Pain Medication Use Agreements: Understand What You're Signing
As I’m sure most of you are aware, there is an ever-increasing push by both the government and medical professionals to prevent and control drug abuse. As a result, those of us who have to take opioid medications to control our pain are faced with greater scrutiny than ever before.
I’ve noticed that I’m asked more questions every time I visit my doctor because she has to justify to the DEA (Drug Enforcement Agency) why she is prescribing pain medication for me. And recently she has begun encouraging me to reduce the amount of pain medication I take, which is a new development.
One thing that makes this particularly interesting in my case is that the only pain medication I take on a regular basis is tramadol. On the federal level, tramadol is not even a scheduled drug. It has, however, been listed as a scheduled drug in my state, so it’s being treated like other more potent opioids. You should also be aware that there is a push to reclassify tramadol on the federal level so it may eventually be a scheduled drug nationally.
Much to my surprise, at my last doctor visit I was asked to sign a Pain Medication Use Agreement for the first time. Since I had studied these agreements in the past so I could share the information with you, I pretty much knew what to expect. Nevertheless, I took my own advice and read it carefully before I signed it.
One line in the agreement did surprise me. It said, "I will not take any sedatives, anti-anxiety medications, alcohol or other pain medications without prior approval of my doctor." I knew I couldn’t take other pain medications but I was surprised by the inclusion of sedatives, anti-anxiety meds and particularly alcohol. I understand why those things are included but just didn’t expect to see them in the agreement.
Treatment agreements will vary some from doctor to doctor, but here are the basic requirements included in most. When you sign the agreement, you:
_Agree to take the medications at the dosage and frequency prescribed _. It’s essential you follow the prescription directions exactly. Don’t take more or less than the prescribed amount every day. Don’t try to take less on good days so you’ll have more left for bad days.
_Agree not to increase, decrease or change in any way how you take the medications without the prior approval of your pain management doctor _. If you feel the dosage prescribed is too little because you’re still having a lot of pain, or too much because you feel spacey all the time, call your doctor a tell him what you’re experiencing. Do not under any circumstances change the dosage on your own. If you’re tested and found to have too much in your system, they’ll assume you’re abusing the drugs. If you have too little in your system, they’ll assume you’re selling or giving them to someone else.
_Agree to random drug testing to assure you’re only taking the prescribed medications in the prescribed amounts _. Although you know you’re trustworthy and wouldn’t abuse drugs, there’s no way for the doctor to know that. Because there is so much drug abuse today, physicians have to be extra vigilant. If they are found to be prescribing controlled substances to people who are either abusing them personally or selling them to others, they face losing their medical license and criminal prosecution.
_Agree to obtain all of your medications at one pharmacy, which you must name, and give your consent for the physician and pharmacist to exchange information about you _. This is because abusers sometimes try to obtain prescriptions from multiple doctors and fill them at different pharmacies. With all prescriptions being fed into computers now, interconnected databases make this much more difficult to get away with.
_Understand that lost, stolen or destroyed prescriptions and medications will not be replaced under any circumstances _. It’s essential that you keep track of your medications and make sure no one else has access to them.
_Agree to inform your pain management physician of all other medications you are taking _.
_Agree to inform your other health care providers of the pain medications you are taking and of the agreement you have signed. This includes emergency care providers _.
_Agree not to request any pain medications or controlled substances from other health care providers _.
_Agree not to use illegal drugs, street drugs, or another person’s prescription _.
_Agree to keep all your scheduled appointments _. Your agreement may require 24-hours notice to cancel an appointment and/or have a maximum number of appointments you can reschedule and still continue to be treated. Canceling an appointment at the last minute isn’t fair to the doctor, who doesn’t have time to fill that slot with another patient. But, perhaps more importantly, they don’t want you cancel appointments because you’ve been using your medications improperly and are afraid you wouldn’t pass a drug test.
