Plain Dealer: Opioid Contracts Humilate Pain Patients

[drusso]

Opioid 'contracts' humiliate some patients with chronic pain, and may not make them safer

"Many of the more than 20 opioid contracts reviewed by The Plain Dealer contained inflammatory and threatening language instructing patients that deviations from the contract would be grounds for the prescriber to stop prescribing opioids "at any time." A template contract provided by the American Academy of Pain Medicine includes the bolded line: "You understand and agree that failure to adhere to these policies will be considered noncompliance and may result in cessation of opioid prescribing by your physician and possible dismissal from this clinic."

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[Ducttape]

treatment agreements are not for the purpose of protecting the patient. they are to help protect the doctor. for once, its not all about "you".


and if a patient has an issue with them, then he shouldn't sign it. guaranteed, both sides will be happier in the long run.

 

[hyperalgesia]

treatment agreements are not for the purpose of protecting the patient. they are to help protect the doctor. for once, its not all about "you".


and if a patient has an issue with them, then he shouldn't sign it. guaranteed, both sides will be happier in the long run.

I avoid language and the argument that an opioid consent is for anything other than safety. I also don't threaten "dismissal from this clinic", unless referring to disruptive behavior that jeopardizes care of other patients.

Even if we are worried about ourselves and our liability, it is directly related to the welfare of the patient or other patients or people. Diversion can lead to drugs sold to children, after all.

You're not wrong but we don't have to cede the high ground here...

 

[drrosenrosen]

I agree that I would never include language about dismissal from clinic for breach of opioid agreement. That is a bridge too far and feels confrontational. I also don't use the word "contract" because it implies that I owe the patient something.

 

[drusso]

Wow, surprised by the responses here so far. I pretty much tell patients, "My pad, my pills, my rules; sign here." I guess I'm a hard-ass...

 

[deleted480308]

If you might cut them off for noncompliance warning them clearly is fair

 

[lobelsteve]

Wow, surprised by the responses here so far. I pretty much tell patients, "My pad, my pills, my rules; sign here." I guess I'm a hard-ass...

Fire the drug, not the patient.
But I tolerate no BS. Had guy with osteomyelitis of knee tell me his surgeon could not rx more meds so sent him to me. He told me 2 docs told him to have it amputated. I said im not your dealer, get the leg amputated as recommended. Meds wont save it.

 

[pastafan]

Fire the drug, not the patient.
But I tolerate no BS. Had guy with osteomyelitis of knee tell me his surgeon could not rx more meds so sent him to me. He told me 2 docs told him to have it amputated. I said im not your dealer, get the leg amputated as recommended. Meds wont save it.

You should have put in a stim.

 

[drusso]

You should have put in a stim.

Prophylactic phantom limb pain management...

 

[lobelsteve]

You should have put in a stim.

Missed opportunities.

 

[drusso]

Missed opportunities.

You could put an ad in Craig's List under "Missed Connections:" I saw you in my exam room with your bum knee and I knew we were meant for each other. I've got an RX pad, a pen, and 15 cm of stereo wire. Let me show you how I can make you tingle. Signed, Make My Boat Payment.

 

[Aether2000]

I agree with firing the drug, not the patient. Dismissing a patient in some states requires written notice (of course certified delivery so you can use it in court if you are sued for patient abandonment) and in some states a 30 day supply of the drug that is already the source of abuse. You are never obligated to refill early or outside of appointments but these should be specified in the agreement. By not firing the patient but continuing treatment with non-opioid therapies, you may actually be doing the patient a favor. If all they want is drugs, they will go elsewhere and you never have to dismiss them from your practice.

 

[NJPAIN]

Wow, surprised by the responses here so far. I pretty much tell patients, "My pad, my pills, my rules; sign here." I guess I'm a hard-ass...

TOTALLY appropriate to be a "hard-ass". Worry about "confrontational" or "inflammatory" language"? Opioid agreements need to have I MEAN BUSINESS written all over them. I have yet to meet a patient who has their candy taken away and wishes to stick around for the NSAID, CBT and PT portion of the performance.

 

[cowboydoc]

Fire the drug, not the patient.

I like that, summarizes my approach. I've been surprised to have some patients stick around after weaning for + THC or no longer filling when UDS was without rx'ed med. First f/u a bit awkward, but expectations are clear.

I guess patients don't have any other options in these parts.

 

[Ducttape]

from my perspective, they do stick around. i have at least 30 inherited Legacy patients taken off opioids for a variety of reasons that i still see on a regular basis.

 

[SeniorWrangler]

I'm not sure that treatment agreements serve any purpose, honestly. Psychiatrist have quit using safety contracts with psychiatric patients because they are totally meaningless; patients will comply, or not, regardless of what you make them sign.

 

[Ducttape]

Yet how many times do you tell them “you aren’t supposed to do that” and patients retort “you never told me i couldn’t”?

 

[hyperalgesia]

I'm not sure that treatment agreements serve any purpose, honestly. Psychiatrist have quit using safety contracts with psychiatric patients because they are totally meaningless; patients will comply, or not, regardless of what you make them sign.

We call it "Opioid Consent". It's not really meant to make pts comply or change their behavior, any more than any other consent. It's to make them aware of your policy and the risks of the meds and to attest to their understanding. Like Ducttape says, it takes away the single biggest argument, "I didn't know".

