What is a Pain Management Contract?
A Pain Management Contract is a formal agreement between a pain management physician and a patient with the purpose of establishing a doctor-patient relationship dedicated to safe prescribing and use of controlled substances for the treatment of chronic intractable pain. In such an agreement, a patient agrees to allow his or her prescribing physician to monitor the use of prescription drugs as a component of their treatment for chronic intractable illness. The Pain Management Contract sets the terms and conditions of the doctor-patient relationship and governs the business aspects of that relationship to include the requirements for the ongoing treatment of the patient by the physician. The Pain Management Contract also operates to establish the patient’s informed consent to treatment via prescription of controlled substances such as opioids, as well as the physician’s right to lab tests, pill counts and patient visits to monitor a patient’s use of prescription drugs. A Pain Management Contract may also provide the patient’s consent to reasonable searches of personal property for the purpose of discovery and return of missing or non-prescribed prescription drugs.
A Pain Management Contract is establishing a working agreement between a physician and a patient for the treatment of chronic pain using prescription drugs. There are a number of stated and unstated purposes of the Pain Management Contract, all aimed at achieving the goal of the medically safe and appropriate care and treatment of chronic pain with prescribed controlled substance . Those purposes include:
Making clear to patients who are in the physician’s practice for the purpose of receiving treatment of chronic pain, the terms and conditions under which that treatment is provided;
Providing a basis for the physician to monitor a patient’s compliance with the terms and conditions under which treatment is provided;
Establishing clear expectations for the quality and quantity of the patient’s use of prescription controlled substances and the physician’s treatment of them;
Allowing and authorizing the physician to monitor patient compliance with those expectations; and
Providing for the physician’s right to dismiss the patient for non-compliance with the agreed upon expectations.
Implementing a Pain Management Contract is usually a beginning step in the doctor/patient relationship. There are a number of professionals typically involved in the treatment of chronic pain with prescription drugs such as radiologists, physical therapists, psychiatrists, psychological counselors, exercise physiologists, and others. A Pain Management Contract is not a tool to be used by one single specialty of the medical community with respect to patient care. Rather, the Pain Management Contract has application to the entire range of specialists involved in the care and treatment of chronic intractable pain. By way of example, a pain management physician may implement an initial Pain Management Contract with a patient but refer the patient to an exercise physiologist for physical therapy. The pain management physician may then take steps to also implement a similar Pain Management Contract between the patient and the therapist. The same situation may occur for referrals to psychological counseling or psychiatric care. Psychiatrists and/or psychologists involved in the care of a patient with chronic pain should consider implementing a Pain Management Contract with the economically at risk patient.
Essential Components of a Pain Management Contract
While there is no universally agreed upon format or language, there are some key provisions common to most pain management contracts. Language may vary depending on the type of practice, i.e. solo versus group and specific policies within a particular practice, but certain elements should be included. It is important to explain these provisions fully in a manner comprehensible to the patient. Your physician assistant/ nurse practitioner/ physical therapist should be trained to discuss the provisions with patients. The following is a simplified discussion of provisions typically contained in a pain management contract:
- Patient Obligations. Patients usually must agree to notify all prescribing physicians with the name and address of the pain management practice provider. They must also agree to keep and bring all prescription medication bottles, and consult the pain management provider prior to using any OTC medications. Additionally, patients must agree to truthfully answer all questions posed by the provider.
- Medication Adherence. Patients will often be required to agree to follow medication management protocols, including taking medication as prescribed, not selling or distributing medication, not combining medications with alcohol or illegal drugs, reporting missed doses to the provider and notifying the provider of all side effects experienced.
- Monitoring Policies. Most pain management practice contracts will require patients to agree to random drug screenings in the event of a positive toxicology screen, blood testing. Additionally, patients may need to agree to allow the practice to contact any and all pharmacies or outside providers where patients obtain prescriptions or receive treatment.
- Consequences of Contract Breach. Patients generally must agree to the consequences for breach of the contract, including possible termination of treatment, referral to a rehabilitation program or 12-step program, referral to a Pain Management Review Board and/or termination from the practice.
