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Shellipoo 11-01-2008 10:58 AM

Can someone explain how a pain contract works please?
I am a migraine sufferer, I get 4-5 migraines a week and mostly I manage them at home. I am on a prevention/abortive/rescue program which enables me to cope. Up until recently this has work well. Our local ER has a new doctor in charge who does not like me, his first reaction to me was that I was a drugseeker! Then after going thru my records he thought I was just a nutcase (I have a long history of depression, if you were in pain all the time you'd be depressed too).

This new ER doctor insisted I had to have a pain contract from my PCP before he'd treat me in the ER. Now I only use the ER for rescue, this is when my migraine reaches a pain level 7 or higher and/or I'm throwing up. Sometimes I go months without this happening, sometimes it happens a couple times a month.

So this pain contract says I can be treated with demerol twice per month. In otherwards they are telling me I can only have two bad migraines per month? My body is going to listen to this?? What if God forbid I have three? [B]Will they send me home in pain or will they treat me but with something else besides demerol?[/B]

I also have chronic kidney stones, I get 3-4 per year...these hurt like hell..worse than childbirth. [B]What if I've used up my allotment of demerol on migraines for the month...will they treat the kidney stone or let me suffer? [/B] From what I understood the pain contract was only supposed to state what medication I could have for the migraines (and the migraines only) when I discussed it with my PCP and [B]definetly not how often I could get the medication since I can't predict how often I'll need it!![/B]

This seems ridiculous! I'm not a drugseeker, I'm not a nutcase. I'm just an unlucky person in pain....what right to they have to tell me how often I can be treated for the pain and often I have to suffer thru it?? Is this really how a pain contract works?? Help explain it to me please and tell me I'm wrong....:(

janiee08 11-01-2008 11:03 AM

Re: Can someone explain how a pain contract works please?
Shelli, Have you ever tried Imitrex? I used to get migraines too and I found that Imitrex worked wonders.Janiee08

Shellipoo 11-01-2008 11:11 AM

Re: Can someone explain how a pain contract works please?
Yes...I use Imitrex and Maxalt MLT for abortives..
Thanks for answering!

Nicole74 11-01-2008 11:47 AM

Re: Can someone explain how a pain contract works please?
I'm getting a massive migraine now every 2-3 days due to the spinal injury I have aquired these past 5 weeks. I take maxalt and fiorinal to abort the headaches, which work well if I take it early enough. The thing I have to becareful of are rebound migraines by using the maxalt too often. I try and only take the medications twice a week. Every time my migraines are so bad I vomit, can't open my eyes, cant sit up or lay down, and the sounds are amplified in my head. It is absolutely horrible and agonizing pain. My husband sometimes has to stay home from work to get the kids off to school because I can't move. It's like living in a constant nightmare. I went online for research for a more natural way to prevent the migraines and I've heard that magnesium works well for a preventive. I picked some up at my local store and they have lessened after the first week. I did mention the magnesium to my doctor when refilling the Maxalt for her approval. In the mean time, I would find a different ER doctor or hospital. That is ridiculous, you should be getting the help you need.

Executor 11-02-2008 07:05 AM

Re: Can someone explain how a pain contract works please?
Sorry to hear about your problem Shellipoo. Migraines are no fun, that's for sure!

What you're describing from your ER Doc is absurd. First of all, what he's describing is not a typical pain contract. Contracts are usually employed by whatever Doc is primarily treating your pain (could be GP or PM Doc). The contracts state that you will only come to them for pain meds and not use any other Doc besides an ER. If you use an ER for emergency type situations, you are to tell them about your contract and your prior conditions & etc. More than likely, the ER would call your pain Doc.

Pain contracts also cover things like early refills, weekend calls, and other administrative factors. Essentially, a contract is often employed by Docs who Rx regular amts of narcotics to patients...The contracts establish the "ground rules" and expectations of the patient.

I've never heard of an ER limiting the amt of meds, or times you can get treatment per month. I'd be tempted to go over his head, but that's just me. You are exactly right...What if something happens a third time? Also, who says it has to be Demerol? What if something less would work? There are a lot of meds at a ER Doc's disposal besides Demerol.

Docs are supposed to use discretion. Maybe two per month on average may be a good starting point (assuming you agree), but that would have to assume an "average", not a absolute maximum (per month). What if one month, you didn't need any help, but the next month, they come in waves, and you get 3 or 4? This is where that "discretion" is important. And if the frequency became too much for their liking,then they would need to refer you to a pain Doc, or some other type of specialist who would prescribe accordingly.

