Pain Contract ..Have you ever had to...??? [Archive]

MamaRider

10-08-2007, 04:10 AM

I have been doing some reading tonight on the "net and it got me to wondering. How many of you,if any, that are on a Pain Contract had to take a Urine sample?(or leave one I guess one be a better term). I have been seeing the same Pain Dr for over five years and never ad to. I have see 4 others and never had to either. I comply with all the other simple rules,,ei, smae Pharmacy,ect. But,that urine sample thingie got me thinking. Not that it is an issue for me, just that he could aks if he wants to. Then I saw on another site that some place ask for FINACAIL records andsuch beore Rxing meds. Good greif!!! Where does this kinda thing end???!!! This kind of looking into not just our health, but our private lives,our homes, our finaces, ect takes our CP issues a bit far don't they? We have a right, do we not, as humans, to expect that if there is pain releif out there, that we should be able to avail ourselves of it? I don't think it is my Dr that would be the one that would be causing al the problems. He doesn't, that GOD! I know tho, one time I was waiting in his office, and he walked a gy out that had a clip board. When I came in and we were talking, he mentioned that the last guy was a Detective looking into a PT he had that had been busted for multi-using Drs and Pharmacies. My Kid's Pain Dr told us last time she was in, he had had a phone call recently from a Pharmacest telling him about one of his Pts that was not only getting Meds from him, but several other Drs. He just sighed when he told us about it. So I know abuses are going on...against Drs that are great about Rxing! I cannot for the life of me figure out why ..well yes I can when I really think about it,..why they abuse the good graces of these DRs. hey are sadly sick and in Pain. Somewhere they got scared, or twisted. It happens. I know. It did to me for a while. I got back on track by having a good Dr, that believed me and helped me. I was so happy to find one for my Kid. (we agreed it wouldn't be a good idea to see the same DR).

So, I guess, I wanna know, do you, or have you ever had to jump thru any hoops for your Pain Contract?

Kira

10-08-2007, 05:18 AM

I have a pain contract, but I think it is a fairly standard one. I go to the pain clinic at a large teachin hospital and they are pretty well-known. The rules on my contract are:
-Take meds as prescribed. No extra doses, taking meds before next dose is due, chewing/crushing tablets, etc.
-No pain meds from other doctors. If another doc is prescribing some other kind of med (i.e. my psychiatrist prescribes my Klonopin and Ambien), the pain clinic MUST know about it. If getting sent hom from a hospital stay, surgical/dental procedure, etc... don't get pain meds prescribed from them, either, unless the doc talks with the pain clinic and gets it approved. Ideally, they will talk to the pain clinic before hospital discharge/surgical procedure, and the pain clinic can prescribe the extra meds.
-Use the same pharmacy every time you pick up your pain meds. Even if you use Walgreens or somewhere like that where they have all of the meds in the computer... you still have to go to the SAME Walgreens each time.
-No sharing meds with other people.
-The pain clinic isn't responsible if your meds are lost or stolen and they don't give replacement prescriptions. Because of this, I am really careful with the prescriptions and with the meds themselves.
-Call the pain clinic if your pain isn't controlled or if you are having problems with the meds, rather than trying to change them around on your own.
-They can request a blood or urine test to see if you are taking the prescribed meds (rather than selling them or something), and to see if you are taking other druges/meds they don't know about. With the blood test, they can also look at how much of the drug is in your system.

I can't remember if there are any more rules on the list. I haven't had any trouble following them except sometimes when I am getting discharged from the hospital, it is hard to get my inpatient team to understand that they have to get my pain doc's approval before they send me home with a script for a few days' worth of increaased dosages or a different med. If it is getting to be time to be discharged and they still haven't spoken with the pain clinic, I call the pain clinic myself and let them know what my team is prescribing and who my inpatient docs are, so that the pain clinic can call the inpatient docs and so that it gets documented in my chart that I informed them about what was happening.

I haven't had to take the urine drug screen there yet. But I don't think there would be any problem because I make sure that they know what all of my meds are.

Mark N

10-08-2007, 05:25 AM

I haven't ever had to sign any contract or go through any hoops. I get my meds through my PCP so that may be why I haven't run across it. i know there are several that have been on this board that have had contracts, maybe they will respond.

We also have a PM that is on the spinal forum, algosdoc, that has talked about the problems he has faced and the steps he has taken to weed out the drug abusers.

As more and more require contracts we will find more of our privacy being invaded. It is bad enough that we have to prove we are worthy of the next dose of meds [ones on the contracts]. Can you imagine them doing the same thing to diabetics, cancer patients, or any other group and their meds?

Kathi49

10-08-2007, 06:38 AM

I never have had to sign a contract either. Originally, and for three years I was also being seen a large university medical center pain management clinic. I didn't have to sign a contract there. And my NS is with a spine group; didn't sign one there either and finally, my PM is now the Director at another spine center and haven't signed on there either. So, like Mark, just haven't had to go through the hoops.

Actually, I never even knew they existed until I started reading these forums. I can see why the docs would want a person to sign one but I am not so sure they are truly beneficial for the patient. Just my own opinion and I am alluding to what Mark is saying. And really, does anyone know WHY some have them and some don't besides attempting to weed out abusers? I am just sitting here thinking of all my specialists and I just never have had to sign a thing...other than a consent for an injection.

debhun

10-08-2007, 08:58 AM

I go to PM and I have a contract. But every one that goes there does this. It is no big seal to me. Mine is perty much like Kira said. I haven't had to take a test of any kind but 1 when I first went there. I have had surgery and I told PM before I had surgery and she told me what to do. I did what she said had No troubles. I went to my PC about 2 weeks ago and he gave me a shot for my pain. I called the next day and told them and they had no troubles.

