A Pained Life: Pain Contracts

A Pained Life: Pain Contracts

What happened to the days when doctors and patients had trust in each other? Did it end when the DEA entered the exam room and doctors became afraid to prescribe what they wanted to? What they believed their patients needed?

There are some doctors who have gone to jail or had their licenses or prescription writing privileges revoked because they were doing what their Hippocratic oath required of them (to help).

Others, though, have gone to prison, and lost their licenses and writing privileges because they over-prescribed to the point of illegal behavior.

bigstock-Filling-Up-Legal-Court-Forms-8174890An opioid contract does not make the doctor promise to behave legally.

Many pain patients are asked to sign a form that includes promises such as “I will not use illegal drugs while being prescribed medications by my pain doctor”. They  agree to “random test drugging when I come for appointments”.

If and when I am asked to sign such a contract I am being presumed a felon. Even the American judicial system assumes innocence until proven guilty. Why is this not true with the pain doctor-pain patient relationship?

Can such a lack of trust and faith go hand in hand with good medical practice?

I posit it cannot.

Most pain patients do not get addicted or abuse their drugs. This is a continuation of the false impression given by the media that pain patients like their meds, how it makes them feel, and easily becoming addicted or dependent. They say there is an “epidemic” of abuse and overdose deaths.

But the so-called epidemic is allowing the government to abuse us by inserting themselves into the exam room.

I have no problem with a pain contract. But a contract requires a promise by both sides: I will do A and you in return will do B.

Pain contracts are one sided. The patient promises not to do things, including illegal behavior. In return, the doctor will continue to see you and behave like a doctor. But that contract is already in play when you see the physician. He always has the right to terminate you as a patient. He is already bound by oath and license to behave like a doctor.

A legitimate contract would require the doctor to behave in certain specific ways: “I will trust my patient to behave in a legal and sensible manner absent proof to the contrary. I will work with my patient to make sure they have adequate pain control.” And so on.

It is not a legitimate contract when only one side is required to make promises.

If a physician can make it through medical school and residency he most probably has the intelligence and ability to discern when he is being played. Yes, he may be misled by a patient or two, but that is true of any medical practice.

You cannot always differentiate between the false complaints of a malingerer, hypochondriac, or con artist and real pain symptoms. Yet no other specialty requests that the patient promise “I will not engage in felonious behavior”.

Chronic pain patients should not treated with suspicion. We should be treated like any other patients, with trust and belief, until and unless our behavior indicates otherwise.

Carol Levy

Carol Levy

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol was accredited to the United Nations Convention on the Rights of Persons with Disabilities, where she helped get chronic pain recognized as a disease.

Carol is the founder of the Facebook support group “Women in Pain Awareness”. Her blog “The Pained Life” can be found here.

The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that!  It is for informational purposes only and represents the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.

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Authored by: Carol Levy, Columnist

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ACE

I live with Central Pain Syndrome or Post-Stroke Pain on the entire right side of my body after four strokes and brain surgery. My 4th stroke occurred during or after the surgery and was missed by the ‘team’ that did the surgery. That is, it showed clearly on the first MRI after surgery, but the radiologist and all the neurosurgeons, ICU nurses everybody missed it. So about nine months after the surgery I was consumed by excruciating/intractable burning. Then I started to feel like my rib was broken or my liver was screwed. My neurologist looked at those MRI’s finally and said, did the neurosurgeon tell you you had another stroke? No! I’m sorry, this pain will be with you most likely for the rest of your life!! Finally I had to quit the work I love and begin my ‘disabled’ and ‘semi-retired’ and still horribly painful life. My neurologists office went through lots of staff, four employees changed twice in my five years with her. One new office manager/nurse began her work and soon I was asked to sign the ‘contract’ as law requires. Then my neuro got sick. She was in the hospital the week my prescriptions expired. Super-nurse told me to call-in my refills a week in advance of the refill. I did, but would still have to wait, as long as four hours once we went in to get the required written prescription. So the week my doc was sick I’d call and super Nurse said she’d go to the hospital and have it signed. Friday came and she said she’d meet me on Saturday if needed. Saturday came, Morphine ran out (after I stretched the dose) and I called the pharmacy to see what we could do. She approved a 3 day ’emergency’ prescription, but only if she could speak to the neurologist for a moment to confirm. I had my neurologist phone numner (she gave it to me) , but had never used it. In desperation I let the pharmacist call her, she did, 3 days of medication was prescribed. On Monday I went in to get the full month prescription and was told by new Nazi-Nurse that she and the doctor were upset with me. The next Monday I received a letter stating that I was being dropped by my neurologist because I had violated the contract which I had signed one week before. A letter would be placed in my record to show why. The only thing that saved me is my most awesome Clinical Psychologist who is a chronic pain specialist. After hearing what happened he was furious. He called my neurologist and my new primary doc and gave them the truth. My primary said he would continue my prescriptions if I got a second opinion on the need for opioids. I went back to the hospital where my surgery occurred and got a new neurologist. The contract should be both sides. My neurologist helped me find the best combo of… Read more »