I would circle back to my GP or whatever Doc is treating your migraines and tell him/her what is going on. I'd see what this Doc recommends. Maybe your Doc could call this ER and give them a "heads up" that you may need their services and why. I'd definitely get some type of new plan implemented....Get the Docs talking somehow, or have a letter written to them and get you a copy for your files...You could even take that with you to the ER if necessary.

I've heard all sorts of ER stories lately, and nothing surprise me...Everything from the very compassionate to no help whatsoever. Again, I think your best option is to talk to your main Doc and see what he/she recommends.

Best of luck to you, and I'm sorry this has happened.



chicubs 11-03-2008 04:21 AM

Re: Can someone explain how a pain contract works please?
I don't know if this will help you or not but I will tell you how my pain contract works for me. When I first started seeing my specialist for my RSD (Reflex Sympathetic Dystrophy), I needed to sign this contract right away.

I guess they figure the contract is very important! My contract states that If I should ever need to see another doctor that wants to prescribe a narcotic, I must tell them that I cannot have another doctor prescribe any narcotic medicine. That is except a doctor in the ER. But I still need to tell the ER about my contract.

My doctor is also very strict about her contract that I had to sign. I can see why this contract is so important. It also states that I may not have of my prescriptions early. That if my medicine is accidentally thrown in the toilet, thrown away, or any other reason, they will not refill it.

I am to call a few days before my medicine is gone to ask for the new prescription. I may be able to pick up the prescription early but it will say on the prescription that I may not have the medicine refilled until the date that she states on the prescription and she even circles that date . The contract also states that a urine sample will be taken randomly. Now I have been going to this doctor for three years and I have yet to have take a urine sample.

If by chance a urine sample comes back dirty I will be dropped from my doctor right there. No questions asked, She will just be finished with me.

I have never had any problems with the contract because I know how serious she is about following her rules.

But I do know someone that had asked for early refills of his medication. He did this more than once. So his doctor dropped him. He went thru some pretty bad withdrawals because he was unable to find another doctor that would treat him once they found out what happened when he was at his previous doctor.

I still feel that with a urine test that they should give you another chance for the test. Because I believe that there is a chance for a misread or mistake. Computers and people have been known to make mistakes!!! But they should take another urine sample from the patient right away. Just in case it is a case of the patients not being truthful with their doctor.

I hope things work out for you. I also hope you understand more on how contracts work. They may be a pain but the doctor's need to do this to protect themselves and because the DEA has such strict rules that the doctors have to enforce. So Good Luck. If things do not work out with your doctor, I do hope they work out with another doctor quickly. I always believe that the truth is be the best route. So just keep telling the truth because that is what will save you in all of this mess.

Take Care and Lots of Hugs,

Executor 11-03-2008 08:00 AM

Re: Can someone explain how a pain contract works please?
I just wanted to say that what Chris has described is very typical of a contract. Mine is very similar in nature. The contracts are very in depth and clearly outline the expectations of the patient. I might add that mine instructs me to not tell anyone about my therapy because if my meds are lost or stolen, they will not be replaced. My contract also states that by telling others about my therapy, I could put myself and my family at risk because someone may try to steal my meds or hurt me/my family in an effort to get them.

Therefore, I just do not understand what the ER Doc was trying to do...Makes no sense. This is why I would circle back to your Doc and inquire.

Good luck,


Shellipoo 11-03-2008 08:35 AM

Re: Can someone explain how a pain contract works please?
Okay...I'm starting to understand. What I signed sounds much like what you described. About how I will not get narcotics from another doctor, fill prescriptions early and all that.

BUT at the bottom of the contract my PCP wrote (at the ER doctor's instructions) that I am allowed to be treated in the ER with demerol no more than twice per month. It was written by hand below our signatures. That's where my confusion comes in. Exactly what does that mean?! :confused: Does it mean I can only be treated in the ER twice per month? Or does it mean I can only receive demerol twice per month?

Executor 11-03-2008 08:44 PM

Re: Can someone explain how a pain contract works please?
Honestly, I think you have to ask your GP. After all, he wrote it. I would discuss my concerns with him. I'm sure there has to be some room there for discretion. I mean after all, what happens if you get in a car wreck or whatever?

Most of the time, these contracts are to establish the ground rules for the patient, or outline the expectations. They may have written that to let you know that you can't run to the ER every weekend (not that you would, but hypothetically).

Take care,


Boxerluver 11-04-2008 06:06 PM

Re: Can someone explain how a pain contract works please?
Shelli, I agree with Ex that you need to speak with your doc and get these things clarified. Things can be added to your contract that both you and your doc agree on. For me personally I would not be comfortable with only being able to get demoral for migraines only 2 times a month if you have a history of needing it more than that. In addition, I would get something clarified concerning your kidney stones as well. That is a little easier as it's easier to prove you are having a kidney stone than a migraine.

