Amazing. MSNBC is running a reprint from Keiser about chronic pain that runs counter to what is mostly in the news about "Pill Mills". This one addresses how dehumanizing the contracts chronic pain clinics force their patients to sign to remain in the good graces of the DEA and State AG's. It was a refreshing change of pace to see a patient advocacy article on chronic pain management. (These contracts do protect the physician, but they are invasive, restrictive and intrusive and I've put a few examples of them below the fold.) More to the point, Kaiser observes:
The agreements may require patients to submit to blood or urine drug tests, fill their prescriptions at a single pharmacy or refuse to accept pain medication from any other doctor. If patients don't follow the rules, the agreements often state that doctors may drop them from their practice.
Some patient advocates and policy experts say that rather than ensuring safety, the agreements invade patients' privacy and damage the trust that's essential to the doctor-patient relationship.
It's true, these contracts make for a wariness between the doctor and their patient. the patient can't be honest about their pain. If they are honest, they can be discharged from the doctor's care for aberrancy. If the doctor isn't vigilant, they will lose their license.
I live in Florida and there's no doubt there is a lot of oxycodone abuse here (pdf) and most remedies to rectify the situation come up short in one way or another. (Imagine, a Republican voting for a bill that essentially is anti-small business.) Most politicians cater to the low hanging fruit and label all oxycodone users as losers or drug trafficers that deserve no respect. The problem is that 24% of the decedents in Florida die with alcohol in their systems at the time of death and that goes without comment, but they focus on 14% of decedents with oxycodone in their blood. It's easy to blame the oxycodone and the doctor that prescribed it.
Before we condemn all Pain clinics and their patients I should note the reputable ones follow rules and standards. You can view a pdf of these standards here. Full disclosure, I perform consulting work with Pain Clinics and assist them with Pain Management Compliance and Risk Management. I'm not a chronic pain patient and don't take these medications. (And, yes, I have declined to work for some of these clinics because of how they operate.)
The Chronic Pain Clinics I work with would like to see the end to the abuses too. Sometimes, when I talk candidly with my physician clients we talk about awful it is that pain patients have to waive their rights to receive pain treatment and that we can't grant exceptions.
Before a Pain Clinic accepts a chronic pain patient, they have to fulfill these basic criteria:
1. Be over 27 years old
2. Patient's pain must have exceeded 4 months in duration and be projected to continue on indefinitely.
3. Have a verifiable (via CT or MRI) physiological problem that is severe enough to qualify them as a chronic pain patient. (Fibromyalgia uses other benchmarks because it is perceptive pain.)
4. Patient must agree to pursue therapies that can alleviate their pain (like physical therapy, weight loss, regular exercise and mental health therapy).
5. Patient intake documentation must be completed and verified (about 25 pages in length and includes psychological and arrest history).
6. The patient agrees to regular drug testing and signs a multitude of disclaimers and contracts.
7. The patient's pain situation is reassessed every 30 days.
You don't see articles about "Pill Mills" describing these criteria, but they exist and every clinic I've worked with follows them. That hasn't stopped the likes of our new State AG, Pam Bondi from targeting these clinics, but she, like others before her, thinks she can win the war on drugs.
The sensible approach is for Florida to implement the narcotic drug prescription data base and monitor for doctor shopping. It will be a pro-business solution that will create jobs and will lead to better patient safety. Law enforcement will have better leads for diversion. It will have chilling effect on drug tourism from Eastern Kentucky and the like. It is privately funded for the most part and it won't cost Floridians, but Governor Rick Scott is against it, so their it dies stands.
No matter how you feel about oxycodone, this drug is cheap and an effective way to treat chronic pain. The CDC focused on pain in their 2006 chart book (pdf) and found that nearly 30% of all adults are in serious pain every day and that just under 5% uses narcotics every day. If the DEA and AG Pam Bondi and Governors Rick Scott were really serious about prescription drug abuse, they'd support single payer, that would make the drug monitoring systems redundant. (snarky heh) Snarky "heh aside, if we had a single payer (or French like) system, with 5% of the adult population in need of pain management; a single payer system would be forced to create and maintain verifiable treatment guidelines and make diversion control obsolete.
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For those of you who are interested in what's contained in a patient contract, I've pulled a few of them from my files. Each patient fills out and signs about 26 pages of material before they see the physician for the first time. No prescriptions are written until a verified imaging study report is faxed in from a referring physician. Legitimate Pain Management Physicians aren't always the bad guys. Even so, the main complaints against them are:
1. Patient Safety - Pain Clinics aren't careful enough in their prescribing habits
2. Diversion - Too many pills are diverted to drug trafficers
3. Not enough safeguards are in place to protect the patient from themselves
4. (The most damning from one DEA agent I know) most of them don't accept insurance.
