Recently I encountered five patients on my morning schedule, all of who presented with a chief complaint of pain and reminded me just how difficult these patients can be to manage. Each patient encounter was a little different, as is the nature of the subjectivity of pain, but each ended with a similar diagnosis and treatment plan.

Pain is the one concern that more often than not prompts people to see a health-care provider, so adequately addressing these complaints can significantly influence the relationship you have with your patients.

Pain knows no age, race, gender or boundaries. It can range from acute to chronic to life-long and can affect the head, the toes and everywhere in between. It is also the one symptom that can take your list of differential diagnoses from two to twenty in a matter of seconds.

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If I had the choice, as a primary care provider I would only treat acute pain, because I know that there is a better chance of reversing it and subsequently gaining my patients’ trust. Treating chronic pain can be challenging. If your patients have access to health care and adequate health insurance, you can refer them to orthopedics, physical therapy or even pain management.

But what do you do if your patients are uninsured, work jobs without security or benefits that require strenuous activity, and the only thing that gets them through the workday is the use of narcotic medication every four to six hours? 

These patients usually see multiple health-care providers. Typically this happens because our medical knowledge and training tells us they are addicted and exhibiting drug-seeking behavior, so we stop prescribing the narcotics. When this happens the patient then finds another provider with hopes of their pain being “fixed” with a similar regimen of three-to-four pills a day, as-needed.

What concerns me is that these patients often have a number of other co-morbidities that need to be managed but are not, because the focus of most of their health-care encounters is pain.

In my experience, a patient treatment contract can be useful to establish appropriate communication with patients’ whose chronic pain you have no other choice but to manage with narcotics. With the right wording and appropriate patient-provider conversations about treatment, these contracts are a good solution to the difficult task of balancing your patients’ needs and safely managing their chronic pain.

Patient treatment contracts are signed by both the provider and the patient, and provide expectations and requirements that must be upheld during treatment. At each encounter, the contract should be reviewed, and both parties held accountable for adhering to its stipulations. Describing side effects of narcotic use, consenting to random urine drug screens, keeping appointments as scheduled and ensuring that pain medication is received only from the provider with whom the patient is in contract, are among useful items to include.

Leigh Montejo, MSN, FNP-BC, provides health care to underserved populations at the Metropolitan Community Health Service’s Agape Clinic in Washington, North Carolina.

Do you have tips for managing patients with chronic pain? Post it in the comment section below or email it to [email protected] and we’ll print them in the Clinical Pearls section.