Pain contracts threaten the doctor-patient relationship

Doctors today are wary about treating chronic pain.

One of the main worries is precipitating fatal opioid overdoses.  Indeed, according to the CDC, and reported by American Medical News, “fatal opioid overdoses tripled to nearly 14,000 from 1999 to 2006 … [and] emergency department visits involving opioids more than doubled to nearly 306,000 between 2004 and 2008.”

Requiring chronic pain patients to sign pain contracts is a way to mitigate this risk.

But how does that affect the doctor-patient relationship?

Indeed, a contract is an adversarial tool.  Essentially, it states that a patient must comply with a strict set of rules in order to receive medications, including where and how often they obtain controlled substances, and may involve random drug testing.  Break the contract and the patient is often fired from the practice.

A recent perspective piece from The American Journal of Bioethics discusses its effects:

“… what is becoming common practice in many pain specialty clinics is using a preprinted, standardized form that says, ‘If we’re going to treat or prescribe controlled substances to you, these are the conditions under which we’ll do so — and sign this document, and if you fail to do so, then we’ll fire you from our practice.’ ”

That kind of adversarial approach is “corrosive to the relationship” and threatens patients in need with abandonment.

Chronic pain is poorly managed in the United States. Ideally, these patients require the services of pain management specialists, as part of a comprehensive, team-based approach to treat their pain. But too few of these centers exist. That leads many primary care doctors to manage pain. And they simply don’t have the time, or the expertise, to adequately deal with these often complex issues.

So some simply take the path of least resistance and prescribe drugs, with the sometimes fatal consequence of an overdose.

With regulatory bodies making high-profile arrests of physicians, it’s understandable that many resort to pain contracts to protect themselves. As the lead author of the perspective piece notes: “I can fully understand why the primary care doctor will say, ‘I don’t want to be in trouble with the medical board. [Pain agreements] seem to be a trend, and then if I get asked by the medical board about this I can say, ‘Look at all these contracts I have in my medical charts.’””

The larger problem is the dearth of pain specialists. Primary care simply isn’t an adequate venue to appropriately manage chronic pain. Perhaps if primary care physicians had more training, and time, to appropriately manage these patients, there would be less reliance on rigid pain contracts that immediately gives the doctor-patient relationship an adversarial start.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.preemieprimer.com Dr. Jen Gunter

    I am board certified in pain medicine and have a lot of experience with this. I do not use a pain contract. I don’t think I ever have in > 20 years. I have a detailed conversation about the risks, how the medication is prescribed, and expectations. But I do this with every medication, including Tylenol.

    This problem is that a percentage of chronic pain patients do abuse their medications. They escalate inappropriately, take other controlled substances without telling us, and some shop around for other prescriptions in the ER or other docs. Some divert. And many docs have a hard time saying “no.”

    In addition, the perception that opioids are “risk free” is common place, but very wrong. I see many people given opioids prescriptions who were never candidates and the # of children and adolescents getting opioids is frightening. The US consumes 80% of world opioid supply yet has 4% of the population and the # of opioid related prescription deaths have skyrocketed. We consume 99% of the world’s hydrocodone supply! There is no doubt that many patients are over medicated.

    But pain contracts don’t prevent over medication or inappropriate prescribing.

    I explain that opioids are DEA controlled, and for a good reason. That we expect functional improvement and if there is any evidence of misuse (and I spell out what that is) then we will not be able to use opioids in the treatment regimen. However, that does not mean the patient will be discharged. I actually use opioids very infrequently (more asa bridge between procedures or to help someone get started with physical therapy) as I have a plethora of non-opioid tools to use. I see very little benefit from long term high dose opioids, although have many people taking low dose methadone who benefit. It is important to remember that chronic pain patients taking opioids have a shorter life expectancy that those following non-opioids regimens.

    But this is not really any different from how I use other meds. For example, if a patient is taking nortriptyline inappropriately I will also stop that prescription. I also screen everyone for depression and with a SOAPP scale to try and assess potential risks before prescribing.

    The issue to me is that a pain contract means the physician doesn’t know how to talk about opioids and then document that discussion in the medical record. And if they have a hard time having the conversation, should they really be prescribing the medication?

    • Kevin

      “The issue to me is that a pain contract means the physician doesn’t know how to talk about opioids and then document that discussion in the medical record. And if they have a hard time having the conversation, should they really be prescribing the medication?”