I also go to a PM at a large teaching hospital.

Deb

BrokenBladder

10-08-2007, 09:04 AM

I have a contract through my rheumy. The contract is pretty simple. I have to use the same pharmacy and take all of my meds as directed. Of course it's in the contract that they can drug test me. It hasn't happened yet but one never knows.

I have never heard of any doctor wanting to know someone's personal financial situation in order to prescrible meds. If I personally ever ran across this I would walk out of the door.

lobelsteve

10-08-2007, 10:48 AM

The term contract should be avoided as it can open up the possibility of contract law disputes. It is more of a consent to treatment with opioids/narcotics. Many state medical boards mandate that this be done. It is essential to take safegaurds in the prescribing, use, supply, and collection/destruction of narcotics. Without safegaurds, the option to prescribe opioids will become more regulated and access will be limited by the federal government.

I do not see new patients until they have completed my initial paperwork and a urine screen. These are the rules. If you do not have your old records, a referral, your current medications, etc- you will be rescheduled.

Arguements regarding privacy, arrogance, not understanding how much pain you are in fall on deaf ears. I am not willing to surrender my license or DEA registration for your RISK of abuse/diversion/misuse.

In the last 15 years, there have been dozens of 70+ y/o grandmothers caught selling their drugs for bingo/gambling money. The cover of Time magazine once had the picture of a dying cancer patient, she was selling her Oxycontin almost up to the day she died (arrested and had to surrender her $80,000 house and $17,000 pickup truck she just bought for her husband.

Attached is my informed consent and treatment agreement form. It is essential to allow for the continued use of narcotics to treat chronic pain.

debhun

10-08-2007, 01:17 PM

That is about what my says. I don't have any trouble going by their rules. The way I see it is they are there to help me to live a normal life as much as they can. I am glad that they are able to help me and I get them the respect to go by the rules. It is not a hard thing to do. There is no different than my PC RX.

That story about the 70+ lady is unreal. If she was in pain she wouldn't have sold her meds. Some time it is hard to believe that people do these things just to get money or high. Just can't understand it why they want to feel that way all their lives. I had a uncle that drank him self to death. It was my dads brother. I couldn't stand to be around him. I would beg my mom to let me stay home when they can't to see my grandfather and grand mother for the fear of seeing him. Till this day I don't want to be around drunks or drug users. My cusin is a drug user and has no life at all. I don't talk to him or see him. He is 40 now but acts like he is 18. My aunt had a stroke over him. When they gave her 12 hours to live he was calling Kitt(stepfather) for money. (But she lived) He was told to stay away from her. Thank God he was and is a in another state. No one in the family see him or talkes to him. It is a shame that we have to do this but it is the only way.

Sorry I went on like that.

Tbackpain1

10-08-2007, 01:24 PM

The consent form I signed, aka Narcotics contract, is pretty much the same as the one Dr. Lobel and Kira put up. In the 6 years I've been in pain management, I have had to submit a urine sample once, after 5 years of treatment, so I can't say I've had to jump through hoops per se.

The biggest issues I've had thus far is with pharmacists refusing to fill a script, saying they've contacted my doc to verify, and when I call the office, no one knows anything about it. Needless to say, its aggrivating, but I just took the time to sit down with the lead pharmacist at the pharmacy I use and we've managed to work it out, so that I don't have problems anymore. The only other problem has been when I've gone to the ER for elevated pain levels that are not controllable with my regular meds. Without fail I get the "don't you know how _____ these medications are???!!!" or the narcotic seeker treatment. I am always upfront about what I've taken, when, how much, etc and that I am only there for rescue treatment, that I don't want any prescriptions, that I'll follow up with my regular PM doc during normal business hours. Usually it ends there, but there have been times when I've had to call my PM doc's after hours service because the ER docs are being turds, and lets just say that things get taken care of after that.

Its terrible that so many people who have legitimate pain issues have to sign agreements for treatment and do more than the average patient to get help for their medical problems, but at the same time, I look at it as another layer of protection for me as well. I'm following the rules to the letter and my PM doc has good documentation on my case from the beginning, so should I need to seek treatment elsewhere, its back-up for me that I've got a legitimate pain issue. It also protects me from being labeled an abuser/seeker, diverter, etc, because I can prove that I've not done those things by good notes and follow ups, like random urine/blood samples and pill counts.

Theresa

Kira

10-08-2007, 02:49 PM

My pain clinic does it a little differently than Dr Steve does things, but I think it accomplishes the same thing.

To get an appointment, you need a referral. The referring doc's office calls the pain clinic and tells them that about you. Then someone from the pain clnic calls, asks intake questions, and schedules your visit. They send a questionnaire & other paperwork to fill out for your appointment. If your other docs are from the same hospital, the pain clinic has access to your records on the computer so you don't have to worry about that. If your other docs are at outside hospitals, then you have to get your records to the pain clinic... especially imaging studies and labs related to whever causes your pain.

Opiates and contracts don't get brought up until sometime during the visit, if the doc thinks they are appropriate. If you're starting on opiates, one of the nurses comes in with paperwork and instructions after you're done with the doctor. Then, once the paperwork is done, the doc writes your scripts. They photocopy the scripts and put a copy of them in your paper chart, and also write in your visit note what they prescribed, how much, and when.

They always give you a one-month supply. Every 4 weeks, you go in and see either the doctor, a nurse, or a PA. At first, it was the doctor every 4 weeks. Then it was alternating doctor & nurse visits. Now I see the doctor, then the nurse, then the PA, then the doctor... so I see the doctor every 12 weeks. You are there every 4 weeks, regardless of who you are seeing, and the nurse/PA can go grab the doctor if needed, and the doctor writes the scripts after the nurse/PA tells her how you're doing. If you need something between visits, they want you to call. They would rather have you call than have you start messing around with your meds on your own.

