Alison Goldsmith got her first lesson in the potential dangers of using opioid painkillers at the age of 13, when she was diagnosed with a chronic pain disorder called reflex sympathetic dystrophy.
Her doctor agreed to prescribe opioids, which have some of the same properties as opiate narcotics, to help her manage her intense pain, but only under one condition: She had to sign an agreement that set forth guidelines for using the painkillers while under his care.
"He wanted to make sure I thoroughly understood everything about the medication, like how dangerous they could be and that I understood ... when to use them, not to share them and to store them in a safe place," said Goldsmith, who is now 22.
The agreement, she said, made it clear that the consequences of misusing these drugs could be serious.
"Being so young, there were a lot of people around me offering me drugs and abusing medications, but I never wanted to use them that way."
Goldsmith was one of an increasing number of patients required to sign pain agreements, and doctors who use them say the documents are an effective way to communicate what the expectations are for the treatment of chronic pain using opioids, and how patients can use these medications safely. Critics of the agreements, sometimes called contracts, say they undermine the patient-provider relationship.
Pain agreements vary from provider to provider, but in general, they outline conditions patients must meet to continue treatment for chronic pain.
"For example, the agreement may say patients have to keep the medication out of of other people's reach, the medication has to be kept in a locked container, there are no early refills, no sharing of medication, they may be required to submit to random tests to determine whether there's compliance and so forth," said Dr. Melvin Gitlin, chairman of the Department of Anesthesiology, Perioperative and Pain Management Medicine at the University of Miami's Miller School of Medicine.
In addition to random testing, doctors may require patients to have their pills counted to make sure they're the only ones taking them, or require them to use only one pharmacy.
Dr. Joel Saper, founder and director of the Michigan Headache and Neurological Institute in Ann Arbor, said he rarely uses opioids to treat chronic headaches, but whenever he does, he requires his patients to sign an agreement.
"We must realize that opioids can be lethal, and that people do become physiologically dependent, and that people who become dependent get desperate if they don't get them," he said. "It's a lot different than any other set of circumstances with other medications. We don't feel that way aobut antidepressants or beta-blockers, for example."
The American Academy of Pain Medicine, the American Pain Society and the Federation of State Medical Boards all recommend the use of opioid agreements in certain circumstances. They started recommending the use of agreements in the late 1990s, according to Gitlin.
But the Center for Practical Bioethics, a Kansas City, Mo., nonprofit policy institute, believes these agreements can create an adversarial relatiionship between patients and providers.
Last November, a panel of pain and policy experts, including some from the Center for Practical Bioethics, published an in-depth discussion of pain contracts.