      Exactly. PCPs aren’t trained in having that conversation (nor do they have the time), hence the proliferation of pain contracts. And no, they shouldn’t be prescribing the medication. The answer is more pain specialists.

      K

      • http://www.preemieprimer.com Dr. Jen Gunter

        Yes, I agree that PCP should not prescribe long term opioids. If more than a 30 days supply is needed then consultation with a pain doc is also needed. The problem is not all pain docs prescribe appropriately either. But more well trained pain docs definitely needed.

        • family practitioner

          Pain docs in my area could not care less about prescribing, they just want to do lucrative procedures.

          • http://msrenegade.com Marie

            This is the experience I have had as a patient – the pain management specialists I have seen are primarily interested in profit and uncomplicated scenarios. Challenging presentations are too time consuming and that affects the bottom line.

            I have chronic pain from a shoulder fracture and subsequent replacement. My situation is complicated by that fact I have MS (which causes its own chronic pain, but that is a separate issue). I have been to three pain specialists, including a ‘super’ specialist in New York. As soon as they see I have MS, they wash their hands. It is very disheartening.

            My PCP, on the other hand, is compassionate and concerned. He listens to me, is open to research I do and is willing to try anything within reason. Our contract is a tacit one of mutual respect. I am so lucky to have him as a doctor.

            And with all due respect to the pain management physician who states his practice does not ‘fire’ patients. You are an exception. As both a patient and as a nurse who has done chart quality review, I have encountered numerous contracts that state they will do just that. And they have.

          • pj

            Totally agree w/F P above- the views of kevin and jen are unrealistic for the majority of patients. Some of us have to things we may not be comfortable doing at first but if the pt has no other choice, it seems draconian to advise ALL PCP’s not to ever agree to the option.

            Same could be said for medical marijuana-many Docs don’t want it simply because they don’t want to authorize pts to use it. I tell them- fine- don’t do it, but please don’t prohibit the rest of us from considering it for our pts.

      • john davey

        I had my pain managed by a internal medicine doctor of which I was his patient for many years until some personal problems forced me to find a new doctor GP and she doesn’t want to write pain med scripts long term so referal to pain management doctor. First appointment took 4 mos to get. Working in the health field I must say that if a GP can’t write pain medicine for pain of any type and any duration then it seems to me the bar needs to be higher for GPs. Then should they even be managing patients in the hospital. The DEA,Addicts, And Death (Overdose) The addict will always be there and will always get their fix…Some will OD and die. The problem is tha people with chronic pain that can benefit from continuous opiod therapy are the ones the abide by the rules and are the ones labled as drug seekers simply because if one doctor refuses to help them they seek another doctor that will. The patient has the right. The right to be as pain free as possible. There are very few pain specialist that are sympathetic to pain as they have never been in chronic pain. Actually I believe all doctors calling themselves pain management specialist should have chronic pain themselves. How can you understand what living with pain daily is like if you have never been there. The cards now are so profoundly stacked against a pain patient that they have to think carefully about what they say in the doctors office as there are so many scales and signs of drug seeking behavior. In my experience in the health field and as a chronic pain sufferer the worst physicians for treating and being sympathetic towards chronic pain are the ones that are actually the pain specialist. Anesthesiologist…Funny isn’t it. No its not…Random drug testing or pill counts is fine. You will never find someone in pain daily that is going to complain or worry about bringing pills in to be counted. I wonder if anyone has done a study to see how many people in chronic pain have committed suicide due to their pain, or on disability because they could not function enough to hold a job. I am an educated pain patient doing more research on my own conditions giving me more knowledge than most physicians that would be treating me, but again you have to be careful because if your knowledge is not clear and you go into a physicians office talking about treatment and narcotics you will be labled a drug seeker. I see patients everyday that are addicts and its tough for a physician to make the right call everytime, but you will never stop the addicts nor the overdoses. You can however try to make a difference in someones life that is suffering just by using your common sense. You don’t need contracts and scales you just need to listen and either believe, or not. Most doctors are flat scared to death of the DEA and it should not have come to this as the only people that are being hurt by this fear are true pain sufferers as the addict will get the pills wherever they have to….There is an area that does need policed and that is the fact that your doctor doesn’t owe you anything. Meaning an explanation. They can terminate you as a patient for any reason they want on a whim, or just for you raising your voice. Now this is an area thats just not right. Nurses and therapist can’t just decide not to see a patient because the patient says or does something the nurse or therapist doesn’t like, but the physician can. Someone said. The doctor works for you…A No!! Except for an ER physician the doctor you have can tell you to hit the road at anytime and this is not right. There needs to be an accounting for every action of this nature. It will get to where you can’t have a disagrement with your physician or raise your voice because they can send you a discharge letter in the mail and you now no longer have a doctor. There are basically three types of doctors. Those that believe pain meds are for acute short term (surgery) or end of life terminal illness. Some that believe even in dying you should suffer and then there is the one that actually tries to be a caring doctor like they were in theory trained to be. The one that listens to your complaints has patience and cares, but those are becoming fewer and fewer. Wake up . There will always be drug addicts and overdose resulting in death, but biofeedback and exercise will not fix all chronic pain…Good luck

