Prescribing Guidelines Spreadsheet 01-13-2016
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StateStatement that Prescribers should not fear disciplinary action if, or provides immunity for, prescribing in the usual course of practiceStatement acknowledging or encouraging alternatives to opioidsStatement encouraging a multidisciplinary approachStatement re: Need for access to pain reliefEvaluation RequirementsThreshold Dosages / DurationsUDTTreatment PlanConsultationPeriodic ReviewInformed ConsentTreatment AgreementsPMPDiscussion of Benefits/RisksTheft and Diversion ControlQualificationsEducationCancer / Non-cancer Distinction?Transition of CareOther
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AlabamaAlabama Board of Medical Examiners. Chapter 540-X-19-.09. (1) Preamble. (e) PHYSICIANS SHOULD NOT FEAR DISCIPLINARY ACTION FROM THE BOARD 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. (rec)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (1) Preamble. (c)...The medical management of pain should be based on current knowledge and research and should include the use of both pharmacologic and non-pharmacologic modalities. (rec)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (1) Preamble. (a) The Board recognizes that principles of quality medical practice dictate that the people of the State of Alabama have access to appropriate and effective pain relief. (rec)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (2) Requirements. (a) Evaluation of the Patient. A 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, current and past treatments for 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 should also document the presence of one or more recognized medical indications for the use of a controlled substance. (rec)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (2) Requirements. (b) Treatment Plan. The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved 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 the patient. Alternative non-opioid treatment modalities or a rehabilitation program may be necessary and should be considered. (rec)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (2) Requirements. (e) 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 pain patients who are at risk for misusing their medications and those whose living arrangements pose a risk for medication misuse or 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. (rec)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (2) Requirements. (d) Periodic Review. At reasonable intervals based on the individual circumstances of the patient, the physician shall review the course of treatment and any new information about the etiology of the pain. The physician shall monitor patient compliance in medication usage and related treatment plans. (req)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (2) Requirements. (c) Informed Consent and Agreement for Treatment. The physician shall 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. (req)Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (2) Requirements. (c) Informed Consent and Agreement for Treatment. ...Written agreements between physician and patient outlining patient responsibilities should be utilized for all patients with chronic pain, and should include:
1. Drug screening with appropriate confirmation
2. A prescription refill policy; and
3. Reasons for which drug therapy may be discontinued (e.g., violation of agreement). 4. The patient should receive prescriptions from one physician and one pharmacy where possible. (rec)
Alabama Board of Medical Examiners. Chapter 540-X-19-.09. (1) Preamble. (d)...Physicians should
be diligent in preventing the diversion of drugs for illegit
imate purposes. (rec)
The same provisions are also found in Alabama Board of Medical Examiners. Chapter 540-X-4-08.
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AlaskaAlaska State Medical Board. Board Issued Guidelines. Document by history or clinical trial that non-addictive modalities are not
appropriate or are ineffective. (rec)
Alaska State Medical Board. Board Issued Guidelines. Perform a work-up sufficient to support a diagnosis, including all necessary tests. (rec)Alaska State Medical Board. Board Issued Guidelines. Document a treatment plan that includes the use of non-addictive modalities, and make referrals to specialists within the profession when indicated. (rec)Alaska State Medical Board. Board Issued Guidelines. Monitor the patient. It is important to follow the patient for the primary condition that necessitates the drug, and for side effects of the drug, as well as the results of the
drug. Drug holidays to evaluate for symptom recurrence or withdrawal are important...Maintain contact with the patient’s family as an objective source of information on the patient’s response and compliance to the therapy. Create an adequate record of care. (rec)
Alaska State Medical Board. Board Issued Guidelines. Obtain informed consent of the patient before using a drug with the potential to cause dependency. Drug companies, the AMA, and other outlets provide printed material in layman’s terms that can be used for patient education. (rec)Alaska State Medical Board. Board Issued Guidelines. Identify drug seeking patients. Review records. If the patient is new, discuss drug and chemical use and family chemical history with the patient. If drug abuse is suspected, consider obtaining a chemical dependency evaluat
ion or contacting local pharmacies. (rec)
Alaska State Medical Board. Board Issued Guidelines. Control the supply of the drug. Keep detailed records of the type, dose, and amount of the drug prescribed. Monitor, record, and control refills. Require the patient to return to obtain refill authorization at least part of the time. Records of cumulative dosage and average daily dosage are valuable.
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ArizonaArizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section I: Preamble. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met. (rec)Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section I: Preamble. The medical management of pain should reflect current knowledge of evidence‐based or best clinical practices for the use of pharmacologic and nonpharmacologic modalities, including the use of opioid analgesics and non‐opioid therapies. (rec) Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section I: Preamble. The Arizona Medical Board recognizes that principles of high‐quality medical practice dictate that the people of the state of Arizona have access to appropriate, safe and effective pain management. (rec)Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Patient Evaluation and Risk Stratification: The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic and reflect an appropriately detailed patient evaluation. Such an evaluation should be completed before a decision is made as to whether to prescribe an opioid analgesic.
The nature and extent of the evaluation depends on the type of pain and the context in which it occurs. For example, meaningful assessment of chronic pain, including pain related to cancer or non‐cancer origins, usually demands a more detailed evaluation than an assessment of acute pain. Assessment of the patient’s pain typically would include the nature and intensity of the pain, past and current treatments for the pain, any underlying or co‐occurring disorders and conditions, and the effect of the pain on the patient's physical and psychological functioning.
For every patient, the initial work‐up should include a systems review and relevant physical examination, as well as laboratory investigations as indicated. Such investigations help the physician address not only the nature and intensity of the pain, but also its secondary manifestations, such as its effects on the patient's sleep, mood, work, relationships, valued recreational activities, and alcohol and drug use.
Social and vocational assessment is useful in identifying supports and obstacles to treatment and rehabilitation; for example: Does the patient have good social supports, housing, and meaningful work? Is the home environment stressful or nurturing?
Assessment of the patient's personal and family history of alcohol or drug abuse and relative risk for medication misuse or abuse also should be part of the initial valuation, and ideally should be completed prior to a decision as to whether to prescribe opioid analgesics. This can be done through a careful clinical interview, which also should inquire into any history of physical, emotional or sexual abuse, because those are risk factors for substance misuse. Use of a validated screening tool (such as the Screener and Opioid Assessment for Patients with Pain [SOAPP‐R] or the Opioid Risk Tool [ORT]), or other validated screening tools, can save time in collecting and evaluating the information and determining the patient's level of risk.
All patients should be screened for depression and other mental health disorders, as part of risk evaluation. Patients with untreated depression and other mental health problems are at increased risk for misuse or abuse of controlled medications, including addiction, as well as overdose.
Patients who have a history of substance use disorder (including alcohol) are at elevated risk for failure of opioid analgesic therapy to achieve the goals of improved comfort and function, and also are at high risk for experiencing harm from this therapy, since exposure to addictive substances often is a powerful trigger of relapse. Therefore, treatment of a patient who has a history of substance use disorder should, if possible, involve consultation with an addiction specialist before opioid therapy is initiated (and follow‐up as needed). Patients who have an active substance use disorder should not receive opioid therapy until they are established in a treatment/recovery program or alternatives are established such as co‐management with an addiction professional. Physicians who treat patients with chronic pain should be encouraged to also be knowledgeable about the treatment of addiction, including the role of replacement agonists such as methadone and buprenorphine. For some physicians, there may be advantages to becoming eligible to treat addiction using office‐based buprenorphine treatment.
Information provided by the patient is a necessary but insufficient part of the evaluation process. Reports of previous evaluations and treatments should be confirmed by obtaining records from other providers, if possible. Patients have occasionally provided fraudulent records, so if there is any reason to question the truthfulness of a patient's report, it is best to request records directly from the other providers.
If possible, the patient evaluation should include information from family members and/or significant others. Where available, the state prescription drug monitoring program (PDMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Periodic Drug Testing: Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non‐prescribed drugs. Drug testing is an important monitoring tool because self‐reports of medication use is not always reliable and behavioral observations may detect some problems but not others. Patients being treated for addiction should be tested as frequently as necessary to ensure therapeutic adherence, but for patients being treated for pain, clinical judgment trumps recommendations for frequency of testing.

Urine may be the preferred biologic specimen for testing because of its ease of collection and storage and the cost‐effectiveness of such testing. When such testing is conducted as part of pain treatment, forensic standards are generally not necessary and not in place, so collection is not observed and chain‐of‐custody protocols are not followed. Initial testing may be done using class-specific immunoassay drug panels (point‐of‐care or laboratory‐based), which typically do not identify particular drugs within a class unless the immunoassay is specific for that drug. If necessary, this can be followed up with a more specific technique, such as gas chromotography/mass spectrometry (GC/MS) or other chromatographic tests to confirm the presence or absence of a specific drug or its metabolites. In drug testing in a pain practice, it is important to identify the specific drug not just the class of the drug.

Physicians need to be aware of the limitations of available tests (such as their limited sensitivity for many opioids) and take care to order tests appropriately. For example, when a drug test is ordered, it is important to specify that it include the opioid being prescribed. Because of the complexities involved in interpreting drug test results, it is advisable to confirm significant or unexpected results with the laboratory toxicologist or a clinical pathologist.

While immunoassay, point of care (POC) testing has its utility in the making of temporary and “on the spot” changes in clinical management, its limitations with regard to accuracy have recently been the subject of study. These limitations are such that the use of point of care testing for the making of more long term and permanent changes in management of people with the disease of addiction and other clinical situations may not be justified until the results of confirmatory testing with more accurate methods such as LC‐MS/MS are obtained. A recent study on LC‐MS/MS results following immunoassay POC testing in addiction treatment settings and found very high rates of “false
negatives and positives”.

Test results that suggest opioid misuse should be discussed with the patient. It is helpful to approach such a discussion in a positive, supportive fashion, so as to strengthen the physician-patient relationship and encourage healthy behaviors (as well as behavioral change where that is needed). Both the test results and subsequent discussion with the patient should be documented in the medical record.
Periodic pill counting is also a useful strategy to confirm medication adherence and to minimize diversion (e.g., selling, sharing or giving away medications). As noted earlier and where available, consulting the state's PDMP before prescribing opioids for pain and during ongoing use is highly recommended. A PDMP can be useful in monitoring compliance with the treatment agreement as well as identifying individuals obtaining controlled substances from multiple prescribers.

If the patient's progress is unsatisfactory, the physician must decide whether to revise or augment the treatment plan, whether other treatment modalities should be added to or substituted for the opioid therapy, or whether a different approach—possibly involving referral to a pain specialist or other health professional—should be employed.

Evidence of misuse of prescribed opioids demands prompt intervention by the physician. Patient behaviors that require such intervention typically involve recurrent early requests for refills, multiple reports of lost or stolen prescriptions, obtaining controlled medications from multiple sources without the physician's knowledge, intoxication or impairment (either observed or reported), and pressuring or threatening behaviors. The presence of illicit or unprescribed drugs, (drugs not prescribed by a physician) in drug tests similarly requires action on the part of the prescriber. Some aberrant behaviors are more closely associated with medication misuse than others. Most worrisome is a pattern of behavior that suggests recurring misuse, such as unsanctioned dose escalations, deteriorating function, and failure to comply with the treatment plan.

Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require a firm, immediate response. Indeed, failure to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempts, arrests and incarceration, or even death. For this reason, physicians who prescribe chronic opioid therapy should be knowledgeable in the diagnosis of substance use disorders and able to distinguish such disorders from physical dependence—which is expected in chronic therapy with opioids and many sedatives. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Development of a Treatment Plan and Goals: The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain‐associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Effective means of achieving these goals vary widely, depending on the type and causes of the patient's pain, other concurrent issues, and the preferences of the physician and the patient.
The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear‐cut, individualized objectives to guide the choice of therapies. The treatment plan should contain information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and nonpharmacologic. It also should specify the objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function.
The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Consultation and Referral: The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed. For example, a patient who has a history of substance use disorder or a co‐occurring mental health disorder may require specialized assessment and treatment, if available.

Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office‐based opioid treatment [OBOT]), so as to make appropriate referrals when needed. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Ongoing Monitoring and Adapting the Treatment Plan: The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient’s overall health and level of function. When possible, collateral information about the patient’s response to opioid therapy should be obtained from family members or other close contacts, and the state PDMP. The patient should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted. As the patient is stabilized in the treatment regimen, follow‐up visits may be scheduled less frequently. (However, if the patient is seen less than monthly and an opioid is prescribed, arrangements must be made for the patient to obtain a refill or new prescription when needed.)

At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the “5As” of chronic pain management; these involve a determination of whether the patient is experiencing a reduction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of Aberrant substance‐related behaviors, and mood of the individual (Affect). Validated brief assessment tools that measure pain and function, such as the three‐question "Pain, Enjoyment and General Activity" (PEG) scale or other validated assessment tools, may be helpful and time effective.

Continuation, modification or termination of opioid therapy for pain should be contingent on the physician’s evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life. Information from family members or other caregivers should be considered in evaluating the patient’s response to treatment. Use of measurement tools to assess the patient's level of pain, function, and quality of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision‐making capacity. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications.
Use of a written informed consent and treatment agreement (sometimes referred to as a "treatment contract") is recommended.

Informed consent documents typically address:

• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short‐ and long‐term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over‐sedation.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long‐term opioid therapy.
• The physician's prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician's policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement). (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Informed Consent and Treatment Agreement: ...Treatment agreements outline the joint responsibilities of physician and patient and are indicated for opioid or other abusable medications. They typically discuss:
• The goals of treatment, in terms of pain management, restoration of function, and safety.
• The patient's responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication).
• The patient's responsibility to obtain his or her prescribed opioids from only one physician or practice.
• The patient's agreement to periodic drug testing (as of blood, urine, hair, or saliva).
• The physician's responsibility to be available or to have a covering physician available to care for unforeseen problems and to prescribe scheduled refills.

Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Patient Evaluation and Risk Stratification: ...If possible, the patient evaluation should include information from family members and/or significant others. Where available, the state prescription drug monitoring program (PDMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record. (rec)Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section II: Guidelines. Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision‐making capacity. (rec)
Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section I: Preamble. Accordingly, the Board expects physicians to incorporate safeguards into their practices to minimize the risk of misuse and diversion of opioid analgesics and other controlled substances. (rec)Arizona Medical Board. Reference for Physicians on the Use of Opioid Analgesics in the Treatment of Chronic Pain, in the Office Setting. Section I: Preamble. This policy has been developed to articulate the Board’s position on the use of controlled substances for pain, particularly the use of opioid analgesics and with special attention to the management of chronic pain. (rec)
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ArkansasTitle 17. Subtitle 3. Chapter 95. Subchapter 7. Chronic Intractable Pain Treatment Act. §17-95-704. (a)(1) A physician shall not be subject to disciplinary a
ction by the Arkansas State Medical Board solely for prescribing dangerous or controlled drugs for the relief of chronic intractable pain. (req)
Title 17. Subtitle 3. Chapter 95. Subchapter 7. Chronic Intractable Pain Treatment Act. §17-95-702. (2) Physicians should recognize the need to make pain relief. (rec)Title 17. Subtitle 3. Chapter 95. Subchapter 7. Chronic Intractable Pain Treatment Act. §17-95-704. (d) Based upon evaluation and management of a patient's individual needs, a physician may:...(4) Administer large doses of dangerous or controlled drugs for pain management if the benefit of relief outweighs the risk of the large dose (rec)
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ArkansasTitle 060. Division 00. Rule 1. 060.00.1-2. Regulation 2.8. However, a physician who prescribes **narcotic agents Schedule 2, 3, 4, and 5, excluding Schedule 4 Propoxyphene products and Ultram or Tramadol and to include the schedule drugs Talwin, Stadol, and Nubain, on a long
term basis (more than six (6) months) for a patient with
pain not associated with malignant or terminal illness will be considered exhibiting gross negligence or ignorant malpractice unless he or she has complied with the following: a. The physician will keep accurate records to include the medical history, physical examination, other evaluations and consultations, treatment plan objective, in
formed consent noted in the patient record, treatment, medications given, agreements with the patient and periodic reviews. (req)
Title 060. Division 00. Rule 1. 060.00.1-2. Regulation 2.8. However, a physician who prescribes **narcotic agents Schedule 2, 3, 4, and 5, excluding Schedule 4 Propoxyphene products and Ultram or Tramadol and to include the schedule drugs Talwin, Stadol, and Nubain, on a long term basis (more than six (6) months) for a patient with pain not associated with malignant or terminal illness will be considered exhibiting gross negligence or ignorant malpractice unless he or she has complied with the following: b. The physician will periodically review the course of schedule drug treatment of the patient and any new information about etiology of the pain. If the patient has not improved, the physician should assess the appropriateness of continued prescribing of scheduled medications or dangerous drugs, or trial of other modalities. (req)Title 060. Division 00. Rule 1. 060.00.1-2. Regulation 2.8. However, a physician who prescribes **narcotic agents Schedule 2, 3, 4, and 5, excluding Schedule 4 Propoxyphene products and Ultram or Tramadol and to include the schedule drugs Talwin, Stadol, and Nubain, on a long term basis (more than six (6) months) for a patient with pain not associated with malignant or terminal illness will be considered exhibiting gross negligence or ignorant malpractice unless he or she has complied with the following: c. The physician will obtain written informed consent from those patients he or she is concerned may abuse controlled substances and discuss the risks and benefits of the use of controlled substances with the patient, his or her guardian, or authorized representatives. (req)
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CaliforniaBusiness and Professions Code. Division 2. Chapter 5. Article 12, §725. (c) A practitioner who has a medical basis for prescribing, furnishing, dispensing, or administering dangerous drugs or prescription controlled substances shall not be subject to disciplinary action or prosecution under this section.
(d) No physician and surgeon shall be subject to disciplinary action pursuant to this section for treating intractable pain in compliance with Section 2241.5. (req)
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CaliforniaBusiness and Professions Code. Division 2. Chapter 1. Article 10.5, §2241.5. (b) No physician and surgeon shall be subject to disciplinary action for prescribing, dispensing, or administering dangerous drugs or prescription controlled substances in accordance with this section. (req)Health and Safety Code; Division 106. Part 4.5. Pain Patient's Bill of Rights. §124960. (e)... In some cases, severe chronic intractable pain is best treated by a team of clinicians in order to address the associated physical, psychological, social, and vocational issues. (rec)Health and Safety Code; Division 106. Part 4.5. Pain Patient's Bill of Rights. §124960. (d) A patient suffering from severe chronic intractable pain should have access to proper treatment of his or her pain. (rec)Health and Safety Code; Division 106. Part 4.5. Pain Patient's Bill of Rights. §124960. (e) Due to the complexity of their problems, many patients suffering from severe chronic intractable pain may require referral to a physician with expertise in the treatment of severe chronic intractable pain... (rec)Business and Professions Code. Division 2. Chapter 1. Article 10.5, §2241.5. (d) A physician and surgeon shall exercise reasonable care in determining whether a particular patient or condition, or the complexity of a patient's treatment, including, but not limited to, a current or recent pattern of drug abuse, requires consultation with, or referral to, a more qualified specialist. (req)
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CaliforniaCalifornia Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Preamble. Since opioids are only one
of many options to mitigate pain, and because prescribing opioids carries a substantial level of risk, these guidelines offer several non-opioid treatment alternatives. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Initiating Opioid Trial. Safer alternative treatments should be considered before initiating opioid therapy for chronic pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 45 days) and with specific evaluation points. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Preamble. The Board recognizes that principles of high-quality medical practice
and California law dictate that the people
of California have access to appropriate, safe and effective pain management. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Patient Evaluation and Risk Evaluation. When considering long-term use of opioids for chronic, non-cancer pain, given the potential risks of opioid analgesics, careful and thorough patient assessment is critical. Risk stratification is one of the most important things a physician can do to mitigate potentially adverse
consequences of opioid prescribing. The nature and extent of the clinical assessment depends on the type of pain and the context in which it occurs. This includes but is not limited to:
• Completing a medical history and physical examination
(Appendix 5).
• Performing a psychological evaluation.
oPsychological assessment should include risk of addictive disorders. Screening tools that can be considered for use include:
 CAGE-AID (Appendix 6);
 PHQ-9 (Appendix 7);
 Opioid Risk Tool (ORT) (Appendix 4); and
 SOAPP®-R (Appendix 8).
 Note: Although the above-listed assessment tools are
well-established with proven effectiveness, physicians
must be aware that seasoned diverters know the right answers to these tools so they look "normal."
• Establishing a diagnosis and medical necessity (review past medical records, laboratory studies, imaging studies, etc. and order new ones, if necessary or if previous studies are outdated). Screening tools that can be considered for use include:
o Pain Intensity and Interference (pain scale) (Appendix
9); and
o Sheehan Disability Scale.
• Exploring non-opioid therapeutic options.

