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Vermont Board of Medical Practice
VERMONT BOARD OF MEDICAL PRACTICE
REPORT OF THE PRESCRIBING PRACTICES COMMITTEE
Statement of Problem
Pain comes in many shapes and sizes: acute pain following random trauma and following surgical procedures; chronic pain associated with cancer and other progressive conditions, chronic pain with other etiologies sometimes difficult to clearly establish. Physicians must conscientiously and adequately treat pain. Many treatment modalities are available, including federally-regulated drugs. Pain management specialists suggest some pain, as examples, chronic cancer pain and post-operative pain, may be inadequately treated because of ill-founded concerns about the development of dependence or addiction. At the other end of the spectrum, physicians may be duped or lulled into over-prescribing controlled drugs for patients with poorly-defined pain complaints.
The Board seldom receives complaints suggesting inadequate treatment of acute pain and cancer pain. In reviewing patient records for other concerns, we do have a non-scientific sample which supports the observation that acute pain and chronic cancer pain are adequately treated by our licensees. However, we must accept literature findings that offer a less favorable picture, that is, both post-operative and cancer pain are often inadequately treated.
We do receive complaints and reports of suspicious prescribing practices for chronic non-cancer pain. Let us emphasize that we recognize that chronic non-cancer pain does exist and should be adequately treated. However, the physician who treats these often challenging patients should adhere to certain basic principles which have been more precisely delineated in recent years.
A surprising number of licensees appear to be unaware of the very real potential for being sought out as a source of controlled substances by drug-seeking individuals who want these agents for purposes other than legitimate pain relief.
The Board of Medical Practice, which must review all complaints and reports, views either under or over treatment (prescribing) as a quality-of-care issue which requires a determination whether the practice rises to the level of unprofessional conduct. This report represents a consensus statement which will guide the Board in the evaluation of complaints regarding treatment of pain in general and prescribing practices for non-cancer pain in particular.
Consensus Statement of Practice Principles
Numerous drug and non-drug therapies are used for pain management. The proper treatment of pain requires careful diagnosis of etiology, selection of appropriate therapies and ongoing evaluation of treatment efficacy. Opioid analgesics and other controlled drugs remain the cornerstone in the management of acute pain due to trauma and surgery and in chronic pain resulting from progressive diseases such as cancer. Large doses may be necessary to control pain, because of severity. Extended therapy may be necessary when pain is chronic. A physician who fails to adequately relieve pain under these circumstances is open to criticism regarding the quality of care provided.
The Board recognizes that opioid analgesics can be useful in the treatment of intractable non-cancer pain, especially when efforts to use other therapeutic modalities have failed. The pain may have multiple etiologies which require several concurrent therapies, including opioid analgesics and other controlled drugs. The extent to which pain is associated with physical and psychosocial impairment varies greatly. Thus, patient selection for a trial of opioid therapy should include a careful assessment of the disability experienced by the patient as well as the pain. Reasonable use of other health resources and evaluation of the results of therapy, including the degree of pain relief and improvements in physical and psychosocial function, are essential parts of the total care plan. As a general rule, the primary treating physician should consult with a specialist in pain management before committing to a long-term opioid treatment plan.
Physicians should pay particular attention to patients who misuse prescriptions or have a history of drug abuse or diversion. Failure to make a conscientious inquiry into these areas could create a problem for the physician in defending the overall quality of the ultimate care plan, while quickly earning a reputation as an "easy mark" for access to drugs for other than legitimate purposes. Managing drug-seeking patients presents a special challenge in monitoring. Undoubtedly, consultation with a specialist colleague with training and experience in pain management and addiction medicine is a wise choice, both for optimal patient care and physician education and protection.
Management of chronic non-cancer pain, especially when long-term opioid therapy is involved, presents a time-consuming challenge to the practitioner. Meticulous attention to adequate record keeping is essential. Careful documentation of the rationale for the management plan provides the best defense against any accusation of inappropriate controlled drug prescribing.
Under federal and state law, it is illegal to prescribe controlled substances for other than legitimate medical purposes. Addiction maintenance or withdrawal therapy is permitted only within a legally-endorsed methadone maintenance program.
We believe the following Basic Principles summarize a reasonable set of requirements for safe and effective management of chronic pain.
Basic Principles
1. History and 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
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 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 psychological impairment.
3. Informed Consent
They physician should discuss the risks and benefits of the use of controlled substances with the patient or guardian.
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 require the use of agreements between the provider and the patient that specify the rules for medication use and consequences arising from misuse.
6. Records
The physician should keep accurate and complete records describing 1 through 5 above.