    • http://whitecoatunderground.com PalMD

      It sounds as if you actually do have a pain contract, just not a written one. You lay out the conditions under which you will use the drugs and they agree to it. It’s a contract.

  • http://Drbradley.com Craig, MD

    Saying that the answer is more pain specialists is just like saying that the answer to TSA hassles and baggage fees and tarmac delays would be having personal dragons to fly us where we want to go.

    Dragons are as likely to happen as adequate pain specialists who care about anything other than procedures, or adequate primary care or adequate mental health care. Unless, of course, we tear down and rebuild the healthcare system and value some of this stuff more appropriately.

    FWIW, I’m a family doc, I treat a fair amount of chronic pain but wish I did not, and I alone in my group don’t use pain contracts for pretty much the reasons in the article.

  • Pam

    As a patient with chronic pain I have never been prescribed nor suggested to take, an opiod – although I really could have used one at times. Instead I have several neuropathic medications and undergo epidural nerve blocks. I believe this is an intentional strategy on the part of my physician, for which I am grateful. It allowed me to continue working for a much longer time than most patients with my condition. I also thank my physician for encouraging me to keep going, not making me feel as if I couldn’t do it.

  • http://Www.myshorterstories.wordpress.com Mary

    I don’t think mismanagent / misunderstanding of chronic pain is limited to the US. I have arthritis and CRPS, and work as an SLP w patients w MS and other conditions resulting in neuropathic pain. The local pain management Center in the UK doesn’t think I’m ‘disabled enough’ for regular PT and time in the hydrotherapy pool, but will give me narcotics by the bucketload. I don’t take them. Pain beats being non-functional and disengaged from life. I would love to meet a doc who would be willing to suggest anything other than meds.

  • rezmed09

    Pain contracts now exist for many reasons, but simply put, they help providers draw lines and help patients understand where those lines are within that provider’s practice.

    As everyone here knows, “chronic pain” represents a spectrum of patients from those with years of suffering from physical pain from well defined illnesses, to those who have no clear cause for a a subjective complaint, to those who are gaming the system and even selling the narcs. There are all sorts of combinations of patients, and of course, there are their families who sometimes take the patients meds for their own use or sale or who will sue you or report you to the board.

    Pain contracts provided needed protection and needed ground rules. For most patients the contracts are merely a slightly unpleasant part of the visit, like paying the co-pay. For others it allows for correction of out of control behaviors. Finally it allows providers to terminate the relationship and be able to sleep at night. And that is good, because we have other patients to take care of who need us to be well rested for.

  • ninguem

    “……Indeed, a contract is an adversarial tool…….”

    So is a stethoscope if you hit someone over the head with it. Use it properly.

    Part of using it properly is to stop using the word “contract”. Call it office policies, practice rules, whatever.

    You expect patients to behave in certain ways. You sign agreements regarding financial policy. You will pay your bill. Fail to pay your bill, you will be dismissed from the practice. Refuse to sign the agreement stating you will pay the bill, you will be dismissed from the practice.

    If the patient fails to pay for services rendered and agreed to in advance, the patient will be told to go elsewhere. The dismissal follows certain rules set down by the State, usually 30 days ongoing care, emergency treatment in the interim, etc.

    If the State rules are followed, it is not “abandonment”, and frankly I could care less what a “bioethics expert” has to say about it.

