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It made my life a little easier: Primary care providers’ beliefs and attitudes about using opioid treatment agreements

Joanna L. Starrels, MD, MS, Bryan Wu, MS, Deena Peyser, BA, Aaron D. Fox, MD, MS, Abigail Batchelder, MA, MPH, Frances K. Barg, PhD, MEd, Julia H. Arnsten, MD, MPH, Chinazo O. Cunningham, MD, MS


Objective: To understand primary care providers (PCPs)’ experiences, beliefs, and attitudes about using opioid treatment agreements (OTAs) for patients with chronic pain.

Design: Qualitative research study.

Participants: Twenty-eight internists and family medicine physicians at two health centers.

Approach: Semistructured telephone interviews, informed by the Integrative Model of Behavioral Prediction. Themes were analyzed using a Grounded Theory approach, and similarities and differences in themes were examined among OTA adopters, nonadopters, and selective adopters.

Results: Participants were 64 percent female and 68 percent white, and practiced for a mean of 9.5 years. Adoption of OTAs varied: seven were adopters, five were nonadopters, and 16 were selective adopters. OTA adoption reflected PCPs’ beliefs and attitudes in the following three thematic categories: 1) perceived effect of OTA use on the therapeutic alliance, 2) beliefs about the utility of OTAs for patients or providers, and 3) perception of patients’ risk for opioid misuse. PCPs commonly believed that OTAs were useful for physician self-protection, but few believed that they prevent opioid misuse. Selective adopters expressed ambivalent beliefs and made decisions about OTA use for individual patients based on both observed data and a subjective sense of each patient’s risk for misuse.

Conclusions: Substantial variability in PCP use of OTAs reflects differences in PCP beliefs and attitudes. Research to understand the impact of OTA use on providers, patients, and the therapeutic alliance is urgently needed to guide best practices.


opioid analgesics, agreement, contract, physician perspective, chronic pain, opioid misuse

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Paulozzi LJ, Budnitz DS, Xi Y: Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006; 15(9): 618-627.

Model Policy for the Use of Controlled Substances for the Treatment of Pain. Federation of State Medical Boards of the United States, 2004.

Washington State Agency Medical Directors’ Group: Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain. 2010.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130.

Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Federation of State Medical Boards of the United States, 2013.

Starrels JL, Becker WC, Alford DP, et al.: Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010; 152(11): 712-720.

Wiedemer NL, Harden PS, Arndt IO, et al.: The opioid renewal clinic: A primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007; 8(7): 573-584.

Fagan MJ, Chen JT, Diaz JA, et al.: Do internal medicine residents find pain medication agreements useful? Clin J Pain. 2008; 24(1): 35-38.

Krebs EE, Ramsey DC, Miloshoff JM, et al.: Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Med. 2011; 12(5): 740-746.

Watkins A, Wasmann S, Dodson L, et al.: An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center. Family Med. 2004; 36(7): 487-489.

Adams NJ, Plane MB, Fleming MF, et al.: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001; 22(3): 791-796.

Boulanger A, Clark AJ, Squire P, et al.: Chronic pain in Canada: Have we improved our management of chronic noncancer pain? Pain Res Manag. 2007; 12(1): 39-47.

Wallace LS, Keenum AJ, Roskos SE, et al.: Development and validation of a low-literacy opioid contract. J Pain. 2007; 8(10): 759-766.

State of Maine Substance Abuse and Mental Health Services: Suggested Framework for Opioid Prescribing. Sample Treatment Agreement. Augusta, ME, 2012. Available at Accessed October 28, 2013.

Fishbein M: The role of theory in HIV prevention. AIDS Care. 2000; 12(3): 273-278.

Fishbein M, Triandis HC, Kanfer FH, et al.: Factors influencing behavior and behavior change. In Baum A, Revenson TA Singer JE (eds.): Handbook of Health Psychology. Mahway, NJ: Lawrence Erlbaum, 2001: 3-17.

Glaser BG, Straus AL: The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine de Gruyter, 1999.

Bergman AA, Matthias MS, Coffing JM, et al.: Contrasting tensions between patients and PCPs in chronic pain management: A qualitative study. Pain Med. 2013; 14(11): 1689-1697.

