Treating patients with chronic pain is one of the more challenging tasks in primary care: how to measure pain, how to quantify disability and quality of life, how to balance to benefits of pain relief with the potential risks of medication, that it is usually multifactorial rather than simple, how to manage the almost always associated significant mood disorder. (If you hurt all the time and can’t sleep, guess what happens?) Some of the most troublesome issues, however, are not clinical. I recently wrote about the increasingly common - but problematic - use of urine drug screens (UDS). Similar issues underlie the (mis)use of ‘narcotic contracts’ as a requirement for prescribing opioids for chronic pain.
The first issue is with the term itself. ‘Contract’ is not a patient-friendly term, but an adversarial legal term: an agreement creating obligations enforceable by law. Medical care is based on respectful and trusting relationships, not on signed legal contracts. Imagine trying to start a new friendship or romantic relationship by insisting during the first encounter that the other party must sign a contract specifying what they must and must not do! Not much chance for a second date….
Narcotic ‘contracts’ are clinician-centric, not patient centric. They have little to do with the patient’s diagnostic or treatment needs and almost never take any account of patient values or preferences. They are designed to protect the clinician by enforcing the clinician’s (or the institution’s) standards on the patient. In essence, they say: “Be a good boy and follow my rules, or I won’t treat your pain.” Contracts are full of hostile language: I am required, under no circumstances, must, illicit, I agree to the following conditions, must be, only means, never under any circumstances, against the law, submit to, violated, abuse. (From the contract at my institution.)
Many institutions, including my own, have responded to criticisms of this approach by renaming the contract: narcotic prescribing agreement. This is rarely accompanied by concomitant changes in the language of the euphemistically renamed contract, let alone in the mindset it represents or the processes it enforces. Calling a lemon an apple does not make it any less sour.
The second issue is with the content of the contract, now euphemistically renamed an agreement. Typical requirements are arbitrary, focused on the provider’s needs and perspectives, and often problematic for the patient:
- Only one prescriber, with no allowance for the fact that a patient with a complex pain problem may have more than one clinician involved in managing their care. Many of my chronic pain patients also see one or more other clinicians for aspects of their pain: a neurologist, a physiatrist, a psychiatrist, a rheumatologist, an anesthesiologist, an orthopedist, or a pain specialist. Imagine asking the patient to sign a contract saying the cardiologist cannot get prescribe any antihypertensives on a shared patient? Or that the ED cannot prescribe antibiotics. This requirement is simply to absolve clinicians of the work and responsibility for communication and collaboration.
- Only one pharmacy, with no allowance for the fact that there may be occasions where the pharmacy near work is more convenient than the one near home, or that several different caregivers may be involved in filling the prescriptions and not live near the same pharmacy, or that the specific pharmacy may be out on a given day. (This is actually surprisingly common.)
- The patient is never allowed to titrate the dose. This means the patient and I are not allowed to collaborate on rules for how to adjust the medication between visits.
- The patient is required to comply with same-day urine drug testing at the discretion of the clinician and with no regard for the impact on work, family obligations, transportation costs. The cost of the drug screen (which is done to protect the clinician) is borne by the patient.
- Losing one’s medication is a violation of the contract and triggers refusal to continue prescribing. From my institution: “Lost or stolen medications are never refilled under any circumstances…”(The patient’s suitcase is lost while traveling? I have seen a patient discharged from a practice for requesting a new supply after his house burned to the ground.)
- Most institutions (including my own) list the patient’s responsibilities (so labelled) and make no mention of the clinician’s responsibilities.
- The language puts all the power in the hands of the clinician. For example (at my institution) it explicitly says that if the clinician does not think there is improvement with the medication, the clinician will taper and discontinue it. It makes no allowance or mention of the patient’s assessment of improvement and does not address what the clinician’s obligations are if the patient feels there is no improvement.
Typical consequences for ‘breach of contract’ are withholding treatment (which had been prescribed based on its medical appropriateness) or dismissal of the patient. If one applies this approach to other areas of medicine, clinicians would refuse to treat heart failure if the patient doesn’t take medication correctly, or will discharge the patients who fill their blood pressure meds at different pharmacies or get their cardiologist to refill a cardiac medication that the PCP originally prescribed.
The final - and by far the most important - issue is what the contract (oops, I mean agreement) does NOT do. It does not contribute to the care of the patient. (It’s predecessor, the comprehensive pain management care plan, did contribute greatly to the care of the patient, but has been replaced by the narcotic contract.)
There is universal agreement among pain specialists that Best Practice in chronic pain management (with or without opioids) must start with a comprehensive and holistic evaluation of the patient, their general medical circumstances, and their pain. The universally accepted second step is to collaboratively (with the patient) establish acomprehensive plan of care . This plan names and describes the problem(s) being treated, the type(s) of pain, the available patient resources, other medical or psychosocial issues, concrete goals of care, treatment modalities planned, and the responsibilities of both the clinician and the patient. Best Practice also recognizes that the focus of care is maximizing the patient’s function and quality of life, and that medications and pain control are only one piece. A formal plan of care that is well documented and shared with the patient is a useful and perhaps necessary way to stay focused on the holistic care of the patient, including not just pain medication, but functionality and quality of life. It provides structure, and can include reminders and tools for assessing response or the need for re-evaluation, new testing, consultation, or changes in approach. One might even say the comprehensive plan based on a comprehensive evaluation is the sine qua non of quality pain management.
Sadly, the focus of most institutions in pain management (responding to external risk-reduction and quality initiatives) ignores this, and focuses instead on marginal issues: is there a signed narcotic contract in the last 12 months, how often are urine drug screens and pill counts done, has the patient been seen every three months?
Some patient-centric things that should be in a comprehensive and collaborative plan of care for chronic pain (but are always absent from narcotic contracts) include:
- The clinician will be available for re-evaluation and to answer question.
- The clinician will arrange regular and timely follow-up care, including but not limited to office visits.
- The clinician will regularly use validated tools to assess the efficacy of treatment on patient function, quality of life, and pain control.
- The clinician will regularly review the accuracy of the diagnosis, especially when the clinical picture changes or treatment is unsuccessful.
- The clinician will evaluate new symptoms and changes in ongoing symptoms in a way that avoid framing and availability bias.
- The clinician will ensure that there is adequate time at appointments to address the clinical needs and answer patient questions.
- The clinician is responsible for ensuring that there are formal and specific functional and quality goals (not just pain), plans to achieve these goals, and metrics to assess progress.
- The clinician will make appropriate use (for both diagnosis and treatment) of other clinicians and all appropriate modalities for both diagnosis and treatment. (Psychologists or psychiatrists, physical and occupational therapy, neurology, physiatry, sports medicine, exercise programs, medication, counseling, CBT, TENS, manipulation…)
The comprehensive care plan (and the patient-clinician discussions) certainly need to deal explicitly with the medical and legal risks and problems associated with narcotics, and probably should address explicitly how such problems are defined, detected and addressed. There is nothing wrong with including in a care plan that misuse or diversion of narcotics is dangerous, often illegal, and will have consequences including the inability to continue prescribing narcotics or caring for the patient. There is everything wrong with making this the focus of our care, and in the process, turning what needs to be a mutually respectful and trusting relationship between an ill patient and their care providers into an adversarial and legalistic dance with no soul.
For me, the bottom line is: if I need a written contract in order to prescribe narcotics to a patient, I probably shouldn’t be prescribing narcotics to them.