The government’s misguided attempt to address the opioid overdoses did more than change prescribing practices. It changed the relationship between doctors and patients, and not for the better.
Before receiving opioid pain medication, many patients today are required to sign a “patient-prescriber agreement,” often called a “pain contract.” The patient agrees to submit to regular drug testing, disclose personal and family histories of substance use, follow strict rules about medication use, and accept that violating those rules may result in discontinuation of care.
Although these agreements are presented as mutual understandings, in practice, they are one-sided behavioral contracts. The physician dictates the terms, and the patient, often already in pain and with few alternatives, must comply or risk losing access to treatment.
How the government normalized suspicion
The federal government itself has helped normalize this approach. The Food and Drug Administration even publishes a model five-page opioid treatment agreement containing roughly three dozen requirements.
Pain contracts are often justified as necessary safeguards against misuse, diversion, and overdose, yet their broader significance is rarely acknowledged: They mark the migration of drug warfare into ordinary medical care. These contracts do not simply regulate patients; they demean them, frighten them, and redefine the doctor-patient relationship around suspicion and control, effectively turning physicians into parole officers.
Doctors are expected to monitor behavior, order drug tests, enforce compliance, and respond to deviations, no matter how minor. These are not traditional clinical roles. The physician becomes, in part, a compliance officer, tasked not only with treating pain but also with policing the conditions under which treatment is allowed.
What makes opioids different?
Physicians did not willingly assume this role. Pain contracts emerged from years of political panic over opioids, aggressive DEA enforcement, pressure from state medical boards, insurer mandates, pharmacy scrutiny, and federal prescribing guidelines that turned opioid prescribing into a legal and regulatory hazard. In response, doctors increasingly practice defensive pain medicine in which surveillance, documentation, and compliance rival clinical judgment itself.
This kind of behavioral contract is virtually unheard of elsewhere in medicine. Patients starting anticoagulants, which carry a real risk of fatal bleeding, are educated about the risks but are not required to certify that they won’t take non-steroidal anti-inflammatory drugs (NSAIDs). Those prescribed benzodiazepines, which can cause dependence and potentially dangerous interactions with alcohol, are not routinely subjected to questioning about their drinking. Nor are other controlled substances, such as stimulants, subject to such scrutiny.
In most of medicine, risk is managed through informed consent and clinical judgment, not through preemptive contracts backed by surveillance and fueled by fear. Nor do we impose this framework on other risky consumer choices. Alcohol contributes to addiction, impaired judgment, accidents, and deadly interactions with other substances. Yet adults are not required to sign contracts before buying bourbon or wine. We rely instead on ordinary laws and personal responsibility.
Opioids are not risk-free, but neither are they uniquely dangerous when properly prescribed and responsibly used. What is unique is the system of suspicion, monitoring, and behavioral control that has grown up around them. The difference is not simply pharmacology. It is political and social stigma.
Patients as presumptive addicts
Over the past two decades, opioid policy has increasingly treated pain patients as presumptive addicts rather than people in need of care. Many chronic pain patients live in constant fear that a misunderstood urine test, a pharmacy issue, a missed appointment, or even an arbitrary interpretation of “noncompliance” could abruptly end their treatment. Some patients report being dismissed from care after testing positive for medications legally prescribed by other physicians. Others describe humiliating monitoring procedures that leave them feeling less like patients and more like probationers.
Worse still, there is surprisingly little evidence that pain contracts meaningfully reduce addiction, overdose, or diversion. But they do provide something else: institutional protection. They signal to regulators, insurers, pharmacies, and prosecutors that physicians are policing patients aggressively enough. That is why these agreements continue to proliferate despite weak evidence of benefit and the obvious costs to trust.
In trying to control risk, policymakers have imported the logic of surveillance and compliance into the exam room itself. The opioid crackdown did not merely regulate drugs. It transformed the culture of medical practice.
Medicine depends on trust: Patients must be able to speak honestly without fear of punishment, and physicians must be free to exercise judgment without constantly acting under the shadow of legal suspicion. When treatment begins with contracts, surveillance, and the presumption of guilt, something essential is lost.
Pain patients deserve the same dignity, privacy, and presumption of trust afforded to every other patient group. And physicians should be allowed to practice medicine, not parole enforcement.
Jeffrey A. Singer is a surgeon. Josh Bloom is a science and medicine writer.
