A 42-year-old man comes to the clinic to discuss pain management. He wants to establish care as a new patient after recently relocating to the area. The patient has chronic back pain due to a motor vehicle collision 5 years ago that led to several back surgeries. The pain usually does not interfere with work or day-to-day activities. Medications include oxycodone, naproxen, and acetaminophen. A review of the state prescription drug monitoring program database shows no irregularities. The patient is asked to sign a controlled substance agreement. After reading through the agreement, the patient becomes upset, saying, "Why do you have to treat me like a drug addict?" Which of the following is the most appropriate response?

Question

A 42-year-old man comes to the clinic to discuss pain management.  He wants to establish care as a new patient after recently relocating to the area.  The patient has chronic back pain due to a motor vehicle collision 5 years ago that led to several back surgeries.  The pain usually does not interfere with work or day-to-day activities.  Medications include oxycodone, naproxen, and acetaminophen.  A review of the state prescription drug monitoring program database shows no irregularities.  The patient is asked to sign a controlled substance agreement.  After reading through the agreement, the patient becomes upset, saying, "Why do you have to treat me like a drug addict?"  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: Opioid misuse (eg, overuse, diversion) poses safety concerns both for the patient and the public. Prior to initiating chronic opioid therapy, both the patient and physician should sign a controlled substance agreement (informally referred to as a "pain contract"), which outlines the following: Informed consent for chronic opioid therapy, including the risks for dependence and addiction Prohibition of use that deviates from the dosage and purpose for which the opioid is prescribed Requirement of random urine drug screens and pill counts Designation of 1 prescriber and 1 pharmacy for all controlled substance prescriptions (barring exceptional circumstances) Statement that lost or stolen medications may not be replaced with an early refill Because the agreement may be perceived as accusatory, the physician should emphasize that it is a standard safety procedure and is required for all patients on chronic opioid therapy. The purpose is not to inflict punishment, although consequences (eg, suspension of future prescriptions) exist for breaching the agreement (Choice C). (Choice A) Emphasizing that the agreement helps identify "who is or isn't an addict" would further reinforce the patient's feelings of being accused by the physician. (Choice B) This response does not address the patient's perception that he is accused of being an "addict." Instead, the physician should rectify the misperception by explaining that the agreement is standard procedure for all patients. (Choice D) Although a physician's medical license may be suspended or revoked for inappropriate prescribing, this information does not explain the purpose of the agreement from the patient's perspective, which is to ensure the patient's safety. Educational objective: A controlled substance agreement should be signed by every patient prior to the initiation of chronic opioid therapy. Although patients may perceive the agreement as accusatory, the physician should emphasize that it is a standard safety procedure. References: How to monitor opioid use for your patients with chronic pain. (http://www.ncbi.nlm.nih.gov/pubmed/25403045)

A 42-Year-Old Man Comes to the Clinic to Discuss Pain