Katie

Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction.

That’s from NIDA (National Institute on Drug Abuse).

http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/there-difference-between-physical-dependence

Sadly, they’re are no protections for chronic or intractable pain patients, especially not these “contracts”. A few states have Intractable Pain laws, but they don’t protect patients. Heck, they don’t even protect the physician’s anymore.

Karey

My last pain mgmt. dr used methadone only, as my only option I went on it. The pain contract did state that doc agrees that should I need to be taken off the med for any reason., I would be tapered very slowly etc. after 5+ yrs on med this doc left pm clinic for better job w/ no notice to any of his patients until a few before leaving. EVERY patient (regardless of doses) was given 4 wk taper. No iformation about dangers or warning signs of withdrawl. Where I live this was the only pm doc prescribing any pain meds in over 100ml area. primary care doc here do not treat chronic pain patients with narcotic meds. Because of that, I was not even able to get into the pcp I had for 9 yrs for withdrawl treatment. Anyway my point is even with the mutual agreement pain contract doc will likely still get away with doing what they want.

Cindi Soutter

Dave, I was wondering if the American Pain Rights Act petition is being posted on Face Book? I signed it, there are at this moment only 163 signatures, I would like to help get more, what can I do? I, too suffer from Chronic Pain and have for 20 years. Lumbar, cervical DDD, Osteoarthritis, scatia, neuropathy, the list keeps getting longer. Could you let me know of anything I can do to help?

Michael Langley, MD

Yes, Karen.

It is sad. I am now on the opposite side of the pain equation. As Dave mentioned, it takes more than training to be a good pain doctor. Yet, I was trained by the American Academy of Pain Management, completing their course through the University of the Pacific in Stockton. received a “Certificate for Pains Studies”. Prior to that I had graduate school where I had majors in anatomy, including two semesters of neuroanatomy. I completed medical school and a general surgery residency. I learned many facts about treating pain in surgery! It is just a different profession when the patient often comes in free of pain and we cause more, albeit temporarily.

I was sanctioned for treating pain patients with compassion, even though I played cop, right along with the rest of the the doctors, trying to keep from being destroyed by the powers that be. Then, I had an accident and the tables turned. I had a fall and L-2 exploded. It was low enough that it did not paralyze me. But, it did major damage to the cauda equina. I ended up with chronic neuropathic pain. The pain doctor I saw, refused to use the hydrocodone that was working for me. But, he wrote in the chart that “all avenues of treatment” had been done and that I qualified for a dorsal column stimulator that he was so eager to implant. I had MRSA after my spinal fracture that was poorly treated (with oral antibiotics). I was switched to IV when an abscess was discovered in an MRI I received, after I developed a severe pain, stuck lying on my back with my legs pulled up. I had to be transported by ambulance, two hours to the hospital! the infection was cured after the IV treatment was, then, started. I have no desire to have another MRSA infection. This time it could be fatal!

I loved the “all in the head” stuff. I told the patients, that had been told such, that there was a treatment. Cutting off the head would eliminate the pain…forever LOL! And, as Dave noted, no one doctor can “know it all”. Sad thing is, we doctors, all, have a lot more that we could learn, or unlearn. Many of the things I learned in medical school and residency have already changed! Ulcers are treated with antibiotics. Proton pump inhibitors, like Prilosec and Nexium had not been invented!