    • ninguem

      A pain “contract” is no more “adversarial” than the financial agreement you have ALL patients agree to, in most any medical practice in the USA.

      • SmartDoc

        Kevin has a point, but these contracts are sadly probably necessary in this era of FDA judicial terrorism against pain management by physicians.

        I am convinced there are pain control indictment quotas by the horror show FDA and some state agencies.

  • MarylandMD

    Kevin, I follow your blog pretty closely. I generally like what you are doing and I find I agree with you more often than not. This time I think you are so far off base on so many points, I feel I have to respond. Some of this comment repeats points others have made so far, but they are points worth reiterating.

    –When these opioid use agreements are discussed, they are more properly referred to as “agreements,” NOT “contracts.” “Contract” is a very specific term that has legal weight in a court of law. Using the word “contract” when discussing this issue is commonly done, but it is sloppy and does not help you look like you know what you are talking about.

    –Fatal opioid overdoses are not one of my main worries regarding the use of these medications. They honestly don’t even make the top 10 worries on my list. In all my years of practicing medicine, I have never ever heard anyone refer to worries about fatal opioid overdoses when we have talked about problems regarding the use of opioids for pain control. Maybe it’s an issue we should worry about and discuss more, but in my experience it really doesn’t register as a major issue. Do you have research to back up your claim that this is “one of the main worries” for physicians, or the claim that it is the reason doctors use opioid use agreements?

    –Your (and the bioethicist’s) description of opioid use agreements is overly simplistic. None the various agreements I have seen state or imply “if you fail to [sign], then we’ll fire you from our practice.” If you refuse to sign the agreement, you simply don’t get narcotics–you will continue to be treated, just not with controlled substances. That is absolutely NOT the same thing as “firing” a patient! Nor do they state that you will get “fired from the practice” if you break the contract. They generally state that if you violate the agreement, you may have your opioids tapered to discontinuation. That is very different from firing as well. Maybe the bioethicist you refer to hasn’t been working around practicing physicians enough to know what an opioid use agreement really is?

    –I find the financial and other forms that I sign before I even see my physicians to be more “adversarial” and “corrosive” than any opioid agreement, but I won’t stop having my patients stop signing them before they see me, nor would I expect any of my physicians to stop using them either!

    –The opioid agreement templates I have seen generally contain several components, including: explanations of risks and benefits of the use of opioids, opioid side effects, addiction vs tolerance, the need for tapering when discontinuing, rules for who can and who can’t prescribe the medications, and rules for refill requests. The good ones also contain or have a separate part that describes the risk of constipation/obstruction and detailed instructions on how to manage constipation when it occurs. In my view, it is more like a combination of written instructions on medication use/side effects (we really should do this with most or all medications, shouldn’t we?) and the typical handout new patients receive that describes the “rules” of the practice for refill requests, referrals, hours, etc. It really comes down to how you handle it. I tell patients that this form helps us have everything clearly stated so there isn’t any confusion on how we handle this special class of medications together. I guess if you present it to the patient and/or have it written out in such a way that it appears to be more of a cudgel than an agreement, then it will be “corrosive to the relationship.” But that doesn’t condemn the concept of agreements, just your handling of it.

    –The first opioid medication agreement I ever saw came from a pain medicine training program at a major medical center. My experience is that pain specialists are more hard-nosed about having agreements and more aggressive/punitive in how they enforce them than primary care physicians.

    –”Primary care simply isn’t an adequate venue to appropriately manage chronic pain.” Wow. I couldn’t believe my eyes when I read that one, especially coming from a fellow primary care physician! I haven’t been practicing medicine for ages, but one thing I have learned over the years is that there are many different ways to practice what we call “primary care.” Maybe managing chronic pain doesn’t fit in with YOUR competencies or YOUR form of primary care, Kevin, but I know many many primary care physicians who are intelligent and experienced enough to be more than capable of managing chronic pain. Such statements remind me of other snobby blanket statements made by specialists which generally take the form of “Primary care simply isn’t an adequate venue to appropriately manage x.” And you can fill in just about any condition/disease process for “x”: diabetes, depression, thyroid disorders, HIV, CHF…

    –To simply state the solution is more pain specialists is getting just plain silly. How many pain specialists are there in rural Iowa? Rural Mississippi? Northern Maine? When do you anticipate we will have enough to cover this nation of over 300 million citizens? And how do you propose to get the pain specialists to move out of the cities to rural and other underserved areas?