I there are a few good reasons for using the contracts. They give patients clear guidelines to follow so they don't end up unintentionally misusing their meds or sending up the dreaded "red flags." They give the clinic some protection against law enforcement, because they have written proof that they've discussed how to use the meds responsibly with all of their patients. By setting clear guidelines, the clinic can more easily identify patients who are not following the rules and then look into whether or not those patients were misusing their meds. And, by protecting docs from getting in legal trouble because patients abuse their meds, contracts can help ensure that those of us who don't abuse our pain meds will continue to have access to pain treatment. As the DEA gets more and more aggressive towards doctors who prescribe opiates, it is important to make sure that we, as patients, do everything we can to protect our access to treatment.

The use of these contracts is highly recommended for pain management docs. I don't know why some of your doctors aren't using them. Maybe they don't want to deal with an extra piece of paperwork, maybe they think the contracts won't be effective, or maybe they're afraid that their patients will be offended.

Oh, and there was nothing at all in the process of getting an initial appointment or in my pain contract about finances. That would seem highly suspicious to me. If I saw a doctor who wanted access to my financial records or to prove ahead of time that I could pay, I would be very wary. This is stuff that insurance should be paying for, and if the clinic is doing stuff that you have to pay for out-of-pocket, then you have to wonder how legitimate their whole operation is.

lobelsteve

10-08-2007, 03:25 PM

Oh, and there was nothing at all in the process of getting an initial appointment or in my pain contract about finances. That would seem highly suspicious to me. If I saw a doctor who wanted access to my financial records or to prove ahead of time that I could pay, I would be very wary. This is stuff that insurance should be paying for, and if the clinic is doing stuff that you have to pay for out-of-pocket, then you have to wonder how legitimate their whole operation is.

Financial statements or records are none of the doctors business. It has nothing to do with medical care and if I were asked by a doctor to provide financial informationother than a copy of my insurance card- I'd report them to the medical board.

As far as having no insurance- it is a red flag for abuse. The context as to why somebody has no insurance is important (I had no insurance for 3 months this year while changing jobs), but no insurance is an independent risk factor for substance abuse.

slipnslide

10-08-2007, 04:06 PM

As far as having no insurance- it is a red flag for abuse. The context as to why somebody has no insurance is important (I had no insurance for 3 months this year while changing jobs), but no insurance is an independent risk factor for substance abuse.

lobelsteve,

May I ask how not having Insurance makes a person more of a risk for substance abuse? I was sort of thinking in the opposite direction, that having insurance gives people easier financial access to an RX, whereas those without insurance think twice before filling a script....or are you not referring to prescription medication abuse? I'm just curious:) .

Thanks,

Kim

Jo6

10-08-2007, 04:25 PM

Well, just turn 65, think you're SS has started, then discover insurance from hubby's work related insur. will no longer cover you, you start staring death in the face. If that is a red flag for mis-using drugs then I guess I have red flags every where.

I am very upset with the "system" they will screw you every way you turn. I have to find a supplement before Oct. 19th. Oh happy birthday to me!! Jo

btw, never mis-used drugs in any form or fashion. Don't intend to start now!

sorry , i'm not Dr. Lobel. J

debhun

10-08-2007, 04:34 PM

I don't have any ins now. DH lost his job Aug 31 but is working now. But as you know it takes 3 months to get ins back. We just have to cut corners and bills to pay for my meds. I am glad that all my meds are due at one time. I didn't plan it that way it just happen that way. I don't go back to PM till Dec. This is the first time I have a 3 month brake with Appt. I had been going once a month.
They send me my RX by mail each month. I had to call them the other day and told them about me not have any ins and they said next time I go in just let them know then.

One thing I have notice is they can never fine me. When I called They said I was there last was June. I told them no I was there Sept4th. They don't seem to keep up their paper work to well. Now that took me by surprised.

Kira

10-08-2007, 06:23 PM

Rates of uninsurance are high (> 14%) and are rising. Insurance premiums increase substantially every year, and employers are finding that they can't afford the same group insurance they offered in years past. It's even harder for small business owners, individuals, unemployed folks, etc. The largest uninsured group is working class people with incomes too high for Medicaid but too low to afford an individual policy, with no group plan offered at work. As health care costs keep rising, more and more people are becoming uninsured. As a nation, we really need to significantly change the structure of our health care system... but who knows if/when that will happen.

Dr. Steve, I'm glad that you included the caveat that doctors need to explore WHY someone is uninsured. More and more "normal" people are uninsured these days due to our dysfunctional health care system and out-of-control costs.

I am wondering how the studies were designed that show lack of insurance to be a risk factor for drug abuse. Were they done years ago, when the population of uninsured folks was different? Or were they done within the last couple of years, more closely reflecting the current composition of the uninsured population? Did they correct for confounding factors like socioeconomic status, unemployment, age structure of the uninsured population, etc? How did they deal with the phenomenon of insured patients claiming to have no insurance to avoid being caught for doctor-shopping?

Obviously, there's a big difference between a small business owner who just can't afford insurance and a doctor-shopper who claims to have no insurance so that they don't get caught. But I bet there are a lot of patients where it is not so obvious as to why they have no insurance.

I think that with these "red flags," it's important to avoid making assumptions until all the facts are known. It's one thing if the red flag is "gets six scripts for Vicodin from six different doctors filled at six different pharmacies every month." But if the red flag is something like "has no insurance," "asks for a particular med," or "doesn't want to do PT," then the doctor has to step back and look at the whole patient in the context of their life.

If they don't have any insurance but otherwise seem pretty legit, then they probably just plain don't have any insurance.

