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Feature: Pain Patients, Pain Contracts, and the War on Drugs

Pain contracts. Pain management contracts. Medication contracts. Opioid contracts. Pain agreements. They go by different names, but they all mean the same thing: A signed agreement between doctor and patient that lays out the conditions under which the patient will be prescribed opioid pain medications for the relief of chronic pain. (To see a standard pain contract, click here.)
Oxycontin pills
For some of the tens of millions of Americans suffering from chronic pain, opioid pain medications, such as Oxycontin or methadone, provide the only relief from a life of agony and disability. But with the Office of National Drug Control Policy's ongoing campaign against prescription drug abuse and the Drug Enforcement Administration's (DEA) ongoing crackdown on physicians it believes are prescribing opiates outside the bounds of accepted medical practice, the medical establishment is increasingly wary of pain patients and adequate treatment of pain is a very real issue for countless Americans.

In recent years, doctors and hospitals have turned increasingly to pain contracts as a means of negotiating the clashing imperatives of pain treatment and law enforcement. Such contracts typically include provisions requiring patients to promise to take the drugs only as directed, not seek early refills or replacements for lost or stolen drugs, not to use illegal drugs, and to agree to drug testing. And as the contract linked to above puts it, "I understand that this provider may stop prescribing the medications listed if... my behavior is inconsistent with the responsibilities outlined above, which may also result in being prevented from receiving further care from this clinic."

"Pain agreements are part of what we call informed consent," said Northern Virginia pain management and addiction treatment specialist Dr. Howard Heit. "They establish before I write the first prescription what I will do for you and what your responsibilities are as a patient. They are an agreement in order to start a successful relationship that defines the mutual responsibilities of both parties. More and more states are suggesting we use agreements as part of the treatment plan with scheduled medications. Such agreements are not punitive; they protect both sides in functional way."

If Heit sees a cooperative arrangement, others disagree. "This is really an indication of how the current DEA enforcement regime has created an adversarial relationship between patients and physicians where the doctors feel the need to resort to contracts instead of working cooperatively with patients," said Kathryn Serkes, spokesperson for the Association of American Physicians and Surgeons (AAPS), which has been a fierce critic of criminalizing doctors over their prescribing practices. "The pain contracts are a tool to protect physicians from prosecution. He can say 'I treated in good faith, here's the contract the patient signed, and he violated it.' It's too bad we live in such a dangerous environment for physicians that they feel compelled to resort to that," she told the Chronicle.

"Patients aren't asked to sign contracts to get treatment for other medical conditions," Serkes noted. "We don't do cancer contracts. It is a really unfortunate situation, but it is understandable. While I am sympathetic to the patients, I can see both sides on this," she said.

"There is no evidence these pain contracts do any good for any patients," said Dr. Frank Fisher, a California physician once charged with murder for prescribing opioid pain medications. He was completely exonerated after years of legal skirmishing over the progressively less and less serious charges to which prosecutors had been forced to downgrade their case. "The reason doctors are using them is to protect themselves from regulatory authorities, and now it's become a convention to do it. They will say it is a sort of informed consent document, but that's essentially a lie. They are an artifact of an overzealous regulatory system," he told the Chronicle.

"When this first started, it was doctors using them with problem patients, but now more and more doctors and hospitals are doing it routinely," Fisher added. "But the idea that patients should have to sign a contract like that or submit to forced drug testing is an abrogation of medical ethics. Nothing in the relationship allows for coercion, and that is really what this is."

The pain contracts may not even protect doctors, Fisher noted. "When they prosecute doctors, they can use the pain contract to show that he didn't comply with this or that provision, like throwing out patients who were out of compliance. The whole thing is a mess."
Michael Krawitz (photo courtesy Drug Policy Forum of Virginia)
It is a real, painful mess for a pair of veterans trying to deal with chronic pain through the Veterans Administration -- and it is the drug testing provisions and the use of marijuana that are causing problems. Michael Krawitz is an Air Force veteran who was injured in an accident in Guam two decades ago that cost him his spleen, pancreas, and part of his intestine. Krawitz also suffered a fracture over his left eye, received an artificial right hip, and has suffered through 13 surgeries since then. He had been receiving opioid pain medication at a VA Hospital in Virginia, but things started to go bad a year ago.

"Last year, I refused to sign the pain contract they had just introduced there, and they cut me off my meds because I refused," Krawitz told the Chronicle. "Then I amended the contract to scratch off the part about submitting to a drug test, and that worked fine for a year, but the last time I went in, they said I had to do a drug test, and I again refused. I provided a battery of tests from an outside doctor, but not an illegal drug screen. That's when my VA doctor sent an angry letter saying I was not going to get my pain medicine."

Krawitz has provided documentation of his correspondence with the VA, as well as his so far unheeded complaint to the state medical board. As for the VA, some half-dozen VA employees ranging from Krawitz' patient advocate to his doctor to the public affairs people to pain management consultants failed to respond to Chronicle requests for interviews.

