Reasonable Exceptions From Unreasonable Policies: Requiring Treatment Agreements for Long-Term Opioid Therapy and...

Since drug overdose deaths began increasing in the United States, policy makers and the medical community have developed tools to try to address the crisis. Opioid Treatment Agreements (OTAs) are one such tool which purportedly seek to promote shared decision-making and informed consent with patients. OTAs are documents that clinicians present to patients when prescribing opioids for chronic pain that describe the risks of opioids and require patients to agree to certain conditions in order to receive their medication. This paper critically explores the ethics of three related features of OTA policies and guidance: First, OTAs typically integrate behavioral requirements that go beyond the detection of opioid misuse and diversion. Second, OTAs often designate for clinicians significant discretion in their responses to individual patient OTA violations. That is, codified in many OTAs is the clinician's discretionary power to decide to stop prescribing LTOT or to dismiss the patient from their practice altogether. Third, governmental policies that recommend OTA use often exempt patients with cancer or terminal illness, allowing them to access this type of chronic pain management without the same requirements. Each of these features may have been created in an attempt to address individual patient needs while also responding to an urgent public health crisis, but they also-on their own and working in concert - raise serious ethical concerns. We argue that these features identify some patients as "respectable" pain patients and others as less-so, risking compounding the stigmatization of pain management and exacerbating health disparities.