Factors that Impact Pain Management Agreement Utilization for Patients on Chronic Opioid Therapy: A Retrospective Chart Review

From the 2021 HVPAA National Conference

Katherine Gonzalez (University of Texas Medical Branch), Alejandro Villasante-Tezanos, Erin Hommel


To combat the growing opioid epidemic, national guidelines recommend several strategies for physicians to mitigate risk of opiate prescribing. One such recommendation is the use of a pain management agreement. These agreements involve limiting the number and frequency of prescription refills, allowing laboratory drug tests and restricting drug management to a single prescriber and pharmacy. The Texas Administrative Code requires a written pain management agreement for all patients on chronic opiate therapy. At the University of Texas Medical Branch (UTMB) in Galveston, only 60% of patients receiving chronic opioids are on a pain management agreement.


A high value care opioid stewardship team was created to target safer opiate prescribing practices including improved utilization of pain contracts. This analysis seeks to understand variables that impact pain contract utilization in order to create a targeted quality improvement approach at our institution. Patient, prescription, and prescriber factors were analyzed.


We performed a retrospective chart review of all opioid prescriptions at UTMB indicated for chronic use from July 2020 through October 2020. This included 2538 patients or 5044 prescriptions. We collected patient data (age, gender, race/ethnicity, insurance status), prescription data (scheduled drug class, frequency of fill, prn/scheduled use, and opioid polypharmacy) and prescriber data (specialty and relationship to specialty on agreement). Statistical analysis was performed using Chi-Square tests and significance was set at 0.05. Analysis was performed in SAS.


Patients on a schedule II opioid were more likely to be on a pain management agreement than patients on a schedule III opioid (71% vs 28%, P <0.0001). Patients with opioid polypharmacy were more likely to be on a pain management agreement than patients on a single opioid prescription (75% vs 47%, P <0.0001). Patients with refills for their opioid prescription were more likely to be on a pain management agreement than patients without opioid refills (69% vs 28%, P <0.0001). Patients with scheduled dosing were more likely to be on a pain management agreement than patients on as needed dosing (66% vs 46%, P <0.0001). Anesthesia had the highest percentage of patients on a pain management agreement (88%) followed by family medicine and internal medicine primary care (42%). Surgical specialties had the lowest percentage of patients on a pain management agreement (7%, differences all statistically significant at p<0.0001).


This analysis shows that patients on schedule II opioids as well as patients receiving opioid polypharmacy, multiple refills and scheduled dosing are all more likely to have a pain management agreement on file. Anesthesia pain services are significantly more likely to abide by the Texas Administrative Code requirement to implement pain management agreements with patients receiving chronic opiate therapy.

Clinical Implications

This analysis allows us to understand local characteristics that may influence our healthcare provider’s likelihood to implement a pain contract with patients on chronic opioid therapy. Targeting patients receiving schedule III opiates and focusing educational interventions on primary care and surgical specialties should drive significant process improvement around pain management agreement utilization at our institution.

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