Opioid medications may not be the appropriate first line of treatment for a patient with chronic pain. Other measures, such as non-opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic drugs, and non-pharmacologic therapies (e.g.,
physical therapy), should be tried and the outcomes of
those therapies documented first. Opioid therapy should be considered only when other potentially safer and more effective therapies have proven inadequate. Resources
that can be consulted include:
o Therapeutic Options for Pain Management (Appendix
10); and
o Non-Opioid Pain Management Tool (Appendix 11).
• Evaluating both potential benefits and potential risks of opioid therapy.
• Being cognizant of aberrant or drug seeking behaviors.
• As a universal precaution, undertaking urine drug testing.
• Reviewing the CURES/PDMP report for the patient. This allows a physician to check to see if a patient is receiving controlled substances from other prescribers in California (assuming the prescription is being filled at a California pharmacy). (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Morphine Equivalent Dose (MED). There are differing opinions among reputable experts and organizations as to what MED should trigger a consultation. The Board recommends
that physicians proceed cautiously (yellow flag warning) once the MED
reaches 80mg/day. Referral to an
appropriate specialist should be considered when higher doses are
contemplated. There is no absolute safe ceiling dose of opioids, however, and caution and monitoring are appropriate for applications of these medications.
The patient should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted. As the patient is stabilized in the treatment regimen, follow-up visits may be scheduled less frequently. (rec)

California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Compliance Monitoring. Physicians who prescribe opioids or other controlled substances for pain should ensure the provisions of a pain management agreement are being heeded. Strategies for monitoring compliance may include: [synopsized] CURES/PDMP Report, Drug Testing, and Pill Counting. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Treatment Plan and Objectives. When considering long-term use of opioids for chronic, non-cancer pain, the physician and the patient should develop treatment goals together. The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain-associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Pain relief is important, but it is difficult to measure objectively. Therefore, it cannot be the primary indicator to assess the success of the treatment. Effective pain relief improves functioning, whereas addiction decreases functionality. Effective means of achieving these goals vary widely, depending on the type and causes of the patient’s pain, other concurrent issues, and the preferences of the physician and the patient. The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear-cut, individualized objectives to guide the choice of therapies. The treatment plan should contain
information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and non-pharmacologic. It also should specify measurable goals and objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function. The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered. The treatment plan should also include an “exit strategy” for discontinuing opioid therapy in the event the tapering or termination of opioid therapy becomes necessary. (rec)

California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Consultation. The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, or an addiction or mental health specialist as needed. For example, a patient who has a history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment, if available. Physicians who prescribe long-
term opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office-based opioid treatment [OBOT]), so as to make appropriate referrals when needed. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Ongoing Patient Assessment. When a trial of an opioid medication is successful and the physician and patient decide to continue opioid therapy, regular review and monitoring should be undertaken for the duration of treatment.
Continuation, modification or termination of opioid therapy for pain should be contingent on the physician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life. Validated brief assessment tools that measure pain and function, such as the three-question “Pain, Enjoyment and General Activity” (PEG)
scale or other validated assessment tools, may be helpful and time effective.
Consider the 5-As method for chronic pain management assessment:
Analgesia: the patient is experiencing a reduction in pain.
Activity: the patient is demonstrating an improvement in level of function.
Adverse: the patient is not experiencing side effects.
Aberrance: the patient is complying with the pain management agreement and there are no signs of medication abuse or diversion.
Affect: the patient’s behavior and mood are appropriate.
“Opioid rotation,” the switching from one opioid to another in order to better balance analgesia and side effects, may be used if pain relief is inadequate, if side effects are bothersome or unacceptable, or if an alternative route of administration is suggested.
Opioid rotation must be done with great care, particularly when converting from an immediate-release formulation to an extended-release/long-acting (ER/LA) product.
Equianalgesic charts, conversion tables and calculators must be used cautiously with titration and appropriate monitoring. Patients may exhibit incomplete cross-tolerance to different types of opioids because of differences in the receptors or receptor sub-types to which different opioids bind, hence physicians may want to use initially lower-than-calculated doses of the switched-to opioid. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Compliance Monitoring. Physicians who prescribe opioids or other controlled substances for pain should ensure the provisions of a pain management agreement are being heeded. Strategies for
monitoring compliance may include: [synopsized] CURES/PDMP Report, Drug Testing, and Pill Counting. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Patient Consent. When considering long-term use of opioids, or in other medically appropriate situations, the physician should discuss the risks and benefits of the treatment plan with the
patient, with persons designated by the patient, or with the patient’s conservator if the patient is without medical decision-making capacity. If opioids are prescribed, the
patient (and possibly family members, if appropriate) should be counseled on safe ways to store and dispose of medications. For convenience, patient consent and a pain
management agreement can be combined into one document. Patient consent typically addresses:
• The potential risks and anticipated benefits of long-
term opioid therapy.
• Potential side effects (both short- and long-term) of the medication, such as nausea, opioid-induced constipation, decreased libido, sexual dysfunction, hypogonadism with secondary osteoporosis and cognitive impairment.
• The likelihood that some medications will cause
tolerance and physical dependence to develop.
• The risk of drug interactions and over-sedation.
• The risk of respiratory depression.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long-term opioid therapy. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Pain Management Agreement. Use of a pain management agreement is recommended for patients:
• On short-acting opioids at the time of third visit within two months;
• On long-acting opioids; or
• Expected to require more than three months of opioids.
Pain management agreements typically outline the joint responsibilities of the physician and the patient and should include:
• The physician’s prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician’s policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement).
• The patient’s responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication to prevent misuse by other household members).
• The patient’s agreement to share information with family members and other close contacts on how to recognize and respond to an opiate overdose, including administering an opioid antagonist, such as naloxone, if necessary. (Appendix 12)
• The patient’s responsibility to obtain his or her prescribed opioids from only one physician or practice and one pharmacy.
• The patient’s agreement to periodic drug testing (blood, urine, hair, or saliva).
• The physician’s responsibility to be available or to have a covering physician available to care for unforeseen problems and to
prescribe scheduled refills, if appropriate and in accordance with the patient’s pain management agreement.
Samples of pain management agreements:
• Patient Pain Medication Agreement and Consent (Appendix 13)
• Treatment Plan Using Prescription Opioids (Appendix 14) (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Patient Evaluation and Risk Evaluation.
• Reviewing the CURES/PDMP report for the patient. This allows a physician to check to see if a patient is receiving controlled substances from other prescribers in California (assuming the prescription is being filled at a California pharmacy). (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Patient Consent. When considering long-
term use of opioids, or in other medically appropriate situations, the physician should discuss the risks and benefits of the treatment plan with the patient, with persons designated by the patient, or with the patient’s conservator if the patient is without medical decision-making capacity. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Patient Consent. Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors usually require a firmer, immediate response. The degree to which the patient has breached the pain agreement and/or the presence of criminal activity should govern the physician’s response. Although an immediate face-to-face meeting with the patient to re-evaluate the treatment plan may be appropriate, in some instances it may be necessary to taper opioid therapy and/or terminate the physician patient relationship. In situations where the patient has engaged in prescription forgery, prescription theft or assaultive behaviors directed towards physician or staff, the physician is strongly encouraged to contact the police/Drug Enforcement Agency (DEA). For other criminal behaviors, the physician is encouraged to contact legal counsel to determine whether it is appropriate to report to law enforcement. Failing to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempts, arrests and incarceration, or even death. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Preamble. [These Guidelines] particularly address the use of opioids in the long-term treatment of chronic pain...they are not meant for the treatment of patients in hospice or palliative care settings and are not in any way intended to limit treatment where improved function is not anticipated and pain relief is the primary goal. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Preamble. These guidelines are intended to help physicians improve outcomes of patient care and to prevent overdose
deaths due to opioid use. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Preamble. Physicians are encouraged to document their rationale
for each prescribing decision. (rec)
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain. Preamble. In order to
cautiously prescribe opioids, physicians must understand the relevant pharmacologic and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual
patient. (rec)

10
ColoradoJoint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Utilize Safeguards for the Initiation of Pain Management. Not all pain requires opioid treatment. Prescribers should not prescribe opioids when
non-opioid medication is both effective and appropriate for the level of pain. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Collaborate with the Healthcare Team. Prescribers and dispensers should collaborate within the healthcare team to prevent under-prescribing, over-prescribing, misuse and abuse of opioids. See the Appendix for
additional resources. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Utilize Safeguards for the Initiation of Pain Management. Diagnosis. Prescribers should establish a diagnosis and legitimate medical purpose appropriate for opioid therapy through a history, physical exam, and/or laboratory, imaging or other
studies. A bona fide provider-patient relationship must exist. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Assess Pain. An appropriate pain assessment should include an evaluation of the patient’s pain for the:
● Nature and intensity
● Type
● Pattern/frequency
● Duration
● Past and current treatments
● Underlying or co-morbid disorders or conditions
● Impact on physical and psychological functioning. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Additional Safeguards. Dosage. Opioid doses >120 mg morphine equivalents per day is a dosage that the Boards agree is more likely dangerous for the average adult (chances for unintended death are
higher) over which prescribers should use clinical judgment, put in place additional safeguards for the treatment plan (such as utilizing a treatment agreement), consult a specialist or refer the patient; and dispensers should be more cautious. Benzodiazepines are known to potentiate the effects of opioids and may increase the risk of adverse outcomes. See the Appendix for additional resources on dose calculators. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Prescribing and Dispensing for Advanced Dosage, Formulation or Duration. Monitoring. The prescribing and dispensing of opioids for chronic pain must be monitored on an ongoing basis, such as: ...
 random drug screening according to the prescriber’s clinical assessment... (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Prescribing and Dispensing for Advanced Dosage, Formulation or Duration. Monitoring. The prescribing and dispensing of opioids for chronic pain must be monitored on an ongoing basis, such as:
 assessing for improved function
 rechecking the PDMP, and
 random drug screening according to the prescriber’s clinical assessment.
These monitoring tools and others should be documented in a treatment agreement signed by the patient, described more below. Prescribers should not increase an initial opioid dosage without rechecking the PDMP. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Prescribing and Dispensing for Advanced Dosage, Formulation or Duration. Treatment Agreements. Prescribers should utilize treatment agreements (also commonly referred to as a plan or contract) and should ensure the patient understands the terms of the agreement. This
may be accomplished by having the patient review and sign the treatment agreement.
A treatment agreement often includes information about proper:
● Goals of treatment
● Patient education (proper use, risks of addiction, alternatives)
● Controls (single prescriber, single pharmacy for refills)
● Random drug testing and restrictions on alcohol use
● Storage, disposal, and diversion precautions (including detailed precautions related to adolescents and/or children and visitors to the home).
● Process and reasons for changing/discontinuing the treatment plan; communicating reduction or increase of symptoms; and referring to a specialist.
See the Appendix for resources on sample agreements. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Utilize Safeguards for the Initiation of Pain Management. Review PDMP. Prescribers and dispensers should utilize the Prescription Drug Monitoring Program (PDMP) prior to prescribing or dispensing opioids. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Utilize Safeguards for the Initiation of Pain Management. Assess Risk. Prescribers should conduct a risk assessment prior to prescribing opioids for outpatient use and again before increasing dosage or duration. Risk assessment is defined as identification of factors that may lead to adverse outcomes and may include:
● Patient and family history of substance use (drugs including alcohol and marijuana)
● Patient medication history (among other reasons, this is taken to avoid unsafe
combinations of opioids with sedative-hypnotics, benzodiazepines,
barbiturates, muscle relaxants or to determine other drug-drug interactions)
● Mental health/psychological conditions and history
● Abuse history including physical, emotional or sexual
● Health conditions that could aggravate adverse reactions (including COPD, CHF,
sleep apnea, elderly, or history of renal or hepatic dysfunction)
● Prescribers and dispensers should observe the patient for any aberrant drug-related behavior and follow-up appropriately when aberrant drug-related behavior is presented. See the Appendix for a description of such behaviors.
See the Appendix for additional resources related to assessment, including resources for alcohol and substance use screening and guidelines for treating patients with risk
factors.
If the assessment identifies risk factors, prescribers should exercise greater caution
before prescribing opioids as detailed in subsequent sections, consider conducting a
drug test or consulting a specialist and put in place additional safeguards as part of the
treatment plan. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Preamble. The Boards further recognize that decreasing opioid misuse and abuse in Colorado should be addressed by collaborative and constructive policies aimed at improving prescriber education and practice, decreasing diversion, and establishing the same
guidelines for all opioid prescribers and dispensers. This includes opioid therapies for both acute and chronic non-cancer pain, because the Boards find that treatment for pain often does not fall clearly into one category or another. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Utilize Safeguards for the Initiation of Pain Management. The decision to prescribe or dispense opioid medication for outpatient use may be made only after a proper diagnosis and complete evaluation which should include a risk assessment, pain assessment, and review of relevant PDMP data. These safeguards apply to acute and chronic, non-cancer pain but not to palliative end-of-life care. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Preamble. To address the dual issues of access to appropriate pain management and opioid-related adverse outcomes, prescribers have dual obligations: to manage pain and improve function while reducing problems resulting from misuse and abuse of prescription opioids in the patient and community. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Additional Safeguards. Dosage. Treatment exceeding 90 days should be re-evaluated as opioids may no longer be as effective.
One way to distinguish pain is as either acute (that lasting less than 90 days) or chronic (that lasting 90 days or greater). Management of each presents its own unique challenges. The overwhelming majority of prescribers treat patients with acute pain; in fact the pain for these patients lasts considerably less than 90 days.
If a prescriber extends short-term treatment, and results in exceeding 90 days, prescribers should re-conduct the risk and pain assessments, review the PDMP and undertake the additional safeguards. (rec)
Joint (Medical, Pharmacy, Nursing, & Dental Boards) Policy for Prescribing and Dispensing Opioids. Patient Education. Prescribers should educate patients regardless of the dosage, formulation and duration of opioid therapy on proper use, risks of addiction, alternatives, storage, and disposal of opioids and the potential for diversion (see the Appendix for resources on disposal).
Risks may include but are not limited to: overdose, misuse, diversion, addiction, physical dependence and tolerance, interactions with other medications or substances, and death.
Pharmacists should offer to review information with the patient about risks, disposal, and other applicable topics.
Providers should educate patients about the risks and benefits of medications that exceed the dosage, formulation and duration guidelines indicated above which may place them at increased risk for long-term dependence and unintended adverse drug effects. Patients who have a previous history of substance use disorder (including alcohol) are at elevated risk.
When alerted to these risk factors, patients can make more informed decisions about their healthcare treatment. For example, some patients have reduced or forgone opioids when alerted to the risk factors. If a decision is made to continue with opioid therapy, a satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function and/or improved quality of life. The use of an interdisciplinary team and family members may be considered as a part of the treatment plan and ongoing monitoring. (rec)
11
ConnecticutMedical Board Guideline. Section I: Preamble. The Board acknowledges the me
dical community’s view that the goals
of effective pain management include...(iv) the use of pharmacologic and non-pharmacologic modalities. (rec)
Medical Board Guideline. Section I: Preamble. The Connecticut Medical Examining Board (Board) recognizes that principles of quality medical practice dictate that the people of the State of
Connecticut have access to
appropriate and effective pain relief. (rec)
Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 1. Evaluation of the Patient. A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. (rec)Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 3. Informed Consent and Agreement for Treatment...If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including
• urine/serum medication levels screening when requested; ... (rec)
Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 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. (rec)
Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 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 with pain who are at risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. (rec)Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 4. Periodic Review. The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician’s evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient’s decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers may be considered in determining the patient’s response to treatment. If the patient’s progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (rec)Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 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 without medical decision-making capacity. The patient should receive prescriptions from one physician
and one pharmacy whenever possible. (rec)
Medical Board Guideline. Section II: Treatment of the Pain Practices. The Board recognizes that the medical community has encouraged the following practices as appropriate for the treatment of pain, including the use of controlled substances: 3. Informed Consent and Agreement for Treatment...If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider 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 all prescription refills; and
• reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec)
Medical Board Guideline. Section I: Preamble. Accordingly, current practice guidelines also note
that effective pain management incorporates safeguards into the practice to minimize the potential for the abuse and diversion of controlled substances such as periodic reviews and written agreements outlining patient responsibility. (rec)
12
DelawareTitle 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.0 Use of Controlled Substances for the Treatment of Pain: Purpose. Licensed practitioners should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. (rec)Title 24. Regulated Professions and Occupations. Department of State.
Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.0 Use of Controlled Substances for the Treatment of Pain: Purpose. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the licensed practitioner. (rec)
Title 24. Regulated Professions and Occupations. Department of State.
Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.0 Use of Controlled Substances for the Treatment of Pain: Purpose. The principles of quality medical practice dictate that citizens of Delaware have access to appropriate and effective pain relief. (rec)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.1.1. Evaluation of the Patient. A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The evaluation must document:
18.1.1.1 etiology, the nature and intensity of the pain, current and past treatments for pain,
18.1.1.2 underlying or coexisting diseases or conditions,
18.1.1.3 the effect of the pain on physical and psychological function, and history of substance abuse,
18.1.1.4 the presence of one or more recognized med
ical indications for the use of a controlled substance. (req)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.4. Agreement for Treatment- If the patient is at high risk for medication abuse or has a history of substance abuse, the practitioner must use a written agreement between the practitioner and patient outlining patient responsibilities, including;
18.4.1 urine/serum medication levels screening when requested;... (req)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.2. Treatment Plan- A written treatment plan is required and must state goals and 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. The treatment plan must address whether treatment modalities or a rehabilitation program are necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment. After treatment begins, the practitioner must adjust drug therapy to the
individual medical needs of each patient. (req)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.6. Consultation- The practitioner shall refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. Special attention must be given to those patients with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a co-morbid psychiatric disorder requires extra care, monitoring, documentation and may require consultat
ion with or referral to an expert in the
management of such patients. At a minimum, practitioners who regularly treat patients for chronic pain must educate themselves about the current standards of care applicable to those patients. (req)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.5. Periodic Review- The licensed practitioner shall periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health. Periodic review shall include, at a minimum, evaluation of the following:
18.5.1 continuation or modification of controlled substances for pain management therapy depending on the practitioner's evaluation of the patient's progress toward treatment goals and objectives.
18.5.2 satisfactory response to treatment as indicated by the patient's decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function must be
monitored and information from family members or other caregivers should be considered in determining the patient's response to treatment.
18.5.3 if the patient's progress is unsatisfactory, the practitioner shall assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (req)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.3. Informed Consent - The practitioner must 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 without medical decision-making capacity. (req)Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.4. Agreement for Treatment- If the patient is at high risk for medication abuse or has a history of substance abuse, the practitioner must use a written agreement between the practitioner and patient outlining patient responsibilities, including;
18.4.1 urine/serum medication levels screening when requested;
18.4.2 number and frequency of all prescription refills; and
18.4.3 reasons for which drug therapy may be discontinued (e.g., violation of agreement).
18.4.4 a requirement that the patient receive prescriptions from one licensed practitioner and one pharmacy where possible. (req)
Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.3. Informed Consent - The practitioner must 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 without medical decision-making capacity. (req)Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.0 Use of Controlled Substances for the Treatment of Pain: Purpose. Accordingly, these regulations mandate that licensed practitioners incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (req)Title 24. Regulated Professions and Occupations. Department of State. Division of Professional Regulation. Chapter 1700. Board of Medical Licensure and Discipline. 18.1. The following criteria must be used when evaluating the treatment of chronic pain but may be applicable to prescribing controlled substances for the treatment of acute pain when clinically appropriate:... (req)
13
DelawareDelaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the physician. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The (name of board) recognizes that principles of quality medical practice dictate that the people of the State of (name of state) have access to appropriate and effective pain relief. (rec)Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Evaluation of the Patient—A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Informed Consent and Agreement for Treatment—... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written
agreement between physician and patient outlining patient responsibilities, including
o urine/serum medication levels screening when requested; ... (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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
with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Periodic Review—The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician’s evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient’s decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient’s response to treatment. If the patient’s progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Informed Consent and Agreement for Treatment—... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written
agreement between physician and patient outlining patient responsibilities, including
o urine/serum medication levels screening when requested;
o number and frequency of all prescription refills; and
o reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 without medical decision-making capacity. (rec)
Delaware Medical Board. Reference to Model Policy on the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Accordingly, the Board expects that physicians incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (rec)
14
District of ColumbiaTitle 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.7 The physician shall consider other treatment modalities or a rehabilitation program if necessary depending on
the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment. (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.3 A licensed physician shall perform an evaluation of the patient by taking a complete medical history and
performing a physical examination. The medical history a
nd physical examination shall be documented in the medical record. The medical record shall contain a description of the following:
(a) The nature and intensity of the patient's pain;
(b) The patient's current and past treatments for pain;
(c) The patient's underlying or coexisting diseases or
conditions;
(d) The effect of the pain on the patient's physical and psychological function; (e) A history of the patient's substance abuse if applicable; and
(f) The presence of one or more recognized medical indications in the patient for the use of a controlled substance. (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.9 If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician shall employ the use of a written agreement between the physician and patient outlining the patient's responsibilities, including, but not limited to:
(a) Urine/serum medication levels screening when requested; ... (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.4 A licensed physician shall maintain a written treatment plan which states the objectives used to determine treatment success, such as pain relief and improved physical and psychosocial function
4616.5 The treatment plan shall indicate if any further diagnostic evaluations or other treatments are planned. (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.11 The physician shall refer the patient, as necessary, to another physician for additional evaluation and treatment in order to achieve treatment objectives. Special a
ttention shall be given to those pain patients who are at risk for misusing their medications and those whose living arrangements pose a risk for medication misuse or diversion.
4616.12 The physician shall consult with or refer to an expert for management the following types of patients:
(a) Patients with a history of substance abuse; or
(b) Patients with comorbid psychiatric disorders that require extra care, monitoring, and documentation. (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.6 The physician shall adjust drug therapy to the individual medical needs of each patient after treatment begins.
4616.10 The physician shall do the following:
(a) Review the course of treatment and any new information about the etiology of the pain at reasonable intervals based on the individual circumstances of the patient;
(b) Continue or modify the pain therapy depending on the physician's evaluation of the patient's progress;
(c) Reevaluate the appropriateness of continued treatment if treatment goals are not being achieved despite medication adjustments; and
(d) Monitor the patient's compliance in medication usage and related treatment plans. (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.9 If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician shall employ the use of a written agreement between the physician and patient outlining the patient's responsibilities, including, but not limited to:
(a) Urine/serum medication levels screening when requested;
(b) Number and frequency of all prescription refills; and
(c) Reasons for which drug therapy may be discontinued, such as violation of an agreement. (req)
Title 17. Business, Occupations, and Professionals. Chapter 46. Medicine. 4616. STANDARDS FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. 4616.8 The physician shall discuss the risks and benefits of the use of controlled substances with the patient, person(s)
designated by the patient, or with the patient's surrogate or guardian if the patient is incompetent. (req)
15
District of ColumbiaDistrict of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met. (rec)District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. The medical management of pain should reflect current knowledge of evidence‐based or best clinical practices for the use of pharmacologic and nonpharmacologic modalities, including the use of opioid analgesics and non‐opioid therapies. (rec) District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. The (name of board) recognizes that principles of high‐quality medical practice dictate that the people of the (name of state) have access to appropriate, safe and effective pain management. (rec)District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Patient Evaluation and Risk Stratification: The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic and reflect an appropriately detailed patient evaluation. Such an evaluation should be completed before a decision is made as to whether to prescribe an opioid analgesic.
The nature and extent of the evaluation depends on the type of pain and the context in which it occurs. For example, meaningful assessment of chronic pain, including pain related to cancer or non‐cancer origins, usually demands a more detailed evaluation than an assessment of acute pain. Assessment of the patient’s pain typically would include the nature and intensity of the pain, past and current treatments for the pain, any underlying or co‐occurring disorders and conditions, and the effect of the pain on the patient's physical and psychological functioning.
For every patient, the initial work‐up should include a systems review and relevant physical examination, as well as laboratory investigations as indicated. Such investigations help the physician address not only the nature and intensity of the pain, but also its secondary manifestations, such as its effects on the patient's sleep, mood, work, relationships, valued recreational activities, and alcohol and drug use.
Social and vocational assessment is useful in identifying supports and obstacles to treatment and rehabilitation; for example: Does the patient have good social supports, housing, and meaningful work? Is the home environment stressful or nurturing?
Assessment of the patient's personal and family history of alcohol or drug abuse and relative risk for medication misuse or abuse also should be part of the initial valuation, and ideally should be completed prior to a decision as to whether to prescribe opioid analgesics. This can be done through a careful clinical interview, which also should inquire into any history of physical, emotional or sexual abuse, because those are risk factors for substance misuse. Use of a validated screening tool (such as the Screener and Opioid Assessment for Patients with Pain [SOAPP‐R] or the Opioid Risk Tool [ORT]), or other validated screening tools, can save time in collecting and evaluating the information and determining the patient's level of risk.
All patients should be screened for depression and other mental health disorders, as part of risk evaluation. Patients with untreated depression and other mental health problems are at increased risk for misuse or abuse of controlled medications, including addiction, as well as overdose.
Patients who have a history of substance use disorder (including alcohol) are at elevated risk for failure of opioid analgesic therapy to achieve the goals of improved comfort and function, and also are at high risk for experiencing harm from this therapy, since exposure to addictive substances often is a powerful trigger of relapse. Therefore, treatment of a patient who has a history of substance use disorder should, if possible, involve consultation with an addiction specialist before opioid therapy is initiated (and follow‐up as needed). Patients who have an active substance use disorder should not receive opioid therapy until they are established in a treatment/recovery program or alternatives are established such as co‐management with an addiction professional. Physicians who treat patients with chronic pain should be encouraged to also be knowledgeable about the treatment of addiction, including the role of replacement agonists such as methadone and buprenorphine. For some physicians, there may be advantages to becoming eligible to treat addiction using office‐based buprenorphine treatment.
Information provided by the patient is a necessary but insufficient part of the evaluation process. Reports of previous evaluations and treatments should be confirmed by obtaining records from other providers, if possible. Patients have occasionally provided fraudulent records, so if there is any reason to question the truthfulness of a patient's report, it is best to request records directly from the other providers.
If possible, the patient evaluation should include information from family members and/or significant others. Where available, the state prescription drug monitoring program (PDMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Periodic Drug Testing: Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non‐prescribed drugs. Drug testing is an important monitoring tool because self‐reports of medication use is not always reliable and behavioral observations may detect some problems but not others. Patients being treated for addiction should be tested as frequently as necessary to ensure therapeutic adherence, but for patients being treated for pain, clinical judgment trumps recommendations for frequency of testing.

Urine may be the preferred biologic specimen for testing because of its ease of collection and storage and the cost‐effectiveness of such testing. When such testing is conducted as part of pain treatment, forensic standards are generally not necessary and not in place, so collection is not observed and chain‐of‐custody protocols are not followed. Initial testing may be done using class-specific immunoassay drug panels (point‐of‐care or laboratory‐based), which typically do not identify particular drugs within a class unless the immunoassay is specific for that drug. If necessary, this can be followed up with a more specific technique, such as gas chromotography/mass spectrometry (GC/MS) or other chromatographic tests to confirm the presence or absence of a specific drug or its metabolites. In drug testing in a pain practice, it is important to identify the specific drug not just the class of the drug.