Sadly, I have heard a few stories where medical records had destroyed some patients’ getting adequate medical care for their chronic pain. They were stories that sounded much like yours!

dave

K Cooper- thanks for sharing your story. Im sorry you have had to go through hell to get some pain care. That is why i wrote a petition to change pain care and give people in pain rights- for the only right people in pain really have is to say no to treatment.
I hope when you are up to it to look at the petitions online to change pain care and you can sign on or create your own- mine is the : American Pain Rights Act- you can google it and sign your name with or without a comment.

dave

Dr Langley- Of course I was referring to the American Academy of Pain Medicine- though I am aware of, and in fact worked with the other AAPM you mentioned on some issues.
With regards to the AAPM, you are merely stating some generalities, which i imagine most of us know- except with regard to the “most training”. I really don’t know what practitioners have the most training-and frankly I don’t think much of the training of those in the AAPM- nor their politics-and they already know what I think in that regard.

You failed to mention that when the AAPM had a summit with the AMA-they both agreed the training of pain specialists was inadequate- and having read a summary of that meeting- they frequently mentioned how “burdensome” people in pain are- I guess maybe that is what you meant when you were referring to imperfect. And didn’t some of their members and a number of APS members talk of people in pain being “catastrophizers” in that 2011 IOM report-and that they didn’t believe in curative treatments for pain? So when it comes to perfection, pain specialists are a far cry from pressing on the mark. With regard to other pain specialists, some at the ASIPP they didn’t want nurses providing interventional pain care- despite the fact we know there are few pain specialists in the country. Yours truly advocated successfully for nurses to provide interventional pain care.

It takes more than training to deliver good pain care. Wasn’t it Dr. Scott Fishman-I’m sure you know of him- who indicated that pain specialists could be less than sensitive, at times, toward people in pain?
Pain specialists are poorly trained in nutrition, poorly trained in psychological issues and even with regard to alternative treatments they advocate- like acupuncture- which normally takes very intensive training- costing typically over $40,000- i find it remarkable that the pain specialists make no distinction between the types of acupuncture- so it would seem they see no difference between Manaka style acupuncture and MSAT- their training in electrotherapies is also quite limited-as indicated by the “official” AAPM book by Deere et al. The same is true of hypnotism- they say they do hypnotism- but make no mention of what type- noesitherapy, 7 path, hemispheric, dual induction, new code nlp, ultra deep?
Frankly, the training of pain specialists convinces me the apple doesn’t far from the tree in the house of medicine-and they largely are focused on biomedical treatments and not the more inclusive biopsychosocial approach. It is not my idea of the biopsychocial paradigm in pain to refer someone in pain to cbt when they “catastrophize’
Finally we all know how much doctors dislike anyone but doctors to have an opinion about health care- so once again you’re not telling us anything we don’t already know.

Anonymous

The DEA is going after legitimate pain patients because we are an easy target! They have lost the drug war, Illegal drugs are more plentiful and cheap than ever! They are an agency that has run amuck! They have no business interfering with legitimate pain patients and their Doctors. We lost a wonderful, compassionate Doctor in my state, because he prescribed Methadone for pain, to people who could not afford the alternative. Unfortunately due to the irrational drug policies and the refusal of so many Doctors to treat people in Pain, he was one of very few Doctors, in a large geographical area, that was even treating pain. This is such a loss! There were some deaths due to the Methadone, Allegedly. So he was targeted. They failed to look at the big picture, he was treating people from another state who were refused treatment. Some of his clients were probably at the end of despair, because the longer the pain goes untreated, the worse it gets! This includes losing everything! Once the pain interferes with your ability to work, maintain relationships, and takes away your dignity, there isn’t much left. The misdiagnosis and under treatment of pain is blamed on the patient. We are told “it is all in our head” or it is a psychological problem. I was actually told, that I just did not want to get better. It was like a Kick in the teeth, dealing with a crippling painful condition, that if it had been diagnosed earlier, I would not be disabled, and then being told I was “crazy” or “hysterical”! I have a copy of The Pain Patients Bill of Rights! It is a useless Document! I have a good knowledgeable Doctor now, but it took years! I have the records of Visits to places like The UNM pain Clinic, where the Doctor did not bother to look at my MRI’s and casually dismissed my pain, Apparently I had an unnatural concern with by back issues! Well of course, I had constant pain! I had ruptured a disc, got that misdiagnosed, as all in my head! I tried to function for 5 years after that, and it got worse. The nerve was so damaged I am lucky I can walk! I truly wanted to die! I was denied any imaging! I still tried to work and attend College after all it was all in my head. One Doc who misdiagnosed me, was coked up, he got busted on a sleazy street with a hooker and Cocaine, yet if I go to the local hospital his ridiculous comment of me being Mentally Ill are still on record, and even with all of the X-rays and imaging I will be treated like a mentally ill drug addict! I actually developed a Mental Diagnosis from all of this Iatrogenic PTSD! My last idiot Doctor who I fired, was so much more concerned with the possibility I might have depression than my spinal issues! I have had 2… Read more »

