White Coat Underground

I recently raised some questions about narcotic therapy contracts and my readers raised even more issues. Some of these questions deserve further discussion.

First, despite the examples I gave, when I’m speaking about narcotic contracts I am talking about people chronically on narcotics. I don’t normally use contracts for people with self-limited problems. That doesn’t mean these patients aren’t susceptible to the same problems as long-term users of narcotics, but the thinking is (based on what data, I don’t know) that people with a clear, self-limited, anatomic problem, such as a kidney stone or broken hip, are less likely to develop a substance use disorder (depending of course on their baseline susceptibilities to such problems). This assumption may be complete and utter bullshit, and certainly there are people who become addicted after using narcotics for self-limited problems. Still, it seems (from crappy, anecdotal experience) that it’s people with vague, chronic pain that end up causing health care providers the most problems.

Second, despite reservations I may have, and other cogent points made by my readers, I’m not about to stop using this tool. It may be a blunt instrument, but it’s what we’ve got for the time being. Even though we may recognize that these contracts may do more to protect providers than patients, and that narcotic use is not entirely volitional, these contracts serve an important purpose. They recognize that narcotics are not like other drugs. While someone may be dependent on insulin, they do not engage in illegal behaviors to obtain it, and they do not end up using it for that yummy insulin high. They do not grow to crave it.

And while these “addiction behaviors” are not entirely volitional, they are at least in part volitional. Narcotics are frequently diverted, and are often used in ways not prescribed. As physicians, if we wish to take advantages of these useful drugs, we have to find ways to make their use as safe as possible. I can give my diabetic as much insulin as they request, and I can be pretty sure they will still use it correctly. Given how narcotics can affect behavior, the same cannot be said of opioids. Strategies to minimize narcotic misuse in those who need them have not, as far as I know, been well studied (note the qualifier “well”, please). Contracts are a behavioral intervention and it may be that they are naive in the face of the physiology of narcotic use, but they can still help keep a patient with chronic, non-cancer pain on a non-escalating dose, and that is, in general, a reasonable goal.

One point that came up a number of times was regarding informed consent (sort of):

One, I find it ironic that you include “informed consent” in the title of your article since item 8 of both of the “contracts” you link to basically require the patient to give up his right to informed consent or any type of consent at all. You have to agree to do anything the provider says or you’re back to constant pain. Two, I would like to point out that these “contracts” are signed under duress. “Agree” to this or I’ll leave you in pain. This does not seem to be the most ethical or compassionate behaviour. You don’t want to give up your rights to say no to any treatment, you don’t want to be treated like a criminal, you don’t want to give up your rights to confidentiality? Well, good luck controlling that pain with aspirin and hot packs. And stop that whimpering, it’s more than most people had through out a lot of history.

and:

I have to disagree. Section 8 means you get no choice at all. No autonomy at all. Period. You have to agree to anything that provider wants with out even knowing what it is. What ever he wants, even if it makes your condition worse, or is degrading, or is more dangerous than you would want to risk, or harms you. It’s do it or go back to the pain. Sure, you can walk away any time you want to go back to the pain. If that is a choice, then last year I chose to let burglars have my TV because I did not stay in my house 24 hours a day, seven days a week.

These comments share a lot with narcotic-seeking behaviors in that they basically say that anything that interferes with obtaining narcotics is “bad” and not the fault of the consumer.

Thoughts?

Comments

#1 WcT
February 4, 2010

It’s do it or go back to the pain

This is an illustration of a common misconception about what informed consent is. Informed consent does not mean “and if you don’t consent to this, I’ll come up with an infinite number of other options to treat you.”

It means “Here is the relevant information to this treatment, take it or leave it. If you say no, maybe I have somethin else to offer, but if i don’t, and you say no, I can’t further help you.”
#2 pelican
February 4, 2010

WcT nails it.
#3 SurgPA
February 4, 2010

These statements reflect a feeling of entitlement to narcotics coupled with the belief that physicians are morally obliged to provide narcotics just because the patient has pain and requests narcotics (perhaps an unintended consequence of the swing away from paternalism in health care). Both comments equate receiving narcotics as the only path to pain relief and fully miss this important point that narcotics are not an end-goal but a tool to achieve an end (pain management.) I fully support shared decision making (I wish shared medical-liability came with it), but in no other disease process would this attitude be acceptable. Imagine that a patient comes to their doctor and says “I have high cholesterol. I want you to prescribe lipitor.” The doctor says, “I understand, but you’re young with otherwise low cardiac risk factors. This drug has certain risks and requires monitoring with periodic blood testing. There might be better ways for you at this point that we could work on to lower your cholesterol.” Would anyone fault the physician for not prescribing lipitor? Or if she did feel it was appropriate would she be faulted for requiring monitoring and blood testing?
#4 SurgPA
February 4, 2010

I see this discussion, perhaps with distorted vision, more broadly as a discussion of chronic pain management, and I haven’t read much here yet about the overlap and role of depression in chronic pain. I won’t claim to know which is chicken and which is egg, but this significantly confounds treatment. Depression can alter perception and cognition. SSRIs, TCAs and other psychoactive medications are commonly used both to treat depression (not to open that can of worms) and as adjuncts for chronic pain. Does any of this factor into patients’ ability to “freely” enter into a narcotic contract?