5. (Second most damning item according to another DEA agent) they accept out of state patients.
Why most pain clinics don't take insurance. It's because most of these patients are uninsured and underinsured. Insurance companies place limits on chronic pain and the patient ends up paying for their meds on their own. A lot of these patients are self-employed and their small businesses can't afford the health insurance premiums that rise 2-3 times a year because of their pain treatment. Eventually patients in this class find it's cheaper to "go bare". These clinics are the only choice for their patients. Physicians that accept insurance don't want an uninsured chronic pain patient. Some of these patients lost their insurance when they lost their jobs. Some have been told they will lose their job if they sign up for their employer's health plan during open enrollment (illegal, but true none the less). Some of them are on disability and are waiting for Medicare.
Out of State Patients is a trickier problem. There is no law against treating out of state patients. There's no law against prescribing pain meds for an out of state patient. Think about it, you visit the House of Mouse, slip and fall somewhere in Orlando and break your wrist. You go to the hospital and? They treat you. They not only treat you, but they give you pain meds. What should happen when your mother comes for a visit and left her "arthritis medication" back home? Shouldn't she be able to see a local doctor and get a script to tide her over until she gets back home? Do you have a different attitude if it was her blood pressure medicine? The point is, if we outlawed out of state patients, you wouldn't be able to have an emergency appendectomy or set a broken bone. The trick is to serve the legitimate patients while sifting out the unscrupulous patient playing the doctor for narcotics. That said, whenever one of my Pain Clinic clients talk to me about out of state patients, I tell them to not take them (except for my clinics on the Florida/Georgia border and the patients live just over the state line.) It's too likely to cause them problems. Plus, it's too easy for the unscrupulous to fake MRI reports.
Patient Safety & Safeguards is the very first item of concern listed by most law enforcement officers, so I'll start with that agreement. Most Pain Clinics have their patients sign an agreement like this one and most chronic pain physicians say this to every patient at every visit.
NON-OVERDOSE CONTRACT
I have chosen to enter into pain management for reasons that are important to me. I understand the medicines used are strong, powerful medicines that carry certain risks in their usage. But the benefits of using these medicines impact my quality of life in such a way that I accept all the risk.
Besides the tolerance and dependency that occur with these medications, there is the risk of death by overdose. My doctor has explained to me that overdose is likely if I:
1. Take too much of my medicine
2. Take more than prescribed of my medicine
3. Combine my medicine with street drugs or alcohol
4. Crush, chew, inhale, smoke, or inject my medicine
If I take my medicines as prescribed, work daily to control my tolerance, have honest discussions with my doctor, and act responsibly at all times, pain management can be a safe and effective lifestyle.
If an overdose does occur and I die from these medicines, I was warned. I was warned not to combine my medicines with street drugs or alcohol. I was warned to take only as prescribed. I was warned not to crush, inhale, smoke, or take my medicines in any way other than prescribed.
If an overdose does occur, I accept the responsibility as my own. I release my doctor and this clinic from all responsibility from an action that I took despite all warnings. Furthermore, I do not want my family, any attorney they may hire, or any government or agency to pursue action against my doctor or this clinic.
I was warned I agreed not to overdose in this contract. I accept the risk of pain management, and I accept all responsibilities of my actions.
Diversion - Most people are familiar with the HIPAA NPP - Notice of Privacy Practices that tells you how your personal information will be used. These are boiler plate, but if you're a Pain Clinic, the NPP is an important document. It allows them to disclose Protected Health Information to law enforcement.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CARE FULLY.
snip, yada, yada, yada
This notice describes how we may use or disclose your protected health information for various purposes. It also describes your rights to access and control your protected health information.
another snip, (you've seen this if you've seen your doctor within the last 3 years, moving on to the pertinent section)
Disclosures Made Without Consent, Authorization. or Opportunity to Object
We may use or disclose your protected health information in the following situation without your consent or authorization. These situations and examples include:
-Required By Law: Limited to the relevant requirements of the law
-Public Health: To control disease, injury, or disability.
-Communicable Disease: To Persons who may have been exposed to a communicable disease.
-Health Oversight: Government agencies performing audits, investigations, and inspections.
-Abuse or Neglect: To public officials authorized to receive reports of abuse or neglect.
-Food and Drug Administration: For things such as product recalls and to report adverse effects.