Physicians need to be aware of the limitations of available tests (such as their limited sensitivity for many opioids) and take care to order tests appropriately. For example, when a drug test is ordered, it is important to specify that it include the opioid being prescribed. Because of the complexities involved in interpreting drug test results, it is advisable to confirm significant or unexpected results with the laboratory toxicologist or a clinical pathologist.

While immunoassay, point of care (POC) testing has its utility in the making of temporary and “on the spot” changes in clinical management, its limitations with regard to accuracy have recently been the subject of study. These limitations are such that the use of point of care testing for the making of more long term and permanent changes in management of people with the disease of addiction and other clinical situations may not be justified until the results of confirmatory testing with more accurate methods such as LC‐MS/MS are obtained. A recent study on LC‐MS/MS results following immunoassay POC testing in addiction treatment settings and found very high rates of “false
negatives and positives”.

Test results that suggest opioid misuse should be discussed with the patient. It is helpful to approach such a discussion in a positive, supportive fashion, so as to strengthen the physician-patient relationship and encourage healthy behaviors (as well as behavioral change where that is needed). Both the test results and subsequent discussion with the patient should be documented in the medical record.
Periodic pill counting is also a useful strategy to confirm medication adherence and to minimize diversion (e.g., selling, sharing or giving away medications). As noted earlier and where available, consulting the state's PDMP before prescribing opioids for pain and during ongoing use is highly recommended. A PDMP can be useful in monitoring compliance with the treatment agreement as well as identifying individuals obtaining controlled substances from multiple prescribers.

If the patient's progress is unsatisfactory, the physician must decide whether to revise or augment the treatment plan, whether other treatment modalities should be added to or substituted for the opioid therapy, or whether a different approach—possibly involving referral to a pain specialist or other health professional—should be employed.

Evidence of misuse of prescribed opioids demands prompt intervention by the physician. Patient behaviors that require such intervention typically involve recurrent early requests for refills, multiple reports of lost or stolen prescriptions, obtaining controlled medications from multiple sources without the physician's knowledge, intoxication or impairment (either observed or reported), and pressuring or threatening behaviors. The presence of illicit or unprescribed drugs, (drugs not prescribed by a physician) in drug tests similarly requires action on the part of the prescriber. Some aberrant behaviors are more closely associated with medication misuse than others. Most worrisome is a pattern of behavior that suggests recurring misuse, such as unsanctioned dose escalations, deteriorating function, and failure to comply with the treatment plan.

Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require a firm, immediate response. Indeed, failure to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempts, arrests and incarceration, or even death. For this reason, physicians who prescribe chronic opioid therapy should be knowledgeable in the diagnosis of substance use disorders and able to distinguish such disorders from physical dependence—which is expected in chronic therapy with opioids and many sedatives. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Development of a Treatment Plan and Goals: The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain‐associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Effective means of achieving these goals vary widely, depending on the type and causes of the patient's pain, other concurrent issues, and the preferences of the physician and the patient.
The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear‐cut, individualized objectives to guide the choice of therapies. The treatment plan should contain information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and nonpharmacologic. It also should specify the objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function.
The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Consultation and Referral: The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed. For example, a patient who has a history of substance use disorder or a co‐occurring mental health disorder may require specialized assessment and treatment, if available.

Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office‐based opioid treatment [OBOT]), so as to make appropriate referrals when needed. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Ongoing Monitoring and Adapting the Treatment Plan: The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient’s overall health and level of function. When possible, collateral information about the patient’s response to opioid therapy should be obtained from family members or other close contacts, and the state PDMP. The patient should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted. As the patient is stabilized in the treatment regimen, follow‐up visits may be scheduled less frequently. (However, if the patient is seen less than monthly and an opioid is prescribed, arrangements must be made for the patient to obtain a refill or new prescription when needed.)

At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the “5As” of chronic pain management; these involve a determination of whether the patient is experiencing a reduction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of Aberrant substance‐related behaviors, and mood of the individual (Affect). Validated brief assessment tools that measure pain and function, such as the three‐question "Pain, Enjoyment and General Activity" (PEG) scale or other validated assessment tools, may be helpful and time effective.

Continuation, modification or termination of opioid therapy for pain should be contingent on the physician’s evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life. Information from family members or other caregivers should be considered in evaluating the patient’s response to treatment. Use of measurement tools to assess the patient's level of pain, function, and quality of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision‐making capacity. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications.
Use of a written informed consent and treatment agreement (sometimes referred to as a "treatment contract") is recommended.

Informed consent documents typically address:

• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short‐ and long‐term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over‐sedation.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long‐term opioid therapy.
• The physician's prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician's policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement). (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Informed Consent and Treatment Agreement: ...Treatment agreements outline the joint responsibilities of physician and patient and are indicated for opioid or other abusable medications. They typically discuss:
• The goals of treatment, in terms of pain management, restoration of function, and safety.
• The patient's responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication).
• The patient's responsibility to obtain his or her prescribed opioids from only one physician or practice.
• The patient's agreement to periodic drug testing (as of blood, urine, hair, or saliva).
• The physician's responsibility to be available or to have a covering physician available to care for unforeseen problems and to prescribe scheduled refills.

Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Patient Evaluation and Risk Stratification: ...If possible, the patient evaluation should include information from family members and/or significant others. Where available, the state prescription drug monitoring program (PDMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record. (rec)District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision‐making capacity. (rec)
District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. Accordingly, the Board expects physicians to incorporate safeguards into their practices to minimize the risk of misuse and diversion of opioid analgesics and other controlled substances. (rec)District of Columbia Medical Board. Reference to Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. This policy has been developed to articulate the Board’s position on the use of controlled substances for pain, particularly the use of opioid analgesics and with special attention to the management of chronic pain. (rec)
16
FloridaTitle 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (1) Pain management principles. (b) ... Physicians should not
fear disciplinary action from the Board or other state
regulatory or enforcement agencies for prescribing, dispensing, or administering controlled substances including opioid analgesics, for a legitimate medical purpose and that is supported by appropriate documentation establishing a valid medical need and treatment plan. (rec)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (1) Pain management principles. (c) ... The medical management of pain including
intractable pain should be based on current knowledge and research and includes the use of both pharmacologic and non-pharmacologic modalities. (rec)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors.
64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (1) Pain management principles. (a) The Board of Medicine recognizes that principles of quality medical practice dictate that the people of the State of Florida have access to appropriate and effective pain relief. (rec)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (a) Evaluation of the Patient. A complete medical history and physical examination must be conducted and
documented in the medical record. The medical record shall document the nature and intensity of the pain, current
and past treatments for 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 shall document the presence
of one or more recognized medical indications for the use
of a controlled substance. (req)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (c) Informed Consent and Agreement for Treatment. ... If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician shall employ the use of a written agreement between physician and patient outlining patient responsibilities, including, but not limited to:
1. Urine/serum medication levels screening when requested; ... (req)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (b) Treatment Plan. The written treatment plan shall state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and shall indicate if any further diagnostic evaluations or other treatments are planned.
After treatment begins, the physician shall adjust drug therapy, if necessary, 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. (req)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (e) Consultation. The physician shall be willing to refer the patient as necessary for additional evaluation and
treatment in order to achieve treatment objectives. Special attention must be given to those pain patients who are at risk for misusing their medications and those whos
e living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder requires extra care, monitoring, and documentation, and may require consultation with or referral to an expert in the management of such patients. (rec)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (d) Periodic Review. Based on the individual circumstances of the patient, the physician shall review the course of treatment and any new information about the etiology of the pain. Continuation or modification of therapy shall depend on the physician's evaluation of the patient's progress. If treatment goals are not being achieved, despite medication adjustments, the physician shall reevaluate the appropriateness of continued treatment. The physician shall monitor patient compliance in medication usage and related treatment plans. (req)Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (c) Informed Consent and Agreement for Treatment. The physician shall 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 shall receive prescriptions from one physician and one pharmacy where possible. (req)Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (c) Informed Consent and Agreement for Treatment. ... If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician shall employ the use of a written agreement between physician and patient outlining patient responsibilities, including, but not limited to:
1. Urine/serum medication levels screening when requested; 2. Number and frequency of all prescription refills; and
3. Reasons for which drug therapy may be discontinued (i.e., violation of agreement). (req)
Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (3) Standards. (c) Informed Consent and Agreement for Treatment. The physician shall 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 shall receive prescriptions from one physician and one pharmacy where possible. (req)Title 64. Department of Health. Subtitle 64B8. Board of Medicine. Chapter 64B8-9. Standards of Practice for Medical Doctors. 64B8-9.013. Standards for the Use of Controlled Substances for the Treatment of Pain. (1) Pain management principles. (d) ... Physicians should be diligent in preventing the diversion of drugs for illegitimate purposes. (rec)Title XXXII. Chapter 458. §458.326. Intractable pain; authorized treatment. (3) Notwithstanding any other provision of law, a physician may prescribe or administer any controlled substance under Schedules II-V, as provided for in s. 893.03, to a person for the treatment of intractable pain, provided the physician does so in accordance with that level of care, skill, and treatment recognized by a reasonably prudent physician under similar conditions and circumstances. (rec)
17
FloridaTitle XXXII. Regulation of Professions and Occupations. Chapter 456. Health Professions and Occupations: General Provisions. 456.44. Controlled substance prescribing. (3) Standards of practice.
(a) A complete medical history and a physical examination must be conducted before beginning any treatment and must be documented in the medical record. The exact components of the physical examination shall be left to the judgment of the clinician who is expected to perform a physical examination proportionate to the diagnosis that justifies a treatment. The medical record must, at a minimum, document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, a review of previous medical records, previous diagnostic studies, and history of alcohol and substance abuse. The medical record shall also document the presence of one or more recognized medical indications for the use of a controlled substance. Each registrant must develop a written plan for assessing each patient's risk of aberrant drug-related behavior, which may include patient drug testing. Registrants must assess each patient's risk for aberrant drug-related behavior and monitor that risk on an ongoing basis in accordance with the plan. (req)
Title XXXII. Regulation of Professions and Occupations. Chapter 456. Health Professions and Occupations: General Provisions. 456.44. Controlled substance prescribing. (3) Standards of practice. (b) Each registrant must develop a written individualized treatment plan for each patient. The treatment plan shall state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and shall indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician shall adjust drug therapy to the individual medical needs of each patient. Other treatment modalities, including a rehabilitation program, shall be considered depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosoc
ial impairment. The interdisciplinary nature of the treatment plan shall be documented. (req)
Title XXXII. Regulation of Professions and Occupations. Chapter 456. Health Professions and Occupations: General Provisions. 456.44. Controlled substance prescribing. (3) Standards of practice. (e) The physician shall refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. Special attention shall be given to those patients who are at risk for misusing their medications and those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder requires extra care, monitoring, and
documentation and requires consultation with or referral to an addiction medicine specialist or psychiatrist. (req) (g) Patients with signs or symptoms of substance abuse shall be immediately referred to a board-certified pain management physician, an addiction medicine specialist, or a mental health addiction facility as it pertains to drug abuse or addiction unless the physician is board-certified or board-eligible in pain management. Throughout the period of time
before receiving the consultant's report, a prescribing physician shall clearly and completely document medical justification for continued treatment with controlled substances and those steps taken to ensure medically appropriate use of controlled substances by the patient. Upon receipt of the consultant's written report, the prescribing physician shall incorporate the consultant's recommendations for continuing, modifying, or discontinuing controlled substance therapy. The resulting changes in treatment shall be specifically documented in the patient's medical record. Evidence or behavioral indications of diversion shall be followed by discontinuation of controlled substance therapy, and the patient shall be discharged, and all results of testing and actions taken by the physician shall be documented in the
patient's medical record. (req)
Title XXXII. Regulation of Professions and Occupations. Chapter 456. Health Professions and Occupations: General Provisions. 456.44. Controlled substance prescribing. (3) Standards of practice. (d) The patient shall be seen by the physician at regular intervals, not to exceed 3 months, to assess the efficacy of treatment, ensure that controlled substance therapy remains indicated, evaluate the patient's progress toward treatment
objectives, consider adverse drug effects, and review the etiology of the pain. Continuation or modification of therapy shall depend on the physician's evaluation of the patient's progress. If treatment goals are not being achieved, despite medication adjustments, the physician shall reevaluate the appropriateness of continued treatment. The physician shall monitor patient compliance in medication usage, related treatment plans, controlled substance agreements, and indications of substance abuse or diversion at a minimum of 3-month intervals. (req)
Title XXXII. Regulation of Professions and Occupations. Chapter 456. Health Professions and Occupations: General Provisions. 456.44. Controlled substance prescribing. (3) Standards of practice. (c) … The physician shall use a written controlled
substance agreement between the physician and the patient outlining the patient's responsibilities, including, but not
limited to:
1. Number and frequency of controlled substance prescriptions and refills.
2. Patient compliance and reasons for which drug therapy may be discontinued, such as a violation of the agreement.
3. An agreement that controlled substances for the treatment of chronic nonmalignant pain shall be prescribed by a single treating physician unless otherwise authorized by the treating physician and documented in the medical record. (req)
Title XXXII. Regulation of Professions and Occupations. Chapter 456. Health Professions and Occupations: General Provisions. 456.44. Controlled substance prescribing. (3) Standards of practice. (c) The physician shall discuss the risks and benefits of the use of controlled substances, including the risks
of abuse and addiction, as well as physical dependence and its consequences, with the patient, persons designated by the patient, or the patient's surrogate or guardian if the patient is incompetent. (req)
18
GeorgiaTitle 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (c) When initially prescribing a controlled substance for the treatment of pain or chronic pain, a physician shall
have a medical history of the patient, a physical examination of the patient shall have been conducted, and informed consent shall have been obtained. (req)
Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (g) When prescribing a Schedule II or III controlled substance for 90 (ninety) consecutive days or greater for the treatment of chronic pain arising from conditions that are not terminal or patients in a nursing home or hospice, a physician must monitor compliance with the therapeutic regimen. This means that body fluid analysis (drug screens) must be performed at least four times a year on a random basis or done at the same frequency proportionate to the period of treatment. Exceptions to the requirement of a clinical visit once every three (3) months may be made for hardship in certain cases and such hardship must be well documented in the patient record. The exception to this monitoring is when the morphine equivalent daily dose (MEDD) is 30 mg or less. In that case fluid monitoring shall be performed at least once per year.
(h) The physician shall respond to any abnormal result of any monitoring and such response shall be recorded in
the patient's record. (req)
Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (i) When a physician determines that a new medical condition exists that is beyond their scope of training, he/she shall make a referral to the appropriate practitioner. (req)
Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (f) When prescribing a Schedule II or III controlled substance for 90 (ninety) consecutive days or greater for the treatment of chronic pain arising from conditions that are not terminal or patients who are not in a nursing home or hospice, a physician must have a written treatment agreement with the patient and shall require the patient to have a clinical visit at least once every three (3) months, while treating for pain, to evaluate the patient's response to treatment, compliance with the therapeutic regimen and any new condition that may have developed and be masked by the use of Schedule II or III controlled substances. The requirement of a visit at a minimum of once every three months can be waived and the clinical visit be at least once per year if the doctor determines there is a substantial hardship and documents such hardship in the patient's record or if the morphine equivalent daily dose (“MEDD”) is 30 mg. or less. (req)Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (c) When initially prescribing a controlled substance for the treatment of pain or chronic pain, a physician shall have a medical history of the patient, a physical examination of the patient shall have been conducted, and informed consent shall have been obtained. (req) Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (f) When prescribing a Schedule II or III controlled substance for 90 (ninety) consecutive days or greater for the treatment of chronic pain arising from conditions that are not terminal or patients who are not in a nursing home or hospice, a physician must have a written treatment agreement with the patient and shall require the patient to have a clinical visit at least once every three (3) months, while treating for pain, to evaluate the patient's response to treatment, compliance with the therapeutic regimen and any new condition that may have developed and be masked by the use of Schedule II or III controlled substances. The requirement of a visit at a minimum of once every three months can be waived and the clinical visit be at least once per year if the doctor determines there is a substantial hardship and documents such hardship in the patient's record or if the morphine equivalent daily dose (“MEDD”) is 30 mg. or less. (req)Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (g) Any physician who prescribes Schedule II or III substances for chronic pain for greater than 50% of that
physician's annual patient population must document competence to the Board through certification or eligibility for certification in
pain management or palliative medicine as approved by the Georgia Composite Medical
Board (“Board”). The Board recognizes certifications in pain medicine or palliative medicine by the American Board of Medical Specialties or the American Osteopathic Association, the American Board of Pain Medicine and the American Board of Interventional Pain Physicians. If the physician does not hold this certification or eligibility he/she must demonstrate competence by biennially obtaining 20 (twenty) hours of continuing medical education (“CME”) pertaining to painmanagement or palliative medicine. Such CME must be an AMA/AOA PRA Category I CME, a board approved CME program, or any federally approved CME. The CME obtained pursuant to this rule may count towards the CME required for license renewal. (req)
Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (e) (e) When a physician determines that a patient for whom he is prescribing controlled scheduled substances is abusing the medication, then the physician shall make an appropriate referral for treatment for substance abuse. (req)Title 360. Georgia Composite Medical Board. Chapter 360-3. Investigations and Discipline. 360-3-.06. Pain Management. (2) (b) When prescribing controlled substances, a physician shall use a prescription pad that complies with state law. (d) When a physician is treating a patient with controlled substances for pain or chronic pain for a condition that is not terminal, the physician shall obtain or make a diligent effort to obtain any prior diagnostic records relative to the condition for which the controlled substances are being prescribed and shall obtain or make a diligent effort to obtain any prior pain treatment records. The records obtained from prior treating physicians shall be maintained by the prescribing physician with the physician's medical records for a period of at least ten (10) years. If the physician has made a diligent effort and is unable to obtain prior diagnostic records, then the physician must order appropriate tests to document the condition requiring treatment for pain or chronic pain. If the physician has made a diligent effort and the prior pain treatment records are not available, then the physician must document the efforts made to obtain the records and shall maintain the documentation of the efforts in his/her patient record. (req)
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HawaiiDivision 1. Title 19. Chapter 327-H. Pain Patient's Bill of Rights. (4) ... In some cases, severe acute pain and severe chronic pain is best treated by a team of clinicians to address the associated physical, psychological, social, and vocational issues. (rec)Division 1. Title 19. Chapter 327-H. Pain Patient's Bill of Rights. (3) A patient who suffers from severe acute pain or severe chronic pain should have access to proper
treatment of pain. (rec)
Division 1. Title 19. Chapter 327-H. Pain Patient's Bill of Rights. (4) Due to the complexity of their problems, many patients who suffer from severe acute pain or severe chronic pain may require referral to a physician with expertise in the
treatment of severe acute pain and severe chronic pain. (rec)
20
HawaiiHawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section I: Introduction. The Board of Medical Examiners (“Board”) recognizes that principles of quality medical practice dictate that the people of the State of Hawaii have access to appropriate and effective pain relief. (rec)Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. Evaluation of the Patient – A medical history and physical examination should be performed and documented in the medical record. The medical record should document the nature and intensity of the pain,
current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on
physical and psychological function, and history of substance abuse or other compulsive behaviors. (rec)
Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. Informed Consent and Agreement for Treatment – ... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should have written treatment agreements outlining the patient’s responsibilities during treatment and should obtain informed consent before prescriptions are provided.
The treatment agreements may specify many of the following items:
• Urine or blood samples will be provided by patients upon request for urine/serum drugs of abuse screening and/or determining medication levels by their physicians; ... (rec)
Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. 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. The treatment plan should be adjusted and documented according to the individual needs of each patient. (rec)
Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. Use of consultation with pain management specialists, addiction medicine specialists, and other medical specialties is encouraged. Physicians should be willing to refer their patients as necessary for additional
evaluations and therapies to achieve treatment objectives. Special attention should be given to those patients with pain who are at risk for medication misuse, abuse or diversion. (rec)
Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. Periodic Review
- The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician’s evaluation of progress toward treatment objectives. (rec)
Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. 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. The patient’s pain medication should be managed by one physician and one pharmacy whenever possible. (rec)Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. Informed Consent and Agreement for Treatment – ... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should have written treatment agreements outlining the patient’s responsibilities during treatment and should obtain informed consent before prescriptions are provided.
The treatment agreements may specify many of the following items:
• Urine or blood samples will be provided by patients upon request for urine/serum drugs of abuse screening and/or determining medication levels by their physicians;
• The number and frequency of all prescription refills may be limited at their physicians’ discretion;
• Therapy with controlled substances may be discontinued by physicians under certain situations (e.g. significant violation of treatment agreements by patients);
• Physician/patient relationships may be discontinued under certain situations (e.g. violation of treatment agreements by patients);
• Medication refills will be provided under specified rules, within mutually agreed upon time-frames (e.g. early refills may not be allowed, lost medications may not be replaced, refills may only occur during regular business hours, etc.);
• All therapies may be provided on a time-limited basis to determine potential effectiveness, and may be discontinued if judged ineffective or
unacceptably toxic;
• Referral of patients to substance abuse treatment programs will occur when use of controlled substances is determined to be due to underlying addiction and not pain. (rec)
Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section III: Practice Guidelines for Chronic Pain Management. 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. The patient’s pain medication should be managed by one physician and one pharmacy whenever possible. (rec)Hawaii Board of Medical Examiners. Pain Mnagement Guidelines. Section I: Introduction. Accordingly,
the Board expects that physicians incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (rec)
21
IdahoIdaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met. (rec)Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. The medical management of pain should reflect current knowledge of evidence‐based or best clinical practices for the use of pharmacologic and nonpharmacologic modalities, including the use of opioid analgesics and non‐opioid therapies. (rec) Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. The Arizona Medical Board recognizes that principles of high‐quality medical practice dictate that the people of the state of Arizona have access to appropriate, safe and effective pain management. (rec)Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Patient Evaluation and Risk Stratification: The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic and reflect an appropriately detailed patient evaluation. Such an evaluation should be completed before a decision is made as to whether to prescribe an opioid analgesic.
The nature and extent of the evaluation depends on the type of pain and the context in which it occurs. For example, meaningful assessment of chronic pain, including pain related to cancer or non‐cancer origins, usually demands a more detailed evaluation than an assessment of acute pain. Assessment of the patient’s pain typically would include the nature and intensity of the pain, past and current treatments for the pain, any underlying or co‐occurring disorders and conditions, and the effect of the pain on the patient's physical and psychological functioning.
For every patient, the initial work‐up should include a systems review and relevant physical examination, as well as laboratory investigations as indicated. Such investigations help the physician address not only the nature and intensity of the pain, but also its secondary manifestations, such as its effects on the patient's sleep, mood, work, relationships, valued recreational activities, and alcohol and drug use.
Social and vocational assessment is useful in identifying supports and obstacles to treatment and rehabilitation; for example: Does the patient have good social supports, housing, and meaningful work? Is the home environment stressful or nurturing?
Assessment of the patient's personal and family history of alcohol or drug abuse and relative risk for medication misuse or abuse also should be part of the initial valuation, and ideally should be completed prior to a decision as to whether to prescribe opioid analgesics. This can be done through a careful clinical interview, which also should inquire into any history of physical, emotional or sexual abuse, because those are risk factors for substance misuse. Use of a validated screening tool (such as the Screener and Opioid Assessment for Patients with Pain [SOAPP‐R] or the Opioid Risk Tool [ORT]), or other validated screening tools, can save time in collecting and evaluating the information and determining the patient's level of risk.
All patients should be screened for depression and other mental health disorders, as part of risk evaluation. Patients with untreated depression and other mental health problems are at increased risk for misuse or abuse of controlled medications, including addiction, as well as overdose.
Patients who have a history of substance use disorder (including alcohol) are at elevated risk for failure of opioid analgesic therapy to achieve the goals of improved comfort and function, and also are at high risk for experiencing harm from this therapy, since exposure to addictive substances often is a powerful trigger of relapse. Therefore, treatment of a patient who has a history of substance use disorder should, if possible, involve consultation with an addiction specialist before opioid therapy is initiated (and follow‐up as needed). Patients who have an active substance use disorder should not receive opioid therapy until they are established in a treatment/recovery program or alternatives are established such as co‐management with an addiction professional. Physicians who treat patients with chronic pain should be encouraged to also be knowledgeable about the treatment of addiction, including the role of replacement agonists such as methadone and buprenorphine. For some physicians, there may be advantages to becoming eligible to treat addiction using office‐based buprenorphine treatment.
Information provided by the patient is a necessary but insufficient part of the evaluation process. Reports of previous evaluations and treatments should be confirmed by obtaining records from other providers, if possible. Patients have occasionally provided fraudulent records, so if there is any reason to question the truthfulness of a patient's report, it is best to request records directly from the other providers.
If possible, the patient evaluation should include information from family members and/or significant others. Where available, the state prescription drug monitoring program (PDMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Periodic Drug Testing: Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non‐prescribed drugs. Drug testing is an important monitoring tool because self‐reports of medication use is not always reliable and behavioral observations may detect some problems but not others. Patients being treated for addiction should be tested as frequently as necessary to ensure therapeutic adherence, but for patients being treated for pain, clinical judgment trumps recommendations for frequency of testing.