Likewise, there are undoubtedly many patients with NO red flags who abuse their meds.

I personally don't know if I would be able to deal with the stress of being a pain doc and knowing that the DEA could come swooping in at any given moment, due to a patient's actions and not my own. I was going to go into pediatrics, and if I am ever well enough to do a residency, that's still what I want to do. I doubt the DEA cares one way or another about how many prescriptions for amoxicillin a pediatrician writes in a month. :rolleyes:

MamaRider

10-08-2007, 08:42 PM

Dr Steve, I too, am glad you added the caveat to the "red flag" comment about no-insurance. Our daughter, age 25, has no insurance, and is living at home,. She iz under Pain Management right now for shoulder pain. Her Dr is great. She isn't even on a Pain Contract (the poop!) LOL. Maybe, because I go every appt. with her.I pay for all apts and all meds and the dr is very aware of this. Plu, he is such a great guy, because she is a cash Pt, he is cutting her a deal on his prices . Which, since I am paying is coo. But, to say, Dr Steve, that cash Pts, are drug seekers/abuser..and Drs should always have a "red flag" about them...I find that a bad way of thinking. Pain Pts already have an uphill battle. You KNOW that. you see that here with us. Please watch that kind of blind prejudgice.

Kathi49

10-08-2007, 08:53 PM

Just a thought and I could be waaaay off base here...so pardon my ignorance about these contracts.

But, since Indiana has State PMP's (Prescription Monitoring Programs) enacted, could that possibly be ONE reason WHY some docs aren't using pain contracts? I think I should let PharmacistSteve answer that one. :) I know it probably wouldn't address all the items in a contract but am just wondering about the medication/prescription aspect of it. It would just seem to me and I do NOT know all the components of the program, that a "red flag" would or could automatically be seen and reported. I also noticed that there seemed to be, and I didn't count them all, around 20 or so states participating or as it said "enacted"...while others were "pending". Then again, I didn't check the website for an update either to see how current that info. was. Anyway, just a thought and again I could be way, way off.

Maggie

10-08-2007, 09:09 PM

The people that causes all of this are the ones who have abused the drugs. We should report anyone, no matter who they are, if we see abuse.

Maggie

Kira

10-08-2007, 09:10 PM

Kathi,

I am not sure if Indiana's participation in the monitoring program makes docs feel like they don't have to do the contracts...

I go to a pain clinic at a major University hospital, and they are pretty active in setting guidelines & doing pain research & stuff at a national level.

Maybe some of the people whose docs aren't using contracts are at smaller clinics (or at least not at teaching/university hospitals)? Also, I know that some people here get their pain meds from PCPs and not from pain clinics... I am sure that PCPs are less likely to be using contracts than big pain clinics.

I also think it is just one of those things that hasn't quite caught on universally throughout medicine yet. There are many other things that are like that... a couple of examples:

-It has been shown in many, many studies that patients with chronic illnesses, like diabetes, get better care if their providers create and use a diabetes registry. This is basically a list of all of a provider's diabetic patients, with fields to keep track of their most recent labs, eye exams, foot exams, prescriptions, etc. The registries can be queried by office staff to quickly generate a list of patients who are overdue for labs, annual eye exams, etc... then the office staff can do phone calls or reminders, and they can also generate a reminder to stick on the chart for the doc to see at the next visit so they remember to do the stuff that is overdue. BUT... many places still do not use diabetes registries, even though they can be made pretty simply with an Excel spreadsheet (or you can make pretty complex ones using all sorts of fancy software). More and more clinics are using them every year, but there are still a LOT of providers that aren't doing this.

-It has also been shown that providers detect diabetic kidney disease at earlier stages if laboratory print-outs include something called eGFR (estimated glomerular filtration rate; basically a number of how much your kidney is filtering). eGFR is calculated from basic labs that are usually ordered. If the laboratory printouts include eGFR, the doc can just plain see if the patient's kidney function numbers are starting to show dysfunction. If the laboratory printouts don't calculate eGFR, the doc either has to calculate it on their own, or more often they just sort of glance at the numbers it is calculated from and leave it at that. It is cheap and simple to add eGFR to the printouts, and there is a general consensus among diabetes and kidney experts/organizations that it should be done. But, currently, only about 30% of the labs in my state report eGFR. This isn't because people don't agree that it should be done, or that it causes any harm to patients whatsoever... it just seems to be that the labs haven't focused on it yet.

(I used diabetes examples because that's what I know from my job, and because diabetes just isn't nearly as loaded an issue as pain meds are).

MamaRider

10-08-2007, 09:14 PM

It is no biggie for me. Funny, when I was reading thru these, I realized, my Dr took me on with no real back records. I was referred in by my Insurance Co. He had no other papework. But, he Rx'd and has been Rxing for me over the years. For about threeyears I had no contract. I sort of mentoned it in passing once to one of the PA's and she insisted I was on a contract. Three visists later, I signed a contract. I had always behaved as if I were on a contract, so it was no biggie to sign it. A pain contract protects the PT as wellas the Dr. IMHO. If we do as we are supposed to do, we will be treated as we shouldbe reated by our Drs. It protects us as much as it protects them when you think about it. I really don't believe, even tho it has the word "contract" in it. That you could take it to court and say " they HAVE to RX me pain meds". I don't beleive it is enforcable in that way.

It is sad about the senoir ditizens that sell their pain meds. Do they need it? Or do they need the money more to simply survive? Sad thought....people so desperate to eat,have shelter, that they give up pain relief. And they are our grandparents. Says something sort of sad about our Social Security, IMHO.

gambles

10-08-2007, 10:14 PM

Nope, I don't have one. My pain doc is actually the head of the addiction treatment department of a major hospital! He sees pain patients 1 hour of one day a week so that is a maximum of 16 total. He has tremendous empathy for pain patients and is determined to do whatever is necessary no matter what or how many narcotics are required. Then he spends the rest of his time dealing with people with pyschological and physical addictions.

