PAINS Policy Brief #4: Opioid Treatment Agreements or “Contracts”

Pain care in the United States presents a complex set of challenges. On the one hand, there is ample documentation that pain, especially chronic pain, is often not well managed, and that as the Institute of Medicine has stated, we need a “cultural transformation in how pain is judged, managed and treated” to advance pain care in the United States.

On the other hand, much of the pain care discussion has centered around a singular aspect of pain management, the so-called opioid analgesic “conundrum.” This conundrum relates to the notion that opioids are classified as “essential medications” for medical practice, but may be abused and misused, sometimes with deadly consequences. For example, according to the Centers for Disease Control and Prevention, nearly three out of four of the 20,044 prescription drug overdose fatalities involve opioid analgesics, representing more overdose fatalities than cocaine and heroin combined. To address these complex problems, a series of policy solutions has been promulgated.

One such policy is the use of prescription drug monitoring programs, now functioning in 47 of the 50 states (with New Hampshire and Nebraska actively implementing theirs, and Missouri being the only state not to have passed enabling legislation). Another is the creation of model policies and guidelines for the use of opioids in the treatment of chronic pain, such as that written by the Federation of State Medical Boards. The Federation of State Medical Boards guidelines and several state departments of health specifically recommend the use of treatment agreements and so-called opioid “contracts” as part of their model policies. In some states, legislatures have directed licensing boards to write rules mandating the use of agreements. These rules vary somewhat in their degree of specificity with respect to the contents of such agreements. This PAINS policy brief addresses the pros and cons of the use of opioid treatment agreements or contracts for the management of chronic pain.