Ethics of Opioid Agreements Challenged

[drusso]

http://www.medscape.com/viewarticle/851543

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[Aether2000]

Dr. Payne adopts a foolish and naive view. The "ethics" of trusting patients is absurd....they cannot be trusted as is shown in the urine drug screens in our real world pain practice. Dr Payne bemoans the fact that patients may be fired from a pain practice for engaging in substance abuse. This view is myopic, totally discounting the fact that if physicians do not fire patients, they overdose and die, or are engaging in dangerous or addictive behaviors. Of course the organization he was presenting to is composed largely of those that do not actually prescribe opioids. Geezzzzzzzz

 

[drusso]

I do think that the concept of a treatment agreement should be revised. I think it should more or less say, "the patient understands that my prescribing a controlled is at my sole discretion and judgment and may be unilaterally modified or terminated at any time..."

 

[deleted480308]

If you are liable for when they do something dangerous, you are well within reason to enforce terms for the privilege of them attaching their medical care to you

 

[hyperalgesia]

Or we could just change the hippocratic oath to say "I promise to do whatever the patient wants..."

 

[drusso]

I think that the author does make a valid point about agreements fostering a "lazy" attitude among some prescribers. For those of us who review cases, one common thing we look for is a treatment agreement. But what does this mean? It means that the prescriber had a process in place, but little else.

 

[lobelsteve]

I think that the author does make a valid point about agreements fostering a "lazy" attitude among some prescribers. For those of us who review cases, one common thing we look for is a treatment agreement. But what does this mean? It means that the prescriber had a process in place, but little else.

Paper in a chart is the first step. Following the policy is the guide used in assessing legality of ongoing prescribing. Document, document, document.

 

[drusso]

Still comes down to process versus outcome.

Cases I'm reviewing utilize EHR's that facilitate all kinds of language about risk versus benefits, SBIRT activities, ORT, SOAPR, UDS pop up reminders, MEQ calculations, etc but I can't see that the patient and physician actually had a meeting of the minds, set functional goals, discussed exit strategies, etc.

In other words, you can do everything right and still be wrong. 88 MEQ's for a 26 year old female with chronic pelvic pain, history of sexual abuse, anxiety disorder, bento tolerant, and first degree family history of ethanolism is destined for problems regardless of what kind of opioid agreement is on the chart.

 

[lobelsteve]

Still comes down to process versus outcome.

Cases I'm reviewing utilize EHR's that facilitate all kinds of language about risk versus benefits, SBIRT activities, ORT, SOAPR, UDS pop up reminders, MEQ calculations, etc but I can't see that the patient and physician actually had a meeting of the minds, set functional goals, discussed exit strategies, etc.

In other words, you can do everything right and still be wrong. 88 MEQ's for a 26 year old female with chronic pelvic pain, history of sexual abuse, anxiety disorder, bento tolerant, and first degree family history of ethanolism is destined for problems regardless of what kind of opioid agreement is on the chart.

But the MD is still within his rights to treat this high risk patient. High risk and not meeting standard of care are not always the same thing. Until it happens it has not happened yet. Risk is not a guarantee it will happen. But she better be working FT or have some amazing hobbies that demonstrate functional status. Chemical coping is not acceptable until the body is broken down and cannot perform these tasks. Then it is just a slippery slope.

 

[Tenesma]

i think the agreements are actually quite stupid... if somebody is addicted or is going to divert he/she will figure out how to do it w/ or without an agreement...

i don't call them agreements anymore - i call them informed consents where i lay out all the risks etc - and that at any point the physician can wean/discontinue treatment.

 

[powermd]

i think the agreements are actually quite stupid... if somebody is addicted or is going to divert he/she will figure out how to do it w/ or without an agreement...

i don't call them agreements anymore - i call them informed consents where i lay out all the risks etc - and that at any point the physician can wean/discontinue treatment.

I've never understood the point of opiate agreements other than to have a piece of paper to hold up to the patient when you cut them off for bad behavior. I doubt that lessens the F bombing in your office.

Isn't it implicit in any medical treatment relationship that continued treatment is at the discretion of the medical professional?

Why would any medical professional want to box themselves into a "contract" with a patient (i.e. quid pro quo). It's not a contract. If anything it's an informed consent, as you say.