    –I have been at times extremely disappointed in how my patients have had their pain managed by pain management specialists. One program at a nearby major medical center won’t even handle chronic pain meds! They start the patient on an opioid and send them back to primary care to manage the refills, side effects, etc. So who is to manage the pain meds if the pain specialist won’t and (by your thinking) I am not capable? Further, even for pain centers that manage chronic opioids, it is quite clear to me that some lose interest in my patients with chronic pain once they have run the gamut of lucrative procedures. At that point, my patients start getting the message that they really aren’t wanted and start coming back to someone like me who will treat them with kindness and respect (or who will at least return their calls!).

    I could go on, but I think you more than get the point. Generally this blog is pretty good. If I wrote a blog, I am sure the vast majority of the posts would be pretty lame. Your output is most impressive, and as I stated before, I generally agree with you more often than not. This time I obviously think you didn’t do so well, but, hey, nobody bats 1000…

    • pj

      Totally agree! Thanks for articulating it so well.

      Another analogy to the TSA and dragons is marinol- The fed gov’t has said there’s no need to allow any access by researchers or anyone else, to marijuana “because we already have medical mj-it’s called marinol”

      Uh, right- tell the 80 + million americans who are uninsured or whose mediciaid won’t pay for marinol, go spend $200-800 a month on marinol, even though you could grow the plant at homefor maybe $10/month upkeep if only big brother would allow it.

  • gzuckier

    i guess i had the opposite problem; saw a renowned back specialist about a spinal anomaly. no pain involved, i was just worried about the prognosis and dissatisfied with the vague answers I had so far received. Well, by the time I had waded through all the initial visits and tests designed to weed out narcotics-seekers, the doctor was no longer participating in my healthplan (and I discovered he was charging $750 per office visit, so out of pocket visits were not going to happen).

  • ninguem

    family practitioner – Pain docs in my area could not care less about prescribing, they just want to do lucrative procedures.

    I would define “my area” as the North American continent.

    Always pleasant and surprising exceptions, but doctors doing medical pain management are few and far between.

    And the insurance companies and Medicare made it that much harder to medically manage pain when they slashed reimbursement for urine drug tests.

    I’ll respectfully disagree with MarylandMD over the fatal overdose matter. I guess it’s still fair to say it’s not my main concern either, but the number of deaths related to opioids is climbing rapidly, all over the country.

    • MarylandMD

      Hey, I didn’t say it *shouldn’t* be a big concern, just that it really isn’t a primary concern for myself or other physicians with whom I have discussed pain management issues. My point was that I didn’t think that worry about overdose deaths is the driving force behind the average physician’s decision to use opioid agreements (which seemed to be one of the initial assertions of the article).

      Let me be clear: I strongly believe we should all be concerned with side effects of opioids, including overdose deaths, and educate our patients on the risks, even when prescribing for just short term/PRN use. But we shouldn’t focus on the still fairly rare problem of overdose deaths and ignore the more common (and potentially as serious) problem of constipation caused by opioids. While I have never seen a case of fatal overdose from prescribed opioids, I have known several patients that have had near fatal intestinal obstructions caused by prescribed opioids that required emergent surgical intervention. If using a preprinted agreement helps physicians make sure they review *all* the major potential side effects with their patients (and gives the patients that information in printed form that they can take home and review later!), then that is a very good thing.

      • ninguem

        That’s why I said “respectfully”…….. ; )

  • Angela

    I am a patient with chronic pain from arthritis and fibromyalgia and have been on Tramadol since 1999. I have taken the same dose for all these years, one 50 mg tablet at noon and two at night. Anything stronger than this doesn’t work for me and believe me I’ve been given far stronger medications for pain after surgery and I still come back to my regular dose of Tramadol. This is the only medication I have found that cuts my pain and takes care of my Restless Leg Syndrome.
    I have never heard of a opioid contract and I don’t believe my doctor would ever make his pain patients sign such a thing. It’s all about finding what works for that patient and getting to the root of the problem not the symptoms. This is his approach to treating his patients and that’s why I go to him.
    I have been to doctors who were quick to hand out all kinds of powerful pain killers but were reluctant to give Tramadol. I have never understood that and that’s why I don’t go to them. I know what works for me and my doctor knows what works for me and that’s all that really matters to me.