Michael Langley, MD

Good to know we have a genius telling us all of the answers, Dave. Doctors will never be perfect. Yet they have the most training of any individuals in the country. AAPM has been attributed to the American Academy of Pain Medicine and the American Academy of Pain Management. They are entirely two different organizations, the first stressing interventional anesthesiologists and the second stressing interdisciplinary pain management. There is a big difference in philosophy. Interdisciplinary treatment has proven to be the best way to treat chronic pain. But, alas, it is expensive and not well covered by insurers. They believe in using physical therapy, acupuncture, psychology, etc. to provide a more complete evaluation and care of the patient. All of the specialists are under one roof and COMMUNICATE with each other for the best outcome a patient can receive form medical care.

And, Karen,
Doctors are too scared to “care” for their patients. Since the CSA and the DEA have inserted themselves in the middle of of the physician /patient relationship, their careers are the biggest gorilla in the room.

It is fairly easy to get a patient off of medications that can cause withdrawal. The question is about the patients’ needs. Is it fair to consider a patient an addict when they take medications as ordered? Or, is the patient’s quality of life more important? Only the future will show us if people are going to be treated humanely, or like a subspecies, like other animals. “They shoot horses don’t they”!

Kellix

My PM has told me about this, and he doesn’t like it either, but him and his firm are following it verbatim. Because he put it in these words. Us doctors are SOOOOO Perfect that we can guess what to give you and that will take care of someone’s pain. He said its laughable because there is no doctor alive that is perfect. Why you think doctors call their professions practices, they aren’t perfect. Its a practice, they try to get the right kind of meds for the user, and at the same time where the person is not overdoing it. My friend said his PM, said basically he was a coach. Telling someone to have to take their meds and basically is a coach. I agree with the contract, we have had to resign that contract 3 times. They will add something new in it also, they have our pictures. Like anybody trying to do something against doctors now a days is crazy. They have the DEA breathing down their necks, and a lot of it was caused by Florida. How bad it got there, I’m in Georgia which they tried to do that here, but the state, closed the door on it quick, One they made it where you have to have special paper to get anything narcotic, 2, they made the doctors the owners of the pain management clinic. Not like these fly by night places, where they just hire a doctor. In Georgia the doctor knows if they get accused of something, they could lose their license, and do jail time. All these things, closed up Georgia quick, also with a database that doctors can tell if some other doctor gave a person something. I think their should be legislation for chronic pain people where they can get their meds and also for doctors, where were not castigated, I have back problems and crohns disease. If anybody doesn’t think its painful. I would love for them to live 5 minutes in my shoes. Because the DEA was created for what? To stop the interdiction of drugs into this country, like the biggies, Heroin, Meth and Cocaine. But what does the DEA do, they screw with doctors and patients. It gets down to it, that’s the FDA’s job, they released the drug, they can also remove the drug. They are having a Heroin epidemic and news people are going, “How did this start?” It was started when a bunch of kids got a hold of pain killers and now their supply is dried up and Heroin is dirt cheap and their friends tell them its just like pain killers and they are dropping dead. The DEA needs to do their job and stop Heroin and quit screwing with us.

Michael Langley, MD

Sorry Dave.

My comment should have been addressed to Jane!

