Chronic Pain Management of the Noncompliant Patient
Question: How do you treat the noncompliant patient?
Answer: First, who are noncompliant patients? They can include those who:
- Repeatedly fail to show up for scheduled appointments
- Fail to take prescribed medications or else take too much or make changes on their own
- Continue to smoke, drink, overeat, or use too much salt
- Do not get imaging studies, laboratory tests, or other diagnostic procedures
- Drop out of physical therapy prematurely
- When referred to specialists, do not make or keep their appointments
- Are abusive to staff members
Most physicians cut such patients slack for extended time periods, especially when dealing with patients’ ingrained behaviors, which we know are difficult to change.
When, however, the patient is being seen for chronic pain and is being prescribed controlled substances, the health care professional’s laxity in dealing with noncompliance is not only deleterious to the patient’s well being, but can also result in regulatory scrutiny and adverse consequences for the prescriber. Most of these problem behaviors are spelled out in pain management agreements that patients are supposed to sign when chronic opioid therapy is begun, and patients are told that breaking any part of the agreement can result in dismissal from the practice or at least in termination of opioid treatment. Noncompliant chronic pain patients may repeatedly report lost or stolen medications, obtain controlled substances from more than one prescriber without legitimate reason, or produce urine drug screens that report illicit substances or fail to show prescribed drugs. These are “red flags” that suggest possible drug abuse, addiction, or diversion.
It is important to investigate every episode of noncompliant behavior, and document in the chart your findings, conclusions, and what actions were taken. Also, check your state’s prescription monitoring program Web site to confirm that controlled substances were not obtained from multiple providers. A single episode of noncompliance can be a learning experience for the patient. Counsel him or her about the importance of obtaining diagnostic studies, going to physical therapy or consultations with specialists, keeping appointments (no-shows should be documented in the chart), and taking medications as prescribed. Claims of stolen medications should be buttressed by police reports and should result in new plans for assuring the safety of the medications, such as keeping them in a lock box. If the behaviors are repeated, consider discharging the patient or, alternatively, offer to continue seeing the patient while no longer prescribing opioids. If the urine contains cocaine, amphetamines, or other drugs of abuse, refer the patient to an addictionist or addiction counselor for diagnosis and treatment as a prerequisite for even considering continuing to prescribe controlled substances.
Many patients just need some education on how to be adherent. As for the rest, many more of the recidivists whom I have had to discharge for noncompliance have had personality disorders—narcissistic or antisocial, leading to a sense of entitlement and belief that the rules do not apply to them, etc—rather than an addiction disorder. It is difficult to persuade patients with personality disorders to change their behavior.
—Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management