Pal – I agree that contracts are a behavioral intervention, but I think in some cases they also serve as a validation for the patient that their use is “ok.” A not-rare qualifier I hear from patients (particularly on higher doses) is “oh, I’m on a contract with my pcp for that,” the implication being “it’s ok, don’t freak out, I’m stable.”
#5 jk
February 4, 2010

Thoughts? Since I have been single out for attack, I have a few thoughts.

You said:
These comments share a lot with narcotic-seeking behaviors in that they basically say that anything that interferes with obtaining narcotics is “bad” and not the fault of the consumer

1. Some people might consider this an argumentum ad hominem. “Oh look, he’s sounds like a druggie (and maybe he is wink, wink) therefore I do not have to respond to his argument. I can just dismiss it and him.”

Based on your past blog entries, I expected better of you. (I really want to say “let’s keep this above the level of the anti-vaxers, but that would be too close to an argumentum ad hominem.)

2. Just for the record, even though it is irrelevant and I should not have to say it, the last prescription that I had for a narcotic pain killer was about 25 years ago when I had some wisdom teeth removed.

I am fortunate enough to not have any conditions that have been demonized, so I haven’t had to deal with this sort of abuse myself. But hey, maybe that will change some day and I have to choose between being able to “say no” and being able to pee.

3. I never said that that anything that interferes with obtaining narcotics is “bad” and not the fault of the consumer. I said making someone give up the right to make any other choices about his medical treatment in order to obtain the right to buy that which he needs to live a normal life is wrong. I don’t care if it is pain medication, insulin, or what ever.

I will say it as plainly as possible. Using pain (or the threat of pain) to take away someone’s right to choose to refuse other treatments/tests/procedures is morally wrong and that is what section 8 does.

(Just to be even more clear, this is not limited to pain medication. For example, a doctor who refused to prescribe birth control pills to a women unless she signed a “contract” agreeing to:
– not engage in extra-martial sex (technical illegal in some states)
– to allow the doctor to do things to check up on her
– to let him tell her husband if the doctor suspects she is having an affair
– and so on

would be equally wrong.)

If you think that a patient is diverting or abusing drug that you are prescribing him, the proper response is to end your relationship with him. It is not proper to instead abuse other patients.

If you want to use a so called “contract” like this as a CYA to protect yourself against the DEA, then that’s different. It is still wrong and abusive, but different. Just be honest about it and don’t pretend that you are not putting your interests first. Don’t pretend that the person you coerced into signing it is still your patient. At that point, he is just a consumer (as you ironically said).

Now, if you dropped clauses 4 and 8, it wouldn’t be nearly as bad. Without those clauses (especially if a clause was added where the doctor agreed to provide adequate pain relief in return was added), I might even reluctantly sign it instead of going through hassle and time to find a new surgeon, although it would certainly destroy any trust I had in him.

For a short term situation like a surgery that would be bad to put off, if I had to “choose” between signing the original contract (with sections 4 and 8 intact) and having the right to refuse treatments and to keep my right to doctor-patient confidentiality , I guess that I would have to “choose” to be in pain as the safer option as I would not be able to trust the surgeon. ( Obviously the better solution would be to find a different surgeon, but this is not always a realistic option.) Hopefully he would still grant me pain medication during the surgery rather than just a paralytic to keep me quiet. (Note for the humour impaired: That last sentence is an attempt at levity.)

Now, if I had a long term condition that required pain medication to have a normal life …. well, I guess that I would just be screwed. When your “choices” are pain, humiliation, or death, most people will cave and do what they have to do to stop the pain. I don’t assume that I am better than most people.

(As a side note, I wonder if when they are injured by real malpractice, if people who are forced to sign “contracts” like this are more likely to sue than people who are not? )

You said:
They recognize that narcotics are not like other drugs. While someone may be dependent on insulin, they do not engage in illegal behaviors to obtain it, and they do not end up using it for that yummy insulin high. They do not grow to crave it.

Well, first, I will point out that some people who don’t need insulin do do illegal things to obtain it. It may not have, as you say, “yummy insulin high”, it be can be used to obtain an unfair advantage in some sports. Or, at least, some athletes and the Word Anti-Doping Agency believe it does. I doubt that anyone has tested this rigorously.

Second, I don’t dispute that some people abuse narcotics. I don’t say that you should dispense them like candy. I’m not saying that you shouldn’t refuse to write a prescription for any drug that you think isn’t medically indicated. (You should, especially with antibiotics.) I am not saying that you don’t have to right to end your relationship with a patient. I’m saying that you don’t have the right to coerce a patient in to give up his right to say no.

Finally, I will add that this attitude that narcotics are so special and magic that preventing their abuse justifies anything doesn’t just affect people with chronic or post surgical pain. It also affects dying. My father died of cancer and despite all the lip service that the drug warriors give about how hospice patients are different and how what they do doesn’t limit the pain relief that the dying get, I can tell you from personal observation that it isn’t true.
#6 Texas Reader
February 4, 2010

I’m not sure that the complaints represent a sense of entitlement so much as a reaction against a perception of something that used to be a common issue in Dr./patient relationships, and sometimes still is – the dynamic in which the Dr. dictates everything and the patient accepts without questions.

