Really weird doctor experience today. Would love insights.
March 16, 2015 1:03 PM   Subscribe

This is a probably a minor doctor issue, but I'm having a hard time figuring out if I should make a complaint or not. Mostly, I don't want to make a complaint if it would not be taken seriously. Content within.

I have been taking tramadol for many years. I also smoke marijuana. I have consistently made clear my marijuana use for many years to every single doctor. I experience excruciating nerve pain, intermittently, that consistently disrupts my sleep and sometimes makes it difficult to work.

Today I went to the doctor because my pain has been worse, and I also want to find ways to control my pain when I can't smoke. I was told that because the DEA declared tramadol a controlled substance, that if I wanted to continue taking tramadol that I had to sign a 'contract' full of little nuggets like 'do not sell your drugs on the streets' and also mandatory urine tests.

My doctor declared that she would not prescribe tramadol if I was smoking marijuana, and then changed her mind.

I asked for a referral to a pain specialist, and I was told that the pain specialist office would not work with me if I was smoking marijuana. Sure, they'll give me medicalized heroin in the form of oxy or whatever, but no weed.

My immediate fix is that I'm getting off the tramadol. A urine test wouldn't hurt anything but my pride, but oh, my pride. And I'll just smoke more weed and white knuckle it when it can't. The doctor said, no, stay on the tramadol and my inner response was ha ha take your U R A junkie contract and shove it up your ass.

But, I was humiliated, my pain was not addressed, and the doctor was combative.

Beyond getting another doctor, one who is not combative and rushed, I would like to contact the office ombudsman and complain about 1) The doctor's affect and 2) This junkie contract and the invasiveness of urine tests. However, especially after today, I sort of feel my pot head status eclipses any complaint I might make.

So my question is: is it even worth the time to complain, especially when I could be using that time to get another doctor. Another question is: am I being completely oversensitive here? Are piss tests routinely required by doctors before they prescribe you medicine?
posted by angrycat to Health & Fitness (16 answers total) 2 users marked this as a favorite
At least in my pain doctor's practice, this is standard. And like you say, it sucks, because I too have in the past found herbal remedies to help with my pain. But if I want to keep getting the tramadol (which helps immensely and which, unlike the other stuff, I can take at work), I have to submit to random piss tests.

I will say that prior to my first appointment with them I bought some home tests cheaply off Amazon to assuage my anxiety over it. I passed those, and I passed the doctor's test, and I've given up self-medicating since so I can stay on my pain contract. It's medieval but that's the way it is these days.
posted by fiercecupcake at 1:19 PM on March 16, 2015

Oh, one more thing. I sounded much like you after my first appointment with the pain doctor. He seemed totally unhelpful, even arrogant, and off-putting. On subsequent appointments, once I'd proved myself to be Not a Junkie and an intelligent and compliant patient, then I got more willingness to work with me, and we've tried several things, one of which has absolutely changed my life. I don't approve of this mindset from doctors, but I can understand it when they basically have to assume everyone coming to them is just trying to score drugs.

This whole system is fucked up, obviously.
posted by fiercecupcake at 1:22 PM on March 16, 2015 [4 favorites]

Hmm, what are you hoping for? The easiest option right now is probably to shop around for doctors until you find one you're comfortable with. Everyone’s style is different and not everyone has a “pain management contract” which you would object to.


If you want to understand where this doctor is coming from, and why providers might have this response, read on:

There is a huge and growing prescription drug abuse problem in this country. Increasingly, people turn to their doctors to get opiates which may or may not be therapeutic, depending in part on how you define therapeutic. Doctors are in a really shitty position of being asked to provide opiates when they may or may not think that those opiates are appropriate. They also tend to lack training in when those medications are appropriate, what the risks are around dependence, etc. Few doctors went to med school to become drug dealers, but, depending on where they practice, a huge amount of their time may be taken up dealing with people coming in requesting pain meds. It doesn’t feel like you’re healing people when you’re doling out pain meds to such large numbers of people, so many practices have created various types of “contracts” (not enforceable by law), requiring patients to meet xyz criteria in order to continue to receive pain meds. Personally, I find these efforts, to put the breaks on massive pain med prescriptions, to be a positive move, but one that can cause quite a bit of consternation and at times suffering to specific individuals. Each provider’s style of presenting these contracts differs and some people have better bedside manner than others (another area in which doctors are woefully undertrained).

