What's trust got to do with it? Revisiting opioid contracts

Abstract

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are 'drug seeking', 'abusing' and 'diverting' prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient-physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient-physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient-physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients' subjective knowledge in enhancing physicians' self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain.

Improving eye care follow-up adherence in diabetic patients with ocular abnormalities: the effectiveness of patient contracts in a free, pharmacy-based eye screening

“…Previous studies have shown that trust between parties is important for contracts to be efficacious and that participants who have an established relationship with the person administering the contract may feel more of an obligation to abide by the agreement. 10 In addition, participants were recruited from an outpatient setting and were not necessarily already seeing an eye care provider. Therefore, they may not have felt an obligation to contact a new physician with whom they had no prior relationship and who did not know about the contract.…”

Reconciling Patient Safety and Epistemic Humility: An Ethical Use of Opioid Treatment Plans

“…As OTAs are generally invoked in a climate of distrust, critics worry that they may destabilize therapeutic relationships and compromise care . Other related concerns include the coercive and unenforceable nature of OTAs, their stigmatizing effects, and the lack of evidence that OTAs reduce addiction or diversion …”

Breaking the pain contract: A better controlled-substance agreement for patients on chronic opioid therapy

“…Similarly, the word "contract" can be perceived as coercive, can erode physician-patient trust, and implies that failure to agree to it will result in loss of access to pain medications. [20][21][22][23] For these reasons, we encourage physicians to adopt the phrase "controlled-substance agreement" or something similar. This label accurately reflects the specificity of the treatment and connotes a partnership between pa-Drug overdose deaths exceed deaths from car crashes TOBIN AND COLLEAGUES tient and physician.…”