I have been going to him since before he got the job there. He was in private practice, and I followed him to the hospital. I cried the first time I met him because he was the first doctor that ever understood!

If he did ask for a contract, I would sign it as I do all the things people mentioned anyway, but he has never asked.

One thing I do is always take my mother with me to appointments. That way I have back up if he is not in a good mood and evidence I am not abusing anything. Given that I couldn't get myself there physically anyway, it is a great thing for me to have her along.

Suzanne

Kathi49

10-09-2007, 08:41 AM

As an afterthought...I should have clarified and I thought I did...but the two PM's I have seen ARE affiliated with various hospitals. The first one was at a major teaching/research university hospital...pain management clinic. And that I had to have a referral to. Also, that group never asked me to sign a contract. But, that was several years ago and they may be doing so now...just don't know. The actual Spine Group I go to are affiliated with 3 hospitals and PM himself is now Director of another spine center at yet another hospital. So, it is not like they are tiny, independent clinics so to speak. In any case, not a one has asked me to sign a contract.

I did look over Dr. Steve's form just to see if I have ever signed anything remotely similar and I haven't. IF my current PM ever asked me to sign one, I would...I don't really consider it a biggie either as I have never abused my meds either. So, from that standpoint, signing an agreement wouldn't bother me. And I have to be honest and say it is NOT the medication or abuse aspect that would disturb me at all. What disturbs me about a contract/agreement is the potential for jumping through hoops to get something accomplished. And, really, I am alluding to what Theresa mentioned; problems she has had with the pharmacy or that sort of thing. I would hate to think I am laying in an ER while several phone calls have to be made. I'm sorry but that just does not sit well with me. Or, if I went into PT and had to stop. Would that then be a cause to disqualify me or boot me out from care? I don't know since I just don't know too much about these agreements. But I don't think I would like my TOTAL care in the hands of one individual or at the discretion of one individual. I much prefer a team approach since there are multiple issues and spinal disorders just being ONE of them. And, well, all the docs get reports from each other and it just never has been issue. And I have always told them all what meds I am taking and why. Anyway, I would definitely want a SAY in what is done or not done. I also believe a patient can be undermedicated as well as overmedicated. So, where would you be then if not getting relief? You would be stuck with the terms of the agreement. But I suppose the agreements can be modified as well. Again, if my own asked me to sign one, I would...it just has never happened. But even if I were asked to, I would ensure it was written in a way that would protect me as well and spell out my own treatment plan if possible. I just think these contracts/agreements should be written and used carefully by the docs...period. I do see my own NS today so I will ask him about contracts/agreements. I really DO want to know why some use and them some don't.

Anyway, not trying to debate what is right, wrong or indifferent or what helps and what doesn't. Just trying to be honest and say that I can see the potential for them acting to the detriment of the patient...and contracts/agreements have a way of doing that..unless they are spelled out very carefully. And MAYBE that is why some use them and some don't.

cindybear

10-09-2007, 09:51 AM

That pain contract of Dr.Steve is basicly the same one my doc has and has me sign yearly..( I have been going to him for over 5 years ) ..He is not replaceable......Not once has he ever ask for a urine sample but I would give him one in a second,,,He is not only my doc but my friend...He has come to my house on several occasion to fish my stocked ponds with his children and to hunt mushrooms (morels ) in our woods...Nothing better than a fried morel. But I think a Doc should have a contract to protect thenselves..Cindy

Tbackpain1

10-09-2007, 01:45 PM

Kathi,

The problems that I've run into have to do with individuals who feel they know better than my PM doc. The pharmacist that had a problem with my scripts has had problems with other patients as well, so its not just me. I talked with the staff at my PM doc's office and they know who it is and what pharmacy, so they are aware and just provide the info for the pharmacist when its needed. Pharmacists do have the right to check a script if they think its not valid, but there comes a point when it goes beyond simple verification and turns into a moral judgement thing, where they just don't want to fill a script for personal reasons, and that DOES NOT fly.

As for the ER issues, its not a matter of my single physican directing care, but when it comes to pain meds, I won't accept anything that hasn't been run by my PM doc first. I have quite a bit of knowledge of the various meds from my education and the last thing I want is to be getting double and triple dosed with a single type of medication. My PM doc does work in conjunction with all my other physicans and they do take a team approach. My PM doc's practice has one other physican that is also a PM&R and between the two, there is always someone available to cover their patients, as well as multiple orthopedic specialists in the group, so should I ever need treatment for a new orthopedic issue, it would still stay "in house".

With regard to the PT issue, I have been in and out of PT since 2001, both because of physical issues that prevented continuation of PT and insurance coverage limitations. At each time when I had to stop, my PM doc had no problem with it, as it is something beyond my control. He was aware of the situations and just recommended to begin again when I was able. The only time he had problems where he asked me "what's going on with PT?" was when I missed 3 appts in a row because of a family emergency and he was fine with that as well. My PT didn't know, just sent a note over letting him know I'd missed appts, but it certainly doesn't keep you from recieving treatment.

In all honesty, I think one of the major problems with chronic pain treatment, when there are problems, is due to a lack of communication. If all parties are aware and honest about whatever the situation is, then it can be addressed as it needs to be. No one patient fits a cookie cutter mold of treatment, be it interventional PM, meds, PT, in addition to any other health problems he/she may have. Sometimes things left out can be major, other times minor, but integral to the provider's assessment of a patient's treatment. These things can lead to huge misunderstandings, and can be a beast to correct.

