As Opioids for Pain Treatment Come Under Greater Scrutiny, Controlled Substance Agreements Matter More

• The number and frequency of substance prescriptions, including the rules for refills, should be outlined;
• The treatment goals should be clearly articulated;
• The measures for outcome should be clearly defined;
• The risks and benefits of the use of the specific controlled substances should be identified;
• The patient’s responsibilities for the use of controlled substances should be identified (e.g., safeguarding the medication, not attempting to get pain medication from another provider without approval from the present provider, not to use any illegal substances and not sharing, selling or trading the medication);
• The single pharmacy the patient will use to fill the prescription should be identified;
• Permission to allow the physician to require the patient to undergo a random blood or urine drug test should be granted;
• Permission to allow the physician to consult with the dispensing pharmacist and any other professional who has provided health care to the patient should be given; and
• The consequences of contractual violation, including that if the patient breaches the agreement, the physician may stop prescribing the pain-control medicines or terminate the physician–patient relationship, should be delineated.

The controlled substance agreement should also remain a flexible document so as not to lead to unintended consequences. For example, if a patient requires an emergency procedure that requires the patient to take a controlled substance that is not included on the controlled substance agreement, the agreement should not be so rigid so that this situation results in a breach of the agreement.

Specifics for Opioids

There are also some key standards of practice for prescribing opioids that should be followed in conjunction with the execution of the pain contract, such as:

Evaluation of the patient, including a pain history and assessment of the impact of pain on the patient, a directed physical examination, a review of previous diagnostic studies, a review of previous interventions, a drug history and an assessment of coexisting diseases or conditions;

Consultation with a specialist in pain medicine or with a psychologist, when necessary. Patients with signs or symptoms of substance abuse should be immediately referred to a pain management specialist, an addiction specialist, or an addiction facility as it pertains to drug abuse or addiction;

Review of treatment efficacy should occur periodically to assess the functional status of the patient, the patient’s progress toward treatment objectives, opioid side effects, quality of life and indications of medication misuse; and