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bioethics of pain contracts

StarshineSStarshine Posts: 68
edited 06/11/2012 - 8:48 AM in Chronic Pain
Everyone who has a pain contract with their health care provider should listen to each one of these tapes.

URL Removed - Please contact Starshine via PM for further info.
How do they impact patient care?
Is it an effective tool?
Does it promote physician/patient relationships?
Is it a legal document or an AGREEMENT?
Are they used to protect the physician (documentation)?
Do they prevent abuse and are useful as a tool for communication?

Has it given any of you some good insight?


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Post Edited by Administrator Dave


  • Sometimes you need to consider something for what it is not what you want it to be. A pain management contract is just a piece of paper. It is not going to stop someone from taking their meds incorrectly. It will not stop someone from selling their meds. It will not stop them from demanding ever increasing dosages.

    It is a piece of paper that says you will do X and the office will do Y. If you don't do X then they don't do Y.

    There is no legal or medical need for a "PM Contract". No law mandates it. No court will enforce it. It could aptly be entitled "Rules for getting narcotics in this office".

    It's a piece of paper, that's all.
  • Kris,

    Very well said!! I think some doctors get "unearned" power or control over people. Most people see a contract as a legally binding document. Hummm....

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Exactly Kris. You can also ask "is this physician going to treat me if I don't sign one?"

    And, of course, if you DON'T have one, you can ask yourself "does it leave me any less at risk of losing my pain care if I am careless or misuse my medications?"


    Does the pain contract or lack thereof leave me any less responsible for taking my medication as directed by my physician?

    Personally, it has never been difficult for me to stick with my prescribed dosage. I know it is the law for controlled substances and I feel that it is my ethical obligation to my doctor. So a pain contract was never an issue for me, as long as it went both ways.

  • Brenda, what do you mean a "binding contract?"

    Like they think they can't switch doctors? I do feel that way sometimes, but not because of the contract. It's just because of the nature of the beast.

  • It is an agreement not a binding contract but take time to listen to what is on this site.

    Interesting how some docs feel and how patients feel about contracts. What's interesting is there is very little research on if these agreements work or not. Some ppl need a contract to abide by what the dr.prescribes and some ppl don't. Dr. should use their skills and ability to decide who needs a contract. It is the communication you have with the dr. that can determine to him or her if you need one.(this is from tapes)

    And it is the doctors responsibility to detect this. After all they have the education. If they feel that they don't have the time or are unable to determine this then they have to have this agreement to protect their licenses and hopefully protect some ppl from the dangers.

    I talk to this about my family member who is an emergency medicine doc. in a county hospital and he has to judge whether to give the patient opiates frequently.

    i wanted to tell you that the tapes on the site answers the questions i posted. I was hoping to get some discussion on what you heard. Anyone?

  • In line with what Kris was saying in so far as "law enforcement" of said "contract." Some people think that if they sign this contract, they are locked into *this* doctor whether they get along or not. As you know, a relationship has to be amicable. So if I don't like this doctor *I* can cancel that contract and go to another.

    To me when a doctor tries to get me to sign that piece of paper, *I* feel like I am being judged. If this doctor agrees that I need pain management, then maybe I should get *him* to sign a contract with me of his ethics and veracity? I guess I don't like the one way street. Trust works both ways. Sorry, I'm rambling..(G)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • But emergency medicine is not pain medicine.

    Pain management doctors face a unique set of challenges. The ER doctor doesn't have to worry daily whether his patient, for example, is going to misuse his medication by taking "just a little extra," and convincing himself that it is within his rights and it will be OK regardless of the fact that the law, professional opinion, etc suggest that taking medications as directed is an important aspect of the doctor-patient relationship. An ER doctor sees a patient once and he's gone.

    I can probably guess that most of us who are, ahem, approaching the hill have friends and loved ones who are doctors, lawyers, etc and have had such discussions. Everyone has an opinion.

    But the reality is that things are only getting harder as far as opiate prescriptions go. For Schedule II meds, doctors are going to have to re-certify, and some are saying that fewer doctors will be available to prescribe the meds. For those of you who take a few schedule III meds here and there, maybe going without a contract is an option- for some of us, our choices are limited at the start, and we're given the choice of contracts or no meds.

    I understand perfectly why my doctor's office has contracts. It is not because the contract will save their a$$ in court, it won't- in California you can't sign away the right to sue for negligence. What it does do is give them an easy out when someone starts exhibiting signs of not being a candidate for opiate therapy. Those signs are on the contract.