-Legal Proceedings: In response to order of the court, in response to a subpoena or discovery request.
-Law Enforcement: Suspicious deaths, possible criminal activity, or information of crime victims.
-Coroners, Funeral Directors, and Organ Donation: For identification or determining cause of death.
-Research: Research approved by a review board with established privacy protocols.
-Threatening Activity: To lessen a threat to the safety of a person or the public.
-National Security: Activities deemed necessary by military command authorities.
-Workers' Compensation: To comply with laws of workers' compensation.
- Inmates: If the information was created by your physician in the course of providing your care.
-Required Uses and Disclosures: We are required by law to make disclosures to you and the Department of Health Services to investigate and determine privacy compliance.
emphasis added
Note the areas that I bolded. They have to do with law enforcement pretty much being able to view what they want. Any Pain Clinic with a dispensary can be inspected by the DEA. They come in and check the logs, verify the prescriptions and double check the details. They can also garner a lot of information that HIPAA supposedly protects. No Pain Clinic is going to interfere with this sort of data collection.
More Diversion - Well, you have to be aggressive about drug trafficing if you are a pain clinic, so you have your patients sign a statement like this one:
DIVERSION POLICY
1. I authorize my physician, and my pharmacy, to cooperate fully with any city, state, or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of my possible misuse, sale, or other diversion of my pain medicine.
2. I authorize my physician to provide a copy of this Agreement to my pharmacy.
3. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.
4. I agree that I will submit to a blood or urine test if required by my physician to determine my compliance with my program of pain control medicine.
5. I agree that I will use my medicine at a rate no greater that the prescribed rate; that use of my medicine at a greater rate will result in my being without medication for a period of time.
6. I will bring all unused pain medicine to every office visit.
7. I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered.
8. A copy of this document has been given to me.
__________ __________
Patient Signature Date
___________ _________
Patient Name Printed Physician's Signature
Safeguard Redundancy - As if these agreements aren't enough, several practices have their patients sign contracts like this:
TREATMENT AGREEMENT- CONDITION TERMS FOR TREATMENT
Patient Name _________ DOB __ / __ / __
To receive treatment with or without narcotic pain medication, the patient must meet the following condition/terms:
1. The patient has never been diagnosed with, treated, or arrested for substance abuse or trafficking.
2. The patient has never been involved in the sale, illegal possession, dispersion, or transport of controlled substances (narcotics, sleeping pills, nerve pills, pain pills);or, under investigation or arrested for such activities.
3. (FEMALEONLY)- The patient certifies that she is not pregnant. The patient agrees and understands that it is her responsibility to notify {Medical Practice Name} immediately if she is planning a pregnancy, or believes that she may be pregnant; and, agrees not to take any medication without approval of OB-GYN doctor, if pregnant.
4. The patient agrees to supply {Medical Practice Name} the name, address, and telephone number of the pharmacy that is filling the prescription of pain medication, and will use only one pharmacy.
5, The patient agrees to have his/her prescriptions prescribed by {Medical Practice Name} physicians, filled by only one pharmacy. In the event a pharmacy does not cover prescribed medication, the patient will attend another office visit to complete appropriate paperwork for pharmacy change per our controlled substance agreement. In the event of an emergency requiring another physician's attention, the patient will immediately inform his/her physician at {Medical Practice Name} of such prescribing physician and dispending pharmacy.
6. The patient agrees to allow his physician at {Medical Practice Name} to send a copy of the agreement to the patient's pharmacy, referring physician(s), and all other physicians involved in the patient's care. The patient agrees to allow the physician at The {Medical Practice Name} to discuss his/her care freely with other physicians.
7. The patient agrees to take the medication only and exactly as prescribed by the physician at {Medical Practice Name} . The patient agrees not to share the medication with other individuals. The patient agrees that medications will only be prescribed that are on plan formulary. The patient will not drink alcohol with controlled medications.
8. The patient agrees not to take any over the counter medication (i.e. Tussionex Robitussin, Vicks inhaler, etc.), Marinol, hemp oil, and/or Chinese herbs.
9. The patient agrees to random urine testing.
10. The patient understands that each prescription is for a specific number of pills, designed to last a certain amount of time. NO EARLY REFILL NO EXCEPTIONS.
11. The patient understands that NO refills will be given if the prescription does not last until the next scheduled visit.
12. The patient understands that NO allowance will be made for lost or stolen prescription pills, or those destroyed by fire, flood, etc. If medications prescribed causes adverse reactions, patient is to stop medicine immediately and inform physician and is required to bring unused medication to next office visit. The patient will safeguard medicines.