Take a patient depressed and/or disabled by unrelenting chronic pain and hand them a contract like that and I can see how the patient might react negatively. I’ve never had to deal with chronic pain, but have had severe pain a couple of times (migraines, kidney stone, endometriosis.)

The contract seems rational – perhaps the way it is presented to the patient can ameliorate some of those fears of the patients that they are enterng into a relationship with the doctor in which they have no control or their concerns are not respected.
#7 jk
February 4, 2010

To WcT and pelican,

You don’t get it. Section 8 isn’t “”Here is the relevant information to this treatment, take it or leave it”; it’s “you’ll do whatever I decide in the future or else. No you don’t need to know what it is.”

The “contract” is clear. The subject has no rights, except to run away. After the subjects signs that, why should the provider explain anything? The subject has already pre-agreed to do what ever the the provider says sight un-seen.
#8 PalMD
February 4, 2010

If you think that a patient is diverting or abusing drug that you are prescribing him, the proper response is to end your relationship with him.

Really?
#9 ZenMonkey
February 4, 2010

Dang, PalMD zeroed in on the exact same comment that I did.

I’m chronically ill and one way I am managed is with narcotics, although thankfully I don’t need to take them every day. I’d be pretty damned insulted if my doctor ended my relationship just because he “thought” I was abusing them. Or let’s say I was in fact abusing them. I would really hope that a person so closely connected with my care would put at least some effort into helping me admit or even manage my addiction, rather than punting me out the door at the first questionable sign.

I agree there’s a point where abusive drug-seeking behavior can make it untenable to continue a relationship with a patient. But if you start to notice a problem with your patient’s health (especially addiction, which it’s quite possible no one else notices, or might not even exist), shouldn’t you, I don’t know, possibly consider having a conversation about it instead of immediately passing judgment?
#10 mackwill
February 5, 2010

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#11 Adam C.
February 5, 2010

While I could see how contracts could be coercive, if they required too much patient autonomy to be given up without due cause, and when the doctor is in a position of power, I don’t think that applies here. When dealing with addictive drugs, it is reasonable, as part of informed consent, to work with the patient to minimize addictive potential. A contract, agreed with the patient, is a reasonable way to both assure the patient has the necessary information, and to encourage them to stick to a difficult treatment regime. Having made a promise is a powerful motivator for many people.

Let me ask you something, as a patient:

I’ve noticed that I seem to experience a fairly strong placebo effect. I’d like to exploit this, but know that I’m too smart to trick myself if I know something’s placebo. I also trust my doctor. As I’m willing to be tricked (when appropriate) by being prescribed placebos, should I talk to my doctor about this?
#12 SurgPA
February 5, 2010

Adam,

When you went to your doctor last year with a head cold and a cough? And he prescribed a Z-pack (azithromycin)? He was giving you placebo. (wink)

Various studies have shown placebo effect to be as high as 50% in some cases, particularly those with a strong subjective compononent to the outcome (pain, mood disorder.)
#13 WcT
February 5, 2010

it’s “you’ll do whatever I decide in the future or else. No you don’t need to know what it is.”

The “contract” is clear. The subject has no rights, except to run away. After the subjects signs that, why should the provider explain anything

Bull.

It does not say “you agree to do whatever I say, and don’t need to know what it is.” Having USED pain contracts before, both in the PCP setting, and inthe ED (many pain contracts have patients agree to go to 1 ED and ONLY one ED for breakthrough pain, where the pain contract will be on file, and the staff will be aware of this relationship.) I can tell you that for the patients, EVERYTHING is spelled out. The patient has the right to accept this treatment, or to not accept this treatment. Niether of the options offered is “run away.”

As for “why should the provider explain anything after that?” You have just expressed a PROFOUND misunderstanding of the doctor patient relationship! The doctor explains things after that, set by set, becuase a patient understandin why they’re doing what they’re doing is how you work with a patient to enable them to BE compliant with therapy – we do much better that which we understand.

It’s a bad idea to try and describe the doctor patient relationship as adversrial just because you don’t like 1 line in a paine contract.
#14 SurgPA
February 5, 2010

@jk

Here’s another type of contract I “make” patients sign every day in order to receive treatment, called a surgical consent form. It is every bit as coercive. In it they sign that I’ve told them they might die, might wake up with a much larger incision (10-15x as long) as they expect, might have significant post-operative pain, might wake up with a colostomy, might bleed and require a blood transfusion, or that I might damage another organ beyond repair. They have no input as to the stipulations of that contract, and if they refuse to sign, they don’t get to have their surgery. Even if failure to operate would result in death.

Do you object to this contract?
#15 PalMD
February 5, 2010

All of the offices I work out of use a general consent to treatment that is unalterable. If a patient doesn’t wish to sign it in its entirety, they cannot be seen. Non-negotiable. Period.

We all have the “right” to be treated with respect, but not to determine exactly what our care will be. A diabetic, to use the earlier example, cannot ethically or legally demand that their doctor prescribe a particular diabetes medication or at a certain dose. If they are unhappy with the way the doctor manages the illness, they can see another doctor.
#16 PalMD
February 5, 2010

All that being said, it is probably true that entering into a “contract” while in pain or while dependent on narcotics is in some ways inherently coercive, but I don’t see a lot of ways around it.
#17 Mu
February 5, 2010

Non-negotiable. Period. … inherently coercive ..