Now THAT I can get on board with. Patients should probably sign informed consent for any medication with unusually common and serious risks.

 

[Ducttape]

No it is not. Patients view treatment as a right, an entitlement. Unless it is explained in a manner that the patient cannot later refute (ie a treatment agreement or a signed informed consent)that opioid therapy is not an entitlement or a mandatory part of pain management, they will view opioid prescribing as a right, like the 2nd amendment, and and will consider litigation as a natural result if such therapy is stopped.

 

[powermd]

No it is not. Patients view treatment as a right, an entitlement. Unless it is explained in a manner that the patient cannot later refute (ie a treatment agreement or a signed informed consent)that opioid therapy is not an entitlement or a mandatory part of pain management, they will view opioid prescribing as a right, like the 2nd amendment, and and will consider litigation as a natural result if such therapy is stopped.

I'm not sure treatment is a right. No one has a "right" to my labor in non-emergent circumstances.

Even if we assume they do have a right to treatment, who are they to dictate exactly what that treatment consists of? Isn't that the whole point of medical judgment?

They can consider all the litigation they want. Has anyone successfully sued and permanently coerced a physician into prescribing opiates by court order?

 

[Aether2000]

No, but the contrary is true. Physicians are considered in at least several states to be practicing substandard medicine, if not engaging in criminal behavior if there is not an opioid agreement in place and being followed when there is a death or OD event. I think it is prudent to tell patients the rules of the clinic without having them guess.

 

[powermd]

No, but the contrary is true. Physicians are considered in at least several states to be practicing substandard medicine, if not engaging in criminal behavior if there is not an opioid agreement in place and being followed when there is a death or OD event. I think it is prudent to tell patients the rules of the clinic without having them guess.

This is mainly an issue of semantics. I think the "opiate agreement" should be called an informed consent. The "I agree to prescribe opiates part" is implicit in the fact you are writing the prescription. The patient's agreement with your policies on tapering or cutting them off is irrelevant. They simply need to know what they are, and sign that they understand. I couldn't care less if they agree or not. Most signatories probably don't agree, but sign anyway to get the drugs.

 

[lobelsteve]

ICAT: Informed consent and agreement for treatment.

 

[Ducttape]

The potential legal aspects are clouding what should be only medical judgement. Lawyers may argue abandonment if a physician stops treatment or discharges a patient if the "rules" are not specified.

Call it informed consent, since it is more apropos than treatment agreement, but some form of documentation is important....

I had a lawyer argue vehemently that the terms treatment agreement and opioid contract was a misnomer and not legal in court, since he didnt really agree....

 

[specepic]

I have found:

- pcp's who use med agreements and urine testing are the better rx'ers I see, the one who dont over presscribe and dont bother b/c they have their heads in the sand

- even when you select carefully a lot of pts trip up. the med agreement helps shopw them what they agreed to. they will say "you didnt tell me I couldnt dribk etoh", and we can say "yes we did" , and do it again and we are done

 

[Aether2000]

Informed consent is a legal document that is required for a treatment to be legally valid, and not coercion, experimentation, etc. An opioid agreement is mandated by some legislatures and may or may not be a legal document. It may or may not be simply semantics given the requirements by the states. In any case, paying attention to detail will save you a world of grief when there is a disagreement with the patient.

 

[hyperalgesia]

In Opiate World, where substance abuse pts live, people are obsessed with being 'singled out'. This is demonstrated by watching them rat on each other, "Why does my friend get meds and he even sells them! I don't sell mine because I NEED them, even though people ask to buy them all the time..." Having a consent in writing shows/reminds the pt that this is not personal and that we are simply executing policy. I can't imagine prescribing chronic opioids without a written consent.

 

[Aether2000]

So true- and even doctors continue to try making the ridiculous assertion that "if a person has pain, they can't get addicted". A physician treating pain stood up and testified this before a reference committee at our state medical association meeting this week. He also repeated the mantra that there is no ceiling on pain medications. Of course he incorrectly believes he is in control of his patient's usage of opioids and all other controlled substances. I wonder what his opioid agreement or informed consent asserts....

 

[Ducttape]

algos, I would hazard the more apropos initial question would be whether that physician actually has an opioid agreement or informed consent...

 

[Aether2000]

True