Advantages of Pain Management Contracts
The use of a pain management contract with patients has become a best practice for large and small practices, healthcare systems, and hospitals. Properly used, a pain management contract can help meet several patient needs. First, it promotes the safe, effective, and appropriate use of pain medications for those patients who need them. Second, it provides the practice or system with documentation that the patient has been properly and thoroughly evaluated prior to prescribing controlled substances and that the patient has been advised of and understands the risks associated with opioid pain medication. Third, a contract can help minimize the risk of misuse and abuse of pain medications by requiring the patient to provide specific information as part of the ongoing treatment, including control over continuing drug therapy, compliance with treatment, and monitoring of progress in resolving the medical condition being treated. It also provides controls concerning the source of the drugs and the manner of treatment.
Common Terms and Provisions in a Pain Management Contract
Some of the common terms and conditions seen in pain management contracts today include:
• Use of at least one pharmacy for all prescriptions.
• Urine testing to confirm that the patient is taking their medications and so that the physician can see how well the medications are or not working for the patient.
• Pill counts when the patient comes for an appointment.
• A notation about attending all scheduled appointments, returning phone calls, etc.
• Notifying the doctor if the patient receives pain medications from another doctor.
• Giving the doctor a copy of the contract so that it is clear to them what they have agreed to regarding treatment.
How to Create a Pain Management Contract
Once you have your policy in place, you will want your pain management contract to reflect those principles. A sample pain management contract is provided at the end of this article for your review. You need to make sure that your contract:
• Clearly states what your practice will be doing with the patient.
• Clearly states what the patient will be doing.
• Clearly states that the patient will be coming into your office to receive care from you after they have been discharged.
• Clearly states that the patient cannot go to another doctor or medical provider for a prescription and receive a prescription for the same medication from another provider since the patient is already receiving the medication from your practice.
• Clearly states that if the practice finds that the medication is not working or you decide to come off the medication, the patient must continue to come to the office to get a medication until they respond to the new medication.
• Clearly states that once the patient’s prescription has been cancelled from the previous provider , the prescription will be cancelled and need to be discharged and refilled from your practice if the patient is transferred to your practice.
• Clarifies that the contracts are signed so that you can inform other medical providers that have seen the patient, that the addiction medication is working or not working or should be withdrawn and you are following the patient to determine whether the medication is working.
• Clearly state that there is a periodic review of the medications or medications will be discontinued if the contract is terminated, the contract is revoked, or the treatment plan is not followed after the contract is signed.
• Clearly states that the practice can monitor the patient to determine whether the medication is being used appropriately and when the medication is being used inappropriately, that the practice can terminate the contract because the practice is being misused.
Pain Management Contract Sample Template
Below is a sample template of a pain management contract you can use. In this sample I have highlighted each section for you to give you an idea of what to include in each section of a pain management contract and also how to customize it either for your practice or for personal use.
PRESCRIPTION PAIN MANAGEMENT CONTRACT
This agreement is made this ___ day of ________, 20____ between ________________ ("Patient") and ________________ ("Provider").
1. Chronic Pain Condition(s)
This agreement applies to treatment of the following chronic conditions:
2. Prescribed Treatment Plan
The Provider has agreed to treat the Patient’s condition(s) with (check all that apply):
COGNITIVE BEHAVIORAL THERAPY (CBT)
PSYCHOTHERAPY
BIOFEEDBACK TRAINING
PROLOGUE
INTERVENTIONAL PROCEDURES
NERVE BLOCKS
STIMULATOR
SPINAL CORD STIMULATOR
3. Controlled Substances Prescribed
To treat the above chronic condition, the Provider has prescribed the following medications: Opioid analgesics such as:
Oxycodone (Oxycontin, Roxicodone, Oxy, Oxycodone ER)
Hydrocodone (Hydrocodone ER, Vicodin, Lor-etab, Lortab, Norco)
Methadone
Acetaminophen with codeine (Tylenol #3)
Fentanyl and buprenorphine pain medications such as:
Fentanyl patches (Duragesic, Fenta-patch)
Fentora
Actiq
Buprenex
Suboxone
Buprenorphine
Subutex
Subsys
Zubsolv
Zubsolv Fan Access
Indivior Foundation
Zyfentyl
4. Drug Testing
The provider will use routine drug testing to confirm compliance with this agreement? (Check one). YES NO
If patient agrees, drug testing may be performed at any time before any scheduled or unscheduled appointment with the Provider. Drug testing will be performed:
Tablet disintegration:
Tablet dissolution:
5. Other Medications
The Patient also agrees to take the following medications only as prescribed by Provider:
Botox injections for migraines: ____________
Lidoderm patches for shingles neuropathic pain: _______________
Muscle relaxants (for instance, Valium): ________________
Depakote to treat chronic migraine headaches
Cymbalta to treat fibromyalgia
6. Non-Compliance with Treatment Plan
In the event of non-compliance with this Agreement, the Patient understands that she/he will be dismissed from the practice.
