|
|
|
Montana State Board of Medical Examiners
MANAGEMENT OF CHRONIC PAIN
STATEMENT ON THE USE OF CONTROLLED
SUBSTANCES IN THE TREATMENT OF INTRACTABLE PAIN
The Montana Board of Medical Examiners continues to be concerned about the use of controlled substances by individuals who seek them for their mood-altering and addictive potential rather than legitimate medical reasons. However, the Board is also concerned about adequate pain management. The Board recognizes that pain from whatever cause is often under treated. The Board is aware that there are a number of factors that continue to interfere with effective pain management. These include exaggerated fears of opioid side effects including addiction, fear of legal consequences when controlled substances are used, low priority of proper pain management in our health care system, and the lack of integration of current knowledge concerning pain management into medical education and clinical practice.
The Board seeks to assure that no Montanan requiring narcotics for pain relief is denied them because of a physician's real or perceived fear that the Board of Medical Examiners will take disciplinary action based solely on the use of narcotics to relieve pain. While improper use of narcotics, like any improper medical care, will continue to be a concern of the Board, the Board is aware that treatment of malignant and especially nonmalignant pain is a very difficult task. The Board does not want to be a hindrance to the proper use of opioid analgesics. Treatment of chronic pain is multifactorial and certainly treatment with modalities other than opioid analgesics should be utilized, usually before long term opioids are prescribed. Use of new or alternative types of treatment should always be considered for intractable pain periodically, in attempts to either cease opioid medications or reduce their use.
The proper use of opioid analgesics for chronic pain must involve certain elements, which are also consistent with any quality medical care. The following guidelines will help assure the proper use of these medications for chronic pain and minimize the improper use:
GUIDELINES FOR PRESCRIBING OPIOID ANALGESICS FOR CHRONIC PAIN
1. Thorough history and physical examination. Included in the history is assessment of the etiology of pain, physical and psychological function of the patient, substance abuse history, other treatments that have been attempted to control the patient's level of pain, identification of underlying or coexisting diseases or conditions and, as much as possible, statements by all treating physicians that the patient's pain is intractable and not controlled by other than the use of opioid analgesics.
2. Treatment plan. A thoroughly documented, written treatment plan should be established and should include how treatment success will be evaluated, such as pain relief and improved physical or psychological functioning. Several treatment modalities should be utilized in most cases and should be done concurrently with the use of opiates. Periodic review by the physician should be accomplished to determine that there are no other appropriate treatment methods that would then be of additional benefit to the patient.
3. Informed consent. The physician should discuss the risks and benefits of the use of controlled substances with the patient and/or guardian and this should be accomplished on an ongoing basis, not just at the initiation of treatment.
4. Appropriate referral. If treatment objectives are not being realized or if patients appear to be at risk for misuse of medications, referral should be made to appropriate specialists including addiction specialists and chronic pain specialists.
5. Documentation. All the above recommendations and guidelines should be recorded accurately and completely in the patient's medical record.
We hope that the above statements and guidelines will help reverse the trend of under treatment of intractable pain, and that they will facilitate the more appropriate use of controlled substances by duly licensed practitioners with prescriptive authority in the State of Montana.
-Montana Board of Medical Examiners, March 15, 1996