I find this really depressing after the discussion on HeLa. On one side you are fighting for the highest ethical standards in the treatment of patients, then you admit to “no paperwork, on my terms, no treatment”. I guess we haven’t really come as far as I thought. Not your personal fault, it’s inherent to the (dominated by legal stuff) system.
#18 Vicki
February 5, 2010

I think part of the disagreement here is on how broad the “accept the doctor’s instructions” part of the narcotic contract is. If it’s “use the narcotics only as agreed, and tell the doctor about anything else you do for pain” that’s a different scenario than if it includes “and if the doctor tells you to quit your job because you report less pain on weekends and holidays, do so, whether or not you have another job or money in the bank.”

I’m assuming that the doctor would know if the patient was also on, say, antibiotics, but might or might not be informed about massage therapy or over-the-counter NSAIDs.
#19 Bill
February 5, 2010

I think we’re getting too hung up on the specific language of the sample contract.

Which is frankly not specific enough.

Section 4 is too vaguely worded to provide any real protection from civil litigation or disciplinary action by the state medical board.

It should reference whatever “doctor shopping/suspected drug addict” laws exist in that particular state to take advantage of specific statutory protections offered to the reporting physician.

E.g., “if we suspect narcotic abuse, we are required under state law XXX to report such to the local district attorney”

NOT “if we suspect narcotic abuse we will disseminate your entire medical file to any government agency we can find”
#20 OleanderTea
February 5, 2010

I can give my diabetic as much insulin as they request, and I can be pretty sure they will still use it correctly.

Sounds like you’ve never seen the episode of Law & Order:SVU where the perp and his (deceased) wife were found to be using insulin in a, um, kinky way….

(I will post a thoughtful and serious response later. But I figured some levity might be good ’bout now.)
#21 leigh
February 5, 2010

i am pretty sure i get the autonomy thing that’s hanging people up about these contracts. what i’m not seeing is how autonomy gets mixed up in drug abuse situations. if things escalate to a state of compulsive drug use rather than a steady-state pain relief- how autonomous is the person, really?
#22 PalMD
February 5, 2010

I’m still missing the gist (or maybe I’m not) of some of the arguments against these contracts.

It’s as if it is being argued that doctors are actually automats for narcs and that anyone should be able to say, “it hurts, give me “x” amount of vicodin” and require nothing in return other than payment.

This is not how medicine works.
#23 Fallsroad
February 5, 2010

It’s as if it is being argued that doctors are actually automats for narcs and that anyone should be able to say, “it hurts, give me “x” amount of vicodin” and require nothing in return other than payment.
This is not how medicine works.

True, but the contracts are apparently for everyone, regardless of how you or the patient approach their individual treatment. They are a blanket solution to a non-universal problem.

PalMD, you seem to be very suspicious of narcotics as prescribed for long term pain management. That seems to come through in your word choice, and the comments you have highlighted, and your responses. That said, I am very glad to see you take this issue up for discussion.

The use of narcotics for pain management and control has always come with an implicit judgment and no small amount of suspicion. This is based, in part, on the facts of the drugs and their potential abuse. It is also based on a Puritanical idea that taking a drug for pain that can also be abused and (God forbid) might make you feel good even when taken at appropriate dosages is somehow “wrong”. Mix a little of that early Calvinist “perseverance through suffering” into the mix and it all gets pretty weird (I recall when my father in law was dying in the hospital, his doctor prescribed regular morphine to make him comfortable until he passed – it was a matter of when, not if, following major complications from surgery. I caught the nurses in the hall using the word “euthanasia” to describe the doctor’s orders. Trust me when I tell you I set them straight, by dragging the attending nurse into the room to take a look at the remnants of a human being that lay on the bed, writhing in pain, unable to speak or reason because his mind was gone).

That attitude has been rampant for decades in this country as the war on drugs grew from a stupid law enforcement idea to a national strategy and took on an outsized moral context that I find false.

I was first prescribed narcotics to attempt to manage pain from a persistent back injury in 2001 (the injury occurred 5 years prior). My doctor and I went through a period where he prescribed several different drugs (not all at once, of course), and I reported back to him on the results – effect on pain, side effects, etc. It took a very long time (including the discovery I was absolutely allergic to one of the meds to the point of puking 3 times a day ) to finally settle on one med, taken in small doses several times a day.

This medication allowed me to walk mostly upright, not be bedridden any longer, and to function as a nominally normal human being in our society.

Then I moved to Florida, changed doctors, and came up against a suspicion of abuse I had never even considered previously. The new doctor was very hesitant to prescribe the same med I’d been taking for almost three years, and it was clear in his manner and the questions he asked that he thought I was drug seeking for fun and pleasure, possibly to feed an addiction. In retrospect I should have walked out of his office, but I was too dense to be insulted, so I talked to him a bit about his unvoiced concerns (I said them aloud, and he didn’t deny that was what he was thinking) and he chose to prescribe.

He soon discovered that the meds worked for me and that I was not diverting or abusing them in an way. But there was a presumption of suspect activity there that I had not been aware existed.