This includes (but is not limited to) the following:
Use or abuse of illegal drugs, alcohol, or use or abuse of prescription medications from other providers or pharmacists without the knowledge and approval of the prescribing physician
Non-compliance with drug testing procedures
Refusal to follow the prescribed treatment plan
Failure to take medications as prescribed
Seeking controlled substances prescription from other doctors or other pharmacies without informing the doctor
Significant behavioral or emotional problems, including suicidal thoughts
7. Medication Refills
The Provider is allowed to provide prescription refills on a _______________ basis: (e.g., monthly, every three months etc.).
If the Patient has scheduled an in-person office visit, payment must be made on the day of the visit or payment must be made through an online payment site established by the Provider on his or her website. Prerecorded telephoned messages will not be accepted as payment. Opioids or other controlled substances will only be prescribed to those patients who are making timely payments. Patients who fail to make timely payments will be advised to pick up their prescriptions from the pharmacy of their choice until payment is received. Patients will be advised that they need not return to the office for a refill if they are not interested in picking it up at their pharmacy.
Legal Issues in Pain Management Contracts
The legal landscape surrounding pain management is complex and challenging for both healthcare providers and patients. When a medical practice enters into a pain management contract with a patient, the practice must be careful to navigate this landscape in a way that complies with all applicable federal and state laws, CMMS regulations, and other industry standards.
Medical professionals have a duty of care to their patients, and this duty extends to the management of pain. However, patients’ legally protected rights must also be upheld, and many patients have difficulty exercising these rights in the face of longstanding stereotypes of drug-seeking behavior that can persist despite evidence to the contrary. In addition, failure to adhere to pain management best practices can open the door to allegations of malpractice or other liability on the part of the practice.
While appropriate pain management will always be a key consideration, pain contracts also should address fees, services to be provided, behavior expectations, and limitations or prohibitions. Pain management providers have a professional and ethical obligation to manage their own pain appropriately. Inconsistency of care or non-evidence-based prescribing are potential sources of liability; therefore, practices have an interest in controlling how medications are prescribed and administered.
Contracts may provide that the practice is not responsible for any injuries arising from medications or treatment used or provided to the patient, except in cases where negligence can be shown . Medical practices have an interest in restricting the patients’ actions in certain ways to prevent liability, such as by explicitly stating that the practice does not provide emergency services and is not liable for injury arising from failure to obtain such services.
Although many patients fear being labeled as being "drug-seeking," many practices find it useful to explicitly include in their contracts a recognition that UTIs, certain diagnostic tests, and medication agreements can be stressful and dehumanizing for the patient. Acknowledging and normalizing their feelings may be a good way to open a dialogue with the patient about fears and concerns.
Medications will be listed in the contract, along with limits on how and when these medications will be delivered and how frequently doses may be filled. The patient will be required to sign a written waiver of liability for the practice, the practitioner, and all employees. In cases where appropriate, this can help prevent liability from claims by current patients or major insurance payers.
For a variety of reasons, including the growing opioid crisis and the increased regulation of prescribing practices, pain management contracts are increasingly popular for both pain management practices and their patients. Effective pain management contracts can help both parties achieve appropriate outcomes and avoid disputes, as well as structure arrangements in a way that prevents liability and malpractice claims.