Where We Stand
Section: Prescribing Guidelines
Policy: Use of Controlled Substances for Treatment of Pain

Appendix B

(Adapted from the policy of the Federation of State Medical Board of the United States, Inc., May 1998 and editorially modified to be applicable to a state medical association as opposed to a state licensing board.  Adopted by the Oregon Medical Association House of Delegates, April 25, 1999)

Section I.- Preamble

The Oregon Medical Association (OMA) recognizes that principles of quality medical practice dictate that the people of the State of Oregon have access to appropriate and effective pain relief.  The appropriate application of up-to-date knowledge and treatment modalities can serve to improve the quality of life for those patients who suffer from pain as well as reduce the morbidity and costs associated with untreated or inappropriately treated pain.  OMA encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially important for patients who experience pain as a result of terminal illness.  All physicians should become knowledgeable about effective methods of pain treatment as well as statutory requirements for prescribing controlled substances.

Inadequate pain control may result from physicians’ lack of knowledge about pain management or an inadequate understanding of addiction.  Fears of investigation or sanction by federal, state, and local regulatory agencies may also result in inappropriate or inadequate treatment of chronic pain patients.  Accordingly, these guidelines have been developed to clarify OMA’s position on pain control, specifically as related to the use of controlled substances, to alleviate physician uncertainty as to the applicable standard of practice, and to encourage better pain management.

OMA recognizes that controlled substances, including opioid analgesics, may be essential in the treatment of acute pain due to trauma or surgery and chronic pain, whether due to cancer or non-cancer origins.  Physicians are referred to the U.S. Agency for Health Care and Research Clinical Practice Guidelines for a sound approach to the management of acute¹ and cancer-related pain².

The medical management of pain should be based on current knowledge and research and includes the use of both pharmacologic and non-pharmacologic modalities.  Pain should be assessed and treated promptly, and the quantity and frequency of doses should be adjusted according to the intensity and duration of the pain.  Physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

The Oregon Board of Medical Examiners is obligated under the laws of the State of Oregon to protect public health and safety.  OMA recognizes that inappropriate prescribing of controlled substances, including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate medical use.  Physicians should be diligent in preventing the diversion of drugs for illegitimate purposes.

Physicians should not fear disciplinary action from the Board of Medical Examiners or other state regulatory or enforcement agency for prescribing, dispensing, or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the usual course of professional practice if based on accepted scientific knowledge of the treatment of pain or if based on sound clinical grounds.  All such prescribing must be based on clear documentation of unrelieved pain and in compliance with applicable state or federal law.

Each case of prescribing for pain should be evaluated on an individual basis.  OMA believes action against a physician is not necessarily justified for failing to adhere strictly to the provisions of these guidelines if good cause is shown for such deviation.  The physician’s conduct should be evaluated to a great extent by the treatment outcome, taking into account whether the drug used is medical and/or pharmacologically recognized to be appropriate for the diagnosis, the patient’s needs – including any improvement in functioning – and recognizing that some types of pain cannot be completely relieved.

1.  Acute Pain Management Guideline Panel. [Acute Pain Management: Operative or Medical Procedures and Trauma.  Clinical Practice Guideline: AHCPR Publication No. 92-0032].  Rockville, MD, Agency for Health Care Policy and Research.  U.S. Department of Health and Human Resources, Public Health Service, February 1994.

2.  Jaycox A, Carr, DB, Payne R. et.al.[Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592.]  Rockville, MD.  Agency for Health Care Policy and Research, U.S.  Department of Health and Human Resources, Public Health Service, March, 1994 diagnosis, the patient’s needs -  including any improvement in functioning - and recognizing that some types of pain cannot be completely relieved.

The following guidelines are not intended to define complete or best practices, but rather to communicate what OMA considers to be within the boundaries of professional practice.

Section II - Guidelines

1.  Evaluation of the Patient -A complete medical history and physical examination must be conducted and documented in the medical record.  The medical record should document the nature and intensity of the pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse.  The medical record also should document the presence of one or more recognized medical indicators for the use of a controlled substance.

2.  Treatment Plan - The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned.  After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient.  Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment.

3.  Informed Consent and Agreement for Treatment - The physician should discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient, or with the patient’s surrogate or guardian if the patient is incompetent.  The patient should receive prescriptions from one physician and one pharmacy where possible.  If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician may employ the use of a written agreement between physician and patient outlining patient responsibilities including: urine/serum medication levels screening when requested; number and frequency of prescription refills; and reasons for which drug therapy may be discontinued (i.e. violation of the agreement).

4.  Periodic Review - At reasonable intervals based on the individual circumstances of the patient, the physician should review the course of treatment and any new information about the etiology of the pain.  Continuation or modification of therapy should depend on the physician’s evaluation of progress toward stated treatment objectives such as improvement in patient’s pain intensity and improved physical and/or psychosocial function, i.e., ability to work, need of health care resources, activities of daily living, and quality of social life.  If treatment goals are not being achieved, despite medication adjustments, the physician should reevaluate the appropriateness of continued treatment.  The physician should monitor patient compliance in medication usage and related treatment plans.

5.  Consultation - The physician should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives.  Special attention should be given to those patients who are at risk for misusing their medications and those whose living arrangements pose a risk for medication misuse and diversion.  The management of pain in patients with a history of substance abuse or with a co-morbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients.

6.  Medical Records - The physician should keep accurate and complete records to include: the medical history and physical examination; diagnostic therapeutic, and laboratory results; evaluations and consultations; treatment objectives; discussion of risks and benefits; treatments; medications (including date, type, dosage, and quantity prescribed); instructions and agreements; and periodic reviews.  Records should remain current and be maintained in an accessible manner and readily available for review.

7.  Compliance with Controlled Substance Laws and Regulations - To prescribe, dispense, or administer controlled substances, the physician must be licensed in the state and comply with applicable federal and state laws and regulations.  Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration and to the most recent edition of OMA Medical-Legal Handbook for specific rules governing controlled substances as well as applicable state law and regulation.

Section III – Definitions

1.  Acute Pain: Acute pain is the normal, predicted physiological response to adverse chemical, thermal or mechanical stimulus and is associated with surgery, trauma and acute illness.  It is generally time-limited and is responsive to opioid therapy, among other therapies.

2.  Addiction: Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm.  Addiction may also be referred to by terms such as “drug dependence” and “psychological dependence.”  Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction.

3.  Analgesic Tolerance: Analgesic tolerance is the need to increase the dose of opioid to achieve the same level of analgesia.  Analgesic tolerance may or may not be evident during opioid treatment and does not equate with addiction.

4.  Chronic Pain: A pain state, which is persistent and in which the cause of the pain cannot be removed or otherwise treated.  Chronic pain may be associated with a long-term incurable or intractable medical condition or disease.

5.  Pain: An unpleasant sensory and emotional experience associated with actual or potential tissues or described in terms of such damage.

6.  Physical Dependence: Physical dependence on a controlled substance is a physiologic state of neuro-adaptation which is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or if an antagonist is administered.  Physical dependence is an expected result of opioid use.  Physical dependence, by itself, does not equate with addiction.

7.  Pseudoaddiction: A pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction.

8.  Substance Abuse:  Substance abuse is the use of any substance(s) for non-therapeutic purposes or use of medication for purposes other than for which it is prescribed.

9.  Tolerance: Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect, or a reduced effect is observed with a constant dose.