Who Uses an Opioid Contract?
Who Uses an Opioid Contract?
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Opioid contracts may play an important role in facilitating effective management of patients with chronic pain.
Source: Touchet BK, et al. Opioid contract use is associated with physician training level and practice specialty. Journal of Opioid Management. 2005;September/October:195-200.
Faculty, residents, and students at the University of Oklahoma College of Medicine participated in a web-based survey regarding the attitudes toward and prescribing of controlled substances. Opioid contract use was significantly associated with status as a resident rather than student or faculty, primary care specialty, estimated alcohol and illicit drug use by patients, and the perceived risk inherent in prescribing controlled drugs. A majority of participants felt that the use of such a tool increased their sense of mastery and their comfort with prescribing controlled drugs.
Commentary
I’ve chosen an article from a brand new journal because its topic is critically important to the practicing obstetrician/gynecologist. Managing pain is one of the most challenging aspects of any practice of obstetrics and gynecology. Concerns surrounding the use of opioids include fear of causing addiction, potential prescription abuse, and discomfort with dealing with regulatory agencies overseeing the use of controlled drugs. As a result, some practitioners avoid prescribing what otherwise might be very useful medications to a population that is commonly sub-optimally treated.
The opioid contract is poorly studied, but purported to potentially address some of these issues. Contracts between patient and physician are felt to foster improved agreement on treatment approach, patient education, and statement on common goals. They outline terms of the agreement, prohibited behaviors, and conditions for patient dismissal. This particular study is an attempt to look at who uses the contracts within a university system.
It is logical that residents are the most likely to use the contracts within a university setting. Students have little/no authority to write prescriptions, and faculty might tend to rely on their own experience and judgment. It is also logical that primary care physicians are more likely than specialists to use the pain contract since specialists tend to have episodic and short-term relationships with patients whereas the primary care provider has a vested interest in the progression of symptoms and long-term management of pain symptoms.
So where does the practicing obstetrician/gynecologist fit? Where does any physician fit who diagnoses and treats endometriosis, vulvar vestibulitis, interstitial cystitis, pelvic pain, dyspareunia, etc? The answer: right in the middle of it all. Since entering full-time practice, I have been impressed at how often patients are sent to me for ongoing management and/or in consultation because their treating physician is uncomfortable using opioids and controlled drugs. It is the logical extension of having observed residents in training withholding pain medication because of the fear that patients would become addicted or the assumption that any pain was, in fact, a way to seek a prescription for drugs to be abused.
The article refers to a useful website of the American Academy of Pain Medicine and offers a sample pain contract that any office can use. The reader is encouraged to view www.painmed.org/productpub/statements/sample.html. I would suggest that most of us in practice are very much like the resident population in this study. We are volunteer participants in the study because we are interested in treating patients with pain. Since we are not "experts" as faculty at the university but are like the primary care physicians who tend to use the contracts, we can learn from our colleagues and try to utilize these tools that will help us manage our patients more effectively and efficiently.
Faculty, residents, and students at the University of Oklahoma College of Medicine participated in a web-based survey regarding the attitudes toward and prescribing of controlled substances.Subscribe Now for Access
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