Medical Marijuana adds an additional layer of confusion. In my state, California, medical marijuana cards are laughably easy to attain. There is very little “medical” about them. While there isn’t really evidence that chronic marijuana use is as physically unhealthy as many other substances, namely the most widely-accepted and also dangerous drug, alcohol, it is not free from problems. Some providers, depending on their personal orientation, may be more uncomfortable with chronic marijuana use due to it’s association with poor motivation, memory loss, depression. Very likely this particular provider just has a bias against marijuana and thinks it’s a drug and drugs are bad sooooo…

Chronic pain involves an extremely complicated stew of physical, social, and psychological factors. Depending on the person, chronic can be improved by exercise, meditation, placebos, and just time passing. Many providers are loathe to get into a long term cycle of giving opiates when the research doesn’t show this to help resolve chronic pain. While this can be critiqued: many researchers believe pain is undertreated, it also comes from, what to me, is a legitimate concern that the treatment is not therapeutic and does have risks.

In any case, as I say, you probably will have the best luck just shopping elsewhere for a different doctor. I doubt you have a basis for a complaint however your provider might benefit from feedback if you thought she was rude or disrespectful.
posted by latkes at 1:23 PM on March 16, 2015 [5 favorites]

I guess it depends what your goal of the complaint is. I sort of doubt that the ombuds office has the power to force the doctor to get rid of their pain med contracts (and I'm not clear which, if any, portions of it could be required by law, given the doctor's statement). Certainly they cannot force the doctor to prescribe you anything. And I'm also skeptical that a complaint will convince the doctor to be nicer, although I suppose it's possible that if many people make this complaint, there could be some pressure depending on how the doctor's office works. But, at the point where you're ready to complain and you don't need THIS doctor because they're a super specialist in your diagnosis, I think the energy is probably better spent on finding someone new who better serves your needs.

I'm also not clear whether this is a new doctor or someone you've been seeing for a while. It certainly does seem odd that if this doc has been prescribing the drug to you for years, you'd suddenly need a big contract to continue the prescription. In that case, it might make sense to push a little if you have otherwise had a good relationship over the years. If it's a brand new person, then I'd just cut my losses.
posted by rainbowbrite at 1:45 PM on March 16, 2015

Response by poster: not that I think that this makes a difference but:
1) My condition is permanent -- spinal cord injury with paralysis. The pain is expected to be life-long.

2) I'm not a new patient. I've been seeing her for years, and been with the practice before that. Each doctor at the practice a) has prescribed tramadol b) known about the marijuana use.

3) The choice I've made is not take the tramadol, and I'm fine with that. I'm not asking the doctor to prescribe it for me -- my aim is not to find a doctor who will prescribe tramadol knowing I'm on weed. Tramadol just doesn't do that much for me, and if it provokes junkie contracts, fuck that.

4) I think the answer is just find another doctor -- not because I need a new drug but because of the very uncivil way in which the issue was addressed -- but if there are any doctors reading this, please know that not all patient pain complaints are illegit, and for christ sakes as a human don't just treat all your patients that they are doing smack on the sly.

Thanks all for your answers -- I sensed going to battle on behalf of potheads in pain was not going to be a good use of time. Maybe volunteering for medical marijuana in PA will distract me from rude doctors.
posted by angrycat at 1:59 PM on March 16, 2015

With 4), just know that doctors dealing with pain issues are apt to be standoffish on the first visit, in the experience of me and close friends. The Catch-22 of it is, too, that trying to be proactive and find a doctor who will work well with you can also make it look like you are doctor shopping. That entire system is set up so that you can't win.

Best thoughts to you. I know this is maddening.
posted by fiercecupcake at 2:04 PM on March 16, 2015 [1 favorite]

As far as I know (as per a relative's dealings with his pain doc) the contracts and piss tests are common nowadays and it's a simple CYA issue (Cover Your Ass) on the doctor's part. Actually as I understand it, at least where I live, the pee tests are required for the doc to keep their licensing.