In addition to the above, you may be required to agree to participate in any medical or psychological assessments recommended by the doctor, or to participate in any program designed to improve your function, whether it be physical, social, psychological, daily activities or work activities. You may also have to agree that, if you have or develop an alcohol or drug addiction problem, you will follow through with any addiction program you’re asked to enter.
Finally, you’ll be told that your pain management physician may stop prescribing medications if you:
Don’t show any improvement.
Develop a rapid tolerance for the treatment.
Develop significant side effects from the medication.
Fail to abide by the terms of the agreement.
That final point - failing to abide by the terms of the agreement - is also likely to result in the doctor refusing to provide any more care for you at all.
Harsh But Necessary
I know some of these things seem harsh and unfair to honest people who are in severe pain and simply looking for some relief so they can function and live a decent life. They are unfair. But as my Mother always told me, "Life’s not fair." Because there are so many people out there who do abuse drugs and who have become experts at cheating the system, those of us who need stronger medications to control our very real pain, are forced to abide by these highly regulated restrictions in order to receive the treatment we need.
We tend to get angry and blame the doctors for making it so difficult to get our medications and for making us feel like we’re suspected of being drug abusers; but the fact is, doctors are mandated by their states and the Federal government to play by these rules. If any question should arise about a physician prescribing controlled substances for a particular patient, that doctor has to be able to provide proof that every care was taken to ensure the patient was taking the drugs properly.
Also, it’s virtually impossible for a doctor to be absolutely sure whether a patient is genuinely in pain or just seeking drugs. Studies have shown that most physicians are not able to discern true pain patients from drug seekers with any reliable degree of consistency. Unfortunately, abusers are often very good at faking it, and there are no lab test that can accurately identify pain levels, so doctors are forced to do the best they can, utilizing tools like treatment agreements and random drug testing to make sure they’re not contributing to someone’s addiction problem.
I wish I had a better solution to the problem, but until someone comes up with a better way, our best option is to make sure we understand the treatment agreement before we sign it, then do our best to strictly abide by the agreement.
Finally, in order to stress how important it is to strictly abide by the agreement, I’d like to share some real-life examples of people who, for seemingly valid reasons, violated their agreements and were dismissed by their doctors. (The names have been changes to protect their privacy.)
Joyce felt like the dosage of oxycodone her pain specialist had prescribed was too strong because she was feeling "high" and had difficulty functioning. Thinking she was doing a good thing, she took less medication. At her next appointment, she was given a drug test, which showed that she did not have the prescribed amount of oxycodone in her system.
Frank had some dental work done and the oral surgeon gave him a prescription for hydrocodone. When Frank took it to the pharmacy, the pharmacist refused to fill it and immediately contacted his pain clinic.
Vivian’s husband hurt his back over the weekend. She couldn’t stand to see him in so much pain, so she gave him some of her oxycodone to help ease his pain until he could get to the doctor on Monday. This caused her prescription to run short, so she cut her dosage in half the last few days of the month. When she went in to get her refill prescription, she was given a drug test, which revealed she only had half the amount of oxycodone in her system that she should have.
Kevin was having a really bad day and his fentanyl patches just weren’t giving him enough pain relief to allow him to get his work done. He had some oxycodone left over from before he started seeing the pain specialist so he took it to help with the breakthrough pain. His doctor’s office called and asked him to come in a couple of days early for his appointment. When he arrived, he was given a drug test, which showed the oxycodone in his system.
These were all well-meaning people who had no intention of abusing drugs, but in each of these cases, the patient was immediately dismissed by his or her doctor/clinic. Because they had been dismissed for failing a drug test, no other doctor was willing to prescribe any kind of opioid pain medication for them.
How can you avoid finding yourself in a similar circumstance? By reading every word of the agreement before you sign it, asking questions about anything you may be unclear on, then following the agreement to the letter.
Sample Opioid Treatment Agreements. Opioids911-Safety. Downloaded 12/30/13.
Karen is the Co-Founder of the National Fibromyalgia Association. She wrote for HealthCentral as a patient expert for Pain Management.