals, and renewing protective naloxone prescriptions. Most of all, we should promise our patients we won’t abandon them. We may elect in certain circumstances to stop an opioid prescription, but seldom should it be done abruptly and never as the final chapter of care.

When Cindy was 17, she listened helplessly from a dingy basement as her family called out for her. This year, Cindy was the one calling for help, and we did not truly hear her.

Physicians often say they won’t risk writing a prescription that leads to an overdose. I hope we can invest similar passion in not abandoning addicted patients when they need us. The silver dove Cindy once gave me sits on my desk as a reminder we can, and should, do better.

Tim Lahey, MD, is an HIV physician, ethicist, and director of education at the Dartmouth Institute for Health Policy & Clinical Practice at the Geisel School of Medicine.

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  • Clean and sober, through the grace of God, St. Clare’s Residence for Women in Hyannis, Framingham-MCI Drug rehab program, AA, NA and a renewed sense of Love for my own being ~ 2-14-2001 – to present. Sobriety delivers what alcohol and drugs promise. I am a Chronic Pain Patient not a criminal. I will not ever change my sobriety date, not for anyone or any drug. I will not walk below the victory Jesus died to give me.

  • Medicine in the US has become more about treating parts and bits rather than treating patients as a whole being. 100 Million chronic pain patients are being abandoned by Physicians due to CDC and the DEA scare tactics. According to the CDC the guidelines were aimed at primary care Docs not Pain Management. Yet Pain Management Docs are using contracts, denying patient scripts and referring to expensive often non-insurance covered treatments over treating the business of pain. Urine screening is one example of the tactics used however; equally addictive and favorable black Market mental health meds are not being targeted in the aggressive nature as Opiods. Why? We need to ask! How about alcohol? Which kills more people per year than opiods yet is taxed by the Government. Lastly apparently we have learned nothing when it comes to prohibition type legislation. Furthermore science tells us there is a distinct difference between medical dependency and addiction. We don’t excuse diabetics of abusing their insulin because we understand diabetics need insulin to live they are medically dependent on insulin. Chronic pain patients are not any less worthy of this acceptance. The guidelines will not curb illegal opiate use. Per the CDC’s own admission the majority those abusing opiates in any form are not getting them legally. Data tells us that less than 5 percent of Chronic Pain Patients abuse their pain meds. So what are we doing? This is discrimination towards sick folk period! When pharmacist have the right to refuse to fill a script without access to medical records- solely on suspicion- this is abuse of the system in an entirely different manner. The assumption that chronic pain equates to addiction is harming people. I am only allowed opiate persciptions quarterly. Yep, once a quarter per my Pain Management Doctor. I’m expected to treat pain related to EDS, AS, and Fibro with Naproxen daily. This is cruel and unusual. I refuse to sign a pain contract on principle. I would prefer to suffer everyday than be treated in a manner as a someone who would sell their scripts or abuse their scripts when I have no history of abuse or addiction. The double standard has to end.

    • V Towsey,
      I would love to know where you got your statistics from? I am writing a paper for college.
      Thanks,
      Rhonda

  • Doctor, why didn’t you step in and help Cindy? Even just a short-term Rx could have saved her without jeopardizing anyone.

    • Asking what could have come been done differently is a valid and productive response when a patient dies. It is how this story began. When addressing such questions, it is important to understand the risks and complexity involved, and to be compassionate.

      Opiate treatment for chronic pain is very risky. The risk of overdose is high in anyone, and particularly high in patients who have struggled with addiction or who take multiple medications with additive overdose risks. In such situations, it’s safest for patients to be under the care of an expert pain specialist who can help balance risks with benefits. Sometimes there’s a safe way to prescribe opiates and sometimes there is not. Whichever option is best for that patient, these are chronic and dangerous illnesses, and there are no simple, short-term, or safe fixes for them. Each patient’s individualized plan needs multi-disciplinary, expert and compassionate delivery of care that is difficult for our current health care system to provide despite the good intentions of the vast majority of providers.

      During our roughly decade-long relationship, “Cindy” said she felt supported and cared for, and I know we gave her years of extra life through HIV treatment. At times I treated her pain, and because I am not a pain management specialist I helped her access more expert care. “Cindy” said she was treated compassionately by her pain management team, and I know they cared. Ultimately, amid transitions between providers and absences from care amid active substance abuse, and the binary off-on use of opiate contracts, “Cindy” died. This was a sad day for many involved, but rather than being the result of a simple mistake made by any single person, as far as I can tell the problem lay somewhere at the intersection between deadly disease and the challenges our system has providing the complex, multi-disciplinary, nuanced, care she needed.

      I hope her story can help us find a middle way in which patients with tough illnesses can get high-quality nuanced multi-disciplinary care delivered with compassion by a team that knows it can’t save everyone but is doing everything possible to try.

  • Dr. Lahey has courageously expressed what many of us know to be true. The best medicine in these situations requires authentic, trusting relationships between clinicians and patients. Opioid contracts have a place, but cannot replace that authenticity.

  • Tim — this was a great read! You were a wonderful ID fellow to me during my residency and I’m glad to see you are doing great work!

    • Thanks Alex – great to hear from you. Hoping that sad experience can help us find a middle way.

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