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Defending Opioid Treatment Agreements: Disclosure, Not Promises

In order to receive controlled pain medications for chronic non-oncologic pain, patients often must sign a “narcotic contract” or “opioid treatment agreement” in which they promise not to give pills to others, use illegal drugs, or seek controlled medications from health care providers. In addition, they must agree to use the medication as prescribed and to come to the clinic for drug testing and pill counts. Patients acknowledge that if they violate the opioid treatment agreement (OTA), they may no longer receive controlled medications. OTAs have been widely implemented since they were recommended by multiple national bodies to decrease misuse and diversion of narcotic medications. But critics argue that OTAs are ethically suspect, if not unethical, and should be used with extreme care if at all. We agree that OTAs pose real dangers and must be implemented carefully. But we also believe that the most serious criticisms stem from a mistaken understanding of OTAs’ purpose and ethical basis.

Many commentators assume that advocates of OTAs believe that a patient’s signature justifies surveillance and monitoring of the patient and justifies cutting off further prescriptions after any violation. We agree with critics that this justification for use and application of OTAs would be seriously questionable. Instead, we believe that the ethical basis for OTAs depends on the public health justification of the overall system of surveillance and monitoring, which aims to address the widespread abuse and misuse of narcotic pain medications. The system of surveillance and monitoring is justified by public health ethics and that once such a system is in place, clinical ethics requires the disclosure that OTAs provide. Our reframing of the ethical basis and role of OTAs allows us to respond to the most serious concerns about them.


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