    Now, a doctor who knows their patient is doing these things and still gives them dangerous medications? With no contract or any other controls? Is that good care? Long-term opiate prescription standards (which differ entirely from short-term standards) *requires* a physician to be on the lookout for signs of misuse and to deal with any signs he sees.
  • Happy,
    Emergency med docs are not pain docs but they do see pts more than once- sometimes frequently because half the pts that come to er's do not have insurance and they come their for pain. And they do worry about the meds they give whether is one dose or 50 doses. Have u seen the nations er's lately- it's a mixture of everything because ppl need health care and can't afford it!!Even people in pain

    Isn't too bad that doc as u say have to find the "easy out" because some try to see pts every 15 minutes or overbook so they can make some money instead of taking the time to find out more about their pt. Love my docs -they spend as much time as i need. Wouldn't have it anyway else

    yes agreed, a doctor has the right to refuse to give pain meds or have a pt sign a contract. It is their responsibility.

  • An ER isn't going to prescribe long-term opiates for anyone. That is what pain management is for, and making sure that the patient is willing to take on their share of the responsibility is part of it.

    And making sure you have good doctors is not an easy task for any specialty. Doctors who care will spend the time, contract or no contract, whether they are a pain doctor or an ophthalmologist.
  • I have never signed one but have seen that they are not all the same. The first one I saw I thought was horrible. It was written by a lawyer and was all about protecting the doctor and giving him complete control over everything.

    Another one I saw more recently was much more patient friendly, but I still did not want to sign it.
  • T9, the first one I saw was written by a doctor who thought he was doing patients a favor by seeing them. It was awful. I not only never saw him again, I complained to to ortho who referred me (not just about the contract- but about the fact that although I told him what was wrong, he didn't believe me and blew me off. He even had the nerve to run his hand down my spine and say "everything looks OK to me." Yes, everything except the MISSING VERTEBRAE! Which, by the way, is easy to feel).

    But the two I've signed have been 2-way contracts that simply lay out the rules of engagement. Very polite and respectful.

  • happyHBmom said:
    But the two I've signed have been 2-way contracts that simply lay out the rules of engagement. Very polite and respectful.
    I've only seen a couple of them (neither of which did I sign), and they were all on the patient and their compliance. Now a 2-way contract, that is what I was talking about - both parties have rules to go by. Not bad, not bad at all. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • I'm so glad I don't have to deal with all of this, and am not looking forward to the day I might have to!! I'm thankful for you posting this Starshine, it does give great feedback from both the site you gave, and members, I will definitely keep it all in mind.
    APROUD CANADIANveteranButNOTa doctor, my thoughts are my own
  • Curious? Why was her link removed? It is an "org" site verses commercial, so just curious as I've been tempted to post some "org" sites. Don't want to waste my or your teams time if "org" sites are a no-no. Thanks in advance.

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Starshine said:
    It is an agreement not a binding contract but take time to listen to what is on this site.
    .... Dr. should use their skills and ability to decide who needs a contract. It is the communication you have with the dr. that can determine to him or her if you need one.(this is from tapes)

    ....And it is the doctors responsibility to detect this.

    Hi Starshine, I haven't heard the tape, I will pm for link

    But from what little law I studied and from knowledge of E & O, consistency is crucial on many levels. These contracts may not be legally binding contracts, but more so an agreement albeit bi or unilaterally, the doctor either uses them or not. It may be construed as discrimination if one patient is asked to sign and not another. Do you see where I am going with this? Even though the doctor as a trained professional, can spot out issues, especially the more experienced physicians.

    If he asks one guy to sign, that guy may know his friend didn't sign, and may think... is it the color of my skin, my type of work, my income level, the way I dress or look?

    Now, the PM may be picking up very evident RED flags from this guy, and may feel obligated to do his due diligence, but you can see how one may twist it into something negative and believe me there will be an attorney who will agree that this guy has been discriminated against..... an audit of just contracts vs total patient base could be used against the doctor. Even though he was doing what he felt best to protect himself & his practice from a possible issue with this specific patient.

    So in my in my opinion and from what little I know, if the doc uses contracts, he needs to have every patient sign them.

    Ps, my pm uses bi-lat contracts, and has even new patient seen for a psych eval.

    Nice topic of discussion,

  • My guess is that it was removed because it was a company that provided bio-ethics consulting to paying members. Just because it says .org does not mean it is reputiable or unbiased.
  • Thanks for the information Starshine.I was lucky enough to get to it last night before it was removed,and I think it's important to view things that interest or involve me from different perspectives before coming to a single idea or thought process on a subject.Generally because we are all so different even lifes experiences can make a big difference in how a person feels about,or sees these contracts.
  • Kris-NY said:
    My guess is that it was removed because it was a company that provided bio-ethics consulting to paying members. Just because it says .org does not mean it is reputiable or unbiased.
    The "pay to be a member" has come to mind with me as well. It's a service option I guess. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • i am not a lawyer but i believe a dr can drop a patient any time they want to and i believe they don't need a reason. i don't think they need a contract. they could say they are cutting down or they feel that another ddr can treat you more effectively. like i said i don't know the legalities. a contract signed or not won't keep a dr with a patient. i don't know the ethics of refusing to see you. i think if they wanted to they could think of a reason contract or not. this would be an interesting question for a lawyer to answer. i can ask my dr next time because he tells me of stories of dropping patients but usually it has to do with abusing drugs or workman comp issues. they could make your appt more of a hassle and uncomfortable mentally to get rid of you. i would think this as unethical myself but if they can drop you they can. if someone knows and not guesses please let us know. years ago i had a dr who retired and his co-worker hassled me about my meds and would not prescribe them for me. i got p.....................................ed and dropped them.
    jon perry mason
    I have 4 fusions from L5-3, the latest last May '12 where they fixed my disc that broke.They went through my side this time. I take 40 mg of oxycontin 4x a day and 4 fenatyl lollipops 300 micro gms 4x a day.
  • I just googled that Jon, and came up with this from emedicinehealth.com:


    The doctor has the duty to continue a patient's health care after consenting to provide medical care unless the patient no longer requires treatment for the illness. The doctor must notify the patient and transfer care to another acceptable doctor if planning to withdraw care. The doctors may be charged with negligent abandonment for ending the relationship with the patient without appropriate referral, transfer, or discharge. Although doctors are free to choose which patients they will treat, doctors should offer optimal care for patients who need emergency first-aid treatment.
    APROUD CANADIANveteranButNOTa doctor, my thoughts are my own
  • with my doc. It's a DEA contract. Says I can't get prescriptions for pain meds from anyone else and I can only get the prescription filled at one pharmacy. It's been in force for over two years now, and I've not had a single problem with it. Actually, I had rotator cuff surgery this summer with another surgeon and when he asked about pain meds, I just said, "I've got a contract with my PCP for those, so you can't give me any. I'll be just fine." He was fine with that, I was fine with that, and there has not been any problem. My file at the doctor's office lists that prescription as "chronic." I'm able to refill it as long as I don't abuse it, and I never have.
    3 level spinal fusion, L3/4, L4/5, L5/S1, November 2008. Stiff, but I can walk.
  • The URL was removed because it leads to advertising and is a paid for service. I'm just enforcing the rules. If I allow this one, then I have to allow the idiot pedaling a health club membership.

  • Dave,

    Thanks much, I didn't even think about the advertising! I guess that gives me my answer on the links I was thinking of posting. Appreciate! :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Hi all...I hope that I can get some advice here...I have congenital hip dysplasia and in 1998 I had a hip reconstruction/osteotomy on my left hip but my right wasn't as bad...also...I had two back surgeries in 2009 and 2010 respectively. The fusion was a failure...it had a 50 50 chance of being successfull. I went to my regular doctor for about two years. I needed more structure with my pain management so I started seeing g a pain management specialist three years ago. I have followed my contract since I signed it. I started to get steroid injections into the hip joint about 2 years ago...Well...we were on vacation the week of Labor day and I tripped and injured my right hip. By the time I got home I couldn't bare any weight on that leg so I had an injection. It did nothing. I asked my pain dr. to increase my medication and he would not. He wanted a mri and it showed a bone bruise and a torn muscle. He said it would heal in a couple of weeks....well he doesnt k ow jack about bone bruises...mine is deep into the marrow nd they take months to heal...so I asked again for an increase and he said no. I have been to the ER twice in the last few weeks when the pain became so unbearable and they just treated me like a drug addict...finally on Friday I saw a bone and joint doctor and he did xrays...what I had been asking the pain doctor to do for months...and it shows no cartilage left in the right hip...it's bone on bone....his suggestion is a total hip replacememt. I am in the process of getting g a second opinion. I have called my pain doctor twice today and have not received a return call. In the meantime I can't walk and I haven't worked in over a week. I refilled my regular prescription last week and said the hell with the contract I have been taking what is keeping upright but unable.to drive safely. Up to this point t I have followed my pain contract each and every month...I feel like the doctor is not holding up his end. His job...which my insurance pays a bundle for...is to keep my pain under control and he is not doing that. It's not like I am asking for a med change for no reason...so finally...my question to the forum is what should I do now??? I have to drive 100 miles to see any pain management specialist as we don't have one where I live. Isn't his part of the contract to keep my pain meds at a level where I can function?? I feel like he isn't doing his job. What should I do? Has this situation happened to others??? Help please...I don't know what to do.
  • SavageSavage United StatesPosts: 5,427
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  • SavageSavage United StatesPosts: 5,427
    I need to see my PM doctor every month for refill of pain meds. And for urine specimen for testing.

    I have asked my PM about if I were to need ER and they medicated me. I also, have other issues.
    My PM told me to go to ER if needed, but to let him know ASAP about situation and medication given.
    Re pain medications, he would then document on my chart and if I was given a script, he would tell me if okay to take or not, or to destroy script if prior to filling.

    With your attempts to call your PM, did you leave message re ER visits and X-ray results and consult with your bone and joint doctor?
    It would be good if they could work together for your best interest.
    Spine-Health Moderator
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