Flash forward, and I move back to Oklahoma. I see a new doctor who also blinks when I tell her what I am taking. She prescribes, then refers me to a pain management specialist (a concept completely unfamiliar to me) who works with back injuries and spinal surgical patients. She told me flat out she was uncomfortable prescribing narcotics. Unlike other doctors, she was willing to say exactly why – fear of the law, fear of a legal environment where pain medications are viewed primarily as a way to get high with barely any legitimate therapeutic purpose.

The pain management doctor examined me and my records and indicated he would continue to prescribe going forward, and offered a range of other treatments he felt appropriate to my situation, none of which I had ever heard of before but was more than willing to pursue. In the course of that visit I was presented with a contract whose primary purpose, it seemed, was to protect him from the possibility that I am or would become a drug abuser and criminal.

It was only a little shocking at this point that I would be considered some sort of abuse risk. My visit with the referring doctor (who is still my physician) and her stated fears of legal retribution for prescribing narcotics to patients in pain had prepared me for this attitude.

I read the form over and signed.

I had little choice.

I lived for 5 years in excruciating pain. It took two more years to finally find a medication that would help alleviate some of that pain without blunting my ability to think and behave normally. It would have been stupid and irrational of me to refuse to sign because I felt coerced.

Because I did feel coerced, though not in a direct “sign this or else” manner, though it is certainly implied. I need those meds to live somewhat normally. Yes, I am dependent upon them (stopping suddenly would engender some manner of withdrawal, I am sure) but not just in the addictive sense, but more particularly in the quality of life sense. And that reality means more to me than an ass covering contract. Because I can envision a world where physicians will refuse to prescribe these meds at all unless they are specifically indemnified against legal prosecution, which most legislatures in this War On Drugs world are not even willing to consider.

I’ll add that my pain management doc is a good guy, one who obviously cares about his patients. We have embarked on a treatment plan that includes regular injections (a steroid/anti-inflammatory cocktail) and what physical therapy I can afford, plus the same prescription I’ve had for years. I use a slightly lower amount of the medication than I did prior to seeing this doctor, and the injections have made regular exercise a reality, which in turn improves the strength and flexibility of my back which makes living a little better.

But to say there was no coercion involved in that contract is to misunderstand the misery of chronic pain and the potential cruelty involved in the implied threat to make access to a medication that alleviates it difficult or impossible.

That said, I felt in my right mind to consent, insofar as consent in such an unequal situation is possible. The problem here (to me) isn’t doctors, it’s the law and this lingering idea that narcotics (though we know they can treat pain) are inherently evil, as if a medication itself can carry any moral freight.

Lastly, I’d rather live without the meds if it were possible. Though the side effects are fairly mild, they still exist. Additionally, it isn’t covered by my insurance, so it comes at considerable expense, and like a lot of people we live very close to the margins already. And to be blunt, I am not happy that I am essentially addicted to or dependent (choose your language) on any drug, but there it is .
#24 PalMD
February 5, 2010

I do agree that there is some coercion involved, and I would choose the word “dependent” based on common usage.

There is no good way that I am aware of to judge the risk of misuse of narcotics before a patient tries them (other than obtaining a positive history of a substance use disorder, and even then it’s questionable).

These contracts not only recognize the legal difficulties, and reflect societal norms (which I, like you, do not agree with) but recognize that these powerful and useful medications have a special risk associated with them, a risk borne primarily by the patient, not the provider.

It is also true that narcotics are both overused (that is diverted or prescribed inappropriately) and underused (not properly prescribed in sufficient doses to the correct patients)—this is a provider-side problem and a good narcotic contract should explicitly state that the provider will do their best to help the patient manage their pain.

The use of high-risk medications is a difficult problem with no easy solutions.
#25 Fallsroad
February 5, 2010

My situation was potentially further complicated by the fact I am an alcoholic, 14 years sober. Fortunately, theories about addictive personalities appear not to apply to me or my use of medication. Or perhaps my history has conditioned me to be more aware of the pitfalls? I don’t know.

The contract I signed was cloaked in the language of mutual protection, but when one considers the current legal regime when it comes to drugs and their abuse, it is pretty clear this benefits the provider primarily, and to a much lesser degree, the patient. And that lesser patient protection comes mostly in the form of a veneer of legitimacy – I have a contract therefore I am a patient, not an addict, and my pain is as real as the sunrise.

Not of much help if the authorities come knocking on the door, but it is of some use to some patents. I personally never felt I was doing something wrong in seeking treatment for pain and following my doctor’s recommendations, so the patient side of the contract really doesn’t do much for me.

I wonder if these contracts would change or fall out of use were the current strategies to deal with substance abuse and illegal drugs to move away from legal sanction and toward treating the problem as a human medical one, not a moral or legal one.

In any case, I’d sign a similar contract if I have cause to change doctors. Despite the coercive nature of them, I’d rather leave my principles at the door in favor of a treatment that is part of me being able to live closer to what was once normal for me than the dreadful, and known alternative.

Constant physical pain is powerful stuff. To me, more powerful than the narcotics I am using as part of treating that pain.

Consequently, I’d do almost anything to avoid returning to a life of severe pain and physical disability. That may sound similar to the language of drug seeking, but it is actually the language of pain remediation.