Theresa

Kathi49

10-09-2007, 07:12 PM

Theresa,

I understand what you are saying and agree but only in part. :) I am NOT saying contracts are good or bad. What I can see and based on viewing examples, is the POTENTIAL for INEFFECTIVE communication and/or jumping through hoops. But if everyone is happy with their agreements, that is fine with me. I just really wasn't sure why as an example my spine group didn't use them since pain management is part of that group. But I got my answer, in least in part from my NS today and since he is a founder I figured he would know.

So, it went like this...

I asked him if they had any type of pain management contracts/agreements on the pain management side of the house. He looked perplexed for a minute and then I asked...does Indiana have some kind of policy or policies in regards to pain management agreements? The he said, and his words, not mine...

"Oh, a lot of doctors do use them but we do not adhere to that philosophy. We believe a patient should see whomever they want to see." And that was that. He did not go into medication, PT or anything else....just said the above and that was it. So, there was my answer for the time being. :)

I will say this much though. I know for a fact he does NOT prescribe opiates 3 months post-op. He just won't although he did once for me...probably because as usual, they know I don't abuse my meds. But as a general rule, he will refer a patient with ongoing pain to the PM's who are "in house". And of course, if a patient feels that they aren't getting adequate care I would presume they could go elsewhere.

And maybe because it is a Spine Group and not a pain management clinic per se, the docs know we aren't faking it just by looking at our MRI's, scans and grimaces on our faces. :eek: :) And if there are little old ladies in there getting their meds and then selling them, I certainly haven't heard anything about it.

BUT...what I should add too. There was a doctor that was investigated and fired but NOT at the spine group. This was a different group...not spinal related. Anyway, he was asking for the patients to bring in their meds so he could do a count. And the patients did. But it seems that several patients noticed some of their pills were missing afterwards. I read the story and couldn't believe it because I know of two people who were seeing him. But there you have it...not even the docs can always be on the up and up. Pure stupidity on his part...as if patients don't know how many pills they have. Anyway, his career went kaput and through no one's fault but his own. Hmmm...maybe the patients should have devised their own contracts. :)

peglem

10-09-2007, 07:58 PM

I'd like to tell you @ my MIL's contract experience. Her insurance is an HMO that runs its own clinics so her Primary care physician is at the clinic. When she asked him for a referral to a pain specialist- because her spine is all messed up and she has constant pain- he offered to prescribe pain meds for her instead, w/ a contract. He prescribed the long acting form of oxycodone.
She begin a few weeks later having problems with anxiety, then started dropping weight like crazy, and later had heart palpitations and breathing problems. This went on for months. When she'd go to the doctor with a complaint- they scheduled her for lots of tests, which all come back negative. She visited urgent care because she was afraid she was going to die when she couldn't breath well-they found nothing wrong. I took her to emergency- they gave her an EKG and did a scan of her lungs. They found nothing wrong and began treating her like a pathetic old woman who just wanted attention. They did give her an inhaler, which didn't help. She's down to skin and bones, afraid to go to sleep every night because she may die in her sleep. She's trying so hard to eat and gain weight. And just as she's about resigned to imminent death- she goes back and reads her journal. She thinks the problems started about the time she began the oxycodone...So, I do a side effects search for her- and wow, looks like all these problems over the last 8 months are side effects of her pain meds. I'm kinda irked because every doctor/specialist she's seen has known about her medication. They ran endless tests that just caused more anxiety because they still couldn't figure out what was wrong with her. What a relief to find out it was the meds! So, she called to get into the doctor the same day we found out (on the web). Her doctor is on vacation, so she sees another clinic doctor who immediately says that yes, oxycodone does that to people and its most likely the medication causing her problems. BUT-since she has a contract w/ Dr. B, he can't change it for her! The clinic makes her an appointment for a month later to see Dr. B. A MONTH!!! She has suffered with this for a very long time- he didn't recognize the side effects and put her through a lot of uneccesary testing and now, because of a contract that was designed to protect them-she is supposed to wait til they get around to dealing with it? For crying out loud-she had to even figure it out for herself! Since these are the long acting meds- she can't just cut the dosage to take less. By calling and complaining everyday- she finally got Dr. B to call her and send a prescription down to the pharmacy for the short acting form, so she can at least reduce dosage. She'll discuss it further with him at that 1 month appointment. But, see, what happens when the doctor is unavailable and nobody else can help you because you have that stinkin' contract?

Kira

10-09-2007, 09:30 PM

Kathi,

Even with the contract, I have a LOT of docs, and I try to get them to communicate with each other so they can function as a team. Here's my list: two metabolic docs, nutritionist, two genetic counselors, PCP, PM&R/pain, PT, neuromuscular, GI, nephrology, cardiology, psychiatry, therapist, ophthalmology, allergy, ENT, and about to add OT.

When I see a specialist, I give them my other docs' names and they cc the visit note to them. Plus, they all have access to the same electronic medical record, so they all see the same list of current meds. I also tell them when I start a new med.

I'm on several meds/supplements from different docs. I get my mito supplements from my metabolic doc, allergy & acne stuff from my PCP, GI stuff from my GI doc, psych & sleep meds from my psychiatrist, and pain meds from my pain doc. They all know what the others prescribe and are all okay with the whole list. The contract DOESN'T mean that I can't get meds from other doctors... just no pain meds from other doctors.

For example, I couldn't get oxycodone scripts from my pain doc, my PCP, and when being sent home from the hospital or ER. I COULD get an oxycodone script from my pain doc, an allegra script from my PCP, and a zofran script from the hospital or ER. While I'm in the hospital or ER, they can give me whatever they need to... but if they want to send me home with a different pain regimen, they need to run it by the pain clinic. Honestly, contract or not, I wouldn't change my pain regimen without talking to my pain doc, so it doesn't bother me.