13. The patient understands that prescriptions will be dispensed only after a scheduled office visit, not over the phone.
14. The patient understands that NO prescriptions for pain medication will be given over the telephone. NO EXCEPTIONS.
15. The patient agrees that they will not seek pain medication at night, on weekends, holidays, or prior to the next visit.
16. The patient agrees not to obtain pain medication from any other physician, emergency room, or other person.
17. The patient agrees to keep all scheduled appointments at {Medical Practice Name} . If the patient is unable to keep an appointment, he/she must give at least 24-hours advance notice. However, NO PRESCRIPTIONS WILL BE CALLED IN.
18. The patient agrees to see the physician at {Medical Practice Name} if the physician feels it is necessary to change the patient's dosage. If the physician suspects the patient is not following his/her orders when asked to cease use of a controlled substance, the patient permits {Medical Practice Name} to pursue remedies which will disable the patient's driving privileges. The patient understands not to drive or operate machinery while taking controlled medications.
19. The patient allows {Medical Practice Name} to call other pharmacies for poly-drug prescriptions and/or usage. All patient are required to undergo a mandatory drug screen at facility of choice (i.e. primary care physician, hospital, or walk-in clinic), and agrees not to use Vicks inhalers, poppy seeds, or cough/cold remedies.
20, The patient certifies they are a legitimate patient needing legitimate care.
21. The patient understands that the physicians at {Medical Practice Name} may stop treatment, and cancel any prescriptions if any of the following occur: a) The patient gives, sells, or misuses the pain medication, or fails to keep appointments b) The patient fails to reach goals such as decreased pain levels, c) The patient attempts to obtain pain medication at night, on weekends, on holidays, sooner than next office visit, from any other physician, from an emergency room, or from any other source d) the patient is released for any reason or fails to show improved function,
22, The patient understands that an accurate diagnosis requires an accurate history, physical exam, and imaging. Therefore, treatment recommendations are not made over the phone, only in person after being seen by a physician.
23. The patient certifies that they have not provided misleading or false information or false medical history to the referring physician or physicians at {Medical Practice Name} , and they are not seeking treatment under false pretense. The patient understands that physicians base treatment, at least 50%,on history and if it is found that the patient has provided false statements they may be released. The patient agrees they (or anyone with them) do not carry concealed weapons, tape recorders, cameras, or other devices. The patient certifies they are not appearing to seek care as part of an ongoing investigation or threat of prosecution. The patient agrees to set a goal such as decreased pain, improved function, return to work, or return to school.
24. The patient will adhere to the advice of the physicians regarding operation of motor vehicles or any other machinery. If {Medical Practice Name} witnesses, or is able to validate information of the patient's driving under the influence (i.e. drugs or alcohol). the patient authorizes {Medical Practice Name} to notify the authorities and not to be held liable for any damages which may occur.
25. The patient agrees their record may be given to Narcotic Detective, DEA, or other authorities and will hold {Medical Practice Name} harmless,and the patient agrees to random drug testing.
26. I authorize {Medical Practice Name} to obtain narcotic profile from DEA and release all past, present, and future profiles to anyone with written authorization to receive medical records, and understand that obtaining controlled medications from more than one physician is a felony.
27. I understand that controlled medications such as codeine, Tylenol#3, Methadone, Morphine, MSContin, Kadian, Avinza, Percocet, Tylox, OxyContin, Roxicet, Darvon, Darvocet, Dilaudid, Lortab, Lorcet. Vicodin, Valium, Xanax, Soma, Ambien, Ativan, Horinol. Restoril, Hydrocodone, etc. have risksassociated with their use, such as drug interactions, respiratory, depression, death addition, drowsiness,allergic reactions, and agree to discussall risks/sideeffects with my pharmacist, family members, family physician, other treating physicians before and during treatment.,
28. I understand obtaining controlled medications from more than one physician/dentist/ clinic is a felony.
29. I understand that I should take the least amount of controlled medications to relieve the symptoms and should never exceed the prescribed amount, and should slowly taper off all controlled substances over several weeks whenever possible. I understand that these medications are only to be taken as needed. I understand the risks of taking controlled medications up to and including death. I will take the minimal amount of medication to improve function.
30. I understand that all medications and any refills will be canceled immediately if, in the opinion of the physician/staff, an unsatisfactory psychological/psychiatric test result is received back after the patient takes the test, any allegations, suspicious information or investigation is initiated by anyone regarding potential violations of this contract is brought to {Medical Practice Name}.