I’m glad to see you take this up, and to read all the comments from so many really sharp people here and in the other thread.
#26 OleanderTea
February 5, 2010

Fallsroad said something worth highlighting for emphasis:

But to say there was no coercion involved in that contract is to misunderstand the misery of chronic pain and the potential cruelty involved in the implied threat to make access to a medication that alleviates it difficult or impossible.

I also had a similar situation as Fallsroad when I moved from Florida to Massachusetts. Despite having my doc in FL send my entire records (with MRIs and test results and five+ years’ of notes), and having my old doc talk to my new doc in MA personally, new doc seemed to think I could be “weaned off” the narcotics. I tried the preventatives he suggested for migraine, and had some success with one of them, but the doc eventually fired me. I’m still not sure why — I never did any of the “suspect” things you hear about, no lost prescriptions, or “my dog ate them” or needing an early refill, or any of that. My “firing” consisted of his nurse just saying the doc wouldn’t see me any more.

And that was damned cruel.
#27 OleanderTea
February 5, 2010

Ok, now back to my comments on narcotics contracts (I got sidetracked on Fallsroad…)

After thinking about this for a few days, I think I’ve figured out why a number of posters had a negative reaction to narcotics contracts, and it’s one I have myself. It’s really disturbing to feel like you are being treated as “pre-addict”, no matter your history or behavior, just because you take a narcotic drug. It’s kind of like women of childbearing age always being treated as “pre-pregnant” and unable to control that fertility no matter their actual sexual and fertility status (lesbian, infertile, celibate, fitted with IUD, etc.).

If an opiate contract consists of a reasonable list of rules and expectations on both sides, then, yeah, I as a patient have no problem agreeing to sign a narcotics contract. Keep appointments, take monthly drug tests, maybe see a mental health professional every three months for a “checkup” on your ADLs and lifestyle, tell the doc all meds and supplements you take, etc. All valid.

But…what worries me are the nebulous bits in the contract. Mine says I have to “comply with treatment”. On the surface it sounds pretty reasonable, but really, are we only talking about taking meds and keeping appointments? Or are we talking about accepting every single suggestion for treatment the doc comes up with? I mean, do I have to agree to see the acupuncturist the docs added to their “multidisciplinary team”? What if, in addition to working more than full-time and looking after myself, and keeping appointments, and having that social life they tell me I need, I’m too bloody tired for thrice-weekly PT?

Doctors aren’t narcotics Pez dispensers, true. But patients also aren’t automations who are going to comply with a doctor’s every command. And the wording on many contracts are does make it sound like the latter could indeed be the expectation.
#28 Silver
February 6, 2010

Good gravy.
I am soooo not a Pez dispenser.
For one thing, I have nothing to offer as tasty as Pez, except for maybe those nummy chewable Lamictal tablets….

For another, I have only my treatment plan to offer. It’s only -my- treatment plan. If someone doesn’t agree with it, he or she can darned well go somewhere else. (And I’m not saying that in the spirit of “Because I Said So And I Know Best;” I sit down and discuss the whole thing, at some length, with the patient and, if patient wishes, any involved family. Which is why I’m just coming back to this blog however many days later in the wee hours.)

Part of the problem, I think, is that people (like me) who have worked in multidisciplinary pain programs have a different expectation of those controlled substance use agreements. And I think those ‘contracts’/agreements were originally generated in similar programs (which are usually, although not always, in academic centers), although don’t quote me on that. That means that someone would be sitting down and developing treatment goals and developing a mutually defined/agreed-upon definition of things such as ‘compliance,’ which could put a very different spin on things, perhaps. (e.g., in my program, we’d be talking about pacing, and discussing the fact that a social life is important, PT is important, work is important, and sleep is important, and that staying within human capacity is important. So how to make those all fit?)

But. Ultimately. I ain’t gonna write a damn thing if I don’t feel it’s appropriate and necessary. And… here’s where the tomatoes get thrown at me, and I’m used to it… I don’t write many chronic opioids for non-malignant pain (hi, one of my other jobs specifically involves people with addiction and chronic pain), and for various reasons, I work with a high risk for addiction population. And treatment boundaries involve a lot of things around defining appropriate behavior. So – those “contracts” – or as I think of them, “boundary defining agreements” – are important on not a “keeping me from the DEA breathing down my neck” level. My documentation and treatment decisions are A-OK, thanks. They’re therapeutically relevant. And I say that having worked in a consultant role for a while now and having seen a wide variety of mistakes made.
#29 Fallsroad
February 6, 2010

They’re therapeutically relevant

Which is as it should be.

But I honestly don’t think all of the physicians who require a contract necessarily see it as you do. I am also confident that law enforcement/legislatures don’t see it this way at all. To them, narcotic use in almost any context is seen first as a potential addiction/legal issue, which is why some of us presented with these contracts feel like quasi-criminals. It may never really occur to them that it is primarily a medical issue, and must remain so.

I’ll state again – I had no problem signing the contract. In the current context of legal issues, addiction issues, and yes, treatment issues, it made a certain sense. Though I was uncomfortable at first blush, I did also recognize that though my rights and expectations were explicitly limited by the contract, there was some language at least indicating my pain management doctor would do everything reasonable (which has no actual definition in the contract) he could to treat my pain and what causes it, and that not all of those treatments would be based on medication.