For Krawitz, who has used marijuana medicinally to treat an eye condition -- he even has a prescription from Holland -- but who says he is not currently using it, it's a fight about principles. "I will not submit my urine for a non-medical test," he said. "The VA doesn't have the authority to demand my urine. It's an arbitrary policy, applied arbitrarily. The bottom line is that we vets feel very mistreated by all this. Some of us have sacrificed limbs for freedom and democracy, and now the VA wants to make us pee in a bottle to get our pain medication?"

The imposition of pain contracts is not system-wide in the VA. A 2003 Veterans Health Administration directive on the treatment of pain notes that "adherence with opioid agreement, if used" should be part of the patient's overall evaluation.

Krawitz is preparing to file a federal lawsuit seeking to force the VA to treat him for pain without forcing him to undergo drug testing. For Tennessee vet Russell Belcher, the struggle is taking a slightly different course. Belcher, whose 1977 back injury and spinal fusion had him in pain so severe he couldn't work after 2000, was cut off from pain meds by the VA after he tested positive for marijuana. Belcher said he used marijuana to treat sleeplessness and pain after the VA refused to up his methadone dose.

"It's a wonder to me that some vet ain't gone postal on them," he told the Chronicle. "They pushed me pretty close. To me, not signing the substance abuse agreement is not an option. If you sign it you're screwed, if you don't sign it, you're screwed. I complained for months about the dose being too low, but they said that's all you get and if you test positive for anything we're kicking you out. When the civilian doctors would find marijuana on a drug screen, they told me they would prefer I didn't do that because it was still illegal, but they didn't kick me out of the program. I was using it for medicinal purposes. I have tremendous trouble sleeping, muscle cramps that feel like they'll pull the joint out of the socket. I had quit using for a long time because of this mess with the drug testing, but then they wouldn't increase my pain medicine. I thought I have to do something; it's a matter of self preservation," he said.

"The pain clinic at the VA has discharged me from their care and said the doctor would no longer prescribe narcotics for me unless I attend the substance abuse program," Belcher continued. "They aren't going to be satisfied until I spend 30 days in the detox unit." While Belcher would like to join Krawitz in taking on the VA, in the meantime he is looking for a private physician.

When asked about the veterans' plight, Dr. Fisher was sympathetic. "They made Krawitz sign a contract under duress with forced drug testing as a condition of his continued treatment," he pointed out. "That violates basic rights like the right of privacy. There is no suspicion he is a drug addict. They want to treat all patients as if they were criminal suspects, and that has little to do with what the nature of the doctor-patient relationship should be."

Dr. Heit, while less sympathetic than Dr. Fisher, was decidedly more so than the VA. When asked about the cases of the vets, he explained that he would be flexible, but would also insist they comply with the terms of their agreements. "In the end, you have to choose whether you want me to do pain management with legal controlled substances or you want to use illicit substances, but you don't get to choose both," he said. "I don't disagree that marijuana may help, but the rules are it's an illicit substance. I can't continue to prescribe to someone who is taking an illicit substance."

And here we are. Patients seeking relief from pain meet the imperatives of the drug war -- and we all lose.

Permission to Reprint: This article is licensed under a modified Creative Commons Attribution license.
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Can anyone help me?

Can anyone help me please?....I just moved here to Vancouver, WA from out of state and I'm having a hard time trying to find a doctor or pain management clinic who will keep prescribing my oxycodone rx. I was legitimately diagnosed with chronic pain, but there are so many people out there who abuse the medications that it's hard if not impossible for us who actually need them to get any help. It's extremely frustrating. I have a broken hip (2 metal plates and 8 screws) and also a broken vertebrae in my lower back along with a herniated disc. Since I no longer live where I can pick up my rx from my old doctor he will not send me my rx or call it in since it is a narcotic. Anyway, I was wondering if anyone knows of a clinic or possible doctor who can help me..?

Thank you to anyone who can help.

narcotic usage contract

I have been on the same medications (Keflex & norco 10) since I feel 25 feet onto concrete in 1989 in which    I shattered my heel into 9 pieces, broke and dislocated my right elbow requiring 2 screws to hold it in place and broke my right  wrist in 2 places. I have been treated at the same medical office for the last 6 years. My regular doctor moved to away and the clinic hired a new doctor. I went in to get my medications refilled and after the new doctor came into the room he seemed surprised I had long hair and a beard. he even commented "oh, my your hair is long" I explained In was part of a renfaire group and my role was that of the guild mage or wizard. The doctor ask why I was there,  I replied to have my foot checked and to renew my medications. I had to explain to him that I have ostiomylitus in my heel/ankle with screws still holding the two together. The ostio infection is inbeded in the marrow of my heel and ankle and when I'm on my feet to much or I walk to much the infection becomes active and builds up until pressure blows of the drain hole in my foot.  This new doctor told me he had no problem refilling my meds but... I had to sign a drug contract. if I refused I wouldn't receive my meds. He told me it was a standard form but when he handed me it I noticed it had my name printed on it. I read the papers and found it lacking on the part of the dr offices obligations. I did say That I would have to submit to random testing and if any abuse was found, they were allowed to inform all medical and law enforcement of my abuse. It said in no clear terms that they could publicly give my private medical info to anyone they deemed needed it. it said other things that if signed, would allow them to give my medical info away without my being able to do anything about it. I noticed this so called contract said what was required and expected of me but said noting about what the doctors office was required to do. If it's a contract then it is supposed to be equally   fai  r fair to both parties. This "contract" only favors the other party.I refused to sign under duress (which is what that is, sign or no meds,)I decided to see if this is legal, forcing people to give up their patients right in order to be treated.

