Opioid contracts, meant to curb addiction, can harm patients

The 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.

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.