Dave

Dr Langley- as you know the aapm was recently under investigation for their role in opioids. I don’t think much of the AAPM’s bill of rights- I think mine is much better. The AAPM is very much focused on biomedical treatments. In their official book by dr. Deere et al on comprehensive pain care- they have less than half a page on nutrition- gee I think the pain from gout, fibromyalgia, ibs, osteoarthritis, migraine- to name a few often should involve nutrition. I guess the AAPM thinks otherwise.
I disagree with your portrayal of “the problem”. The problem is doctors longterm prejudice toward people in pain- Blacks and Latinos receive half the pain care of whites- that is not due to the DEA. Woman, children and elderly are also subject to the prejudice of doctors. Doctors have, since before the time of Oliver Wendell Holmes been “deluded by exaggerating the value of drugging for generations” as he indicated. It is easy to dispatch of a person in pain by writing a prescription and get to the next billable patient then to have adequate education in pain care and make intelligent use of frequency specific microcurrent, microwave resonance therapy, kototoma acupuncture, LENS, Neurofield, biomagnetic pair, noesitherapy, coping skills training and the Alexander technique.
It is apparent doctors are just too biased, uneducated, tendentious and stuck in their ways when it comes to pain care. Let us try to be honest and accurately assess what is really going on in pain care so our fellow citizens can get decent pain relief- and yeah my dorsolateral prefrontal cortex and right temporoparietal junction are methylated enough for that conversation.

Michael Langley, MD

Dave,

There is a pain patients’ “Bill of Rights”. Google it! It can be found at the American Academy of Pain Management, if you don’t find it with a Google search. Thing is, doctors are not required to follow it. Too many physicians have to play cop, because of the CSA and DEA! Too many of them seem to enjoy refusing adequate care. All they want is for Medicare to pay the bills!

I recently had a pain doctor write down false information in my chart, so he could get Medicare’s permission to insert a dorsal column stimulator, prior to getting any physical therapy, acupuncture, or massage therapy, (etc.) consultations were done! He refused to use the opiate that was controlling my pain pretty adequately. I am not an addict and I don’t even drink alcohol! The system is broken and abused because of a population of less than 5% that would be obtaining the medications for criminal use! It is like throwing the baby out with the bathwater!

Katie

Carol, While I agree with the majority of what you said here, I have to say that I don’t with “most patients don’t get addicted (to their meds)”. I was diagnosed with fibromyalgia almost ten years ago, and from day one I was prescribed a medication called tramadol (ultram). I implore you to take any medication, no matter how low the content of opioid, for so long and try to come off of it. I have taken medications that ranged from nuerontin, gabapentin, and other such drugs to vicodin inn addition to the tramadol, and I found that after taking the one medication for so long, I experienced withdrawal symptoms that I still have nightmares about. I was given this by my primary care doctor, but in October last year I was referred to a pain management clinic to treat the pain from there on. At the second appointment, I was asked (even though I provided the information at the first appointment, as well as brought the bottle with me) who prescribed the tramadol to me. I showed him the bottle for the second time and explained how long I had been taking it. He told me that he didn’t want me to take it anymore and began to prescribe 7.5 mg Norco. I tried to not take the tramadol but my body had grown to expect its presence, and it made me both physically and even slightly mentally ill. I asked his office for help, to which they replied I would be discharged from the clinic if the doctor found out. I had to gradually pull myself off of it. I have 4 children, and I was seeing this doctor to help make me better so I could take care of them, but they didn’t care. At the February appointment following January’s drug test, I had finally come off of them. But not in time for the drug test, of course-and was discharged on Valentine’s day. I don’t know what to do anymore. I just want to not hurt, to be able to hug my children and be able to feel the joy rather than wincing away from the pain. I want to be able to go out and play with them no matter what the temperature is outside, not tell them “I’m sorry, babies, the cold hurts mommy too bad.” Thanks to your opinion and my last experience, however, IF I should find myself at another pain clinic, I will be sure to run this past my prospective physician. As much as he/she wants to be assured that he/she won’t be penalized in some way for treating me, I need to be assured that I will not be penalized as well. I need someone that understands the concept of mutual respect, one that will look in my chart at the information I’ve provided rather than accuse me, one that can understand that my wellness is the priority. I sincerely appreciate this, it does make me think about why… Read more »

Jane Hapner

Patients need to band together to get a comprehensive “Patients Bill of Rights. Medical patients in the US don’t have anything reguarding their rights or responsibility reguarding the doctor-patient relationship.

Dave

Carol- I agree- Also, most doctors have no training in pain medicine, addiction medicine or pain medication. So it is pretty outrageous for them to require their patients to sign contracts when they seem to have made no real commitment themselves to ensure they are practicing pain care properly.
It is unfortunate, that people in pain don’t band together to establish a comprehensive set of rights that will ensure they are treated humanely, respectfully and receive both adequate assessments and treatments. Sadly, I believe that the powers that be will continue to mistreat people in pain and will continue to provide restrictions on what they have access to.