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Rhode Island Board of Medical Licensure and Discipline
BOARD OF MEDICAL LICENSURE AND DISCIPLINE
ADOPTS GUIDELINES FOR LONG TERM PAIN MANAGEMENT
The Rhode Island Board of Medical Licensure and Discipline continues to see cases in which serious problems in the management of long-term intractable pain are encountered by patients and physicians. The board is aware of the perception that many physicians "under-treat" such patients based on a fear of "causing addiction"; on the other hand, we receive many allegations of the improper, sometimes illegal, "over-use" of controlled substances. The prescribing of controlled substances in every state is regulated by state and federal law. The Board is aware that there is a national problem relating to pain management. Accordingly, the Board has undertaken a review of guidelines adopted by various state medical boards (Colorado, Texas, New Jersey, Massachusetts and California) concerning the appropriate management of patients with long-term intractable pain. The Board of Medical Licensure and Discipline was most impressed with the guidelines that the State of California has released.
The California guidelines resulted from a state sponsored summit in which 120 health care practitioners, professional and public educators, representatives from professional schools and associations and health care consumers met to recommend solutions to legal, professional, and educational barriers to effective pain management. A report, Summit on Effective Pain Management: Removing Impediments to Appropriate Prescribing, was issued by the Governor of California. This comprehensive report was reviewed by the Board of Medical Licensure and Discipline as part of its decision to adopt the following guidelines to help the practicing physician dealing with this difficult problem.
GUIDELINES FOR LONG TERM PAIN MANAGEMENT
1. HISTORY/PHYSICAL EXAMINATION
A medical history and physical examination must be accomplished. This includes an assessment of the pain, physical and psychological function, substance abuse history, assessment of underlying or coexisting diseases or conditions, and should also include the presence of a recognized medical indication for the use of a controlled substance.
2. TREATMENT PLAN, OBJECTIVES
The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. The physician should tailor drug therapy to the individual medical needs of each patient. Several treatment modalities or a rehabilitation program may be necessary if the pain has differing etiologies or is associated with physical and psychosocial impairment.
3. INFORMED CONSENT
The physician should discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative. This discussion should be documented and signed by the patient, guardian or authorized representative.
4. PERIODIC REVIEW
The physician should periodically review the course of opioid treatment of the patient and any new information about the etiology of the pain. Continuation or modification of opioid therapy depends on the physician's evaluation of progress toward treatment objectives. If the patient has not improved, the physician should assess the appropriateness of continued opioid treatment or trial of other modalities.
5. CONSULTATION
The physician should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. In addition, physicians should give special attention to those pain patients who are at risk for misusing their medications including those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse requires extra care, monitoring, documentation and consultation with addiction medicine specialists, and may entail the use of agreements between the provider and the patient that specify the rules for medication use and consequences for misuse.
6. RECORDS
The physician should keep accurate and complete records according to items 1-5 above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, agreements with the patient, and periodic reviews.
7. COMPLIANCE WITH CONTROLLED SUBSTANCES LAWS AND REGULATIONS
To prescribe controlled substances, the physician must be licensed appropriately in Rhode Island, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration and the General Laws of the State of Rhode Island relating to the Board of Medical Licensure and Discipline and the Division of Drug Control of the Rhode Island Department of Health.