Treating patients with narcotic analgesics is not simple. Narcotics can be very effective at relieving pain, but they come with a whole set of problems, including risk of adverse effects such as nausea, constipation, and altered mental status; overdose; and dependence. As I’ve written before, narcotic-dependent patients can be a challenge to treat. One of the tools we use is the “narcotic contract”, a document which explicitly states the rights and responsibilities of the health care provider and the patient (although in practice, it tends to put more emphasis on the rights of the provider and the responsibilities of the patient). Two typical examples of such contracts can be found here and here.
These contracts are essential, especially from the doctor’s perspective, in that they give us a mechanism to prescribe narcotics transparently, with clear rules, and they allow us to put to the curb patients who violate these written expectations.
Narcotic contracts seem to put more burden on the patient than the physician, but there are hidden burdens. A doctor puts herself at risk every time she prescribes narcotics. If they are diverted, the doctor can end up in serious trouble. If they are misused, the doctor can end up in serious trouble. There are many doctors who despite the benefits of narcotics will not prescribe them. There are also doctors who despite the risks will prescribe them without significant additional safeguards. I find the contracts to be the best balance we have.
My lingering question is about informed consent. If a patient comes to see me already on narcotics, and I have them sign a contract, my foremost thought is, “this thing is going to prevent me from being abused.” In other words, it’s about me. I have to consciously remind myself that the proper use of narcotics to treat the patient’s pain is primary. When a patient violates the contract, I inform them how they violated it and tell them what the consequences are (usually either discontinuation of narcotics or discharge from my care). Given the known affects of narcotics, how informed is their consent? What did signing the contract really mean to them? I’m not questioning whether they were in a clear state of mind when they signed—that’s a separate issue. I’m questioning whether narcotic dependence itself creates a situation where the contract is not as effective a tool as it might otherwise be. Does being a chronic narcotic user, and the physical changes this entails, make adhering to this contract prima facie implausible?