In this issue of the Hastings Center Report, Joshua Rager and Peter Schwartz suggest using opioid treatment agreements as public health monitoring tools to inform patients about “the requirements entailed by undergoing opioid therapy,” rather than as contractual agreements to alter patients’ individual behavior or to benefit them directly. Because Rager and Schwartz's argument presents suspected OTA violations as a justification to stop providing opioids yet does not highlight the broader epistemic and systemic context within which clinicians prescribe these medications, (...) their proposal may perpetuate a climate of distrust and stigmatization without correcting systemic factors that may have placed patients and others at risk in the first place. Given the context of epistemic uncertainty regarding opioid safety and efficacy, insufficient training for opioid prescribers, and inadequate patient education, I propose replacing OTAs, which have a narrow focus on patient behaviors, with opioid treatment plans, which would promote mutual, collaborative, and shared decision-making on the most appropriate pain management program. An OTP can be ethically justified as a tool to prevent and treat iatrogenic addiction under a specific paradigm—one that adopts a default position of professional epistemic humility and holds all collaborative parties accountable in chronic pain management. (shrink)

Opioid treatment agreements are written agreements between physicians and patients enumerating the risks associated with opioid medications along with the requirements that patients must meet to receive these medications on an ongoing basis. The choice to use such agreements goes beyond the standard informed consent process, and has a distinctive symbolic significance. Specifically, it suggests that physicians regard it as important to hold their patients accountable for adhering to various protocols regarding the use of their opioid medications. After laying out (...) a taxonomy of accountability relationships between physicians and patients, I argue that opioid treatment agreements are only justifiable for physicians to use in their provision of care if they improve public health outcomes, which has yet to be demonstrated. (shrink)

In this issue of the Hastings Center Report, Joshua Rager and Peter Schwartz reframe the justification for the use of opioid treatment agreements. Instead of documents used to define the roles and responsibilities of doctors and patients to one another in the course of opioid treatment for chronic pain and to describe the risks and benefits of therapy for the individual, OTAs are now proposed for use as “surveillance and monitoring” instruments. As such, they are specifically meant to disclose the (...) risks of opioid therapy and to describe the other processes and tools used to monitor abuse and diversion of medications. Given the crisis of the opioid overdose and death epidemic, along with this repurposing of OTAs as disclosure documents primarily, Rager and Schwartz argue that patient consent is not needed and that OTAs should be universally applied in clinical practices. We can all agree on the big picture goal of limiting the number of opioid prescriptions in order to minimize the tragedy of opioid overdose deaths. We disagree, though, about the acceptable level of collateral damage to people in pain who fall victim to fighting the war against the so-called opioid epidemic. (shrink)