  • Reta Russell Houghton

    I am a chronic pain patient with CRPS that has been enrolled into a Pain Clinic with a so called “pain contract” and one without. But I have to go further and say that contracts destroys the doctor patient relationship before it begins.

    Have any of you read one of these contracts? The one I was forced to sign, in order to begin to receive treatment was one of the most vile and accusatory documents I had ever read. I felt like I had been ruled guilty without a trial. In essence, I was a dirt bag and a druggie because I needed help with my chronic pain. I was only taking Celebrex, prescribed by my PCP..

    Even though this a well known and very large Pain Management group in my city, I was convinced this doctor was in it for the money. I saw him monthly for 6 months and the only thing he prescribed me was 6 Valium before a test. And when I had a reaction to the Valium, there was no one to help me. I fired that doctor and found another one.

    My new clinic that helped me gain better pain control. I still take the Celebrex but I have stronger drugs for the bad days, which I manage. I will see my doctor 3 times this year, unless things get worse. And this clinic does not have a pain contract.

    Let me say I can understand some of the purpose of the pain contract but they go too far and assume abuse and illegal activity before any action has taken place. I am convinced is is the direct result of government intrusion into health care.

    • ninguem

      I’ve lost count. About eight patients as I recall, last year, in my solo practice with primary care and a good deal of medical pain management (I have the training to go with it). Shown the door for doctor-shopping. Four docs prescribing the same meds. Last month I had one doing that, AND had negative drug screens. He didn’t have a drug problem. He was selling. That was actually his line of work.

      Confronted, he admitted same, and acted like that was his legal right. And he got legalistic, when did you tell me I couldn’t do that. You don’t need a “contract” to deal with a patient who’s committing a felony. But they act like you do.

      The problem is…..there **IS** a lot of lying, and downright criminal activity, associated with this endeavor.

      And……the trial bar is nothing but creative, we are now starting to see attempts to create third-party liability for the doctor’s prescriptions. So yes, when I have a patient on narcotics, and I see the name in the papers for DUI’s and domestic complaints, yes I will make it my business and stop the narcotics. I don’t want to have a person injured in a DUI accident claiming it’s my fault because the patient didn’t understand he shouldn’t drive after smoking oxycontin.

  • Sara Hogan

    I have been trying to find a decent pain management specialist for my husband for two years. We don’t have insurance, primary care doctors are paranoid of the DEA, and pain management specialists are expensive and think my husband is out for drugs because he is a white man with long hair.

    Nobody gets that once his pain is managed reliably, he can work and save up towards the expensive, longer-lasting procedures.

    It’s the opiate abusers that are truly ruining it for all the people who suffer chronic pain. *sigh*

  • Heather Paladine

    As a family doctor, I disagree that we don’t have the time or the training to manage chronic pain. We generally have the deepest relationship with the patient, and we are trained to evaluate pain and functionality on a holistic basis.

    I have seen a lot of variety in my work – some pain specialists are wonderful, and do a great job integrating into the whole care of the person. Some seem very focused on procedures or only certain diagnoses. Some won’t treat patients at all who are considered difficult. And I’ve worked with some insurances that only cover one visit to a pain specialist. Or areas where the pain specialists don’t accept Medicaid.

    I think chronic pain agreements should work both ways. I include my resonsibilties toward the patient, as well as their responsibilities in treatment. I start with a form, but individualize it to include the treatment options we are using on addition to medications.

  • Jacob

    I’ve been a chronic pain patient for 10 years. I’ve tried a lot of meds for the pain, and the only ones that work and have side effects I can tolerate are opioids. They do not make me non-functional or withdrawn from life at all, but on the contrary, allow me to be more functional (not functional compared to a “normal” standard, though, as I have other problems, including COPD and chronic, severe fatigue), and allow me to do things like play music and paint, whereas without them I’d be curled up on my bed suffering (i.e. withdrawn from life).