As for the marijuana, even here in CA all of my relative's doctors decline to prescribe it even though they could if they wanted to - they say it makes them uncomfortable. There's still a big bindspot there for doctors culturally. (Although my relative's pain doc contract states that you can take it with your pain meds as long as another doctor is overseeing.)

So while you can complain about all of this stuff and look for new dr's it's unlikely to do you any good.

Have you tried any other non-narcotics? Gabapentin helps some people with nerve pain.
posted by bleep at 2:19 PM on March 16, 2015 [1 favorite]

Yeah, unfortunately, the War on Drugs has set its sights on doctors, not just patients. Doctors who are found to be prescribing painkillers to patients who are "drug seekers," or prescribing too much, or prescribing without putting draconian monitoring requirements on their patients, can be charged with crimes, lose their medical licenses, and even go to prison. Do some research on your state's laws, but it may be that your doctor has no choice in the matter.

That said, even if the doctor is under ridiculous restrictions, there's no reason to be rude to you, and if you don't like her bedside manner, find a new doctor.
posted by decathecting at 2:52 PM on March 16, 2015

My doctor declared that she would not prescribe tramadol if I was smoking marijuana, and then changed her mind.

My surgeon and pain management doctors that I've been to all require this type of contract. It's to make sure your taking your drugs and not selling them, not to bust you for smoking pot. In the end your doctor agreed to provide you with the medicine if you sign the contract. It's not that big of a deal, I've had to do it with several doctors.
posted by Grumpy old geek at 3:22 PM on March 16, 2015

I'm sorry your doctor's interpersonal manner was abrupt and you felt so frustrated by the experience. I'd like to just clarify some of the things that are probably going into their decision to have you sign a contract. This isn't meant to devalue your experience, just to provide some clarification.

Tramadol was reclassified as a DEA Schedule IV drug last summer, which means that it is now subject to oversight and restrictions that it wasn't before. Your doctor's office may have been doing these pain contracts/urine tests before now for people on other narcotic medications but had not asked you for one because it wasn't on their list of controlled substances.

There have been a number of high-profile cases of doctors being sued for malpractice or even for criminal behavior due to insufficient oversight of patients on controlled substances--physicians have been successfully prosecuted for prescribing controlled substances to patients who had red flags for abuse or misuse (which can include taking opiate medications with recreational drugs of any kind), even when the patient had a good reason to need the medication in question. In addition, misuse/abuse of prescription medications is now being recognized as a very serious cause of both hospitalization and death and doctors are under increasing pressure to provide justifications for their use of controlled substances as well as to monitor patients who are receiving them.

Having a pain/narcotic agreement with patients and doing regular urine drug screens for all patients on chronic scheduled medications are now considered to be clinical best practices. The reason for the contract is that having an agreement up front helps set mutual expectations about how the medication will be handled (refill frequency, dose adjustments, etc). I used to work in a big practice that had a lot of patients on chronic opiates and there seriously was not a single day that went by without someone complaining that they had lost their prescription, or that it had been stolen, or that their pain was just so bad that they had taken their whole month's supply of pills in the last 10 days. I'm not making a judgment here about the patients' truthfulness, people do lose stuff and have their things stolen, but when you're asking practitioners with different levels of comfort with habit-forming medications to deal with these issues every day, it makes sense to have a practice-wide policy on these things that everyone can agree with and which is disclosed to patients up front instead of leaving it to the individual provider and the patient to work out on a one-to-one basis every time.

The urine drug screens are unpopular and a bit of a blunt instrument, but are the closest thing available to objective evidence about how people are taking their medication. In general, the guidelines for using them suggest that they be used with ALL patients on controlled substances. The reason for doing this is that getting these tests only when you have a suspicion that someone is misusing/abusing medication will 1) ruin any doctor-patient trust and 2) fail to identify most of the people who are actually misusing/abusing the medication. If you're going to do it, it's better to do it for everyone.

