Pain Contracts: Do They 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.
*This blog post was originally published at KevinMD.com*
I think there also needs to be a change in the culture of pain specialists. Most of them don’t want to work with patients with certain kinds of conditions (such as mine, chronic migraines) or will only do so within a very limited scope. I’ve been to a dozen pain specialists and most of them were willing to do expensive procedures with little evidence of benefits and sent me on my way when the procedures did not bring about the desired effect. My primary care physician is one of the only care providers who has taken my pain management needs seriously, so she largely manages my pain. It’s unfortunate.
the contractual aspect of the physician/patient relationship is just a symptom of three much more adversarial contracts dominating health care: insurance company contracts with employers, employer benefit contracts with their insured employees and malpractie attorneys with their clients. These are three for-profit contractors–and you think the pain contract is unethical?