The contract also doesn't mean that I have to go to PT. It is more that we have to use non-opiate strategies, too, when possible, rather than just taking pain meds and not trying anything else. For most things that hurt, there's SOMETHING you can do to improve quality of life besides just taking pain meds... even for terminally ill patients on hospice/palliative care, they do other things (like positioning, massage, heat/ice, etc). It is about looking at the patient as a whole, rather than zeroing in on simply relieving/masking pain... asking "What can be done to make this person's life better?"... coming up with ways of improving the person's ability to function.

For example, while PT doesn't do much for my pain, it does help with range of motion, loosening up scarred muscle tissue, improving my exercise tolerance, etc. There are several non-opiate things that decrease the number of rhabdomyolysis attacks... supplements, eating better, less vomiting, better exercise tolerance, aggressively treating infections/fever/dehydration, etc. I'm also working with my therapist on coming to terms with my illness... and while that doesn't decrease the pain, it does decrease my suffering from the pain. I can have just as much pain, but my mental approach to the pain changes how much it makes me suffer.

Anyway, all of those things are non-opiate strategies for dealing with my pain. I know that there are some cases where you can't do much except treat the pain... my disease, for example, is barely treatable, not curable, and progressive... but even then, you can often do things to decrease the frequency of flares, maximize functioning, decrease suffering, etc. I'm NOT trying to say that they should make patients with severe pain try all of the non-opiate stuff before giving them pain meds. I'm just saying that, together with pain meds, there are other things to do to decrease suffering. (Kathi, for you, this might be stuff like heat/ice, hot baths, your soft collar, your lumbar support, injections, etc).

The contract is just a way of putting the rules in writing so that later on, if a problem comes up, there are clear guidelines that both the patient and the clinic knew about in advance. When used correctly, they protect both patients and doctors.

Kathi49

10-09-2007, 09:44 PM

Kira,

Thank you for your input and if a person is happy with their agreements, that is fine. :) My take on it is different...that's all. :)

Kira

10-09-2007, 09:47 PM

Peglem,

What happened to your MIL sounds horrible, and I'm glad that they were able to figure it out.

The contract I have with my pain clinic doesn't specify that it has to be my doctor herself writing the scripts... just that they have to come from that pain clinic. The nurses and PAs at the clinic are pretty involved in patient care there, so there is usually someone there who knows you when you call. That way, if a prescription is needed and your own doctor isn't there, one of her colleagues can write the script after looking through your chart and talking with the nurse or PA about you.

When she sees her doctor next, I would DEFINITELY ask him what she is supposed to do in an urgent situation like this in the future. I would also really recommend that she tries to get him to refer her to the pain clinic, where they are more familiar with the meds & side effects... especially since she had so much trouble with this med. PCPs do get some training in pain management, and many people are able to get good pain management from their PCPs... but the doctors at a pain clinic receive specialized training in pain management and usually know more about it than PCPs. I hope she starts feeling better soon.

krashleen

10-10-2007, 03:54 PM

I would like to hear the response from Dr Steve in regards to the uninsured question and abuse of medication.
I took a buyout from my company in 2005, and had COBRA for a year and half, then the new insurance wouldn't cover pre-existing, but I have an established relationship with my PM doc. He understood.

Would your practice?

debhun

10-10-2007, 04:08 PM

Yes I would like to know my self about the uninsured. For I am one of them now. My DH lost his job and is at a new job but has to work x amount to get ins. So we will be without ins for 4 month I would take it. If we pay our bills and meds why would it send a flag up? You would think it wold be the ones that have ins. For it would cost less for meds and could sale them for more moneys. I really don't understand.

Deb

kimee100

10-10-2007, 07:54 PM

Just a quick note to those that no longer have insurance. I am waiting for SS approval and have no income and as we all know the pain meds are very expensive. I wrote to Purdue Pharmecutical and they have approved me for their rx assistance plan for 1 year. I am able to obtain my Oxycontin and my Oxycodone, for $25.00 per rx. The limit on the Oxycontin is up to 360mgs and the limit for Oxycodone is 1000 mg. So the 160mg of Oxycontin and the 90mg of Oxycodone I take every day is covered. I believe the Oxycontin would normally run somewhere in the range of $600.00 a month,so this rx assistance is a tremendous help. Just thought I would pass this along.

krashleen

10-10-2007, 08:18 PM

Pike

10-11-2007, 06:54 AM

Never signed one and probably have no reason to do so if I continue to live where I now live.

In small towns 2,000 people in counties with 35,000 people most Drs will know who you are, what you do and when you do it.

If I were to hit a deer with my car on a Monday night my Dr would know about it when he got up and listened to the local news or from office workers who heard about it.

Law enforcement in small towns know the people that do illegal drugs or hang around with people who do illegal drugs and if there happened to be a boatload of morphine on the streets it would not be difficult to find out who sold their meds as I doubt that 15 people in a 30 mile radius take MSContin so the list would be short.

Family Drs and small town living can be intrusive but it sure makes life more simple.

Pike

kimee100

10-11-2007, 03:30 PM

How did you write to them? I have their 'coupon' but it doesn't help me. I have capped out on my so-called insurance that is no better than a discount plan.
And we cannot get insurance on our own because of my husband's pre-existing condition, Hep-C. So there are MANY, many reasons why someone doesn't have insurance.