Urine may be the preferred biologic specimen for testing because of its ease of collection and storage and the cost‐effectiveness of such testing. When such testing is conducted as part of pain treatment, forensic standards are generally not necessary and not in place, so collection is not observed and chain‐of‐custody protocols are not followed. Initial testing may be done using class-specific immunoassay drug panels (point‐of‐care or laboratory‐based), which typically do not identify particular drugs within a class unless the immunoassay is specific for that drug. If necessary, this can be followed up with a more specific technique, such as gas chromotography/mass spectrometry (GC/MS) or other chromatographic tests to confirm the presence or absence of a specific drug or its metabolites. In drug testing in a pain practice, it is important to identify the specific drug not just the class of the drug.

Physicians need to be aware of the limitations of available tests (such as their limited sensitivity for many opioids) and take care to order tests appropriately. For example, when a drug test is ordered, it is important to specify that it include the opioid being prescribed. Because of the complexities involved in interpreting drug test results, it is advisable to confirm significant or unexpected results with the laboratory toxicologist or a clinical pathologist.

While immunoassay, point of care (POC) testing has its utility in the making of temporary and “on the spot” changes in clinical management, its limitations with regard to accuracy have recently been the subject of study. These limitations are such that the use of point of care testing for the making of more long term and permanent changes in management of people with the disease of addiction and other clinical situations may not be justified until the results of confirmatory testing with more accurate methods such as LC‐MS/MS are obtained. A recent study on LC‐MS/MS results following immunoassay POC testing in addiction treatment settings and found very high rates of “false
negatives and positives”.

Test results that suggest opioid misuse should be discussed with the patient. It is helpful to approach such a discussion in a positive, supportive fashion, so as to strengthen the physician-patient relationship and encourage healthy behaviors (as well as behavioral change where that is needed). Both the test results and subsequent discussion with the patient should be documented in the medical record.
Periodic pill counting is also a useful strategy to confirm medication adherence and to minimize diversion (e.g., selling, sharing or giving away medications). As noted earlier and where available, consulting the state's PDMP before prescribing opioids for pain and during ongoing use is highly recommended. A PDMP can be useful in monitoring compliance with the treatment agreement as well as identifying individuals obtaining controlled substances from multiple prescribers.

If the patient's progress is unsatisfactory, the physician must decide whether to revise or augment the treatment plan, whether other treatment modalities should be added to or substituted for the opioid therapy, or whether a different approach—possibly involving referral to a pain specialist or other health professional—should be employed.

Evidence of misuse of prescribed opioids demands prompt intervention by the physician. Patient behaviors that require such intervention typically involve recurrent early requests for refills, multiple reports of lost or stolen prescriptions, obtaining controlled medications from multiple sources without the physician's knowledge, intoxication or impairment (either observed or reported), and pressuring or threatening behaviors. The presence of illicit or unprescribed drugs, (drugs not prescribed by a physician) in drug tests similarly requires action on the part of the prescriber. Some aberrant behaviors are more closely associated with medication misuse than others. Most worrisome is a pattern of behavior that suggests recurring misuse, such as unsanctioned dose escalations, deteriorating function, and failure to comply with the treatment plan.

Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require a firm, immediate response. Indeed, failure to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempts, arrests and incarceration, or even death. For this reason, physicians who prescribe chronic opioid therapy should be knowledgeable in the diagnosis of substance use disorders and able to distinguish such disorders from physical dependence—which is expected in chronic therapy with opioids and many sedatives. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Development of a Treatment Plan and Goals: The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain‐associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Effective means of achieving these goals vary widely, depending on the type and causes of the patient's pain, other concurrent issues, and the preferences of the physician and the patient.
The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear‐cut, individualized objectives to guide the choice of therapies. The treatment plan should contain information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and nonpharmacologic. It also should specify the objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function.
The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Consultation and Referral: The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed. For example, a patient who has a history of substance use disorder or a co‐occurring mental health disorder may require specialized assessment and treatment, if available.

Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office‐based opioid treatment [OBOT]), so as to make appropriate referrals when needed. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Ongoing Monitoring and Adapting the Treatment Plan: The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient’s overall health and level of function. When possible, collateral information about the patient’s response to opioid therapy should be obtained from family members or other close contacts, and the state PDMP. The patient should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted. As the patient is stabilized in the treatment regimen, follow‐up visits may be scheduled less frequently. (However, if the patient is seen less than monthly and an opioid is prescribed, arrangements must be made for the patient to obtain a refill or new prescription when needed.)

At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the “5As” of chronic pain management; these involve a determination of whether the patient is experiencing a reduction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of Aberrant substance‐related behaviors, and mood of the individual (Affect). Validated brief assessment tools that measure pain and function, such as the three‐question "Pain, Enjoyment and General Activity" (PEG) scale or other validated assessment tools, may be helpful and time effective.

Continuation, modification or termination of opioid therapy for pain should be contingent on the physician’s evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life. Information from family members or other caregivers should be considered in evaluating the patient’s response to treatment. Use of measurement tools to assess the patient's level of pain, function, and quality of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision‐making capacity. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications.
Use of a written informed consent and treatment agreement (sometimes referred to as a "treatment contract") is recommended.

Informed consent documents typically address:

• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short‐ and long‐term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over‐sedation.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long‐term opioid therapy.
• The physician's prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician's policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement). (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Informed Consent and Treatment Agreement: ...Treatment agreements outline the joint responsibilities of physician and patient and are indicated for opioid or other abusable medications. They typically discuss:
• The goals of treatment, in terms of pain management, restoration of function, and safety.
• The patient's responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication).
• The patient's responsibility to obtain his or her prescribed opioids from only one physician or practice.
• The patient's agreement to periodic drug testing (as of blood, urine, hair, or saliva).
• The physician's responsibility to be available or to have a covering physician available to care for unforeseen problems and to prescribe scheduled refills.

Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Patient Evaluation and Risk Stratification: ...If possible, the patient evaluation should include information from family members and/or significant others. Where available, the state prescription drug monitoring program (PDMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record. (rec)Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II: Guidelines. Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision‐making capacity. (rec)
Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. Accordingly, the Board expects physicians to incorporate safeguards into their practices to minimize the risk of misuse and diversion of opioid analgesics and other controlled substances. (rec)Idaho Medical Board. Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I: Preamble. This policy has been developed to articulate the Board’s position on the use of controlled substances for pain, particularly the use of opioid analgesics and with special attention to the management of chronic pain. (rec)
22
IndianaTitle 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-4 Evaluation and risk stratification by physician. Sec. 4. (b) Where medically appropriate, the physician shall utilize nonopioid options instead of or in addition to prescribing opioids. (rec)Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-4 Evaluation and risk stratification by physician. Sec. 4. (a) The physician shall do the physician's own
evaluation and risk stratification of the patient by doing the following in the initial evaluation of the patient:
(1) Performing an appropriately focused history and physi
cal exam and obtain or order appropriate tests, as indicated.
(2) Making a diligent effort to obtain and review records from previous health care providers to supplement the
physician's understanding of the patient's chronic pain problem, including past treatments, and documenting this
effort.
(3) Asking the patient to complete an objective pain assessment tool to document and better understand the patient's specific pain concerns.
(4) Assessing both the patient's mental health status and risk for substance abuse using available validated screening
tools.
(5) After completing the initial evaluation, establishing
a working diagnosis and tailoring a treatment plan to
meaningful and functional goals with the patient reviewing
them from time to time. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-9 Morphine equivalent doses above 60; revising of assessments and treatment plans. Sec. 9. When a patient's opioid dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day, a face-to-face review of the treatment plan and patient
evaluation must be scheduled, including consideration of referral to a specialist. If the physician elects to continue providing opioid therapy at a morphine equivalent dose of more than sixty (60) milligrams per day, the physician must develop a revised assessment and treatment plan for ongoing
treatment. The revised assessment and treatment plan must be documented in the patient's chart, including an assessment of increased risk for adverse outcomes, including death, if the physician elects to provide ongoing opioid treatment. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-8 Drug monitoring testing. Sec. 8. (a) After December 31, 2014, at any time the physician determines that it is medically necessary, whether at the outset of an opioid treatment plan, or any time thereafter, a physician prescribing opioids for a patient shall perform or order a drug monitoring test, which must include a confirmatory test using a method selective enough to differentiate individual drugs within a drug class, on the patient.
(b) In determining whether a drug monitoring test under subsection (a) is medically necessary, the physician shall
consider, subject to the provisions of subsection (c), each of the following factors where applicable and reasonably
feasible:
(1) Whether there is reason to believe a patient is not taking the prescribed opioids or is diverting the opioids.
(2) Whether there has been no appreciable impact on the patient's chronic pain despite being prescribed opioids for a period of time that would generally have an impact.
(3) Whether there is reason to believe the patient is taking or using controlled substances other than opioids or other drugs or medications including illicit street drugs that might produce significant polypharmacological effects or have other detrimental interaction effects.
(4) Whether there is reason to believe the patient is
taking or using opioids in addition to the opioids being prescribed by the physician and any other treating physicians.
(5) Attempts by the patient to obtain early refills of
opioid containing prescriptions.
(6) The number of instances in which the patient alleges
that their opioid containing prescription has been lost or
stolen.
(7) When the patient's INSPECT report provides irregular
or inconsistent information. (8) When a previous drug monitoring test conducted on the patient raised concerns about the patient's usage of
opioids.
(9) Necessity of verifying that the patient no longer has
substances in the patient's system that are not appropriate under the patient's treatment plan.
(10) When the patient engages in apparent aberrant behaviors or shows apparent intoxication.
(11) When the patient's opioid usage shows an unauthorized dose escalation.
(12) When the patient is reluctant to change medications or is demanding certain medications.
(13) When the patient refuses to participate in or coopera
te with a full diagnostic workup or examination.
(14) Whether a patient has a history of substance abuse.
(15) When the patient has a health status change (for example, pregnancy).
(16) Co-morbid psychiatric diagnoses.
(17) Other evidence of chronic opioid use, controlled substance abuse or misuse, illegal drug use or addiction, or medication noncompliance.
(18) Any other factor the physician believes is relevant to making an informed professional judgment about the
medical necessity of a prescription.
(c) It shall not be considered a violation of this section for a physician to fail to conduct a review of all eighteen (18)
factors listed in subsection (b) if the physician reasonably determines following a review of less than all of the factors listed in subection [sic] (b) that a drug monitoring test is medically necessary.
(d) Nothing about subsection (b) shall be construed to
prohibit the physician from performing or ordering a drug
monitoring test at any other time the physician considers appropriate.
(e) If a test performed under subsection (a), or conducted under subsection (d), reveals inconsistent medication use patterns or the presence of illicit substances, a review of the current treatment plan shall be required. Documentation of the revised treatment plan and discussion with the patient must be recorded in the patient's chart. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-9 Morphine equivalent doses above 60; revising of assessments and treatment plans. Sec. 9. When a patient's opioid dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day, a face-to-face review of the treatment plan and patient
evaluation must be scheduled, including consideration of referral to a specialist. If the physician elects to continue providing opioid therapy at a morphine equivalent dose of more than sixty (60) milligrams per day, the physician must develop a revised assessment and treatment plan for ongoing
treatment. The revised assessment and treatment plan must be documented in the patient's chart, including an assessment of increased risk for adverse outcomes, including death, if the physician elects to provide ongoing opioid treatment. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-6 Patient visits to physician. Sec. 6. (a) Physicians shall not prescribe opioids for patients without periodic scheduled visits. Visits for patients with a stable medication regimen and treatment plan shall occur face to face at least once every four (4) months. More frequent visits may be appropriate for patients working with the physician to achieve optimal management. For patients requiring changes to the medication and treatment plan, if changes are prescribed by the physician, the visits required by this subsection shall be scheduled at least once every two (2) months until the medication and treatment has been stabilized.
(b) During the visits required by subsection (a), the physician shall evaluate patient progress and compliance with the patient's treatment plan regularly and set clear expectations along the way, such as attending physical therapy, counseling, or other treatment options. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-5 Physician discussion with patient; treatment agreement. Sec. 5. The physician shall discuss with the patient the potential risks and benefits of opioid treatment for chronic pain, as well as expectations related to prescription requests and proper medication use. In doing so, the physician shall:... (7) Together with the patient, review and sign a “Treatment Agreement”, which shall include at least the following:
(A) The goals of the treatment.
(B) The patient's consent to drug monitoring testing in circumstances where the physician determines that drug monitoring testing is medically necessary.
(C) The physician's prescribing policies, which must include at least a: (i) requirement that the patient take the medication as prescribed; and (ii) prohibition of sharing medication with other individuals.
(D) A requirement that the patient inform the physician: (i) about any other controlled substances prescribed or taken by the patient; and (ii) if the patient drinks alcohol while taking opioids.
(E) The granting of permission to the physician to conduct random pill counts.
(F) Reasons the opioid therapy may be changed or discontinued by the physician.
A copy of the treatment agreement shall be retained in the patient's chart. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-7 INSPECT report. Sec. 7. At the outset of an opioid treatment plan, and at least annually thereafter, a physician prescribing opioids for a patient shall run an INSPECT report on that patient under IC 35-48-7-11.1(d)(4) and document in the patient's chart whether the INSPECT report is consistent with the physician's knowledge of the patient's controlled substance use history. (req)Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-5 Physician discussion with patient; treatment agreement. Sec. 5. The physician shall discuss with the patient the potential risks and benefits of opioid treatment for chronic pain, as well as expectations related to prescription requests and proper medication use. In doing so, the physician shall:
(1) Where alternative modalities to opioids for managing pain exist for a patient, discuss them with the patient.
(2) Provide a simple and clear explanation to help patients understand the key elements of their treatment plan.
(3) Counsel women between fourteen (14) and fifty-five (55) years of age with child bearing potential about the risks to the fetus when the mother has been taking opioids
while pregnant. Such described risks shall include fetal opioid dependency and neonatal abstinence syndrome (NAS).
(4) Discuss with the patient risks of dependency and addiction.
(5) Discuss with the patient safe storage practices for prescribed opioids.
(6) Provide a written warning to the patient disclosing the risks associated with taking extended release medications that are not in an abuse deterrent form, if the physician prescribes for the patient a hydrocodone-only extended release medication that is not in an abuse deterrent form. (req)
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-3 Triggers for imposition of requirements; exemptions. Sec. 3. (a) This section and sections 4 through 10 of this rule establish requirements concerning the use of opioids for chronic pain management for patients. (b) Notwithstanding subsection (a), this section and sections 4 through 10 of this rule shall not apply to the use of opioids for chronic pain management for the following:
(1) Patients with a terminal condition.
(2) Residents of a health facility licensed under IC 16-28.
(3) Patients enrolled in a hospice program licensed under IC 16-25.
(4) Patients enrolled in an inpatient or outpatient palliative care program of a hospital licensed under IC 16-21 or a hospice licensed under IC 16-25.
Title 844. Medical Licensing Board of Indiana. Article 5. Standards of Professional Conduct and Competent Practice of Medicine. Rule 6. Opioid Prescribing Requirements. 844 IAC 5-6-3 Triggers for imposition of requirements; exemptions. Sec. 3. (c) The requirements in the sections identified in subsection (a) only apply if a patient has been prescribed:
(1) more than sixty (60) opioid-containing pills a month for more than three (3) consecutive months;
(2) a morphine equivalent dose of more than fifteen (15) milligrams per day; for more than three (3) consecutive months;
(3) a transdermal opioid patch for more than three (3) consecutive months; (4) at any time it is classified as a controlled substance under Indiana law, tramadol, but only if the patient's tramadol dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day for more than three (3) consecutive months; or
(5) a hydrocodone-only extended release medication that is not in an abuse deterrent form. (req)
23
IowaAgency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(148,272C) Standards of practice-appropriate pain management. 4. Physicians should not fear board action for treating pain with controlled substances as long as the physicians' prescribing is consistent with appropriate
pain management practices. Dosage alone is not the sole measure of determining whether a physician has complied with appropriate pain management practices. The board recognizes the complexity of treating patients with chronic pain or a substance abuse history. Generally, the board is concerned about a pattern of improper pain management or a single occurrence of willful or gross overtreatment or undertreatment of
pain. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(148,272C) Standards of practice-appropriate pain management. This rule establishes standards of practice for the management of acute and chronic pain. The board encourages the use of adjunct therapies such as acupuncture, physical therapy
and massage in the treatment of acute and chronic pain. This rule focuses on prescribing and administering controlled substances to provide relief and eliminate suffering for patients with acute or chronic pain. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). e. Consultation/referral...The board encourages a multidisciplinary approach to chronic pain
management, including the use of adjunct therapies such as acupuncture, physical ther
apy and massage. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(148,272C) Standards of practice-appropriate pain management. 5. The board recognizes that the undertreatment of pain is a serious public health problem that results in decreases in
patients' functional status and quality of life, and that adequate access by patients to proper pain treatment is an important objective of any pain management policy. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). a. Patient evaluation. A patient evaluation that includes a physical examination and a comprehensive medical
history shall be conducted prior to the initiation of treatment. The evaluation shall also include an assessment
of the pain, physical and psychological function, diagnostics
tudies, previous interventions, including medication
history, substance abuse history and any underlying or coexisting conditions. Consultation/referral to a physician
with expertise in pain medicine, addiction medicine or substance abuse counseling or a physician who specializes
in the treatment of the area, system, or organ perceived to be the source of the pain may be warranted depending
upon the expertise of the physician and the complexity of the presenting patient. Interdisciplinary evaluation is
strongly encouraged. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). i. Drug testing. A physician who prescribes controlled substances to a patient for more than 90 days for the
treatment of chronic pain shall consider utilizing drug testing to ensure that the patient is receiving appropriate
therapeutic levels of prescribed medications or if the physician has reason to believe that the patient is at risk of drug abuse or diversion. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). b. Treatment plan. The physician shall establish a comprehensive treatment plan that tailors drug therapy to the individual needs of the patient. To ensure proper evaluation of the success of the treatment, the plan shall clearly state the objectives of the treatment, for example, pain relief or improved physical or psychosocial functioning. The treatment plan shall also indicate if any further diagnostic evaluations or treatments are planned and their purposes. The treatment plan shall also identify any other treatment modalities and rehabilitation programs utilized. The patient's short- and long-term needs for pain relief shall be considered when drug therapy is prescribed. The patient's ability to request pain relief as well as the patient setting shall be considered. For example, nursing home patients are unlikely to have their pain control needs assessed on a regular basis, making prn (on an as-needed basis) drugs less effective than drug therapy prescribed for routine administration that can be supplemented if pain is found to be worse. The patient should receive prescriptions for controlled substances from a single physician and a single pharmacy whenever possible. (rec)Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). e. Consultation/referral. A specialty consultation may be considered at any time
if there is evidence of significant adverse effects or lack of response to the medication. Pain, physical medicine, rehabilitation, general surgery, orthopedics, anesthesiology, psychiatry, neurology, rheumatology, oncology, addiction medicine, or other consultation may be appropriate. The physician should also consider consultation with, or referral to, a physician with expertise in addiction medicine or substance abuse counseling, if there is evidence of diversion or a pattern of
substance abuse. The board encourages a multidisciplinary approach to chronic pain
management, including the use of adjunct therapies such as acupuncture, physical ther
apy and massage. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). d. Periodic review. The physician shall periodically review the course of drug treatment of the patient and the
etiology of the pain. The physician should adjust drug therapy to the individual needs of each patient. Modification or continuation of drug therapy by the physician shall be dependent upon evaluation of the patient's progress toward the objectives established in the treatment plan.
The physician shall consider the appropriateness of continuing drug therapy and the use of other treatment modalities if periodic reviews indicate that the objectives of the treatment plan are not being met or that there is evidence of diversion or a pattern of substance abuse. Long-term opioid treatment is associated with the development of tolerance to its analgesic effects. There is also evidence that opioid treatment may paradoxically induce abnormal pain sensitivity, including hyperalgesia and allodynia. Thus, increasing opioid doses may not improve pain control and function. (req)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). c. Informed consent.
The physician shall document discussion of the risks and benefits of controlled substances with the patient or person representing the patient. (req)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). g. Pain management agreements. A physician who treats patients for chronic pain with controlled substances shall consider using a pain management agreement with each patient being treated that specifies the rules for medication use and the consequences for misuse. In determining whether to use a pain management agreement, a physician shall evaluate each patient, taking into account the risks to the patient and the potential benefits of long-term treatment with controlled substances. A physician who prescribes controlled substances to a patient for more than 90 days for treatment of chronic pain shall utilize a pain management agreement if the physician has reason to believe a patient is at risk of drug abuse or diversion. If a physician prescribes controlled substances to a patient for more than 90 days for treatment of chronic pain and chooses not to use a pain management agreement, then the physician shall document in the patient's medical records the reason(s) why a pain management agreement was not used. Use of pain management agreements is not necessary for hospice or nursing home patients. A sample pain management agreement and prescription drug risk assessment tools may be found on the board's Web site at www.medicalboard.iowa.gov. (rec)Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(7). Prescription monitoring program. The Iowa board of pharmacy has established a prescription monitoring program pursuant to
Iowa Code sections 124.551 to 124.558 to assist prescribers and pharmacists in monitoring the prescription of controlled substances to patients. The board recommends that physicians utilize the prescription monitoring program when prescribing controlled substances to patients if the physician has reason to believe that a patient is at risk of drug abuse or diversion. A link to the prescription monitoring program may be found at the board's Web site at www.medicalboard.iowa.gov. (rec)
Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(5). c. Informed consent. The physician shall document discussion of the risks and benefits of controlled substances with the patient or person representing the patient. (req)Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-13.2(148,272C) Standards of practice-appropriate pain management. 1. This rule is intended to encourage appropriate pain management, including the use of controlled substances for the treatment of pain, while stressing the need to establish safeguards to minimize the potential for substance abuse and drug diversion. (rec)Agency 653 Medicine Board. Chapter 13 Standards of Practice and Principles of Medical Ethics. 653-11.4(272C) Continuing education and training requirements for renewal or reinstatement. d. Training for chronic pain management for permanent or special license renewal. The licensee shall complete the training for chronic pain management as part of a category 1 credit. The licensee may utilize category 1 credit received for this training during the license period in which the training occurred to meet continuing education requirements in paragraph 11.4(1)"a."
(1) A licensee who regularly provides primary health care to patients in Iowa must complete at least two hours of category 1 credit for chronic pain management every five years. "A licensee who regularly provides primary health care to patients" means all emergency physicians, family physicians, general practice physicians, internists, neurologists, pain medicine specialists, psychiatrists, and any other physician who regularly provides primary health care to patients.
(2) A licensee who had a permanent license on August 17, 2011, has until August 17, 2016, to complete the chronic pain management training, and shall then complete the training once every five years thereafter. (req)
24
IowaJoint Board Policy Statement. A licensed health care practitioner involved in the care of a patient in pain should not be at risk of disciplinary action from their respective licensing board for prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose, based on accepted scientific knowledge, sound clinical judgment and adequate documentation. (rec)Joint Board Policy Statement. 2. ... Utilize non-pharmacological and pharmacological approaches to the treatment of pain and suffering. (rec)Joint Board Policy Statement. 2. Draw on the expertise that other health care practitioners offer in treating patients’ pain and work cooperatively with them to balance between pain relief and sedation, keeping in mind each patient’s level of pain, overall health and need to attend to family and other responsibilities. (rec)Joint Board Policy Statement. Patients deserve to have their pain well managed, whether it’s acute or chronic, mild or severe. Health care practitioners should, within their legal scope of practice, attend to patients’ pain. (rec)Joint Board Policy Statement. 1. Routinely assess all patients for pain. All pain should be evaluated with an appropriate history and physical and with laboratory and diagnostic testing, if indicated. (rec)Joint Board Policy Statement. 3. Regularly evaluate the effectiveness of the treatment plan and work together to alter the plan or seek consultation/referrals if the treatment is not providing optimal pain relief. (rec)Joint Board Policy Statement. 3. Regularly evaluate the effectiveness of the treatment plan and work together to alter the plan or seek consultation/referrals if the treatment is not providing optimal pain relief. (rec)Joint Board Policy Statement. 4. Document the assessment, plan of care and response to care in a clear, consistent, thorough and accurate manner. Patients should be informed of the risks and benefits when controlled substances or highly abusable drugs are prescribed in the ambulatory care setting. Documentation should be sufficiently detailed so that other practitioners can understand the original practitioner’s findings and thought processes. (rec)Joint Board Policy Statement. 8. Minimize the risk of diversion of drugs by using a pain management contract for chronic pain patients prescribed controlled substances and other abusable drugs. (rec)
25
KansasChapter 65. Article 49. Pain Patient's Quality of Care. §65-4976. The legislature finds and declares that pain is a significant health problem, and that the diagnosis and treatment of pain is complex, and can involve several therapeutic modalities.Chapter 65. Article 49. Pain Patient's Quality of Care. §65-4976. (b) Nothing in this act shall be construed to prevent, restrict or limit a physician or other person authorized to prescribe drugs from prescribing, dispensing, administering, or distributing a controlled substance to a patient for the treatment of pain, when it is for a valid medical purpose and based on appropriate clinical indications.
(c) Nothing in this act shall be construed to require a physician or other person authorized to prescribe drugs to prescribe, dispense, administer, or distribute a controlled substance to a patient for the treatment of pain if in the judgment of the prescriber the use of a controlled substance is not clinically indicated or the most appropriate therapeutic modality.
26
KansasKanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Physicians should not fear disciplinary action from the Board for prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the usual course of professional practice. (rec)Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The medical management of pain should be based on current knowledge and research and include the use of both pharmacologic and non-pharmacologic modalities. (rec)Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The Kansas State Board of Healing Arts recognizes that principles of quality medical practice dictate that the people of the State of Kansas have access to appropriate and effective pain relief. (rec)Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 1. Evaluation of the Patient
The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of 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 indications for the use of a controlled substance. (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 3. Informed Consent and Agreement for Treatment
... 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; ... (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 pain is associated with physical and psychosocial impairment. (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 pain patients who are at risk for misusing their medications and those whose living arrangement pose a risk for medication misuse or 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. (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 3. Informed Consent and Agreement for Treatment
... 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 all prescription refills; and
- reasons for which drug therapy may be discontinued (i.e., violation of agreement). (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Physicians should be diligent in preventing the diversion of drugs for illegitimate purposes. (rec)Kanasas Medical Board Guidelines. Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. All such prescribing must be based on clear documentation of unrelieved pain and in compliance with these guidelines. If such prescribing meets these criteria, the Board will support physicians whose use of controlled substances has been questioned by another regulatory or enforcement agency. (req)
27
KansasJoint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Health care providers who competently treat pain should not fear disciplinary action from their licensing board. (rec)Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. All health care providers who treat patients in pain, whether acute or chronic, and whether as a result of terminal illness or non-life-threatening injury or disease, should become knowledgeable about effective methods of pain treatment. The management of pain should include the use of both pharmacologic and non-pharmacologic modalities. (rec)Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 1. Assessment of the Patient. Pain should be assessed and reassessed as clinically indicated. Interdisciplinary communications regarding a patient’s report of pain should include adoption of a standardized scale for assessing pain. (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 4. Agreement for Treatment of High-Risk Patients. If the patient is determined to be at high risk for medication abuse or to have a history of substance abuse, the health care provider should consider requiring a written agreement by the patient outlining patient responsibilities, including:
• Submitting to screening of urine/serum medication levels when requested; ... (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 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 drug therapy plan should be adjusted to the individual medical needs of each patient. The nurse’s skill is best utilized when an order for drug administration uses dosage and frequency parameters that allow the nurse to adjust (titrate) medication dosage. 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. If, in a healthcare provider’s sound professional judgment, pain should not be treated as requested by the patient, the healthcare provider should inform the patient of the basis for the treatment decisions and document the substance of this communication. (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 6. Consultation.
The health care provider 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 pain patients who are at risk for misusing their medications and those whose living arrangement poses a risk for medication misuse or 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. (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 5. Periodic Review. At reasonable intervals based on the individual circumstances of the patient, the course of treatment and any new information about the etiology of the pain should be evaluated. Communication among health care providers is essential to review of the medical plan of care. The health care providers involved with the management of pain should evaluate progress toward meeting treatment objectives in light of improvement in patient’s pain intensity and improved physical 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 health care provider’s should reevaluate the appropriateness of continued treatment. (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 3. Informed Consent. The physician retains the ultimate responsibility for obtaining informed consent to treatment from the patient. All health care providers share the role of effectively communicating with the patient so that the patient is apprised of the risks and benefits of using controlled substances to treat pain. (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 4. Agreement for Treatment of High-Risk Patients. If the patient is determined to be at high risk for medication abuse or to have a history of substance abuse, the health care provider should consider requiring a written agreement by the patient outlining patient responsibilities, including:
• Submitting to screening of urine/serum medication levels when requested;
• Limiting prescription refills only to a specified number and frequency;
• Requesting or receiving prescription orders from only one health care provider;
• Using only one pharmacy for filling prescriptions; and
• Acknowledging reasons for which the drug therapy may be discontinued (i.e., violation of agreement). (rec)
Joint Board Policy Statement. Use of Controlled Substances for the Treatment of Pain. Section II: Principles. 3. Informed Consent. The physician retains the ultimate responsibility for obtaining informed consent to treatment from the patient. All health care providers share the role of effectively communicating with the patient so that the patient is apprised of the risks and benefits of using controlled substances to treat pain. (rec)
28
KentuckyTitle 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(j) The physician shall initially attempt, to the extent possible, or establish and document a previous attempt by another physician, of a trial of noncontrolled modalities and lower doses of a controlled substance in increasing order to treat the pain and related symptoms associated with the primary medical complaint, before continuing with long term prescribing of a controlled substance at a given level. (req)Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (1) Before a physician commences to prescribe or dispense any controlled substance to a patient sixteen (16) years or older for pain or other symptoms associated with the same primary medical complaint for a total period of longer than three (3) months, the physician shall comply with the mandatory professional standards established in subsection (2) of this section...(2)(a) The physician shall obtain the following information from the patient and record all relevant information in the patient's medical record:
1. History of present illness;
2. Past medical history;
3. History of substance use and any prior treatment for that use by the patient, and history of substance abuse by first degree relatives of the patient;
4. Past family history of relevant illnesses and treatment; and
5. Psychosocial history.
(b) The physician shall conduct an appropriate physical examination of the patient sufficient to support the medical indications for prescribing or dispensing a controlled substance on a long-term basis.
(c) The physician shall perform appropriate baseline assessments to establish beginning values to assist in establishing and periodically evaluating the functional goals of any treatment plan.
(d) If a specific or specialized evaluation is necessary for the formulation of a working diagnosis or treatment plan, the physician shall only continue the use of a controlled substance after determining that continued use of the controlled substance is safe and medically appropriate in the absence of that information.
(e) If the physician determines that the patient has previously received medical treatment for the presenting medical complaint or related symptoms and that review of the prior treatment records is necessary to justify long-term prescribing of a controlled substance, the physician shall obtain those prior medical records and incorporate the information therein into the evaluation and treatment of the patient.
(f)1. Based upon consideration of all information available, the physician shall promptly formulate and document a working diagnosis of the source of the patient's medical complaint and related symptoms without simply describing or listing the related symptoms. 2. If the physician is unable, despite best efforts, to formulate a working diagnosis, the physician shall consider the usefulness of additional information, such as a specialized evaluation or assessment, referral to an appropriate specialist, and the usefulness of further observation and evaluation, before attempting again to formulate a working diagnosis. 3. If the physician is unable to formulate a working diagnosis, despite the use of an appropriate specialized evaluation or assessment, the physician shall only prescribe long term use of a controlled substance after establishing that its use at a specific level is medically indicated and appropriate. (req)
Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(g)4. The physician shall obtain and document a baseline drug screen. (req) Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 5. Professional Standards for Continuing Long Term Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(k)1. During the course of long-term prescribing or dispensing of a controlled substance, the physician shall utilize drug screens, appropriate to the controlled substance and the patient's condition, in a random and unannounced manner at appropriate times. If the drug screen or other information available to the physician indicates that the patient is noncompliant, the physician shall:
a. Do a controlled taper;
b. Stop prescribing or dispensing the controlled substance immediately; or
c. Refer the patient to an addiction specialist, mental health professional, pain management specialist, or drug treatment program, depending upon the circumstances.
(req)
Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(g)1. To the extent that functional improvement is medically expected based upon the patient's condition, the physician shall formulate an appropriate treatment plan.
2. The treatment plan shall include specific and verifiable goals of treatment, with a schedule for periodic evaluations. (req)
Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(g)2. If, after screening, the physician determines that there is a reasonable likelihood that the patient suffers from substance abuse or dependence, or a psychiatric or psychological condition, the physician shall take the necessary actions to facilitate a referral to an appropriate treatment program or provider. The physician shall appropriately incorporate the information from the treatment program or provider into the evaluation and treatment of the patient. (req)Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 5. Professional Standards for Continuing Long Term Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (1) If a physician continues to prescribe or dispense a controlled substance beyond three (3) months to a patient sixteen (16) years or older for pain and related symptoms associated with the primary medical complaint, the physician shall comply with the professional standards established in subsection (2) of this section...
(2)(a)1. The physician shall ensure that the patient is seen at least once a month initially for evaluation and review of progress. The physician may determine that the patient is to be evaluated less frequently, on a schedule determined by the physician's professional judgment after the physician has determined:
a. The controlled substance prescribed or dispensed has been titrated to the level appropriate and necessary to treat the medical complaint and related symptoms;
b. The controlled substance prescribed or dispensed is not causing unacceptable side effects; and
c. There is sufficient monitoring in place to minimize the likelihood that the patient will use the controlled substance in an improper or inappropriate manner or divert it for an improper or inappropriate use.
(b) At appropriate intervals, the physician shall:
1. Ensure that a current history is obtained from the patient;
2. Ensure that a focused physical examination is considered, and performed, if appropriate; and
3. Perform appropriate measurable examinations as indicated in the treatment plan.
(c) At appropriate intervals, the physician shall evaluate the working diagnosis and treatment plan based upon the information gained to determine whether there has been functional improvement or any change in baseline measures. The physician shall modify the diagnosis, treatment plan, or controlled substance therapy, as appropriate.
(d) If the physician determines that the patient presents a significant risk of diversion or improper use of a controlled substance, the physician shall discontinue the use of the controlled substance or justify its continued use in the patient record.
(e) If the medical complaint and related symptoms continue with no significant improvement in function despite treatment with a controlled substance, and if improvement is medically expected, the physician shall obtain appropriate consultative assistance to determine whether there are undiagnosed conditions to be addressed in order to resolve the medical complaint.
(f) For a patient exhibiting symptoms suggestive of a mood, anxiety, or psychotic disorder, the physician shall obtain a psychiatric or psychological consultation for intervention if appropriate.
(g) If a patient reports experiencing episodes of breakthrough pain, the physician shall:
1. Attempt to identify the trigger or triggers for each episode;
2. Determine whether the breakthrough pain may be adequately treated through noncontrolled treatment; and
3. If the physician determines that the nonmedication treatments do not adequately address the triggers, and after considering the risks and benefits, determines to add an as-needed controlled substance to the regimen, take appropriate steps to minimize the improper or illegal use of the additional controlled substance.
(h) At least once a year, the physician shall perform or shall ensure that the patient's primary treating physician performs a preventive health screening and physical examination appropriate to the patient's gender, age, and medical condition.
(i)1. At least once every three (3) months, the physician shall obtain and review a current KASPER report, for the twelve (12) month period immediately preceding the request, and appropriately use that information in the evaluation and treatment of the patient.
2. If the physician obtains or receives specific information that the patient is not taking the controlled substance as directed, is diverting a controlled substance, or is engaged in any improper or illegal use of a controlled substance, the physician shall immediately obtain and review a KASPER report and appropriately use the information in the evaluation and treatment of the patient.
3. If a KASPER report discloses that the patient is obtaining a controlled substance from another practitioner without the physician's knowledge and approval, in a manner that raises suspicion of illegal diversion, the physician shall promptly notify the other practitioner of the relevant information from the KASPER review.
4. The physician shall obtain consultative assistance from a specialist if appropriate.
(j) If appropriate, the physician shall conduct random pill counts and appropriately use that information in the evaluation and treatment of the patient.
(k)1. During the course of long-term prescribing or dispensing of a controlled substance, the physician shall utilize drug screens, appropriate to the controlled substance and the patient's condition, in a random and unannounced manner at appropriate times. If the drug screen or other information available to the physician indicates that the patient is noncompliant, the physician shall:
a. Do a controlled taper;
b. Stop prescribing or dispensing the controlled substance immediately; or
c. Refer the patient to an addiction specialist, mental health professional, pain management specialist, or drug treatment program, depending upon the circumstances.
2. The physician shall discontinue controlled substance treatment or refer the patient to addiction management if:
a. There has been no improvement in function and response to the medical complaint and related symptoms, if improvement is medically expected;
b. Controlled substance therapy has produced significant adverse effects; or
c. The patient exhibits inappropriate drug-seeking behavior or diversion.
(req)
Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(i) After explaining the risks and benefits of long-term use of a controlled substance, the physician shall obtain the written informed consent of the patient in a manner that meets professional standards. (req)Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(g)3. If, after screening, the physician determines that there is a risk that the patient may illegally divert a controlled substance, but determines to continue long term prescribing of the controlled substance, the physician shall use a prescribing agreement that meets professional standards. The prescribing agreement and informed consent document may be combined into one (1) document. (req)Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 5. Professional Standards for Continuing Long Term Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(i)1. At least once every three (3) months, the physician shall obtain and review a current KASPER report, for the twelve (12) month period immediately preceding the request, and appropriately use that information in the evaluation and treatment of the patient.
2. If the physician obtains or receives specific information that the patient is not taking the controlled substance as directed, is diverting a controlled substance, or is engaged in any improper or illegal use of a controlled substance, the physician shall immediately obtain and review a KASPER report and appropriately use the information in the evaluation and treatment of the patient.
3. If a KASPER report discloses that the patient is obtaining a controlled substance from another practitioner without the physician's knowledge and approval, in a manner that raises suspicion of illegal diversion, the physician shall promptly notify the other practitioner of the relevant information from the KASPER review.
4. The physician shall obtain consultative assistance from a specialist if appropriate. (req)
Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 4. Professional Standards for Commencing Long Term Use of Prescribing or Dispensing of Controlled Substances for the Treatment of Pain and Related Symptoms Associated with a Primary Medical Complaint. (2)(i) After explaining the risks and benefits of long-term use of a controlled substance, the physician shall obtain the written informed consent of the patient in a manner that meets professional standards. (req)Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:310. Continuing medical education. Section 6. (1) For each three (3) year continuing education cycle beginning on January 1, 2015, a licensee who is authorized to prescribe or dispense controlled substances within the Commonwealth at any time during that cycle shall complete at least four and one-half (4.5) hours of approved continuing education hours relating to the use of KASPER, pain management, addiction disorders, or a combination of two (2) or more of those subjects. A licensee may satisfy this requirement by completing a single approved program of four and one-half (4.5) hours or longer or by completing multiple approved programs for a total of four and one-half (4.5) hours or longer for that cycle.
(2) Each physician licensed to practice medicine or osteopathy within the Commonwealth of Kentucky who is authorized to prescribe or dispense controlled substances within the Commonwealth from July 20, 2012 through the end of the three (3) year continuing education cycle beginning on January 1, 2012 and ending on December 31, 2014 shall complete at least four and one-half (4.5) hours of approved Category I Credit continuing medical education hours relating to the use of KASPER, pain management, addiction disorders, or a combination of two (2) or more of those subjects on or before December 31, 2014. The licensee may satisfy this requirement by completing a single approved program of four and one-half (4.5) hours or longer or by completing multiple approved programs for a total of four and one-half (4.5) hours or longer for this cycle.
(3) Each physician licensed to practice medicine or osteopathy within the Commonwealth of Kentucky who is authorized to prescribe or dispense controlled substances during the calendar years 2013 and 2014, but not during any portion of 2012, shall complete at least three (3) hours of approved Category I Credit continuing medical education hours relating to the use of KASPER, pain management, addiction disorders, or a combination of two (2) or more of those subjects on or before December 31, 2014. The licensee may satisfy this requirement by completing a single approved program of three (3) hours or longer or by completing multiple approved programs for a total of three (3) hours or longer for those two (2) years.
(4) Each physician licensed to practice medicine or osteopathy within the Commonwealth of Kentucky who is authorized to prescribe or dispense controlled substances during calendar year 2014, but not during any portion of 2012 or 2013, shall complete at least one and one-half (1.5) hours of approved Category I Credit continuing medical education hours relating to the use of KASPER, pain management, addiction disorders, or a combination of two (2) or more of those subjects on or before December 31, 2014. The licensee may satisfy this requirement by completing a single approved program of one and one-half (1.5) hours or longer or by completing multiple approved programs for a total of one and one-half (1.5) hours or longer for that calendar year.
(req)
Title 201. General Government Cabinet. Chapter 9. Board of Medical Licensure. 201 KAR 9:260. Professional standards for prescribing and dispensing controlled substances. Section 1. Applicability. (2) The professional standards established in this administrative regulation shall not apply to a physician prescribing or dispensing a controlled substance:
(a) To a patient as part of the patient's hospice or end-of-life treatment;
(b) To a patient admitted to a licensed hospital as an inpatient, outpatient, or observation patient, during and as part of a normal and expected part of the patient's course of care at that hospital;
(c) To a patient for the treatment of pain associated with cancer or with the treatment of cancer;...(req)
29
LouisianaTitle 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations.
A. 1. Evaluation of the Patient. Evaluation of the patient shall initially include relevant medical, pain, alcohol and substance abuse histories, an assessment of the impact of pain on the patient's physical and psychological functions, a review of previous diagnostic studies, previously utilized therapies, an assessment of coexisting illnesses, diseases, or conditions, and an appropriate physical examination. (req)
Title 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations. B.2. Drug Screen. If a physician reasonably believes that t
he patient is suffering from substance abuse or that he is
diverting controlled substances, the physician shall obtain a drug screen on the patient. It is within the physician's discretion to decide the nature of the screen and which type of drug(s) to be screened. (req)
Title 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations. A. 3. Treatment Plan. An individualized treatment plan shall be formulated and documented in the patient's medical record which includes medical justification for controlled substance therapy. Such plan shall include documentation that other medically reasonable alternative treatments for relief of the patient's noncancer-related chronic or intractable pain have been considered or attempted without adequate or reasonable success. Such plan shall specify the intended role of controlled substance therapy within the overall plan, which therapy shall be tailored to the individual medical needs of each patient. (req)Title 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations. B.4. 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 pain patients who are at risk for misusing their medications and those whose living
arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation, and consultation with or referral to an expert in the management
of such patients. (rec)
Title 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations. B. 1. Assessment of Treatment Efficacy and Monitoring. Patients shall be seen by the physician at appropriate intervals, not to exceed 12 weeks, to assess the efficacy of treatment, assure that controlled substance therapy remains indicated, and evaluate the patient's progress toward treatment objectives and any adverse drug effects. Exceptions to this interval shall be adequately documented in the patient's record. During each visit, attention shall be given to the possibility of decreased function or quality of life as a result of controlled substance treatment. Indications of substance abuse or diversion should also be evaluated. At each visit, the physician should seek evidence of under treatment of pain. (req)
Title 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations. A. 4. Informed Consent. A physician shall ensure that the patient and/or his guardian is informed of the benefits and risks of controlled substance therapy. Discussions of risks and benefits should be noted in some format in the patient's record. (rec)Title 46. Professional and Occupational Standards. Part XLV. Medical Professions. Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain. § 6921. Use of Controlled Substances, Limitations. A. 4. Informed Consent. A physician shall ensure that the patient and/or his guardian is informed of the benefits and risks of controlled substance therapy. Discussions of risks and benefits should be noted in some format in the patient's record. (rec)Title 46. Professional and Occupational Standards
Part XLV. Medical Professions.
Subpart 3. Practice. Chapter 69. Prescription, Dispensation, and Administration of Medications. Subchapter B. Medications Used in the Treatment of Non-Cancer-Rela
ted Chronic or Intractable Pain.
§ 6915. Scope of Subchapter.
A. The rules of this Subchapter govern physician responsibility for providing effective and safe pain control for patients with noncancer-related chronic or intractable pain. (req)
.
30
Maine02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. II. Joint Statement on the Treatment of Pain. Clinicians should not fear disciplinary action from the Boards for ordering, prescribing, dispensing or administering
controlled substances, including opioid analgesics, for
a legitimate medical purpose and in the course of rofessional practice. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. II. Joint Statement on the Treatment of Pain. The management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the clinician. (rec)02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. II. Joint Statement on the Treatment of Pain.
The Boards recognize that principles of quality medical, dental and advanced nursing practice dictate that the people of the State of Maine have access to appropriate and effective pain relief. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 1. Evaluation of the Patient -- A medical history and appropriate physical examination must be obtained, evaluated and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function and history of substance abuse. It is recommended that the State's Controlled Substance
Prescription Monitoring Program Database (PMP) be utilized. The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 3. Informed Consent and Agreement for Treatment -- ... If the patient is at high risk for medication abuse or has a history of substance abuse or substance dependence, the clinician should use a written agreement between clinician and patient outlining patient responsibilities, including:
a. urine/serum medication levels screening when requested;... (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 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 clinician 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. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 5.
Consultation or Referral -- The clinician should consult or refer, as necessary, for additional evaluation and treatment in order to achieve treatment objectives. Special attention should be given to those patients with pain who are at risk for medication misuse, abuse or diversion. Chronic pain often has, as a component, emotional, psychological, or psychosocial stress. In these situations, a number of patients may benefit from psychoactive medications, as
well as controlled substances for pain control. The combination of opiates with psychoactive medications, e.g., benzodiazepines, may place the patient at greater risk. The risk may be associated with drug interaction, potentiation, or abuse. In these situations, consultation with or referral to an expert in the management of such patients may be required. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 4.
Periodic Review of Treatment Efficacy -- The clinician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on the clinician's evaluation of progress toward treatment
objectives. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient's response to treatment. If the patient's progress is unsatisfactory, the clinician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. Likewise, the clinician should periodically review the course of treatment where psychoactive drugs are used for the treatment of components of chronic pain, e.g., emotional, psychological, or psychosocial stressors, and assess the appropriateness of continued use of the current treatment plan if the patient's progress is unsatisfactory. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 3.
Informed Consent and Agreement for Treatment -- The clinician 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 without medical decision-making capacity. The patient should receive prescriptions from one clinician and one pharmacy whenever possible. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 3. Informed Consent and Agreement for Treatment -- ... If the patient is at high risk for medication abuse or has a history of substance abuse or substance dependence, the clinician should use a written agreement between clinician and patient outlining patient responsibilities, including:
a. urine/serum medication levels screening when requested;
b. pill count when requested;
c. number and frequency of all prescription refills; and
d. reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec) 02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. IV. Controlled Substances Contract. Suggested elements of a controlled substance contract are as follows:
1. Specifies that the clinician is the single source of controlled substances;
2. May specify the pharmacy;
3. Provides written, informed consent to release contract to local emergency departments and pharmacies;
4. If written consent is given for release to local emergency departments and/or pharmacies, consent is also being given to the other clinicians and providers such as pharmacists to report violations of the contract back to the prescribing clinician;
5. Specifies that if the clinician becomes concerned that there has been illegal activity, the clinician may notify the proper authorities;
6. Provides that if the clinician has obtained a written release, ER personnel and other providers shall report violations of the contract back to the doctor who prescribed the controlled substance(s);
7. Specifies that a violation of the contract will result in a tapering and discontinuation of the narcotics prescription;
8. Specifies that a risk of chronic narcotics treatment is physical dependence (as defined);
9. Specifies that a risk of chronic narcotics treatment is addiction (as defined);
10. Specifies that it is the responsibility of the patient to be discreet about possessing narcotics and keeping medications in an inaccessible place so that they may not be stolen;
11. If the patient violates the terms of the contract, the violation should be documented. The clinician response to the violation should be documented, as well as the rationale of and changes in the treatment plan;
12. Clinician may consider “fill only at _________________ pharmacy” on the prescription form; 13. Specifies use of urine/serum medications levels screening when appropriate; and
14. Specifies use of a pill count when appropriate. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 1. Evaluation of the Patient -- ...It is recommended that the State's Controlled Substance Prescription Monitoring Program Database (PMP) be utilized. (rec)02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 3.
Informed Consent and Agreement for Treatment -- The clinician 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 without medical decision-making capacity. (rec)
02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. II. Joint Statement on the Treatment of Pain. Accordingly, the Boards expect that clinicians will incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (rec)02. Department of Professional and Financial Regulation. 373. Board of Licensure in Medicine. Chapter 21. Use of Controlled Substances for Treatment of Pain. Sec. III. Principles of Proper Pain Management. 7. Reportable Acts -- Generally, information gained as part of the clinician/patient relationship remains confidential. However, the clinician has an obligation to deal with persons who use the clinician to perpetrate illegal acts, such as illegal acquisition or selling of drugs; this may include reporting to law enforcement. Information suggesting inappropriate or drug-seeking behavior, should be addressed appropriately and documented. Use of the PMP is recommended. (rec)
31
MassachusettsTITLE 243: BOARD OF REGISTRATION IN MEDICINE. CHAPTER 2.00: LICENSING AND THE PRACTICE OF MEDICINE. 2.02: Initial Licensure for Graduates of Medical Schools in the US, CA, and PR. (1) Prerequisites to Initial Licensure. The Board shall determine whether an applicant is qualified to hold a full active license to practice medicine. In order to qualify for a full medical license, an applicant shall meet all of the following minimum requirements for licensure:...(g) Complete Pain Management training, as described in M.G.L. c. 94C, § 18. (2) Procedure for Obtaining an Initial Full License for Graduates of Medical Schools in the United States, Canada and the Commonwealth of Puerto Rico. In order to qualify for a full medical license, an applicant shall meet the prerequisites to licensure in 243 CMR 2.02(1) and the following requirements, in addition to other requirements for licensure as set forth in the Board's regulations (243 CMR) and M.G.L. c. 112...(e) Pain Management Training. Applicants who prescribe controlled substances shall, as a prerequisite to obtaining or renewing a medical license, complete appropriate pain management training and opioid education, according to M.G.L. c. 94C, § 18 and 243 CMR 2.00. Pain Management training shall consist of at least three credits of Board-approved con-tinuing professional development and may be used toward the required ten credits of risk management training. (req)
TITLE 243: BOARD OF REGISTRATION IN MEDICINE. CHAPTER 2.00: LICENSING AND THE PRACTICE OF MEDICINE. 2.06: License Renewals. (6) Continuing Professional Development...(d) Opioid Education and Pain Management Training. Renewing licensees who prescribe controlled substances, as defined in M.G.L. c. 94C, § 1, shall, as a prerequisite to renewing a medical license, complete three credits in pain management training, pursuant to St. 2010, c. 283. Pain management training shall include, but not be limited to, training in how to identify patients at high risk for substance abuse and training in how to counsel patients on the side effects, addictive nature and proper storage and disposal of prescription medicines. Three credits of opioid education and pain management training shall be required of licensees when they biennially renew their licenses. Opioid education and pain management training may be used toward a licensee's required risk management credits of continuing professional education. (req)
32
MassachusettsMassachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. (rec)Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the physician. (rec)Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble.
The Massachusetts Board of Registration in Medicine recognizes that principles of quality medical practice dictate that the people of the Commonwealth of Massachusetts have access to appropriate and effective pain relief. (rec)
Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. (rec)
Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Informed Consent and Agreement for Treatment— ... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including
o urine/serum medication levels screening when requested; ... (rec)
Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. (rec)Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Periodic Review—The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician’s evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient’s decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient’s response to treatment. If the patient’s progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (rec)Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. (rec)
Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. Informed Consent and Agreement for Treatment— ... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including
o urine/serum medication levels screening when requested;
o number and frequency of all prescription refills; and
o reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec)
Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 without medical decision-making capacity. (rec)
Massachusetts Medical Board. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Accordingly, the Board expects that physicians incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (rec)
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MichiganChapter 333. Act 368 of 1978. Article 15. Part 161. § 333.16204. Completion of courses in pain and symptom management as condition for license renewal; applicability. (1) Effective for the renewal of licenses or registrations issued under this article and expiring after January 1, 1997 if the completion of continuing education is a condition for renewal, the appropriate board shall by rule require an applicant for renewal to complete an appropriate number of hours or courses in pain and symptom management. Rules promulgated by a board under section 16205(2) for continuing education in pain and symptom management shall cover both course length and content and shall take into consideration the recommendation for that health care profession by the interdisciplinary advisory committee created in section 16204a. A board shall submit the notice of public hearing for the rules as required under section 42 of the administrative procedures act of 1969, being section 24.242 of the Michigan Compiled Laws, not later than 90 days after the first interdisciplinary advisory committee makes its initial recommendations and shall promulgate the rules as expeditiously as possible. (req)
34
MichiganJoint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Physicians should not fear disciplinary action from the Board 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. (rec)Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The medical management of pain should be based on current knowledge and research and include the use of both pharmacologic and non-pharmacologic modalities. (rec)Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. The Michigan Boards of Medicine and Osteopathic Medicine & Surgery recognize that principles of quality medical practice dictate that the people of the State of Michigan have access to appropriate and effective pain relief. (rec)Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. 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, current and past treatments for 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 indications for the use of a controlled substance. (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 3. Informed Consent and Agreement for Treatment. ... 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
o urine/serum medication levels screening when requested; ... (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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 pain patients who are at risk for misusing their medications and those whose living arrangement pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 3. Informed Consent and Agreement for Treatment. ... 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
o urine/serum medication levels screening when requested;
o number and frequency of all prescription refills; and
o reasons for which drug therapy may be discontinued (i.e., violation of agreement). (rec)
Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section I: Preamble. Physicians should be diligent in preventing the diversion of drugs for illegitimate purposes. (rec) Joint Board Guideline. Michigan Guidelines for the Use of Controlled Substances for the Treatment of Pain. Section II: Guidelines. 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. (rec)
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MinnesotaHealth. Chapter 152. §152.125. Intractable Pain. Subdivision 2. No physician shall be subject to disciplinary action by the Board of Medical Practice for
appropriately prescribing or administering a controlled substance in Schedules II to V of section 152.02 in the course of treatment of an individual for intractable
pain, provided the physician keeps accurate records of the purpose, use, prescription, and disposal of controlled substances, writes accurate prescriptions, and prescribes medications in conformance with chapter 147. (req)
Health. Chapter 152. §152.125. Intractable Pain. Subdivision 1. Reasonable efforts for relieving or curing the cause of the pain may be determined on the basis of, but are not
limited to, the following: (1) when treating a nonterminally ill patient for intractable pain, evaluation by the attending physician and one or more physicians specializing in pain medicine or the treatment of the area, system, or organ of the body perceived as the source of the pain. (rec)
Health. Chapter 152. §152.125. Intractable Pain. Subdivision 4. Prior to treating an individual for intractable pain in accordance with subdivision 2, a physician shall discuss with the individual the risks associated with the controlled substances in Schedules II to V of section 152.02 to be prescribed or administered in the course of the
physician's treatment of an individual, and
document the discussion in the individual's record. (req)
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MinnesotaMINNESOTA BOARD OF MEDICAL PRACTICE.
POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section I: Preamble. Physicians should not fear disciplinary action from the Board for prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE.
POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section I: Preamble. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the physician. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE.
POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section I: Preamble. The Minnesota Board of Medical Practice ("Board") recognizes that principles of quality medical practice dictate that the people of the State of Minnesota have access to appropriate and effective pain relief. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE.
POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 1. Evaluation of the Patient. A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE. POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 3. Informed Consent and Agreement for Treatment... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including
• urine/serum medication levels screening when requested; ... (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE.
POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 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. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE. POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 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 with pain who are at risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE. POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 4. Periodic Review. The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician's evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient's response to treatment. If the patient's progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE. POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 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 without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE. POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 3. Informed Consent and Agreement for Treatment... If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider 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 all prescription refills; and
• reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE. POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section II: Guidelines. 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 without medical decision-making capacity. (rec)
MINNESOTA BOARD OF MEDICAL PRACTICE.
POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN. Section I: Preamble. Accordingly, the Board expects that physicians incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (rec)
37
MinnesotaJoint Board Statement. It is, therefore, incumbent upon Minnesota physicians, nurses and pharmacists to work cooperatively and effectively to address the dimensions of pain and to provide maximum pain relief with minimal side effects. (rec)Joint Board Statement. To effectively assist patients in the management of pain, health care professionals should, within their scope of practice:

• Consistently and thoroughly assess all patients for pain. If pain is reported, the pain should be evaluated with a complete history and physical with laboratory and diagnostic testing, if indicated. The assessment of pain should be individualized, on-going and clearly documented; (rec)
Joint Board Statement. To effectively assist patients in the management of pain, health care professionals should, within their scope of practice: • Work collaboratively in a multi-disciplinary approach to develop and implement an individualized, written treatment plan utilizing pharmacologic and non-pharmacologic interventions with specific objectives for the patient; (rec)Joint Board Statement. To effectively assist patients in the management of pain, health care professionals should, within their scope of practice: • Consult with, and refer patients to, other providers when appropriate; (rec)Joint Board Statement. To effectively assist patients in the management of pain, health care professionals should, within their scope of practice: • Regularly evaluate the effectiveness of the treatment plan, using a consistent, developmentally appropriate, standardized pain scale, and make adjustments as needed;
• Document all aspects of pain assessment and care in a timely, clear, consistent, complete and accurate manner;
• Anticipate and effectively manage side effects of pain medications; (rec)
Joint Board Statement. To effectively assist patients in the management of pain, health care professionals should, within their scope of practice: • Be aware of the risks of diversion and abuse of controlled substances and take appropriate steps to minimize these risks. (rec)
38
MississippiBoard of Medical Licensure. 30-17-2640:1.7. B. Notwithstanding any other provisions of these rules, a physician may prescribe, administer, or dispense controlled substances in Schedules II, IIN, III, IIIN, IV and V, or other drugs having addiction-forming and addiction-sustaining liability to a person in the usual course of treatment of that person for a diagnosed condition causing chronic pain. (req)Board of Medical Licensure. 30-17-2640:1.7. C. Notwithstanding any other provisions of these rules, as to the prescribing, administration, or dispensation of controlled substances in Schedules II, IIN, III, IIIN, IV and V, or other drugs having addiction-forming and addiction-sustaining liability, use of said medications in the treatment of chronic pain should be done with caution. A physician may administer, dispense or prescribe said medications for the purpose of relieving chronic pain, provided that the following conditions are met: [...] 1. Before initiating treatment utilizing a Schedules II, IIN, III, IIIN, IV or V controlled substance, or any other drug having addiction-forming and addiction-sustaining liability, the physician shall conduct an appropriate risk/benefit analysis by reviewing his or her own records of prior treatment or review the records of prior treatment which another treating physician has provided to the physician, that there is an indicated need for long-term controlled substance therapy. Such a determination shall take into account the specifics of each patient's diagnosis, past treatments and suitability for long-term controlled substance use either alone or in combination with other indicated modalities for the treatment of chronic pain. This shall be clearly entered into the patient medical record and shall include consultation/referral reports to determine the underlying pathology or cause of the chronic pain. (req)
2. Documentation in the patient record shall include a complete medical history and physical examination that indicates the presence of one or more recognized medical indications for the use of controlled substances. (req)
Board of Medical Licensure. 30-17-2640:1.7. C. Notwithstanding any other provisions of these rules, as to the prescribing, administration, or dispensation of controlled substances in Schedules II, IIN, III, IIIN, IV and V, or other drugs having addiction-forming and addiction-sustaining liability, use of said medications in the treatment of chronic pain should be done with caution. A physician may administer, dispense or prescribe said medications for the purpose of relieving chronic pain, provided that the following conditions are met: [...] 3. Documentation of a written treatment plan which shall contain stated objectives as a measure of suc-cessful treatment and planned diagnostic evaluations, e.g., psychiatric evaluation or other treatments. The plan should also contain an informed consent agreement for treatment that details relative risks and bene-fits of the treatment course. This should also include specific requirements of the patient, such as using one physician and pharmacy if possible, and urine/serum medication level monitoring when requested. (req)Board of Medical Licensure. 30-17-2640:1.7. C. Notwithstanding any other provisions of these rules, as to the prescribing, administration, or dispensation of controlled substances in Schedules II, IIN, III, IIIN, IV and V, or other drugs having addiction-forming and addiction-sustaining liability, use of said medications in the treatment of chronic pain should be done with caution. A physician may administer, dispense or prescribe said medications for the purpose of relieving chronic pain, provided that the following conditions are met: [...] 4. Periodic review and documentation of the treatment course is conducted at reasonable intervals (no more than every six months) with modification of therapy dependent on the physician's evaluation of progress toward the stated treatment objectives. This should include referrals and consultations as neces-sary to achieve those objectives. (req)Board of Medical Licensure. 30-17-2640:1.15. I. Physicians and physician assistants practicing in a registered pain practice must be registered with the Mississippi Prescription Monitoring Program (MPMP). A report shall be obtained on the initial visit and at intervals deemed appropriate for good patient care from the MPMP for every patient receiving controlled substances in a registered pain management practice. (req)Board of Medical Licensure. 30-17-2640:1.7. E. No physician shall administer, dispense or prescribe a controlled substance for treatment of chronic pain to any patient who has consumed or disposed of any controlled substance or other drug having addic-tion-forming and addiction-sustaining liability other than in strict compliance with the treating physician's directions. These circumstances include those patients obtaining controlled substances or other abusable drugs from more than one physician and those patients who have obtained or attempted to obtain new pre-scriptions for controlled substances or other abusable drugs before a prior prescription should have been consumed according to the treating physician's directions. This requirement will not be enforced in cases where a patient has legitimately temporarily escalated a dose of their pain medication due to an acute exac-erbation of their condition but have maintained a therapeutic dose level; however, it will be required of the treating physician to document in the patient record that such increase in dose level was due to a recognized indication and was within appropriate therapeutic dose ranges. Repetitive or continuing escalations should be a reason for concern and a re-evaluation of the present treatment plan shall be undertaken by the physician. (req)Board of Medical Licensure. 30-17-2640:1.15. H. Training Requirements for All Physicians Practicing in Pain Management Medical Practices. Effective July 1, 2014, physicians who have not met the qualifications set forth in subsections (1) through (5) below, shall have successfully completed a pain residency fellowship or a pain medicine residency that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). All physicians prescribing or dispensing controlled substance medications in pain management practices registered by the Board must meet one (1) of the following qualifications:
1. board certification by a specialty board recognized by the American Board of Medical Specialties (ABMS) or the American Board of Addiction Medicine (ABAM) and hold a subspecialty certification in pain medicine;
2. board certification by a specialty board recognized by the American Osteopathic Association Bureau of Osteopathic Specialists (BOS) in pain management;
3. board certification in pain medicine by the American Board of Pain Medicine (ABPM);
4. successful completion of a residency program in physical medicine and rehabilitation, anesthesiology, neurology, or neurosurgery and approved by the ACGME or the AOA; or
5. successful completion of 100 hours of in-person, face to face, live participatory AMA or AOA Category 1 CME courses in pain management. (req)
Board of Medical Licensure. 30-17-2640:1.15. Upon qualifying under any of the 5 subsections above [see "Qualifications"], physicians must also document completion of 30 hours of live lecture format, Category 1 CME in pain management for renewal of a pain practice certificate. [Applies only to those practicing in a "Pain Management Medical Practice"] a. Live lecture format participation may be in person or remotely as is the case of teleconferences or live Internet webinars.
b. CME must have emphasis in the specific areas of pain management, addiction and/or prescribing of opiates.
c. CME is to be included with the forty hour requirement for licensure renewal.
d. Excess hours may not be carried over to another two year cycle. For the purpose of this regulation, the two year period begins with the fiscal year July 1, 2014, and every two years thereafter to be concurrent with the licensure requirement. (req)
Yes. Board of Medical Licensure. 30-17-2640:1.7. (A) 1. “Chronic Pain” is a pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts including, but not limited to, evaluation by the attending physician and one or more physicians specializing in the treatment of the area, system, or organ of the body perceived as the source of the pain. Further, if a patient is receiving controlled substances for the treatment of pain for a prolonged period of time (more than six months), then they will be considered for the purposes of this regulation to have “de facto” chronic pain and subject to the same requirements of this regulation. “Terminal Disease Pain” should not be confused with “Chronic Pain.” For the purpose of this rule, “Terminal Disease Pain” is pain arising from a medical condition for which there is no possible cure and the patient is expected to live no more than six (6) months. (req)
39
MissouriV.A.M.S. 334.106. 1. Notwithstanding any other provision of law to the contrary, a physician may prescribe, administer or dis-pense controlled substances for a therapeutic purpose to a person diagnosed and treated by a physician for a condition resulting in intractable pain, if such diagnosis and treatment has been documented in the physician's medical records. No physician shall be subject to disciplinary action by the board solely for prescrib-ing, administering or dispensing controlled substances when prescribed, administered or dispensed for a therapeutic purpose for a person diagnosed and treated by a physician for a condition resulting in intractable pain, if such diagnosis and treatment has been documented in the physician's medical records. [...] 4. Drug dependency or the possibility of drug dependency in and of itself is not a reason to withhold or pro-hibit the prescribing, administering or dispensing of controlled substances for the therapeutic purpose of treatment of a person for intractable pain, nor shall dependency relating solely to such prescribing, adminis-tering or dispensing subject a physician to disciplinary action by the board. (req)V.A.M.S. 334.107. Nothing in section 334.106 and this section shall deny the right of the board to deny, revoke or suspend the license of any physician or otherwise discipline any physician who: […] (2) Fails to keep complete and accurate records of controlled substances received, prescribed, dispensed and administered, and disposal of drugs listed in the Missouri comprehensive drug control act contained in chap-ter 195 or of controlled substances scheduled in the Federal Comprehensive Drug Abuse Prevention and Con-trol Act of 1970, 21 U.S.C. 801, et seq. A physician shall keep records of controlled substances received, pre-scribed, dispensed and administered, and disposal of these drugs shall include the date of receipt of the drugs, the sale or disposal of the drugs by the physician, the name and address of the person receiving the drugs, and the reason for the disposal or the dispensing of the drugs to the person; (req)
40
NebraskaNeb.Rev.St. § 71-2419. A physician licensed under the Medicine and Surgery Practice Act who prescribes, dispenses, or administers or a nurse licensed under the Nurse Practice Act or pharmacist licensed under the Pharmacy Practice Act who administers or dispenses a controlled substance in excess of the recommended dosage for the treatment of pain shall not be subject to discipline under the Uniform Credentialing Act or criminal prosecution under the Uniform Controlled Substances Act when: (1) In the judgment of the physician, appropriate pain manage-ment warrants such dosage; (2) the controlled substance is not administered for the purpose of causing, or the purpose of assisting in causing, death for any reason; and (3) the administration of the controlled substance conforms to policies and guidelines for the treatment of pain adopted by the Board of Medicine and Surgery. (req) Neb.Rev.St. § 71-2420. The Board of Medicine and Surgery shall adopt policies and guidelines for the treatment of pain to ensure that physicians who are engaged in the appropriate treatment of pain are not subject to disciplinary action, and the board shall consider policies and guidelines developed by national organizations with expertise in pain management for this purpose. (req)Neb.Rev.St. § 71-2418. (1) The Legislature finds that many controlled substances have useful and legitimate medical and scientific purposes and are necessary to maintain the health and general welfare of the people of Nebraska. Principles of quality medical practice dictate that the people of Nebraska have access to appropriate and effective pain relief. (2) The Legislature finds that 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. The Legislature therefor en-courages physicians to view effective pain management as a part of quality medical practice for all patients with pain, acute or chron (3) The Legislature finds that a physician should be able to prescribe, dispense, or administer a controlled substance in excess of the recommended dosage for the treatment of pain so long as such dosage is not ad-ministered for the purpose of causing, or the purpose of assisting in causing, death for any reason and so long as it conforms to policies and guidelines for the treatment of pain adopted by the Board of Medicine and Surgeryic, including those patients who experience pain as a result of terminal illness. (rec)No. Neb.Rev.St. § 71-2418. (2) The Legislature finds that 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. The Legislature therefor en-courages physicians to view effective pain management as a part of quality medical practice for all patients with pain, acute or chronic, including those patients who experience pain as a result of terminal illness.Neb.Rev.St. § 71-2418. (4) The Legislature finds that a health care facility, hospice, or third-party payor should not forbid or restrict the use of controlled substances appropriately administered for the treatment of pain. (rec)
41
NevadaN.R.S. 630.3066. A physician is not subject to disciplinary action solely for: 1. Prescribing or administering to a patient under his or her care a controlled substance which is listed in schedule II, III, IV or V by the State Board of Pharmacy pursuant to NRS 453.146, if the controlled substance is lawfully prescribed or administered for the treatment of intractable pain in accordance with regulations adopted by the Board. (req) N.R.S. 633.521. An osteopathic physician is not subject to disciplinary action solely for: 1. Prescribing or administering to a patient under his or her care: [..] (c) A controlled substance which is listed in schedule II, III, IV or V by the State Board of Pharmacy pursuant to NRS 453.146, if the controlled substance is lawfully prescribed or administered for the treatment of intractable pain in accordance with accepted standards for the practice of osteopathic medicine. (req)No. NAC 630.255. For the purposes of NRS 630.3066, “intractable pain” means a condition of discomfort for which the cause cannot be removed or otherwise treated and for which a method of providing relief, or of which a cure for the cause, has not been found after reasonable efforts have been taken in accordance with accepted standards for the practice of medicine, including, but not limited to, evaluation by an attending physician and one or more physicians specializing in the treatment of the area, system, or organ of the body which is believed to be the source of the discomfort.
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New HampshireBoard of Medicine's Guidelines for Pain Management. Physicians should not fear disciplinary action from the Board or other state regulatory or enforcement agency for prescribing or administering controlled substances for a legitimate medical purpose and in the usual course of professional practice. The Board has concern in those cases where inadequate pain control results from either lack of current knowledge of pain management or inappropriate fear of investigation for providing narcotics where indicated. (rec)Board of Medicine's Guidelines for Pain Management. The Board encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, be it acute or chronic, due to either malignant or benign disease, and particularly when associated with terminal illness. For many physicians, fear of investigation or sanction for dispensing large or prolonged narcotic prescriptions has impeded effective and appropriate treatment. Accordingly, these guidelines have been developed to clarify the Board's position of pain control specifically as related to the use of controlled substances, to alleviate physician uncertainty, and to encourage better pain management. (rec)Board of Medicine's Guidelines for Pain Management. An accurate and complete medical history and physical examination must be documented in the medical record. The medical record should document the nature and intensity of the pain and relevant co-existing condition (including current or past substance abuse.) The results of relevant diagnostic studies, other evaluations and consults should be part of the record. (req) [...] The physician should keep accurate and complete records to include documentation of; (1) medical history and physical examination; (2) relevant diagnostic, therapeutic and laboratory results; (3) results of evaluation and consultation; (4) treatment objectives; (5) discussion of risks and benefits; (6) treatments and treatment responses; (7) medications (including date, type, dosage, refills, and quantity prescribed); (8) instructions and agreements; and (9) periodic reviews. Records should remain current, be maintained in an accessible manner and be readily available for review. (req/rec)Board of Medicine's Guidelines for Pain Management. A treatment plan should state objectives that will be used to determine treatment success, such as pain relief, and/or improved physical or psycho social function. The record should indicate if any further diagnostic evaluations or treatments are planned. Other treatment modalities might include a rehabilitation program, physical therapy or the like, or other treatment plan deemed appropriate for the patient's treatment objectives. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. (rec)Board of Medicine's Guidelines for Pain Management. The physician should refer the patient for additional evaluation and treatment as necessary and reasonable in order to achieve adequate control of pain and any other treatment objectives. Special attention should be given to those pain patients who are at risk for misusing their mediations and those whose living arrangement pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse, or with comorbid psychiatric disorder, requires extra care in structuring, monitoring, and documentation. When indicated and available, consultation with, or referral to, an expert in the management of chronic pain is advised. (rec)Board of Medicine's Guidelines for Pain Management. At reasonable intervals, the physician should review the course of opioid treatment and any new information about the etiology and impact of the pain. Continuation or modification of opioid therapy should depend on the physician's evaluation of progress toward stated treatment objectives. If reasonable treatment goals are not being achieved, despite medication adjustments, the physician should re-evaluate the appropriateness of continued opioid treatment. The physician should monitor patient compliance in medication usage and related treatment plans. (rec)Board of Medicine's Guidelines for Pain Management. Informed Consent and Agreement for Treatment
The physician should discuss the risks and benefits of the use of controlled substances with the patient, appropriate significant other, and/or guardian. The patient should receive prescriptions from one physician and one pharmacy when chronic narcotic use is adopted, and should authorize communication between both parties. Frequently, the physician may elect to use a written agreement with the patient, especially where risk of medication abuse is a concern. A written agreement may; (1) indicate a specific pharmacy and prescribing physician; (2) give permission for communication between care providers; (3) detail amount and frequency of medication and prescription refills; (4) define expected follow-up and participation in any other pain treatment activities; (5) provide reasons for which opioid therapy may be discontinued; (6) include an agreement to have urine/serum medication or drug levels/screens when requested ; and (7) document other inclusions appropriate for management of the individual patient. (rec)
Board of Medicine's Guidelines for Pain Management. Informed Consent and Agreement for Treatment
The physician should discuss the risks and benefits of the use of controlled substances with the patient, appropriate significant other, and/or guardian. The patient should receive prescriptions from one physician and one pharmacy when chronic narcotic use is adopted, and should authorize communication between both parties. Frequently, the physician may elect to use a written agreement with the patient, especially where risk of medication abuse is a concern. A written agreement may; (1) indicate a specific pharmacy and prescribing physician; (2) give permission for communication between care providers; (3) detail amount and frequency of medication and prescription refills; (4) define expected follow-up and participation in any other pain treatment activities; (5) provide reasons for which opioid therapy may be discontinued; (6) include an agreement to have urine/serum medication or drug levels/screens when requested ; and (7) document other inclusions appropriate for management of the individual patient. (rec)
Board of Medicine's Guidelines for Pain Management. The physician should discuss the risks and benefits of the use of controlled substances with the patient, appropriate significant other, and/or guardian. (rec)Board of Medicine's Guidelines for Pain Management. The guidelines are not rigid rules. They serve as a model for physician practice, and to communicate what the Board considers to be within the boundaries of professional practice. While the Board will likely not take disciplinary action against a physician for failing to adhere strictly to the provisions of this protocol, "significant deviation" from the guidelines will likely result in investigation and/or sanction of a physician practice. Key features of the guidelines include accurate documentation, some form of a treatment plan, acceptance of the plan by the patient, and appropriate evaluations and/or consultations. Compliance with all controlled substances laws and regulations is mandatory. The Board will judge the validity of prescribing based on the physician's treatment of the patient and on available documentation, rather than on the quantity and chronicity of prescribing. The goal is to control the patient's pain for its duration while effectively addressing other aspects of the patient's functioning, including physical, psychological, social and work related factors. (req)
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New HampshireControlled Drug Act. 318-B:10. I. A practitioner other than a veterinarian, in good faith, in the course of his professional practice, and for a legitimate medical purpose, may administer and prescribe controlled drugs, or the practitioner may cause the same to be administered by a nurse or intern under his direction and supervision. [...] IX. If, in the judgment of a physician licensed under RSA 329, appropriate pain management warrants a high dosage of controlled drugs and the benefit of the relief expected outweighs the risk of the high dosage, the licensed physician may administer or cause to be administered such a dosage, even if its use may increase the risk of death, so long as it is not furnished for the purpose of causing, or the purpose of assisting in causing, death for any reason and so long as it falls within rules of the board of medicine. (req) Controlled Drug Act. 318-B:10. I. [...] In a bona fide emergency situation, the practitioner may dispense a controlled drug to a patient under his care but only in a quantity not to exceed a 48-hour supply for all schedule II substances or a 7-day supply of schedule III, IV, or V substances. (req)
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New JerseyBoard of Medical Examiners 13:35–7.6. (a) When prescribing, dispensing or administering controlled substances, a practitioner shall ensure that a patient's medical history has been taken and physical examination accomplished, including an assessment of physical and psychological function, underlying or coexisting diseases or conditions, any history of substance abuse and the nature, frequency and severity of any pain. The medical record shall reflect:
1. A recognized medical indication for the use of the controlled substance;
2. The complete name of the controlled substance;
3. The dosage, strength and quantity of the controlled substance; and
4. The instructions as to frequency of use. (req)
Board of Medical Examiners 13:35–7.6. (b) With respect to Schedule II controlled substances, unless the requirements of (c) below are met, a practitioner shall not authorize a quantity calculated to exceed 120 dosage units or a 30–day supply, whichever is less.
(c) A practitioner may exceed the 120 dosage unit or 30–day supply limitations for Schedule II controlled substances in (b) above in the following circumstances:
1. For the 120 dosage unit limitation, the practitioner follows a treatment plan designed to achieve effec-tive pain management, which has been tailored to the needs of a patient who is suffering pain from can-cer, intractable pain or terminal illness. The treatment plan shall state objectives by which treatment success is to be evaluated, such as pain relief and improved physical and psychological function, and shall indicate if any further diagnostic evaluations or other treatments are planned. The practitioner shall discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative;
2. With regards to the 30-day supply limitation, a practitioner may prescribe the use of an implantable in-fusion pump which is utilized to achieve pain management for patients suffering from cancer, intractable pain or terminal illness. A prescription for such an implantable infusion pump may provide up to a 90-day supply, as long as the physician evaluates and documents the patient's continued need at least every 30 days; and
3. With regards to the 30-day supply limitation, a practitioner may prescribe multiple prescriptions authorizing a patient to receive a total of up to a 90-day supply of a Schedule II controlled dangerous substance provided that:
i. Each separate prescription is issued for a legitimate medical purpose by the practitioner acting in the usual course of professional practice;
ii. The practitioner provides written instructions on each prescription, other than the first prescription if it is to be filled immediately, indicating the earliest date on which a pharmacy may fill each pre-scription;
iii. The practitioner determines that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse; and
iv. The practitioner complies with all other applicable State and Federal laws and regulations. (req)
Board of Medical Examiners 13:35–7.6. (c) A practitioner may exceed the 120 dosage unit or 30–day supply limitations for Schedule II controlled substances in (b) above in the following circumstances:
1. For the 120 dosage unit limitation, the practitioner follows a treatment plan designed to achieve effective pain management, which has been tailored to the needs of a patient who is suffering pain from cancer, intractable pain or terminal illness. The treatment plan shall state objectives by which treatment success is to be evaluated, such as pain relief and improved physical and psychological function, and shall indicate if any further diagnostic evaluations or other treatments are planned. The practitioner shall discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative; (req)
Board of Medical Examiners 13:35–7.6. (e) If treatment objectives are not being met, the practitioner: […]
2. Shall consider referring the patient for independent evaluation or treatment in order to achieve treatment objectives. […] (g) The practitioner shall keep accurate and complete records including that information required by (a) above as well as: [...] 2. Other evaluations and consultations; (rec/req)
Board of Medical Examiners 13:35–7.6. (d) When controlled substances are continuously prescribed for management of pain for three months or more, the practitioner: 1. Shall review, at a minimum of every three months, the course of treatment, any new information about the etiology of the pain and the patient's progress toward treatment objectives;
2. Shall remain alert to problems associated with physical and psychological dependence; and
3. Shall periodically make reasonable efforts, unless clinically contraindicated, to either stop the use of the controlled substance, decrease the dosage, try other drugs such as nonsteroidal anti-inflammatories, or treatment modalities in an effort to reduce the potential for abuse or the development of physical or psychological dependence. (req) [...] (e) If treatment objectives are not being met, the practitioner:
1. Shall assess the appropriateness of continued treatment with controlled substances or undertake a trial of other drugs or treatment modalities; [...] (g) The practitioner shall keep accurate and complete records including that information required by (a) above as well as: [...] 7. Periodic reviews conducted. (req)
Board of Medical Examiners 13:35–7.6. (g) The practitioner shall keep accurate and complete records including that information required by (a) above as well as: […] 4. Evidence of informed consent; (req)Board of Medical Examiners 13:35–7.6. (f) A practitioner shall remain alert to the possibility that controlled substances may be misused or diverted. A practitioner managing pain in a patient with a history of substance abuse shall exercise extra care by way of monitoring, documentation and possible consultation with addiction medicine specialists, and should consider the use of an agreement between the practitioner and the patient concerning controlled substance use and consequences for misuse. (rec) [...] (g) The practitioner shall keep accurate and complete records including that information required by (a) above as well as: [...] 6. Any agreements with the patient; (req)Board of Medical Examiners 13:35–7.6. (c) 3. With regards to the 30-day supply limitation, a practitioner may prescribe multiple prescriptions au-thorizing a patient to receive a total of up to a 90-day supply of a Schedule II controlled dangerous sub-stance provided that: [...] iii. The practitioner determines that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse; [...] (f) A practitioner shall remain alert to the possibility that controlled substances may be misused or diverted. A practitioner managing pain in a patient with a history of substance abuse shall exercise extra care by way of monitoring, documentation and possible consultation with addiction medicine specialists, and should consid-er the use of an agreement between the practitioner and the patient concerning controlled substance use and consequences for misuse. (req)Board of Medical Examiners 13:35–7.6. 2. With regards to the 30-day supply limitation, a practitioner may prescribe the use of an implantable in-fusion pump which is utilized to achieve pain management for patients suffering from cancer, intractable pain or terminal illness. A prescription for such an implantable infusion pump may provide up to a 90-day supply, as long as the physician evaluates and documents the patient's continued need at least every 30 days; and (req)
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New MexicoMedical Board. 16.10.14.8. A. The treatment of pain with various medicines or controlled substances is a legitimate medical practice when accomplished in the usual course of professional practice. It does not preclude treatment of patients with addiction, physical dependence or tolerance who have legitimate pain. However, such patients do require very close monitoring and precise documentation. (req)Medical Board. 16.10.14.8. (2) A practitioner shall be familiar with and employ screening tools as appropriate, as well as the spectrum of available modalities, in the evaluation and management of pain. The practitioner shall consider an integrative approach to pain management. (req)Medical Board. 16.10.14.6 OBJECTIVE: It is the position of the board that practitioners have an obligation to treat chronic pain and that a wide variety of medicines including controlled substances and other drugs may be prescribed for that purpose. When such medicines and drugs are used, they should be prescribed in adequate doses and for appropriate lengths of time after a thorough medical evaluation has been completed. (rec)Medical Board. 16.10.14.8. (1) A practitioner shall complete a physical examination and include an evaluation of the patient's psychological and pain status. The medical history shall include any previous history of significant pain, past history of alternate treatments for pain, potential for substance abuse, coexisting disease or medical conditions, and the presence of a medical indication or contra-indication against the use of controlled substances. (req) [...] (5) Complete and accurate records of care provided and drugs prescribed shall be maintained. When controlled substances are prescribed, the name of the drug, quantity, prescribed dosage and number of refills authorized shall be recorded. (req)Medical Board. 16.10.14.8. (2) A practitioner shall be familiar with and employ screening tools as appropriate, as well as the spectrum of available modalities, in the evaluation and management of pain. The practitioner shall consider an integrative approach to pain management. (req)Medical Board. 16.10.14.8. (3) A written treatment plan shall be developed and tailored to the individual needs of the patient, taking age, gender, culture, and ethnicity into consideration, with stated objectives by which treat-ment can be evaluated, e.g. by degree of pain relief, improved physical and psychological function, or other accepted measure. Such a plan shall include a statement of the need for further testing, consul-tation, referral or use of other treatment modalities. (req)Medical Board. 16.10.14.8. (6) The management of patients needing chronic pain control requires monitoring by the attending or the consulting practitioner. The practitioner shall periodically review the course of treatment for chronic pain, the patient's state of health, and any new information about the etiology of the chronic pain at least every six months. In addition, a practitioner shall consult, when indicated by the patient's condition, with health care professionals who are experienced (by the length and type of their prac-tice) in the area of chronic pain control; such professionals need not be those who specialize in pain control. (req)Medical Board. 16.10.14.8. (5) Complete and accurate records of care provided and drugs prescribed shall be maintained. When controlled substances are prescribed, the name of the drug, quantity, prescribed dosage and number of refills authorized shall be recorded. Prescriptions for opioids shall include indications for use. For chronic pain patients treated with controlled substance analgesic(s), the prescribing practitioner shall use a written agreement for treatment with the patient outlining patient responsibilities. As part of a written agreement, chronic pain patients shall receive all chronic pain management prescriptions from one practitioner and one pharmacy whenever possible. (req)Medical Board. 16.10.14.10 PRESCRIPTION MONITORING PROGRAM (PMP) REQUIREMENTS: The intent of the New Mexico medical board in requiring participation in the PMP is to assist practitioners in balancing the safe use of controlled substances with the need to impede illegal and harmful activities involving these pharmaceuticals.
A. A health care practitioner who holds a federal drug enforcement administration registration and a New Mexico controlled substance registration shall register with the board of pharmacy to become a regular participant in PMP inquiry and reporting.
B. A health care practitioner shall, before prescribing, ordering, administering or dispensing a controlled substance listed in Schedule II, III or IV, obtain a patient PMP report for the preceding 12 months when one of the following situations exists:
(1) the patient is a new patient of the practitioner, in which situation a patient PMP report for the previous 12 months shall only be required when Schedules II, III, and IV drugs are prescribed for a period greater than 10 days; and
(2) during the continuous use of opioids by established patients a PMP shall be requested and reviewed a minimum of once every six months. (req)
Medical Board. 16.10.14.8. (4) The practitioner shall discuss the risks and benefits of using controlled substances with the pa-tient or surrogate or guardian, and shall document this discussion in the record. (req)Medical Board. 16.10.14.8. B. (7) If, in a practitioner's medical opinion, a patient is seeking pain medication for reasons that are not medically justified, the practitioner is not required to prescribe controlled substances for the patient. C. Pain management for patients with substance use disorders shall include:
(1) a contractual agreement;
(2) appropriate consultation;
(3) drug screening when other factors suggest an elevated risk of misuse or diversion; and
(4) a schedule for re-evaluation at appropriate time intervals at least every six months. (req)
Medical Board. 16.10.14.11 PAIN MANAGEMENT CONTINUING EDUCATION: This section applies to all New Mexico medical board licensees who hold a federal drug enforcement administration registration and licensure to prescribe opioids. Pursuant to the Pain Relief Act, in order to ensure that all such health care practitioners safely prescribe for pain management and harm reduction, the following rules shall apply.
A. Immediate requirements effective November 1, 2012.Between November 1, 2012 and no later than June 30, 2014, all New Mexico medical board licensees who hold a federal drug enforcement administration regis-tration and licensure to prescribe opioids, shall complete no less than five continuing medical education hours in appropriate courses that shall include: (1) an understanding of the pharmacology and risks of controlled substances, (2) a basic awareness of the problems of abuse, addiction and diversion, (3) awareness of state and federal regulations for the prescription of controlled substances, (4) management of the treatment of pain, and (5) courses may also include a review of this rule (16.10.14 NMAC) the applicability of such courses to-ward fulfillment of the continuing medical education requirement is subject to medical board approval. Practitioners who have taken continuing medical education hours in these educational elements between July 1, 2011 and November 1, 2012, may apply those hours toward the required five continuing medical education hours described in this subsection.
B. Triennial requirements for physicians.Beginning with the July 1, 2014 triennial renewal date, as part of the 75 continuing medical education hours required during each triennial renewal cycle, all New Mexico medical board physician licensees who hold a federal drug enforcement administration registration and license to prescribe opioids, shall be required to complete and submit five continu-ing medical education hours. Appropriate courses shall include all of the educational elements de-scribed in Subsection A of this section. The applicability of such courses toward fulfillment of the continuing medical education requirement is subject to medical board approval. These hours may be earned at any time during the three-year period immediately preceding the triennial renewal date. The five continuing medical education hours completed prior to July 1, 2014, as defined in Subsection A above, may be included as part of the required continuing medical education hours in pain manage-ment in either the triennial cycle in which these hours are completed, or the triennial cycle immedi-ately thereafter.
C. Biennial requirements for physician assistants.Beginning with the July 1, 2014 biennial renewal date, in addition to the NCCPA certification required during each biennial renewal cycle pursuant to 16.10.15.16 NMAC, all New Mexico medical board physician assistant licensees who hold a federal drug enforcement administration registration and license to prescribe opioids, shall be required to complete and submit three continuing medical education hours. Appropriate courses shall include all of the educational elements described in Subsection A of this section. The applicability of such courses toward fulfillment of the continuing medical education requirement is subject to medical board approval. These hours may be earned at any time during the two-year period immediately pre-ceding the renewal date. Three of the five continuing medical education hours completed prior to July 1, 2014, as defined in Subsection A above, may be included as part of these required three continuing medical education hours in pain management in either the biennial cycle in which these hours are completed, or the biennial cycle immediately thereafter. Any or all three of these hours may also be applied to satisfy NCCPA requirements for certification.
D. Biennial requirements for anesthesiologist assistants.Beginning with the July 1, 2014 biennial renewal date, all New Mexico medical board anesthesiologist assistant licensees who hold a federal drug enforcement administration registration and license to prescribe opioids, shall be required to complete and submit three continuing medical education hours. Appropriate courses shall include all of the educational elements described in Subsection A of this section. The applicability of such courses toward fulfillment of the continuing medical education requirement is subject to medical board approval. These hours may be earned at any time during the two-year period immediately pre-ceding the renewal date. Three of the five continuing medical education hours completed prior to July 1, 2014, as defined in Subsection A above, may be included as part of these required three continuing medical education hours in pain management in either the biennial cycle in which these hours are completed, or the biennial cycle immediately thereafter.
E. Requirements for new licensees.All New Mexico medical board licensees, whether or not the New Mexico license is their first license, who hold a federal drug enforcement administration registration and license to prescribe opioids, shall complete five continuing medical education hours in pain management during the first year of licensure. These five continuing medical education hours com-pleted prior to the first renewal may be included as part of the hours required in Subsections B, C or D, above.
F. The continuing medical education requirements of this section may be included in the total contin-uing medical education requirements set forth at 16.10.4.8 NMAC, 16.10.15.16 NMAC and 16.10.19.15 NMAC. (req)
Yes. Pain Relief Act. § 24-2D-2. D. “chronic pain” means pain that persists after reasonable medical efforts have been made to relieve the pain or its cause and that continues, either continuously or episodically, for longer than three consecutive months. “Chronic pain” does not include pain associated with a terminal condition or with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition; (req)Medical Board. 16.10.14.8 REGULATIONS: The following regulations shall be used by the board to determine whether a health care practitioner's prescriptive practices are consistent with the appropriate treatment of pain. [...] E. The board will review both over-prescription and under-prescription of pain medications using the same standard of patient protection. (req)
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New MexicoPain Relief Act. § 24-2D-3. A. A health care provider who prescribes, dispenses or administers medical treatment for the purpose of re-lieving pain and who can demonstrate by reference to an accepted guideline that the provider's practice sub-stantially complies with that guideline and with the standards of practice identified in Section 24-2D-4 NMSA 1978 shall not be disciplined pursuant to board action or criminal prosecution, unless the showing of substan-tial compliance with an accepted guideline by the health care provider is rebutted by clinical expert testimony. If no currently accepted guidelines are available, then rules issued by the board may serve the function of such guidelines for purposes of the Pain Relief Act. The board rules shall conform to the intent of that act. Guidelines established primarily for purposes of coverage, payment or reimbursement do not qualify as an “accepted guideline” when offered to limit treatment options otherwise covered within the Pain Relief Act. (req) Pain Relief Act. § 24-2D-4. Nothing in the Pain Relief Act shall prohibit discipline or prosecution of a health care provider for: A. failing to maintain complete, accurate and current records documenting the physical examination and medical history of the patient, the basis for the clinical diagnosis of the patient and the treatment plan for the patient; (req)Pain Relief Act. § 24-2D-3. D. In an action brought by a board against a health care provider based on treatment of a patient for pain, the board shall consider the totality of the circumstances and shall not use as the sole basis of the action: […] (5) the absence of consultation with a pain specialist; (rec)Pain Relief Act § 24-2D-5.1. A board shall require non-cancer pain management continuing education as determined by its rules for health care providers under the board's jurisdiction who hold a federal drug enforcement administration registration and licensure to prescribe opioids. (req) Yes. Pain Relief Act § 24-2D-5.1. A board shall require non-cancer pain management continuing education as determined by its rules for health care providers under the board's jurisdiction who hold a federal drug enforcement administration registration and licensure to prescribe opioids. (req)
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North CarolinaPolicy for the Use of Opiates for the Treatment of Pain. Generally, safer alternative treatments including non-pharmacologic and minor interventions and first line pharmaco-therapy with over the counter medications, non-steroidal anti-inflammatory drugs, and acetaminophen should be considered before initiating opioid therapy. (rec)Policy for the Use of Opiates for the Treatment of Pain. The North Carolina Medical Board is obligated under the laws of the State of North Carolina to protect public health and safety. This obligation is reflected in the Board’s mission statement to “…regulate the practice of medicine and surgery for the benefit and protection of the people of North Carolina.” The Board believes that a fundamental component of good medical practice includes the appropriate evaluation and management of pain. Responsibly prescribed opiate medications may help North Carolina physicians treat their patients’ pain safely and effectively, and improve their quality of life. The Board is aware that the undertreatment of pain is recognized as a serious public health problem that compromises patients’ function and quality of life (2, 3). (rec)Policy for the Use of Opiates for the Treatment of Pain. The physician should personally participate in the process of every patient’s evaluation. The nature and extent of the evaluation depends on the type of pain and the context in which it occurs. For example, meaningful assessment of chronic pain demands a more detailed evaluation than an assessment of acute pain. Assessment of a patient’s pain should include the nature and intensity of the pain, past and current treatments for