That is of some value to me, though the relationship is still very unequal. And it may need to be that way.
#30 SurgPA
February 6, 2010

There is a recurring theme here that the primary role of the contract is to somehow indemnify the clinician from prosecution (civil or criminal) for prescribing a particular regimen of narcotics. I’d like to propose that that impression is a fallacy. Responsible use of narcotics to manage pain does not put you in jeopardy with law enforcement/DEA/legislatures, and simply enacting a contract is not sufficient evidence that your prescribing habits are responsible. A couple of arguments:
1. The DEA simply does NOT target providers for prescribing narcotics. As long as you document an appropriate evaluation of the disease/injury causing the pain, document a treatment plan, and document ongoing reevaluation of the treatment efficacy and safety, they are not going to second-guess your clinical judgement. I’ve been told this at multiple CME lectures, told by the New Hampshire Board of Pharmacy, and told by multiple colleagues in chronic pain specialty. Among people who routinely prescribe chronic narcotics, it’s just not the over-riding concern.
2. Legislatures can change law, but they don’t have the power to go after individual providers. Local law enforcement doesn’t have the resources to go after every provider who prescribes narcotics. They are also not necessarily antagonistic toward doctors. The only doctors they MIGHT pursue are those who are simply egregious, and even then they are much more likely to go through the board of medicine or board of pharmacy.
3. Based on #1, simply having a contract does not indemnify the clinician. It’s a one-time document that documents only your intention to treat with narcotics. It does nothing to document appropriate evaluation or follow-up and ongoing reevaluation.
#31 atheismisdead
February 6, 2010

add comment moderation to your blasphemy blog, you little fool…

forum.amateurscientist.org/forum/index.php?topic=1413.0
#32 Suggestive Stuart
February 7, 2010

Pal, you should blog about this story:

http://www.nytimes.com/2010/02/07/us/07nurses.html?hp
#33 Fallsroad
February 7, 2010

@SurgPA:

The language in the contract I signed is pretty unambiguous, quasi-legal in tone, and its restrictions are definitely intended to demonstrate that my physician is responsibly and carefully prescribing narcotics for me (which is the correct way, obviously) and is operating within the parameters of the law. I read it three times before signing, and asked myself “why am I being asked to do this?”

Treatment considerations aside, some of the language reads exactly like a preemptive defense for my physician in the event of any legal inquiry that might follow from me abusing my medication.

It is clear as day.

Again, that said, it also includes significant language about parameters of treatment that are useful for both my physician and I, but the ass-covering attempt cannot be mistaken for anything else.

As you say, it may not hold any legal water, but in the event, say, I were caught by police selling my meds the subsequent investigation into how I procured them will turn up both my doctor and his signed contract. That contract may well be enough for law enforcement to decide my doctor is not guilty of anything (which would be true without the contract, but that isn’t always enough to slow the wheels of zealous drug warriors).

It also gives my doctor the written, unlimited right to terminate my treatment at any time for any reason, which explicitly includes any attempt on my part to obtain any type of pain medication (including non-narcotic) from any other doctor. There are legitimate treatment reasons why he should want to do that, but it is also a clear response to the concept of doctor shopping, which often comes to light when prescription meds are being resold in violation of the law.

I think it naive to believe that none of these contracts were written or are employed without any forethought given to purely legal considerations. I also recognize that legal considerations may not be the primary reason doctors use these contracts, and in some cases may not be any consideration at all.

I don’t see my pain management doctor again for several months, but I intend to ask him about the contract he had me sign, specifically about potential legal issues. The doctor who referred me to him was not shy in speaking about her legal considerations and did mention, in that context, a contract I may be asked to sign.

Note: It is worth considering that I live in Oklahoma, a state that pioneered the move of common cold medicines from the store shelves to behind the counter and added a requirement ID be shown in order to obtain them (plus s monthly limit on how much can be purchased). Soon we will need prescriptions for many of these medications as part of the endless war on crystal meth.

In this atmosphere, it is not inconceivable a physician would choose to take steps to insulate him or herself from potential legal liability when prescribing narcotics to patients. The penalties involved in illegal use of, possession of, and sale of drugs here are rather harsh. Responses to the War on Drugs need not be entirely rational, as any sane person can see how irrational that entire enterprise is.
#34 SurgPA
February 7, 2010

Fallsroad,

I don’t mean to imply that the documents aren’t legally binding in their requirements of the patient and physician, nor that physicians aren’t motivated by a perception that this contract protects them from legal ramifications of narcotic prescription. My point is two-fold. First, there is no DEA witch-hunt against physicians who prescribe narcotics responsibly. Second, the belief that the contract by itself protects physicians is a false-belief. To use your example of a patient diverting meds, that contract won’t protect the physician if it turns out he had the contract signed, then became a pez dispenser without any evidence of ongoing evaluation and monitoring.

