Using a Pain Management Contract

Sample pain management contract included in article.

Impact of a Narcotic Contract in a Residency Training Center

By Michael A. Patmas, MS, MD, MMM, FACP, CPE, FACPE and Elizabeth Waltz, MSW, LCSW

Managing patients with chronic pain is one of the more challenging aspects of ambulatory practice. Compassion for those with pain requiring narcotics must be balanced with vigilance to prevent those intending to divert prescriptions and those with addictions from acquiring them.

Residency training clinics may have a higher proportion of such patients. The Providence Ambulatory Care and Education Center (PACE) in Portland, Ore., is the ambulatory training facility associated with the internal medicine residency program at Providence Portland Medical Center.

As an urban program with a mission emphasizing care for the poor and vulnerable, PACE has many patients with chronic pain, addictions, mental health disorders and criminal backgrounds. As such, distinguishing which patients legitimately require narcotics for chronic pain has been a challenge.

Oregon law allows physicians to prescribe long-term narcotics for chronic non-malignant pain under certain circumstances. The patient must have a diagnosis confirmed by a specialist who corroborates the need for chronic narcotics.

The medical record must contain evidence that alternative treatments have been tried without success. The patient must sign a material risks notice which provides informed consent for treatment that delineates the risks and specifies the drug, dose, amount and frequency of refills.

The material risks notice is, in effect, a contract between the physicians and patient that places mutual obligations upon both parties. The physician agrees to provide narcotics for a legitimate, corroborated diagnosis while the patient agrees to use the medication in a controlled manner as directed by the physician, not to exceed the prescribed amount, seek narcotics from any other providers or use any other controlled substances or street drugs. Random urine drug testing is also provided for under the terms of the contract.

http://www.acpe.org/leadingedge/July_2004_Vol1_No2/narcotic.htm