    People talk about the dangers and side effects of opioids, but in my experience and research they are no worse, and in many cases much better, than other pharmaceuticals. Do opioids have worse side effect profiles than anti-depressants? Than Neurontin and the like? Certainly not for me personally. Furthermore, opioids have been around and used medically for a lot longer than most of these other drugs. They are tried and true. We never know everything, but with opioids we basically know what to expect and what the long term effects are. The only reason why there is this stigma with opioids is because it is also a drug of abuse and causes physical dependence and in some cases addiction. Well, the same holds true for alcohol, and I don’t even need a prescription for that.

    For many years I had a good relationship with my doctor, My pain was under good control, and when I ran out, he wrote a new prescription. Simple. He knew I wasn’t abusing my meds because we had a doctor patient relationship, we talked, he listened (and his trust in me was confirmed when later I passed all my pill counts and UAs). Then came the pain contracts, and the “pain staff” in charge of managing pain prescriptions, contracts, screening, etc. (and who seem to never be able to get anything right. I don’t think I’ve went a single month without mistakes in my prescription, misunderstandings, etc., ever since they came along. They may be incompetent, but I think it’s more likely the complex and convoluted system they are working with).

    Then, I had to switch meds because methadone was causing severe central sleep apnea, as methadone is wont to do (yes, other opioids can cause central apnea and general RD, but methadone seems to be by far the worst offender. I haven’t had a problem on morphine, nor did I on oxycodone).

    I haven’t had good pain control since switching, because once my tolerance got to a certain level, he was no longer comfortable raising my dosage.

    So he sent me to the local pain doc, who just wanted to put me on Nortriptyline, which simply aggravates my severe fatigue and makes me less functional. He claims that at 30mg of morphine q4h, I am on a “boatload of morphine.” Well, to an opioid naive patient, that would be true. But for an opioid tolerant pain patient who’s been taking opioids for 10 years, it’s well within therapeutic levels. I can’t even tell I am on a drug, don’t have much constipation, etc. The only side effect, other than my long standing dependence, is a little bit of orthostatic hypotension.

    So, I am now chronically under treated.

    Then, the other day, I ran out of my meds. I had forgotten to call in three days in advance, as is in my contract. I have severe memory problems, and can’t help it. But I wrote a message via their email system (it was Sunday when I realized I needed a refill), and called it in the next day as well. When I went to pick it up, the doctor told me I would have to wait until the next day, because the pain staff was not there to figure out what I needed and print the script.

    He also told me I needed to come up with a system to make sure I was not late in calling it in again (which would do no good as I would forget the “system”).

    It was as if he was punishing me.

    They had all day Monday to print my script. In any case, the doctor should have been able to write my new script himself. At the very least he could have wrote me a few pills to last me the night.

    Instead, he was willing to force a patient to endure moderately severe pain and severe withdrawals all night.

    Adversarial? Well, I am nail spitting mad and ready to fire the physician who has been my doctor for over 20 years, and who I used to respect. Five years ago I would have told you my doctor is a good and compassionate doctor.

    Yes, I’d say we now have a pretty adversarial relationship, and it’s about to get more adversarial when I write him a letter to tell him just how I feel about what he did. I might even file a grievance. And if I can find another doctor who will treat me better and won’t allow his patients to suffer torture because he can’t seem to write a prescription, I will drop him like a wet turd, wash my hands, and move on.

    That’s my story.

  • http://profiles.google.com/judloved Judith Delgado

    Drugs have completely changed the medicine industry and have played a great role in curing many diseases. However on many occasions these are misused. Prescription drug abuse is using these drugs without any medical supervision. In a recent survey it has been found that gender also plays a key role in prescription drug abuse. The survey was carried out among several people half of whom were men and the remaining half of them were women. They had been taking pills for chronic non cancer pains. This study had continued for five months and then after careful evaluation the researchers came towards a result.

    Findrxonline.com/talk

  • Anonymous

     
     I am a chronic pain patient and I have been saying what you wrote for years. In addition to what you write a pain contract is in fact not even a contract. A contract is an agreement mutually entered into between two or more parties with each party having roughly equal bargaining power. So a pain contract is anything but a contract. What it really is is an ultimatum.

  • Anonymous

     I am a chronic pain patient and I have been saying what you wrote for years. In addition to what you wrote a pain contract is not in fact a contract. A contract is a mutually entered into agreement between two or more parties presumably with roughly equal bargaining power. In other words in a real contract each party loses if the contract is not agreed upon. What a pain contract really is is an ultimatum.