It is quite illustrative to look at the DEA’s website; they list all cases of physician “wrong-doing” which the DEA pursues and results conviction (usually by guilty plea.) The site is here:

http://www.deadiversion.usdoj.gov/crim_admin_actions/index.html

In 2007 (latest data year), there were just 8 administrative actions, none look like simple “physician used questionable judgement in diagnosis/treatment.” The list of criminal cases against doctors is much longer, but all the cases I saw were truly egregious; online-prescription services that clog my junk-mail box, a dentist who drilled-out the teeth of a smuggler so he could fill them with coke, writing narcotics for the office staff, smuggling out of country. The picture painted is not one of legal jeopardy for physicians making good-faith efforts at responsible practice.

My point in this argument -if it seems like an unrelated tangent- is to ask the question “if there is no boogeyman (ie physicians are not assuming an extraordinary legal liability by treating chronic pain), why are we trying to protect ourselves from him? If a narcotic contract doesn’t significantly reduce our liability, what purpose does it serve (leaving aside the specific language of Pal’s examples?) As I’ve suggested before, for me it serves as a consent-to-treat form. I am intending to treat your chronic pain. This is what I intend to do (use narcotics, monitor with appropriate testing, have you utilize one pharmacy etc…) Do you give consent for me to treat your pain, or do you wish to seek treatment elsewhere?

I’d be happy to discuss the merits of the specifics of various contracts, but I think the specifics are a separate issue from the larger concept of the contract as a tool.
#35 Fallsroad
February 7, 2010

@SurgPA:

All good points. You’ve given me a lot to think about.

FWIW, the existence of a bogeyman, corporeal or not, can have interesting effects on people’s decisions.

I do find it odd that my referring doctor spoke specifically about the potential legal/criminal hazards of prescribing narcotics when she mentioned the certainty I’d have to sign a contract with the doc she was sending me to see.

I’m going to ask my pain management doctor specifically next time I see him why he chose to employ the contract he uses, and see what manner of response I get. He’s a very straightforward person, so I expect he’ll be open about his reasons.
#36 jane
February 8, 2010

Do the “compliance” clauses pertain only to that specific drug treatment, or to anything the MD wishes to do to you? If, for example, you have endometriosis and want pain pills for it, can the MD order you to have surgery or lose your prescription even if you think the harm-benefit ratio is lousy or you just can’t afford it? What about conditions that aren’t even related to the pain-causing condition – can your doctor order you to take a statin or lose your back pain medication? (Can you blame anyone for trying an acupuncturist?)
#37 PalMD
February 8, 2010

They are all different. I’m betting many of these contracts would benefit from clearer wording. The ones I use most often require compliance in keeping appointments.
#38 James Sweet
February 9, 2010

I seem to remember reading several years ago that the data confirms your impression that patients taking narcotics for an isolated event like a broken arm or what-have-you are less likely to transition to abuse. I’ll be damned if I have a source though, so this is just hearsay There may be a source out there, though, if I am not misremembering.
#39 DLC
February 10, 2010

I don’t like those contracts. The 8th clause really needs rewritten to read more like “I understand that my doctor (medical service provider) has (will) work out a personalized plan of treatment for my pain, and I agree to follow that plan, and I will not deviate from that plan without further consultation with the Doctor.” The privacy issue in part 4 is also a concern. No patient should ever be coerced into giving blanket permission to provide medical records to law enforcement. I just don’t like the idea of that “on request” being made permanent. Right now you need a whole bunch of probable cause to get court order for medical records, and that’s how it should be.
#40 Jay Fleming
June 7, 2010

In 1997 after my doctor William Hurwitz lost his license, I had a hard time finding pain medication. After a lot fighting and a four part article about my problem finding pain relief in the Kingman Minor newspaper, where the Arizona Medical Board admitted they had no guidance for doctors treating chronic pain, a couple months later the medical board issued SP7, the first guidelines for the use of controlled substances for the treatment of chronic pain.

Now I have another problem, my doctor is violating our pain contract. I signed a pain contract and have been seeing the same pain clinic for a year now. I have never seen the same PA twice because the practice has a high turnover. The doctor hires PA’s to do the prescribing, but I think they become uncomfortable writing so many Schedule II drugs and quit.

Another problem is the lady who actually signs the prescriptions, is an office worker who pulls charts, not a PA or doctor.

I live in Arizona where it gets to 120 degrees, and want to go see kids in Oregon and Montana this summer. The clinic requires patients to be seen every 3 months, and call in for their prescriptions each month.

I don’t understand why they don’t just write 90 days of medication. DEA changed the rules allowing doctors to write 90 days of Schedule II drugs in 2007.

This is a busy practice with hundreds of patients, and there is regularly a steady stream of 20 patients picking up prescriptions. As a former narcotics investigator, if I saw all these patients lined up, it would be a red flag, and I would look into the practice.

Last visit I gave the PA a copy of the DEA changes allowing doctors to write 90 days of Schedule II drugs. I ask him for 90 days worth of my meds so I can go see kids this summer. The PA went into the office area, then came back and told me that he would only give me 30 days of meds, but that I could look for other doctors as I travel, and they wouldn’t drop me as a patient for violating the pain contract. I guess I’m supposed to go from ER to ER begging for pain medication.

I don’t see where the doctor can change the contract verbally, any more than I can. If I said I didn’t want to take a drug test required by the contract, they would say I violated the contract and drop me. I feel the pain contract enhances the doctor patient relationship, and the doctor has the responsibility to supply the 90 days of medication I need.