 

[kstarm]

Had a patient last week that I took over to wean after her previous "Pain" clinic had ramped her up on oxys for her foot pain (really it was her dissociate personality disorder). She overused once and I reduced her to bi weekly scripts. She was out 9 days early on her meds at revisit. I told her the option was suboxone or we can manage her withdrawal. She told me I could go F%$k myself. I offered her withdrawal meds but told her I would not see her back in clinic after our interaction that day and sent a referral to a different addiction/pain clinic. I struggled a little with this one, if I should have fired her or not. Should I have fired the drug and kept the patient in this case as people above are advocating?

 

[pastafan]

Had a patient last week that I took over to wean after her previous "Pain" clinic had ramped her up on oxys for her foot pain (really it was her dissociate personality disorder). She overused once and I reduced her to bi weekly scripts. She was out 9 days early on her meds at revisit. I told her the option was suboxone or we can manage her withdrawal. She told me I could go F%$k myself. I offered her withdrawal meds but told her I would not see her back in clinic after our interaction that day and sent a referral to a different addiction/pain clinic. I struggled a little with this one, if I should have fired her or not. Should I have fired the drug and kept the patient in this case as people above are advocating?

Keep her and you would have been fulfilling her directions as to what to do.

 

[drusso]

Had a patient last week that I took over to wean after her previous "Pain" clinic had ramped her up on oxys for her foot pain (really it was her dissociate personality disorder). She overused once and I reduced her to bi weekly scripts. She was out 9 days early on her meds at revisit. I told her the option was suboxone or we can manage her withdrawal. She told me I could go F%$k myself. I offered her withdrawal meds but told her I would not see her back in clinic after our interaction that day and sent a referral to a different addiction/pain clinic. I struggled a little with this one, if I should have fired her or not. Should I have fired the drug and kept the patient in this case as people above are advocating?

Fire her.

 

[244913]

Had a patient last week that I took over to wean after her previous "Pain" clinic had ramped her up on oxys for her foot pain (really it was her dissociate personality disorder). She overused once and I reduced her to bi weekly scripts. She was out 9 days early on her meds at revisit. I told her the option was suboxone or we can manage her withdrawal. She told me I could go F%$k myself. I offered her withdrawal meds but told her I would not see her back in clinic after our interaction that day and sent a referral to a different addiction/pain clinic. I struggled a little with this one, if I should have fired her or not. Should I have fired the drug and kept the patient in this case as people above are advocating?

Terminate with extreme prejudice

 

[hyperalgesia]

Had a patient last week that I took over to wean after her previous "Pain" clinic had ramped her up on oxys for her foot pain (really it was her dissociate personality disorder). She overused once and I reduced her to bi weekly scripts. She was out 9 days early on her meds at revisit. I told her the option was suboxone or we can manage her withdrawal. She told me I could go F%$k myself. I offered her withdrawal meds but told her I would not see her back in clinic after our interaction that day and sent a referral to a different addiction/pain clinic. I struggled a little with this one, if I should have fired her or not. Should I have fired the drug and kept the patient in this case as people above are advocating?

In this situation I would not offer ANYTHING, other than an ER referral. You can argue she is not safe to take ANY prescribed meds. I would just say "I can see you again but I don't have any treatments that will help you." She will self D/C and you don't have to fire her.

 

[Agast]

She overused once and I reduced her to bi weekly scripts. She was out 9 days early on her meds at revisit.

So she finished 15 days of medication in 5 days, or 3 times as much as you recommended. When a patient demonstrates to me that they have no concern for their safety and will not follow my directions, I do not write them for any medication as any instructions I write are meaningless. If a patient does not want me to practice medicine then they do not want me to be their doctor.

 

[Ducttape]

The doctor patient relationship depends on there being mutual respect between the 2 parties.

She demonstrates no respect for you. Document her words and actions, that you did take in to account the situational stress, but her derogatory and demeaning words and attitude prevent continuing any previous relationship.

Mail her a discharge letter and include local contact sources of addiction care.

 

[Aether2000]

She is hostile, and is addicted. Good call , and have to discharge her because of her mouth

 

[hyperalgesia]

I agree there is nothing wrong with firing this disruptive pt.

 

[powermd]

We call it "Opioid Consent". It's not really meant to make pts comply or change their behavior, any more than any other consent. It's to make them aware of your policy and the risks of the meds and to attest to their understanding. Like Ducttape says, it takes away the single biggest argument, "I didn't know".

This makes a lot more sense to me than "agreements" or "contracts". If you don't trust a patient such that you need a written agreement stating that they won't behave badly, what are you doing handing them a prescription in the first place?

Do contracts really do anything to lessen the F bombs from a jackass patient who misbehaved and had his narcs cut off?

 

[Agast]

Put it this way: you don’t have every single law memorized. But ignorance of the law does not mean you aren’t responsible for breaking the law. “I didn’t know it wasn’t legal to download 1000s of songs from a piracy website” doesn’t mean you don’t get fined. “I didn’t know I couldn’t get 90 oxycodone from you and 120 tramadol from my PCP” doesn’t mean you don’t get fired.