All this is to say that it sounds like your doctor didn't communicate well with you, but that the decision to ask you to sign a pain agreement and do urine tests is probably not about you and your marijuana use per se, but more about changes in the regulatory environment for pain management in general and tramadol in particular. This isn't medical advice, but I think it's reasonable for you to try to find a pain specialist, especially since it sounds like your pain isn't well controlled, but you should probably be aware that most pain specialists also now have similar protocols in place.
posted by The Elusive Architeuthis at 3:26 PM on March 16, 2015 [7 favorites]

Response by poster: but do doctors have to be assholes about it tho

seriously, I understand the legislative landscape now, thanks to the above comments.
posted by angrycat at 3:34 PM on March 16, 2015

The ombudsperson might be unresponsive in regards to the contract and your continuing pain, but the bedside manner issue is in their wheelhouse. You shouldn't leave a doctor's appointment feeling "humiliated." Even if nothing happens as a direct consequence of your complaint, something good could come of the information down the road. You're probably not the only one who has left an appointment with that doctor feeling that way.
posted by MrBobinski at 4:13 PM on March 16, 2015

Hey angrycat! I came here to second what it seems MrBobinski has just said above. I live and work in California (a mmj state) where access is a nonissue, and most doctors are relatively up to speed with this (despite what at least one commenter above said... at which point I decided to stop reading comments nad just respond to you).

Whether or not your state has legal mmj, the 'community' of medical researchers and practitioners in the US is very, very keenly aware of not only the debate over its effectiveness in the pharmacopeia, but also the bullshit nature of the most common old-nut physician complaints about it. And I'm saying this as a regulatory toxicologist who reads through new drug applications' pharmacological safety submissions every day.

So, yes, you're not going to be granted an exception, but you can and should get in touch with the ombudsman (and follow up with them) for their failure to address your concerns with adequate care, sensitivity, and--importantly--information. If your doctor suggested that, for instance, you are using your injury as an excuse to seek drugs (or however it was phrased), an ombudsman complaint is a way to ensure that has been documented in the appropriate way. If you've already decided to break your relationship with said physician, I'd also send a letter to their offices noting as much, and indicating that you'd complained to the ombudsman.

Lastly, as someone with Crohn's who sought mmj for fourteen bitter years rather than make due with prednisone and nsaids per received medical wisdom, I can't tell you how much better my quality of life has been since moving to a place where it's legal. My dispensary is a nonprofit that hosts pain clinics, convenes zen meditation and mindfulness hours, organizes chronic pain support groups with volunteer doctors and massage therapists, and offers precisely zero judgment. Pfizer et alia don't do that, and neither have any of my previous pre-mmj physicians. I didn't move here because of that, but looking back, had I known the ease it would bring to my life, I would have. If you can't get to where access is safer, I hope it comes to your place of residence sooner than later.
posted by late afternoon dreaming hotel at 4:35 PM on March 16, 2015 [3 favorites]

I just wanted to add a voice of support in agreement that a 'contract' is ridiculous and pee tests are condescending and dismissive. I would absolutely complain and state very clearly that you have been seen by other doctors in the clinic for years, are not a junky off the street AND ARE IN PAIN(!!!!)

Just because you are a patient doesn't make you a child. And there are ample states now that have legalized marijuana for medical purposes (and research to support its use) that there isn't any reason a doctor has to give you a hard time about it. If they want to cover their butt, they should say so and apologize for making you sign a dumb contract. And if they are doing this because it is contraindicated they should say so.

I'm mad for you.
posted by Toddles at 9:34 PM on March 16, 2015 [1 favorite]

If they want to cover their butt, they should say so and apologize for making you sign a dumb contract. And if they are doing this because it is contraindicated they should say so.

I'm mad for you.

Me too. And the fact that you've been seeing her for years makes her inept handling of the situation even more galling.
posted by homunculus at 12:00 AM on March 17, 2015

I think the above posters covered the legal situation pretty well- its a damn bad time to be a pain specialist in the USA right now, and between insurance, your elected representatives, and the War on Drugs, and their own conscience, desire to help, and, well, the really really bad patients they see day in and day out- and trust me, pain doctors often/sometimes see out and out junkies... it gets really hard and really frustrating.

However, you are paying them $$$ to not be an ass to you. I sincerely doubt any drug testing/contract stuff was MEANT to be be condescending/accusatory or abrasive... after all, those ARE a reality in the legal drug world now. But if you felt she went too abrasive in trying to explain it, that is 100% a grounds for discussion with her or her supervisors. Is there an office manager?
posted by Jacen at 3:25 PM on March 18, 2015

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