Opioid contracts that require injured workers to give informed consent to long-term narcotic prescriptions are useful in preventing improper use of pain medications, experts say.
It's unclear whether such contracts have a direct effect in preventing opioid dependency or overdoses, sources say. But they agree that contracts are helpful in informing patients and physicians about the long-term dangers of such painkillers, and can give doctors a legal recourse if a patient appears to be heading toward prescription abuse.
“I think we're seeing it become a much more common practice, partly because providers are seeing the benefits of it and partly because in some states and other jurisdictions they're actually requiring that they be used,” said Robert Twillman, director of advocacy and policy for the Sonora, Calif.-based American Academy of Pain Management.
Opioid contracts, therefore, are appearing more often in workers comp-related care as the insurance industry looks to stem addiction and overdoses related to the narcotics.
Minnesota passed legislation in May requiring injured workers to sign written contracts with their providers when receiving long-term prescriptions for opioids or other controlled substances.
Washington state, which has used an opioid contract since 2000, updated the form in July to include several new points, including a section saying that doctors will verify patients' opioid prescription history with the state's prescription monitoring program.
Washington's contract, considered by sources to be one of the nation's leading examples of such documents, includes language saying the patient will take opioids “only at the dose and frequency prescribed,” and won't “ask for opioids or any other pain medicine from another provider.” A second page informs patients of the risks of opioids, including psychological dependence, tolerance, and “breathing too slowly,” which can lead to death if a patient overdoses.
The contract informs patients that their provider can stop prescribing medications or change the patient's treatment plan if they violate various points of the agreement.
The largest benefit of opioid contracts is that they inform patients and providers about the risks of narcotic prescriptions and allow physicians to set boundaries for prescribing such drugs, said Jaymie Mai, pharmacy manager for the Washington State Department of Labor and Industries, which is the state's monopoly workers comp insurer.
“It sets expectations and lets the worker or the patient know about their responsibility, and it also allows the provider to talk about the benefits,” Ms. Mai said.
Contracts set limits that can help physicians keep patients in line with proper treatment protocols, said Mike Farrand, Radnor, Pa.-based national technical director for workers comp medical cost containment at Willis Group Holdings P.L.C.
For instance, some contracts indicate that patients can be subject to drug testing, and could be refused treatment by their doctor if a test shows that medications are being abused. That scenario could lead to better prescription compliance for patients who don't want to lose necessary medications, Mr. Farrand said.
“An employee who needs these (medications) or feels as though they need them, they're risking a lot knowing that this doctor's going to test them,” Mr. Farrand said.
Though sources could not quantify the effectiveness of opioid contracts, each of them said contacts are part of a cadre of tools that should be used in unison to protect patients who take opioids over a long term.
“They may not be fully aware that the risk is different when you're taking opioids... for your broken ankle versus when you're taking it chronically (after) the broken ankle has healed,” Washington's Ms. Mai said of how contracts combine with other safety measures to help protect patients.
Mr. Twillman of the American Academy of Pain Management said his organization recommends opioid contracts as a best practice in pain management. However, he cautions that the wording in some contracts has the potential to create an adversarial relationship between the doctor and patient.
“Many times, patients who have no history of misusing their medications in any way and are perfectly fine using them will perceive being asked to do one of these as an indication that the doctor doesn't trust them,” Mr. Twillman said.
Experts agree that doctors should be educated on how to present opioid treatment contracts to patients. Mr. Twillman said that can include giving doctors a script that can help them establish common ground with a patient, rather than making the patient feel they're receiving a contract because they're under suspicion.
“I think if you present it in a way that says, "This is just so we're all clear on how we're going to be using these medications' ... then patients are very accepting of that,” Mr. Twillman said.
While many contracts say patient care can be terminated if the agreement is violated, Mr. Twillman said providers should consider contracts that allow care to be modified in a way that helps the patient stay on track with their medications.
“Some people can't do what they need to do with their medications appropriately when you give them a whole month's supply,” Mr. Twillman said. “But some people, if you only give them a week's supply, they're fine. Sometimes imposing a little bit more structure is really what's needed to help patients.”