Vallerand A, Nowak L: Chronic opioid therapy for nonmalignant pain: The patient’s perspective. Part II—Barriers to chronic opioid therapy. Pain Manag Nurs. 2010; 11(2): 126-131.

Collen M: Opioid contracts and random drug testing for people with chronic pain—Think twice. J Law Med Ethics. 2009; 37(4): 841-845.

Lieber SR, Kim SY, Volk ML: Power and control: Contracts and the patient-physician relationship. Int J Clin Pract. 2011; 65(12): 1214-1217.

Roskos SE, Keenum AJ, Newman LM, et al.: Literacy demands and formatting characteristics of opioid contracts in chronic nonmalignant pain management. J Pain. 2007; 8(10): 753-758.

Penko J, Mattson J, Miaskowski C, et al.: Do patients know they are on pain medication agreements? Results from a sample of high-risk patients on chronic opioid therapy. Pain Med. 2012; 13(9): 1174-1180.

Savage S: The patient-centered opioid treatment agreement. Am J Bioeth. 2010; 10(11): 18-19.

Nicolaidis C: Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Med. 2011; 12(6): 890-897.

Fishman SM, Gallagher RM, McCarberg BH: The opioid treatment agreement: A real-world perspective. Am J Bioeth. 2010; 10(11): 14-15.

Manchikanti L, Manchukonda R, Damron KS, et al.: Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician. 2006; 9(1): 57-60.

Goldberg KC, Simel DL, Oddone EZ: Effect of an opioid management system on opioid prescribing and unscheduled visits in a large primary care clinic. J Clin Outcomes Manag. 2005; 12(12): 621-628.

Sullivan MD, Leigh J, Gaster B: Brief report: Training internists in shared decision making about chronic opioid treatment for noncancer pain [see comment]. J Gen Intern Med. 2006; 21(4): 360-362.

Fox AD, Kunins HV, Starrels JL: Which skills are associated with residents’ sense of preparedness to manage chronic pain? J Opioid Manag. 2012; 8(5): 328-336.

Chen JT, Fagan MJ, Diaz JA, et al.: Is treating chronic pain torture? Internal medicine residents’ experience with patients with chronic nonmalignant pain. Teach Learn Med. 2007; 19(2): 101-105.

Matthias MS, Parpart AL, Nyland KA, et al.: The patient-provider relationship in chronic pain care: Providers’ perspectives. Pain Med. 2010; 11(11): 1688-1697.

Dobscha SK, Corson K, Flores JA, et al.: Veterans affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008; 9(5): 564-571.

Katz MH: Long-term opioid treatment of nonmalignant pain: A believer loses his faith. Arch Intern Med. 2010; 170(16): 1422-1424.

Merrill JO, Rhodes LA, Deyo RA, et al.: Mutual mistrust in the medical care of drug users: The keys to the “narc” cabinet. J Gen Intern Med. 2002; 17(5): 327-333.

Green CR, Wheeler JR, Marchant B, et al.: Analysis of the physician variable in pain management. Pain Med. 2001; 2(4): 317-327.

Katz NP, Sherburne S, Beach M, et al.: Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003; 97(4): 1097-1102.

Vijayaraghavan M, Penko J, Guzman D, et al.: Primary care providers’ judgments of opioid analgesic misuse in a community-based cohort of HIV-infected indigent adults. J Gen Intern Med. 2011; 26(4): 412-418.

Vijayaraghavan M, Penko J, Guzman D, et al.: Primary care providers’ views on chronic pain management among high-risk patients in safety net settings. Pain Med. 2012; 13(9): 1141-1148.

Becker WC, Starrels JL, Heo M, et al.: Racial differences in primary care opioid risk reduction strategies. Ann Fam Med. 2011; 9(3): 219-225.

Hausmann LR, Gao S, Lee ES, et al.: Racial disparities in the monitoring of patients on chronic opioid therapy. Pain. 2013; 154(1): 46-52.

Gourlay DL, Heit HA, Almahrezi A: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005; 6(2): 107-112.

Chapman CR, Lipschitz DL, Angst MS, et al.: Opioid pharmacotherapy for chronic non-cancer pain in the United States: A research guideline for developing an evidence-base. J Pain. 2010; 11(9): 807-829.



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