I also get kidney stones all the time and I have only had problems a few times. Our local hospital has a policy if you go to the ER saying you have a kidney stone, instead of having you pee in a cup, they cath you and get a sample that way. I refuse. The last thing I need when I am having a kidney stone and am spasming is having a tube shoved up there so I refuse. I tell them to call my doc. They say they do the cath to get a clean sample, but I know they do it that way so addicts can't put blood in the sample. It's horrible how we have to have unnecessary things done to us to prove we are not drug seeking.

Sorry, didn't mean to go off there. What I was saying was unless they admit me when I am having stones, I might need to go to the ER a lot as stones can take weeks to pass, so you do not want to be limited in how many times you can go. Hopefully your doc will talk with you and you guys can compromise on what is reasonable. Personally I think you should be able to go and have as many shots as you need until your pain is managable and that may be 1 shot or 4. If your doc is not willing to work with you, I'd seriously consider finding a new one. I know that is a big hassle, but there are good docs out there. I heard of a doc who gave his migraine patient 3 shots a month. They kept the syringes at home so they didn't have to run to the ER. If they needed more, they called him and he called the ER with orders. So there are good docs out there you just have to find them.

Take care

Yeek 09-18-2011 04:45 AM

Re: Can someone explain how a pain contract works please?
I am an ER doc and I'd like to shed a little light onto this problem.

I actually think your doctor is taking some sensible precautions. Here's why:
1) Demerol is a notoriously dangerous drug - read Goldfrank's toxicology if you need more information. It has tons of severe drug interactions and toxic metabolites, to the point where it has been removed from the formulary of most ERs in New York City. Demerol is also known to produce a particular form of euphoria (in part because of its serotonergic activity) that makes it a big-time "seeker" drug. As one toxicologist put it, "it's an okay painkiller but gives a GREAT high." Any ER doctor who has a patient coming in frequently requesting Demerol is smart to be (a) worried about toxic effects and (b) concerned about drug abuse.

2) Opioid medications (dilaudid, morhpine, demerol, tramadol, percocet, vicodin, etc.) are famously bad migraine management drugs. Almost any neurologist will not recommend these as first line - they may be temporarily effective, but tend to enhance migraine rebound.

3) What I recommend is this: if you are one of the few migraine sufferers who can only be effectively treated with narcotics, you are indeed a rarity. Have your neurologist WRITE YOU A LETTER explaining this, with his/her contact information attached, and bring it with you to the ER the next time you have an attack. ENCOURAGE the doctor to call (many people forge such letters - don't act secretively or reluctantly about it). Remember, the ER doctor doesn't work for your neurologist, but they may work with them to treat you. Your ER doc is smart to be careful and not give you a dangerous synthetic narcotic right off the bat for your migraines - she can't just take your word for it. Give her evidence, and you'll probably find she's open to considering it.

PorcelainChild 09-20-2011 12:21 AM

Re: Can someone explain how a pain contract works please?
I am a chronic migraine sufferer myself and I have to agree with Yeek when they say that narcotics are typically the last line of treatment AND not particularly effective for most people. I'm not implying anything against you. It goes without saying that people respond differently to different treatments. However, I don't understand your need to go to the ER for demerol in the first place.... if your doctor believes that this is a good treatment method for you then why isn't he writing a prescription for a small supply? Also, what current preventative medicine are you on and if you don't mind me asking what other abortive migraine medicines have you tried? Sorry to hear you are suffering so badly. I hope things start to ease up soon<3

Yeek 09-20-2011 10:11 AM

Re: Can someone explain how a pain contract works please?
Lastly, I should point out that any pain contract between you and your doctor is an agreement between the two of you - it is not something that a third doctor (e.g. the ER doctor) is obligated to follow. There are some bad pain contracts out there, and there are times when certain drugs are just plain dangerous to give. The safety of a treatment must be based on the CURRENT condition of the patient, not on a piece of paper that was written weeks ago.

Therefore, I recommend presenting a pain contract as evidence of a chronic condition that you are trying to manage with your physician. This type of evidence goes a long way in showing the ER doctor that you are not someone who is randomly showing up demanding a controlled substance with a story that cannot be confirmed (especially on Friday nights, for example). Don't present a pain contract as something the ER doctor 'must' follow because another doctor - who is not present and is not aware of the current medical condition of the patient - agreed to as a guideline in the past. Most of this is plain common sense and politeness - if you treat your doctor like a pawn, she may treat you like a checker. Nobody needs any of that.

NOTSONUTSO 09-22-2011 01:15 PM

Re: Can someone explain how a pain contract works please?
I hate when I click on what looks like a new post only to find it's a thread from 3 years ago. We are not supposed to "resurrect" old threads.

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