Monday, August 5, 2013

Pain contracts threaten the doctor-patient relationship

 
 
A friend with chronic post-injury pain was recently asked to sign a pain contract when she had to see another doctor in her PCP's practice while her regular doctor was on vacation.  From the x-rays, there's no question that she has major physical damage; she's not faking when she says she has severe pain.  And there's no question about why she wasn't seeing her regular doctor -- he was out of town when her renewed-every-month prescription needed to be refilled.  This was simply a doctor playing CYA and shaming the patient simply for needing a refill of the prescription that keeps her going. 
 
My friend is now in a bad place psychologically because of the emotional abuse of being pressured to sign this contract in order to get her medication ... and because, when she took it to the pharmacy, as directed, the pharmacist noted that it didn't include all the prescriptions she takes, only the one that doctor wrote, so for her to have signed it the way the doctor filled it out means that she could get in trouble for violating the pain contract by taking her other prescriptions.
 
KevinMD notes "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."
 
Why not make patients getting psych drugs sign contracts promising to attend weekly counseling sessions, not attempt suicide, not drink, etc.?  Those are things that are just as important as asking a pain patient to comply with strict rules and random drug testing.  But apparently only legitimate pain patients are irresponsible, and certified cookoos are so reliable that they don't need to promise to play by the rules.
 
What's the penalty to the doctor for leaving my friend an emotional wreck with this blackmail, "sign this or you don't get your medication"?  None.  The doctor knows nothing about my friend's situation (she's had a number of major personal losses recently), how close to the edge she was to begin with -- and therefore didn't know or care that this bullying "sign it or else" was going to have on an emotionally-fragile patient.  The only thing this doctor cared about was covering his own ass; patient's well-being be damned.
 
 
Philip Smith asks: "Who benefits from these contracts? It doesn't appear to be the patients, who are basically treated as criminal suspects for wanting to relieve their pain. And how does the Hippocratic Oath fit into this? I'll be digging into the whole sorry issue. Stay tuned."
 
Are there addicts who will lie to get drugs to party with?  Absolutely.  But there are ways to weed them out. 
 
For SEVEN YEARS, I was begging for pain relief from doctors whose circular reasoning was that I couldn't have pain because there were no x-rays showing damage, and there was no need to do the x-rays to prove I had pain, so there would never be the proof they required to show I had a physical condition producing the pain.  Asking for the x-rays to be done, just like asking for a sleep study to be done, simply got me a terse "No" or maybe the longer "you don't need that", and with no income, you don't spend the money hiring a lawyer to demand that they order testing.
 
I got consistently sicker from lack of sleep because I couldn't get the pain relief necessary to be able to fall asleep, while the doctors patted themselves on the back for preventing me from becoming addicted.  So what if I died from lack of sleep causing my immune system to shut down entirely, the only thing they cared about was making sure the Feds didn't come after them for writing prescriptions for pain pills.
 
Even after a chiropractor did x-rays showing three fractured vertebrae that no one knew about because no one wanted to order x-rays, I still had trouble getting pain pills because their CYA was more important than their "first, do no harm" obligation to their patient.
 
Perhaps I need to have my own contracts with me, to bully the doctors into signing "Patient asked for pain relief/x-rays/sleep study and I refused", so that when it comes down to it, it's not their word against mine, with them claiming that I never asked for such a thing.  Maybe turning the tables on them and making them sign a document confessing to their inadequacies and/or incompetence is what it takes to get the care you need.
 
I did learn one thing -- if the doctor sends a bill after the appointment instead of asking for payment in advance, I have control; I can refuse to pay that bill and return it to Admin with a letter explaining that I'm not paying for an appointment that didn't yield results.  I made the doctor wait months for payment while I battled with Admin and Disability.  I'm sure he was just as unhappy with the outstanding bill as I was with the ongoing health problems that he was doing nothing to solve (because assuring the patient "it's all in your head", "you're imagining things", "you're exaggerating", is NOT a valid treatment for any medical condition).

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