31. We reserve the right to require the patient to submit to psychological/psychiatric evaluation and/or pain patient profile and release this information as part of any medical records request.
32. The patient understands that physical dependence is a normal response to many types of medications including steroids, antidepressants, and controlled medications, but tolerance to pain relieving effects are rare.
33. The patient understands that impaired control, craving, compulsive use, continued use despite negative consequences inability to take medications as prescribed, isolation from friends and family, doctor shopping, using illegal drugs, intoxication, apathy, depression, noncompliance, and inability to function represent abnormal behavior patterns and agree to discontinue medications, and immediately seek psychiatric care, and notify {Medical Practice Name} and primary care provided.
34. The patient realizes pain medication may interfere with endocrine function, i.e. interference with libido, sexual function, etc and the patient agrees to see their family physician or endocrinologist if they have any of these problems.
35. If I develop any feelings of hopelessness, suicidal thoughts, or desire to hurt myself or others, I agree to immediately seek immediate psychiatric care, and notify {Medical Practice Name} and primary care provider. I will return all medication to the office if this feeling happens.
36. The patient agrees that {Medical Practice Name} physicians/staff may cancel medications at any time without cause and without warning for any medical or non medical reason, suspicious incarceration, or even without a specific reason, and understand to see primary care provider, mental health provider immediately when medications are canceled or treatment discontinued.
37. I understand that not taking medications as prescribe or over dosing on medications usually causes death.
38. I have told (or will tell)my family members and caregivers of my use of controlled medications for treatment of pain and discontinue treatment if family is not in agreement, or my family physician is not in agreement, or if I fail to reach goals.
39. I will discuss my diagnosis and treatment with family, family physician, mental health provider, second opinion physician, and if they are not in agreement, will discontinue treatment and notify {Medical Practice Name} .
40. I hereby authorize any pharmacy of records to release any and all Information to the physician and/or nursing staff of {Medical Practice Name} upon their request.
41. I agree that I have been seen and examined by a {Medical Practice Name} physician today and have no complaints, regarding any diagnosis, treatment plan, physicians, or staff at {Medical Practice Name} , and if I do have problems will hand deliver it in writing to office manage today. I agree to discontinue treatment if I don't reach set goals such as decreased pain, improved function, return to work and return to school.
42. I have read the conditions and terms stated above and have had all of my questions regarding these conditions and terms explained to my satisfaction. I have met the conditions, and I agree to honor all of the terms unconditionally. I also understand that if I violate any term of this agreement, it is cause for the physicians at {Medical Practice Name} to refuse prescriptions and/or treatment. I agree that if I am unable to read or write that this has been verbally explained to my satisfaction.
43. The patient will notify {Medical Practice Name} if they have been or are currently receiving treatment at a Methadone Clinic.
44. The patient will notify {Medical Practice Name} if they have been or are currently receiving treatment at a Pain clinic
45. The patient will notify {Medical Practice Name} if they have been or are currently receiving treatment from a Psychiatrist.
46. If you are having a serious reaction to medication or a severe pain problem, call our office or contact Dr. __ through the answering service.
47. You agree to a family conference or a conference with a close friend or significant other if the physician feels it is necessary.
48. Medication in its original container should be brought in to each office visit.
49. Medications will not be replaced if they are lost, get wet, are destroyed, left on an airplane, etc. If your medication has been stolen/lost, you will need to bring a police report regarding the theft/loss.
50. Iam aware that certain other medications such as nalbuphine (Nubain™), pentazocine (Talwin™),buprenorphine (Buprenex™)and butorphanol (StadoI™) may reverse the action of the narcotic medicine I am using for pain control. Taking any of these other medications while I am taking my pain medications can cause symptoms like a bad flu, called a withdrawal syndrome. I agree not to take any of these medications and to tell any other doctors that I am taking an opioid as my pain medicine and cannot take any of these medications listed above.
51. (Males only) I am aware that chronic opioid use has been associated with low testosterone levels in males. This may affect my mood, stamina, sexual desire and physical and sexual performance. I understand that my doctor may check my blood to see if my testosterone level is normal.
The above agreement has been explained to me by and I agree to its terms so that {Dr.__ } can provide quality pain management using opioid therapy to decrease my pain and increase my function.
Patient Signature _____________ Date _____
Pharmacy Name _____________ Date ______
Medical Practice Name Staff __________ Date _____
Staff Witness ______________ Date _____
So, if you are with this this long, you now know some of what a chronic pain patient submits to to get relief. It's a lot to go through if you're faking it.