Blog | Friday, September 28, 2018

Opioid contracts for chronic pain patients threaten the doctor-patient relationship

A contract is an agreement stipulating the rights and obligations of the signatories. In most cases, a contract is consulted when a dispute arises. When all is proceeding swimmingly, the contract remains dormant in a file drawer or in a digital file. In general, decent people resolve differences in the old fashioned way utilizing the twin arcane legal techniques of reasonableness and compromise. Remember them? Yes, it is possible to settle disputes without consulting an attorney.

I learned recently about the existence of opioid contracts, an agreement between a patient and a physician regarding the use of opioids. I have read through various OC templates and, although I have no law degree, they seem extremely lopsided in that one party seems coerced to accept numerous stipulations while the other, the doctor, serves as the enforcer. Although many of these agreements require both the patient and the physician to sign and date the forms, there really are no requirements of the doctor, except to provide the prescription. The agreements basically catalogue a very long list of required behaviors that patients must agree to and be prepared to document. Here's a sampling:
• I will agree to random drug testing.
• I will agree to cancel any office visit at least 24 hours in advance.
• Only one lost opioid prescription will be replaced annually.
• I will agree to psychiatric care and counseling, if necessary.
• I will treat the office staff respectfully.
• I will store my medicines safely.
• I agree to waive any right to privacy or confidentiality if any law enforcement agency is investigating alleged misuse of my opioid medicines.

To begin, it is not clear to me why “agreeing to cancel any office visit at least 24 hours in advance” or treating “the office staff with respect” is so unique to opioid users that it is included in some OCs. Explain to me please the relevance with respect to the opioid issue. Why shouldn't these terms apply to all patients?

Of course, I understand the rationale behind these contracts. But, this coercive effort seems like OperationOVERKILL. To me, it seems like a humiliating experience for patients and risks eroding trust and weakening the doctor-patient relationship. I would think that preserving and enhancing this relationship would be particularly important in caring for these patients.

If these medical diktats are truly necessary for opioid users, then why shouldn't every patient sign an agreement promising to take all medicines as prescribed, never arrive to the office late, refrain from disparaging the practice, never request a refill on a night or a weekend and limit their phone calls to the office to one per month. How would patients react to this? One advantage of this approach is that it would clear out doctors' crowded waiting rooms.

I don't object to the content of the agreements; but I think forcing a signature on a written contract is unseemly and unnecessary. Medical care should not be rendered as a transactional business matter.

Physicians often rightly complain that our work is treated as a business by insurance companies and others. With regard to opioid contracts, who deserves the blame?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.