The Pain Treatment Agreement
The Pain Treatment Agreement
By David B. Brushwood, R.Ph., J.D.
University of Florida
It is increasingly common for physicians to require that patients sign a â€œPain Treatment Agreementâ€ as a condition of their receiving therapy for chronic pain, particularly when opioid analgesic medications are prescribed. Formalized written agreements have the potential to improve communication between physicians and patients, and enhance the relationship of trust between physicians and patients, when they are used primarily as a tool to facilitate care. However, such agreements may instead create a barrier to effective communication, leading to a climate of distrust and suspicion, when they are used primarily to limit physician responsibilities.
According to the â€œModel Guidelines for the Use of Controlled Substances for the Treatment of Pain,â€ adopted by the Federation of State Medical Boards, a physician may use a written agreement outlining patient responsibilities â€œif the patient is determined to be at high risk for medication abuse or have a history of substance abuse.â€ The model guidelines suggest the inclusion of these pieces of information:
* Urine/serum medication levels screening when requested;
* Number and frequency of all prescription refills; and
* Reasons for which drug therapy may be discontinued (i.e., violation of agreement).
Some physicians have chosen to label their pain treatment agreements as â€œcontractsâ€ between themselves and their patients, with the intent of unilaterally obligating the patient to â€œfollow doctorâ€™s ordersâ€ or be dismissed from the physicianâ€™s practice. However, most pain treatment agreements fall far short of the requisites for status as legally enforceable contracts. They are offered to vulnerable patients in pain on a â€œtake it or leave itâ€ basis. There is no room for negotiation on terms of the agreement. Patients who want relief of pain have no choice but to sign the agreement. These documents may accurately describe the physician-patient relationship, but legally they are unconscionable contracts of adhesion, and they are not valid. Pain management agreements should be viewed as patient care records, and not as legally binding contracts.
Overly burdensome conditions specified within a pain treatment agreement â€œmay set patients upâ€ to fail. For example, an agreement may stipulate that a patient shall receive opioid prescriptions from no other physician, without making provisions for meeting the patientâ€™s needs during extended vacations by the physician. Or a physician may specify that a patient cannot use prescribed medications more rapidly than directed in the initial prescription, without anticipating that pain may suddenly worsen and require an immediate increase in dosing. When patients fail to adhere to these conditions, physicians may feel betrayed. They may become distrustful of the â€œnon-compliantâ€ patients. Inflexible pain treatment agreements may interfere with the physician-patient relationship rather than enhance that relationship.
The use of a pain management agreement offers a valuable opportunity to document an understanding between a physician and patient. The documentation of understandings can prevent misunderstandings. A constructive agreement may state the therapeutic goals, side effects and drug interactions of anticipated therapies. It may define the pain patientsâ€™ role in the receipt of care, specifying that the patient must use a single pharmacy, provide urine or blood samples for screening as needed, and refrain from sharing medications with friends or family. It may define the physicianâ€™s role in the provision of care, stipulating that the physician will see the patient during regular office hours, provide services as long as the need exists and reasonable expectations are met, and taper the patientâ€™s medication when the relationship ends. All of these factors should be discussed prior to the presentation and signing of a document. The document should be a reflection of an understanding derived from discussion, not a substitute for discussion.
Pain treatment agreements work well for some physicians with some of their patients, but rarely will a signed agreement be useful or appropriate for every patient. A very few pain management specialists, whose practice is entirely comprised of high-risk referral cases, will use agreements with every patient. However, most primary care physicians will discover that requiring all patients to sign a rigid pain treatment agreement is unnecessarily offensive to many of them. Pejorative language about the consequences of diverting controlled substances and the criminality of drug addiction is unwarranted for patients who can be expected to behave responsibly without a written agreement.
Pain patients should not be surprised if a physician establishes a requirement for a signed pain treatment agreement prior to the initiation of therapy. Correspondingly, physicians should not be surprised if a patient wants to negotiate the conditions of the agreement before signing. There are many challenges in the provision of proper pain management, and in the avoidance of drug diversion. Simplistic reliance on pain treatment agreements as a universal remedy for the problems of controlled substance diversion and abuse is misplaced. Pain treatment agreements can be a useful tool for improving the quality of pain management, but they should not be used in so legalistic and insulting a way that they interfere with the physician-patient relationship.
David Brushwood is Professor of Pharmacy Health Care Administration at the University of Florida in Gainesville. He is a Mayday Scholar with the American Society of Law, Medicine and Ethics (ASLME). For information about ASLME pain policy projects, go to ASLME.