I was so offended because I know I was ask to sigh this only because my hair is long and the doctor viewed me as a criminal or an addict.

Tis is unfair to those of us that are not abusing or selling our meds 

pain contracts

I suffered in pain for YEARS without any medicine. when I could stand it no longer, I would go to the ER and they would do their usual miserly here have a few pills and that would have to sustain me. as I grew older my pain grew in intensity, so much that I had no choice but to find out what the hell was up. I have degenerative disease of my lower back, and my xrays were proof that I had a lot of problems that could not be addressed with talk therapy, acupuncture, chiropractic, and walking it off. I eventually was forced into a pain contract. my problems increased ten fold. for now the clinic I go to gives me shit every month. every GODDAMN month my wait to refil gets longer. this time their foot dragging put me in the hospital WITH A PULSE OVER 106, HIGHEST BLOOD PRESSURE IV EVER HAD AND ALL BECAUSE I WAS IN WITHDRAWAL FROM THEIR NOT KEEPING TO THEIR OWN GODDAMN PAIN CONTRACT.  If i had just one lawyer who had the balls to stand up to this bullshit id lay my burden down and cry for joy. but no, they dont exist here. so I suffer the pain of someone who cant deal with it any more. they dont care. NO ONE GIVES A GODDAMN ABOUT ME IN THE LEAST. HERE IN THE USA BECAUSE WE ARE EITHER VETS  OR LOSERS ON MEDICAL ASSISTANCE SO THERE FOR WE ARE CATTLE. THIS HAS TO STOP AMERICA, YOU CANT KEEP BEATING US UP. LASTLY AND MOST DRAMATIC WAS THAT THE FEDERAL GOVERNMENT LIFTED THE BAN ON OPIOIDS HAVING TO BE CUT WITH TYLENOL. IM GUESSING PEOPLE WERE DIEING FROM LIVER DAMAGE. I HAVE NO LOVE FOR WHAT THIS COUNTRY HAS DONE WITH THEIR INSANE DRUG WAR.

my higher power

I have been  under pain management care about 10 years, Ive been through hell.  I recently moved from Texas to Kentucky to find out my trouble has just begun.  I have a pain pump which no one within 100 miles takes care of, Im finally established with a new Dr. but he wanted to change everything. This month I was told by my Dr I had a positive urine for alcohol, actually it showed 2 months previosly.  And this is the only positive Ive ever had in 10 years. Now he says Im noncompliant, he demands first I go to CHURCH, get affadavid from pastor, saying Im going to services, I have my own beliefs and higher power, I dont go to church.  Also I have to get 2 people to sign affadavids stating I dont buy, sell, or transport illegal or prescription drugs.  Now besides enraging me, this does not improve my many health problems, including my pain.  Strangers dont need to know my health or anything else for that matter.  Now if I dont comply with his orders, he is stopping my narcotics or not even going to see me, for what, having 1 drink in I dont know how long, what or who does he think he is "GOD" himself.         Very Stressed

AM 46 yr old disabled female unable2 getpain meds anymore.

  1. been

forced test

No problem with having to take a test the problem is is you signed a contract because you have to have it under these drug laws. but a forced test is not a consensual test. Dr use in no medical purpose. but you pay for the Dr appointment and then end up getting this bill from some lab somewhere that you are required to pay. Now on my job I was fired take drug tests and because they were forced we didn't have to pay for them. So why are we forced to pay hundreds of dollars for a test that cost $22 at the drugstore. If you're going to be forced to pay for non medical procedure then you shouldn't have to be forced to take it. Especially with a hot cost of doctors appointments and the medication that you have to pay top this of insurance companies will not pay for drug tests because they are a non-medical required procedure.

Pain Management

I'm a veteran, who didn't use the benefits of VA since 1985 and in past 4 years had to get help. I have diabetes,neuropathy,arthritis in hands, middle back, have no social security. I have followed all guidelines , with VA doing pee,test, answer drug questions. Now they tell me DEA is in control of my pain meds that serve as only relief I have during the day. I have a simply question how does the VA doctor give the DEA patients information? This is confidential patient /doctor. 

I understand that there are drug abuse in America, the (DRUG WAR) but, I do not see our veterans as drug addicts, this new contract with DEA is a joke. It is in violation of our basic rights as Americans. I sure hope there is a better outcome in our future than policies being dictated by a failed DEA. Do your job and leave the Veterans medications alone.


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