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This paper critiques the increasingly prevalent approach in pain management that urges the universal adoption of medication adherence contracts and random urine drug screening as tools for managing the risk involved in prescribing and consuming opioid analgesics. We assess the use of such “universal precautions” through a two-tiered analysis consisting of dyadic and population-level perspectives, a combination of approaches that has rarely been deployed simultaneously in the bioethics literature on the undertreatment of pain. Specifically, in the first portion of the paper, we criticize the turn to opioid contracts in terms of the physician-patient relationship, and demonstrate that properly understood, applied, and documented, scrupulous adherence to informed consent offers all of the benefits and none of the burdens of opioid contracts. In the second portion, we balance the prior emphasis on the therapeutic dyad by leveraging techniques drawn primarily from population-level bioethics. We focus on disease stigma, explain why it is a pressing ethical issue on both descriptive and normative grounds, and show how the use of opioid contracts as part of a universal precautions approach is much more likely to intensify than to ameliorate stigma, contrary to the claims of its proponents.

Pharmacovigilence and the Plight of Chronic Pain Patients: In Pursuit of a Realistic and Responsible Ethic of Care