Pain medication contracts

One of the things about worker's comp patients is that most of them have chronic pain that has to be treated with narcotics (think Dr. House and his Vicodin addiction). Obviously, nobody likes to just give out narcotics (well, unless you're on House, in which case, everyone gives it out like candy). There are a lot of legal and ethical issues involved in prescribing narcotics, so the doctors try not to do it without thought.

So at the OSU Occupational Medicine clinics, the patients must sign pain medication contracts once a year before they can be prescribed narcotics. The contract is a couple of pages long, and I won't bore you with all the details, but some of the points they have are that the patient must agree that they will only get narcotics from the occupational medicine doctors (ie, they can't go to the ER for pain meds), that they will take them only as prescribed, that they will agree to random drug screens (both to make sure they are taking their medications and to make sure they aren't taking anything else), and that if they break any of the rules, they won't get any more narcotics.

Well, we had a patient yesterday (Friday) who Dr. Wynd is trying to wean off Percocet. She had been prescribed 1 pill four times a day, and a few months ago, Dr. Wynd decreased it to 1 pill three times a day. So, to make what was actually a really long and convoluted story short, she was still taking 1 pill four times a day, which Dr. Wynd confirmed by counting the remaining pills. So, she wasn't taking it as prescribed, and that means no more Percocet. Dr. Wynd prescribed Ultram instead (a non-narcotic pain med) and pretty much said, you knew the rules and you chose to break them.

I'm not saying the patient didn't have pain; she had quite a lot of pain, both leading to and resulting from a knee replacement surgery and three back surgeries. However, pain or not, rules are rules, and she knew them and broke them. If she was having as much pain as she said she was having (leading to the increased intake of her meds), she should have called for an earlier appointment to ask for another prescription, instead of just changing the dosage on her own. That way, she wouldn't have been in violation of her contract.

Unlike on TV, doctors are aware that narcotics can be addictive. They are also aware that they are sometimes necessary. The tricky part is getting things down so the pain can be treated without causing further harm to the patient.