So, I would like clarification on the insurance issue.
Krashleen
I went to this site: https://www.pparx.org/Intro.php. Sign up for free, put in ALL the meds you are on, look them up and then they will give you a list of who to contact to either get them for free or to get a discount. When I put in Oxycontin it gave me a number to call and I was advised to have my doctor call and they would fax him the application, he filled out his part, I filled out my part. I got word about 2 wks later that I was approved for any medications this company made for a year and that all I had to do was send in an original prescription with $25.00 per prescription and they would send to me overnight to my house. So I get OxyIR and Oxycontin for $50.00. I get Lamictal free from Bridges to Access, Cymbalta free from Lilly Foundation as well as Klonopin. I had medicaid but when that stopped I have no income and no insurance, so I just started typing in "Free Medication" in my Google search and come up with tons of companies that can help you, but found this to be the best one. Another one is RX Outreach that has pretty good deals on meds.
Good Luck
kim

Kathi49

10-11-2007, 05:13 PM

Okay, I can't help it...I have to tell you all what happened today and it did make me think of these contracts. I am still laughing.

My husband came home for lunch to check on our landscaping we are having done. I followed him upstairs...just talking and well, he was using the restroom but also said he had a headache. So, right as he reached for the TYLENOL, he evidently hit another bottle in the medicine cabinet and toppled the little bottle of Tylenol which went right down the toilet as it was flushing! I was laughing so hard. So, I guess he just isn't good a multitasking LOL! Accident? Yes. Should he have just waited before reaching the bottle? Probably. But these things happen.

But it got me to thinking...wonder if that had been my Vicodin (which by the way I keep on my counter not in the cabinet)? I can see it now, "Uh, doctor, my Vicodin went right down the toilet." And the doctor say, "Yeah, likely story too!" So, and no offense to Dr. Steve but per your contract it states SPECIFICALLY that no replacement medication will be prescribed if misplaced, stolen or DESTROYED.

So, you see...this is one reason among many that I take issue with how they are written or implemented. There is really too much diversity, no standardization that I have seen in other examples and not enough studies to prove efficacy. And in this particular instance and HAD it been MY medication and HAD I been under contract, I would have definitely been SOL! But, by having the TRUST and RELATIONSHIP with my own PM, he probably would have refilled it.

Anyway, just so it is clear...my REAL issue is not so much with medication or pharmacy rules anyway. I was just relaying what happened today. My real beef is with all the ad-ons. The whole point really is...ANYTHING can happen that could be a detriment to care. And just my own opinion. These agreements are pretty restrictive and that is the part I do not care for.

debhun

10-11-2007, 06:52 PM

Accident do happen But I have learned from one of mine. I use to keep my meds in the kitchen window above my sink. Well one day was getting my perc and it had a child proof cap on it. I couldn't get the darn thing off. Than all at once it open and they went in the sink of water. all of them about 20. I was pissed.
I called my PC Dr who at the time was RX them to me. But my doc knows me very well. He laughed and told me not to put any med there again. One thing now I don't have those child proof caps any more and I keep all meds in a Makeup Case. So I will always have them if I have to leave in a hurry.

lobelsteve

10-12-2007, 11:09 AM

Jo6

10-12-2007, 05:31 PM

I just sent a nice little insulting post off and it must have gone on to the lost post heaven!! Just once, I forget to save it. oh well, I'll try again

truely I have forgotten what the topic of this hot little thread was called. OH, Hey MamaR! Good to see you.:)

I have a contract with my PM. I sign it every month when I get my refils. Half the time I forget the last page and end up not even signed. It says about what Dr. Lobel's said. Also Kara & Deb's. Pretty simple.

I think too much of my PM than to screw it up for crap!! I need him, but he probably don't need me anymore, but I got there first:eek:

I read all of this thread, by the end it felt like we had about 6 topic's going. Maybe we could take them one topic at a time and go wild.;)

I felt a bit of anger when it seemed that so many thought a Contract was only for weeding out drug abusers . There are many ways to abuse your meds. Know doubt that is one of the reasons for Contrack , but not the only reason. We can save that one for another day.

I do not mind signing and I don;t feel like my rights are being steped on. Course that is just me. In 6+ years I have had to go over to Hospital and tinkle in that lil old bottle twice.

One of them showed that blasted bladder infection that I can't seem to make go away and I don't remember what else. Also I have quiet a walk to get to lab at the hospital and that really sets my back on fire and I wanted to lay down on the cement and cry.

Time to shut the heck up, Jo

krashleen

10-23-2007, 06:02 PM

THere is an obligation to continue seeing existing patients no matter what insurance they change to, including self pay.

There is no obligation to see or treat any patient in my practice. If there is something I think I can help, I have my staff make an appointment. Patients that were dismissed from several pain clinics do not get appointments with me. Patients that have DUIs, arrests for narcotoc violations or violent crimes, do not get appointments. There are many qualified pain docs in my area. I do not have to fall on a sword and take all comers.

The data indicating uninsured patients have a greater risk to abuse medication comes from studies published in respected pain journals.

I agree with some points, but others I have a bone of contention with. But of course, you are the treating physician and your word is the final word.

Chronic pain, chronic illness is devastating on the wallet, on finances. We lose our jobs, and hence our 'safety net' of insurance. If we lose our insurance we do become self-pay, and unless we are able to continue living where we live, we sometimes have to change doctors. Or our doctors discontinue their practice. In that case, we are thrown to the wind, and left to fend for ourselves. In that case, no insurance and sometimes no doctor and no one left to treat our pain. Right or wrong? How do we plead our case? Do we go through the 'gatekeeper' of your appointment takers at the front office? There is something lacking in the humanity of this. Thats my only point.
I am not a felon, never been charged nor convicted of ANY crime. Yet my 'crime' may be being self-pay. If you are speaking for yourself, you cannot be the only one. I would imagine that myself, armed with this knowledge would say that I am insured, and then explain my case to the doctor once I got in the door.

JMHO