the pain, any underlying or co-occurring disorders and conditions, and the effect of the pain on the patient’s physical, functional and psychosocial activities (29).
For every patient with pain, the initial work-up should include a systems review and relevant physical examination, a nd laboratory investigations as indicated (30, 31, 32, 33). Such investigations help the physician address the nature and intensity of the pain, and its impact on the patient’s physical, functional and psychosocial activities, and alcohol and drug use.

Social and vocational assessment is useful in identifying supports and obstacles to treatment and rehabilitation. For example, does the patient have good social supports, housing, and meaningful work? Is the home environment stressful or nurturing (34)? When applicable, the patient’s evaluation should include information from family members and/or significant others (35, 36, 37, 38).

Assessment of the patient’s personal and family history of alcohol or drug abuse and relative risk for medication misuse or abuse should be part of the initial evaluation (39, 40, 41, 42, 43, 44). These assessments, should ideally be completed prior to a decision to prescribe opioid analgesics, and should inquire into any history of physical, emotional or sexual abuse, which are risk factors for substance misuse (45, 46, 47, 48). Use of a validated screening tool, such as the Screener and Opioid Assessment for Patients with Pain (SOAPP-R;
49) or the Opioid Risk Tool (ORT; 50) can save time in collecting and evaluating information and determining the patient’s level of risk.
Patients who have a history of substance use disorder (including alcohol) are at elevated risk for failure of opioid analgesic therapy and are at high risk for experiencing harm from this therapy, since exposure to addictive substances often is a powerful trigger of relapse ( 51, 52, 53). Whenever possible treatment of a patient who has a history of substance use disorder should involve consultation with an addiction specialist before opioid therapy is initiated and include follow-up as needed. Patients who have an active substance use disorder should not receive opioid therapy until they are established in a treatment/recovery program (54), or alternatives such as co-management with an addiction professional are established. Physicians who treat patients with chronic pain are strongly encouraged to be knowledgeable

about addiction, including recognizing behaviors that indicate addiction, and how and when to refer patients for addiction evaluation and treatment.

All patients should be screened for depression and other mental health disorders as part of risk evaluation. There is a clear association between mental illness and opioid related morbidity and mortality. Patients with untreated depression and other mental health problems are at increased risk for misuse or abuse of controlled medications, addiction, and overdose (55).
Information provided by the patient is a necessary but insufficient part of the evaluation process. Reports of previous evaluations and treatments should be confirmed by obtaining records from other providers. Patients occasionally provide fraudulent records. If there is reason to question the truthfulness of a patient’s report, records should be requested directly from the patients other providers (56, 57).

Information from the North Carolina Controlled Substance Reporting System (NCCSRS) should be part of every patient’s initial evaluation and subsequent monitoring program. Physicians should register with the NCCSRS and become familiar with analyzing and using NCCSRS data. Information from the NCCSRS should be used to help confirm each patient’s compliance with treatment plans and opiate medication agreements. Relevant information from the NCCSRS should become part of the patient’s medical record.

Obtaining a toxicology screen, such as a urine drug screen, is a useful tool in the setting of risk assessment prior to prescribing opioids. It may reveal the use of controlled medications such as opioids or benzodiazepines other than those prescribed or may reveal the use of other illicit drugs.

In dealing with a patient who is taking opioids prescribed by another physician— particularly a patient on high doses - evaluation and risk stratification assume even greater importance (58, 59, 60). As with all patients the physician’s decision to prescribe opioid analgesics should reflect the totality of the information collected, the physician’s own knowledge and comfort level in prescribing and the resources for patient support that are available in the community (61, 62, 63). (rec)
Policy for the Use of Opiates for the Treatment of Pain. Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs (115, 116). Drug testing is an important monitoring tool because self-reports of medication use and behavioral observations are not always reliable (117, 118, 119, 120, 121). Urine may be the preferred biologic specimen for testing because of its ease of collection and storage and the cost-effectiveness of such testing (122). When testing is conducted as part of pain treatment, forensic standards are generally not employed. Sample collection may not need to be observed, and chain-of-custody protocols are not customarily followed. Initial testing may be done using class-specific immunoassay point-of-care or laboratory-based tests. These tests do not typically identify a particular specific drug within a class. However, the tests are available as panels and immunoassays for specific drugs can be included. It is important that the clinician formulate these panels to include the specific medications being prescribed, and, if possible, the drugs commonly abused in the local community. If necessary, initial testing can be followed with more specific techniques, including gas chromatography/mass spectrometry (GC/MS) or other chromatographic tests (123). In drug testing in a pain practice, it is important to identify the specific drug not just the class of the drug.

Physicians should be knowledgeable about the specific drug tests they order. They should be aware of the limitations, sensitivity and specificity of the tests they order, and take care to order tests appropriately (124). When a drug test is ordered, it is important to specify that it include the opioid being prescribed (125). Because of the complexities involved in interpreting drug test results appropriately, it is advisable to confirm significant or unexpected results with the testing laboratory’s toxicologist or a clinical pathologist ( 126, 127).

While immunoassay, point of care (POC) testing has utility in the making of temporary and “on the spot” changes in clinical management, its limitations with regard to accuracy have recently been the subject of study. The use of point of care testing for making long term and permanent changes in patient management may not be justified until the results of confirmatory testing with more accurate methods such as LC-MS/MS are obtained. A recent study on LC-MS/MS results following

immunoassay POC testing in addiction treatment settings found very high rates of “false negatives and positives” (128, 129).

Test results that suggest illicit or prescribed medication misuse should be discussed with the patient. The discussion should occur in a positive, supportive fashion, to strengthen the physician-patient relationship, encourage healthy behaviors, and produce behavioral change when needed. Results of drug testing and subsequent discussion with the patient should be documented in the medical record (130). Periodic pill counting is a useful strategy to confirm medication adherence and minimize diversion. Data from the North Carolina Controlled Substance Reporting System (NCCSRS) should be reviewed before beginning opiates and as a routine part of monitoring and adapting a patient’s treatment plan. ( 131, 132, 133, 134, 135 ) . If the patient’s progress is unsatisfactory, the physician must decide whether to revise or augment the treatment plan, whether other treatment modalities should be added to or substituted for the opioid therapy, or whether a different approach—possibly involving referral to a pain specialist or other health professional—should be employed (136, 137, 138, 139, 140).

Evidence of misuse of prescribed opioids demands prompt intervention by the physician ( 141, 142, 143 , 144 , 145 , 146). Patient behaviors that require such intervention typically involve recurrent early requests for refills, multiple reports of lost or stolen prescriptions, obtaining controlled medications from multiple sources without the physician’s knowledge, intoxication or impairment (either observed or reported), and pressuring or threatening behaviors (147). The presence of illicit or un- prescribed drugs, (drugs not prescribed by a physician) in drug tests requires action on the part of the prescriber. Some aberrant behaviors are more closely associated with medication misuse than others (148, 149). Most worrisome a r e patterns of behavior that suggests recurring misuse, such as unsanctioned dose escalations, deteriorating phys i c a l , functional or psychosocial activities, and failure to comply with a treatment plan (150).

Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require a firm, immediate response (151, 152, 153, 154). Failure to respond can place the patient and others at significant risk of adverse

consequences, including accidental overdose, suicide attempt, arrest and incarceration, or death (155, 156, 157, 158). For this reason, physicians who prescribe chronic opioid therapy should be knowledgeable about substance use disorders and be able to distinguish substance use disorders from physical dependence on opiates. (rec)
Policy for the Use of Opiates for the Treatment of Pain. In chronic pain the goals of treatment include reasonably attainable improvement in pain and activity; improvement in pain-associated problems such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications (64, 65). According to the International Association of the Study of Pain, activity goals should be set in three separate domains. The physical domain is the exercise program the patient follows,. The functional domain involves tasks of everyday living. The social domain relates to pleasurable social activities (66). Effective means of achieving treatment goals vary widely, depending on the type and causes of the patient’s pain, other concurrent issues, and the preferences of the physician and the patient.

Early treatment with non-pharmacologic interventions including physical therapy, exercise, and cognitive behavioral techniques, should be employed whenever possible. First line pharmaco-therapy should be the appropriate use of non-opioid analgesics including over the counter medications, non-steroidal anti-inflammatory drugs, and acetaminophen. Other treatment modalities including minor interventions such as anesthetic and steroid joint injections, cutaneous stimulators, topical anesthetics, and local therapies employing heat, massage, and manipulations should be considered before using opiates.

The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly. Clear-cut, individualized goals for pain relief and improved physical, functional and psychosocial activity should be set to help guide the choice and response to treatment (67). The treatment plan should contain information supporting the selection of pharmacologic and nonpharmacologic therapies. The plan should specify the objectives that will be used to evaluate the control of pain and achievement of specific physical, functional and psychosocial activity goals (68, 69, 70, 71). The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered (72, 73, 74, 75). (rec)
Policy for the Use of Opiates for the Treatment of Pain. The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction, or mental health specialist as needed ( 160, 16 1) . For example, a patient who has a history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment (162, 163).
Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office-based opioid treatment [OBOT]), so as to make appropriate referrals when needed (164, 165, 166, 167). (rec)
Policy for the Use of Opiates for the Treatment of Pain. The physician should regularly review the patient’s progress, including any new information about the etiology of the pain or the patient’s overall health and level of activities (90, 91, 92). When possible, collateral information about the patient’s response to opioid therapy including the medications’ effects on physical, functional, and psychosocial activities, as well as signs of adverse effects such as sedation or other impairment should be obtained from family members or other

close contacts. The physician should regularly review North Carolina Controlled Substance Reporting System data. The patient should be seen more frequently while the treatment plan is being initiated and when the opioid dose is being adjusted (93 - 100). As the patient is stabilized in the treatment regimen, follow-up visits may be scheduled less frequently.
At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the “5As” of chronic pain management. These include a determination of whether the patient has had a reduction in pain (Analgesia), improved physical, functional and psychosocial Activity, the presence of Adverse effects, evidence of Aberrant substance-related behaviors, and a change in Affect (101, 102). Validated brief assessment tools that measure pain and physical, functional and psychosocial activities, such as the three- question “Pain, Enjoyment and General Activity” (PEG) scale (103) may be helpful and more time efficient in general medical settings.

Continuation, modification or termination of opioid therapy for pain should be contingent on the physician’s evaluation of the patient’s progress toward treatment goals and assessment of substantial risks or adverse events (104, 105, 106, 107). A satisfactory response to treatment would be indicated by a reduced level of pain, and improved phys i c a l , f unc t i o na l a nd ps yc hos o c i a l a c t i vi t i e s (108, 109). Information from family members or other caregivers should be considered in evaluating the patient’s response to treatment (110, 111, 112). Use of measurement tools to assess the patient’s level of pain, activity, and quality of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes (113, 114).

Risks associated with opioids increase with escalating doses. The physician should avoid opiate dose escalation without adequate attention to risks or alternative treatments. Clinicians should avoid over-reliance on opioids as the primary or only treatment modality, including using opioid dose escalation as the only response to a complaint of inadequate pain relief. The physician should be continuously attentive to the use of opiates with other respiratory depressants such as benzodiazepines or alcohol, and using opiates in the setting of other comorbidities such as mental illness, respiratory disorders and sleep apnea, and a pre-existing substance use disorder. (rec)
Policy for the Use of Opiates for the Treatment of Pain. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity (76, 77). If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications (78, 79).

When treating chronic pain, use of a written informed consent, and a treatment agreement are recommended (80, 81, 82, 83, 84). They may be combined into one document for convenience.
Informed consent documents typically address:
• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short- and long-term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over-sedation, including the increased risk of using opiates in diseases and conditions such as obesity and sleep apnea.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long-term opioid therapy.
• The physician’s prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician’s policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement). (rec)
Policy for the Use of Opiates for the Treatment of Pain. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity (76, 77). If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications (78, 79).
[...] Treatment agreements outline the joint responsibilities of physician and patient in the management of chronic pain (85, 86, 87) and may be applicable in some cases of acute pain. Treatment agreements are indicated when opioid or other abusable medications are prescribed. A g re em en t s typically discuss:
• The goals of treatment, in terms of pain management, restoration of activities, and safety.
• The patient’s responsibility for using medication safely (e.g., not using more medication than prescribed, not using an opioid in combination with alcohol or other potentially dangerous substances; storing medications in a secure location; and safely disposing of unused medication).
• The patient’s responsibility to obtain prescribed opioids from only one physician or practice.
• The patient’s agreement to periodic drug testing of blood, urine, hair, saliva, or other body material.
• The physician’s responsibility to be available or to have a covering physician be available to care for unforeseen problems and to prescribe scheduled refills. (rec)
Policy for the Use of Opiates for the Treatment of Pain. Every physician who treats patients for chronic pain must maintain accurate and complete medical records. The medical record should include the following: […] • Instructions to the patient, including discussions of risks and benefits with the patient and any significant others. (rec)Policy for the Use of Opiates for the Treatment of Pain. Tips on Diversion: One of the most difficult duties that a physician has as it relates to the prescribing of opioids to patients with chronic pain is the issue of opioid diversion. Even in light of a failed urine drug screen (UDS) with confirmation, an inconsistent NCCSRS report, and or noncompliance (not attending physical therapy, failure to obtain prescribed imaging, failure to attend appropriate interventional procedures, etc.) it is difficult to know when a patient is diverting prescription opioids. However, the prescriber may feel the patient is diverting after ascertaining a history, or the medical office receives a phone call from an anonymous source that the patient is selling his/her opioid medication. Perhaps the most effective way to appropriately decide if the patient is diverting is the combination of a random pill count and a concomitant UDS with a confirmation.
If you believe a patient may be diverting a medication, he or she should be notified to come in to the office between scheduled appointments for a random pill count. [Goes on for 3 pages...] (rec)
Policy for the Use of Opiates for the Treatment of Pain. Discontinuing Opioid Therapy:
Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate (168). Opioids should be tapered or discontinued when a patient’s pain is poorly controlled on appropriate doses of medication OR if there is no improvement in physical, functional or psychosocial activity with opioid treatment. Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, deteriorating physical, functional or psychosocial activities, or significant aberrant medication use (169, 170).
If opioid therapy is discontinued, in the setting of appropriate use but inadequate response and the patient has become physically dependent, they should be provided with a safely structured tapering regimen. In the setting of abuse or addiction, when it is necessary to discontinue opioids quickly because of safety, withdrawal can be managed either by the prescribing physician or by referring the patient to an addiction specialist (171). The termination of opioid therapy should not mark the end of treatment, which should continue with other modalities, either through direct care or referral to other health care specialists, as appropriate (172, 173, 174). (rec)
Policy for the Use of Opiates for the Treatment of Pain. For the sake of simplicity, in the document that follows the word “physician” is used to represent all North Carolina Medical Board Licensees who use opiates for the treatment of pain. […] The guidelines provide the Board a framework to assess physicians’ treatment of pain, and a means to determine whether opiate medications are used in a manner that is medically appropriate and in compliance with North Carolina State and federal laws and regulations. [...] Initiating an Opioid Trial:
Generally, safer alternative treatments including non-pharmacologic and minor interventions and first line pharmaco-therapy with over the counter medications, non-steroidal anti-inflammatory drugs, and acetaminophen should be considered before initiating opioid therapy. When the decision to use an opiate has been made, it should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 days) and with specified evaluation points. The physician should explain that progress will be carefully monitored for benefit and harm in terms of the effects of opioids on the patient’s level of pain, and on the patient’s physical, functional and psychosocial activities. Attention will be focused on adverse events and risks to safety (88). Patients at risk of an opiate overdose should be identified. The Board expects physicians who prescribe opiates to help insure that naloxone is readily available to patients who are identified as being at risk of an opiate overdose. Readers are referred to the Board’s Position Statement, “Drug overdose prevention.”
When initiating opioid therapy, the lowest dose possible should be given to an opioid naïve patient and titrated to affect while monitoring for complications. Opioid therapy should begin with a short acting drug and rotate to a long acting/extended release if indicated. A decision to continue opioid therapy beyond the trial period should reflect a careful evaluation of benefits, adverse events, and potential risks (89). (rec)
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North CarolinaJoint Statement on Pain Management in End-of-Life Care (Adopted by the North Carolina Medical, Nursing, and Pharmacy Boards). Through dialogue with members of the healthcare community and consumers, a number of perceived regulatory barriers to adequate pain management in end-of-life care have been expressed to the Boards of Medicine, Nursing, and Pharmacy. The following statement attempts to address these misperceptions by outlining practice expectations for licensees and other health care professionals authorized to prescribe medications, as well as nurses and pharmacists involved in this aspect of end-of-life care. [Goes on for 3 pages--I just included to illustrate some level of terminal/non-terminal distinction.] (rec)
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North Dakota§ 19-03.3-02. Notwithstanding any other provision of law, a physician may prescribe or administer controlled substances to a patient in the course of the physician's treatment of the patient for pain. A physician shall keep records of purchases and disposals of controlled substances prescribed or administered under this section. The records must include the date of purchase, the date of sale or administration by the physician, the name and address of the patient, and the reason for the prescribing or the administering of the substances to the patient. (req) § 19-03.3-03. No hospital or health care facility may forbid or restrict the use of controlled substances when prescribed or administered by a physician having staff privileges at that hospital or health care facility for a patient diagnosed and treated by a physician for pain. (req) § 19-03.3-04. The board may not discipline a physician for prescribing or administering controlled substances in the course of treatment of a patient for pain under this chapter. (req)No. § 19-03.3-01. 2. “Pain” means acute pain and chronic pain. Acute pain is the normal, predicted physiological response to a noxious chemical or thermal or mechanical stimulus and typically is associated with invasive procedures, trauma, or disease, and is generally time-limited. Chronic pain is a state that persists beyond the usual course of an acute disease or healing of an injury or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.§ 19-03.3-02. A physician shall keep records of purchases and disposals of controlled substances prescribed or administered under this section. The records must include the date of purchase, the date of sale or administration by the physician, the name and address of the patient, and the reason for the prescribing or the administering of the substances to the patient. (req) § 19-03.3-05. This chapter does not apply to a person being treated by a physician for chemical dependency because of the person's use of controlled substances not related to treatment for pain. (req)
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OhioState Medical Board. 4731.052. (C) When a physician diagnoses a patient as having chronic pain, the physician may, subject to division (D) of this section, treat the pain by managing it with controlled substances and products containing tramadol. The physician's diagnosis and treatment decisions shall be made according to accepted and prevailing standards for medical care. [...] (F) A physician who treats chronic pain by managing it with controlled substances or products containing tramadol is not subject to disciplinary action by the board under section 4731.22 of the Revised Code solely because the physician treated the chronic pain with controlled substances or products containing tramadol. (req) Medical Board. 4731-21-06. (B) A practitioner who treats intractable pain by utilizing prescription drugs is not subject to disciplinary action by the board under section 4731.22 of the Revised Code solely because the practitioner treated the in-tractable pain with prescription drugs. The practitioner is subject to disciplinary action only if the prescrip-tion drugs are not utilized in accordance with section 4731.052 of the Revised Code and the rules adopted under this chapter of the Administrative Code. (req)State Medical Board. 4731.052. (C) […] . For the purpose of assisting with the diagnosis of chronic pain, the physician shall obtain and review all available medical records or detailed written summaries of the patient's treatment for chronic pain or the con-dition causing the chronic pain. It is recommended that the physician also consider having the patient evalu-ated by one or more other physicians who specialize in the treatment of the area, system, or organ of the body perceived as the source of the pain. (req/rec) (D) For each patient a physician diagnoses as having chronic pain, the physician shall maintain a written record of all of the following:
(1) Medical history and physical examination of the patient;
(2) The diagnosis of chronic pain, including signs, symptoms, and causes;
(3) The plan of treatment proposed, the patient's response to treatment, and any modification to the plan of treatment, including all of the following:
(a) Documentation that other medically reasonable treatments for relief of the patient's chronic pain have been offered or attempted without adequate or reasonable success;
(b) Periodic assessment and documentation of the patient's functional status, including the ability to engage in work or other purposeful activities, the pain intensity and its interference with activities of daily living, qual-ity of family life and social activities, and physical activity of the patient;
(c) Periodic assessment and documentation of the patient's progress toward treatment objectives, including the intended role of controlled substances or products containing tramadol within the overall plan of treatment;
(d) Periodic assessment and documentation for indicators of possible addiction, drug abuse, or drug diversion;
(e) Notation of any adverse drug effects.
(4) The dates on which controlled substances or products containing tramadol were prescribed, furnished, or administered, the name and address of the patient to or for whom the controlled substances or products con-taining tramadol were prescribed, furnished, or administered, and the amounts and dosage forms for the con-trolled substances or products containing tramadol prescribed, furnished, or administered;
(5) A copy of any record or report made by another physician that was used or consulted for the purpose of diagnosing the patient's chronic pain or treating the patient for chronic pain. (req) Medical Board. 4731-21-02. (A) When utilizing any prescription drug for the treatment of intractable pain [...] (1) An initial evaluation of the patient shall be conducted and documented in the patient's record that includes a relevant history, including complete medical, pain, alcohol and substance abuse histories; an as-sessment of the impact of pain on the patient's physical and psychological functions; a review of previous diagnostic studies and previously utilized therapies; an assessment of coexisting illnesses, diseases or conditions; and an appropriate physical examination; (req)
Medical Board. 4731-21-02. (3) Based on evidence or behavioral indications of addiction or drug abuse, the practitioner may obtain a drug screen on the patient. It is within the practitioner's discretion to decide the nature of the screen and which type of drug(s) to be screened. If the practitioner obtains a drug screen for the reasons described in this paragraph, the practitioner shall document the results of the drug screen in the patient's medical record. If the patient refuses to consent to a drug screen ordered by the practitioner, the practitioner shall make a referral as provided in paragraph (C) of this rule; (rec/req)Medical Board. 4731-21-02. (3) An individualized treatment plan shall be formulated and documented in the patient's medical record. The treatment plan shall specify the medical justification of the treatment of intractable pain by utilizing prescription drugs on a protracted basis or in amounts or combinations that may not be appropriate when treating other medical conditions, the intended role of prescription drug therapy within the overall plan, and, when applicable, documentation that other medically reasonable treatments for relief of the patient's intractable pain have been offered or attempted without adequate or reasonable success. The prescription drug therapy shall be tailored to the individual medical needs of each patient. The practitioner shall document the patient's response to treatment and, as necessary, modify the treatment plan; (req)State Medical Board. 4731.052. (C) […] . For the purpose of assisting with the diagnosis of chronic pain, the physician shall obtain and review all available medical records or detailed written summaries of the patient's treatment for chronic pain or the condition causing the chronic pain. It is recommended that the physician also consider having the patient evalu-ated by one or more other physicians who specialize in the treatment of the area, system, or organ of the body perceived as the source of the pain. (req/rec) Medical Board. 4731-21-02. (A) (4) (a) The practitioner's diagnosis of intractable pain shall be made after having the patient evaluated by one or more other practitioners who specialize in the treatment of the anatomic area, system, or organ of the body perceived as the source of the pain. For purposes of this rule, a practitioner “spe-cializes” if the practitioner limits the whole or part of his or her practice, and is qualified by ad-vanced training or experience to so limit his or her practice, to the particular anatomic area, system, or organ of the body perceived as the source of the pain. The evaluation shall include review of all available medical records of prior treatment of the intractable pain or the condition underlying the intractable pain; a thorough history and physical examination; and testing as required by accepted and prevailing standards of care. The practitioner shall maintain a copy of any report made by any practitioner to whom referral for evaluation was made under this paragraph. A practitioner shall not provide an evaluation under this paragraph if that practitioner would be prohibited by sections 4731.65 to 4731.69 of the Revised Code or any other rule adopted by the board from providing a designated health service upon referral by the treating practitioner; and (b) The practitioner shall not be required to obtain such an evaluation, if the practitioner obtains a copy of medical records or a detailed written summary thereof showing that the patient has been evaluated and treated within a reasonable period of time by one or more other practitioners who spe-cialize in the treatment of the anatomic area, system, or organ of the body perceived as the source of the pain and the treating practitioner is satisfied that he or she can rely on that evaluation for purpos-es of meeting the further requirements of this chapter of the Administrative Code. The practitioner shall obtain and review all available medical records or detailed written summaries thereof of prior treatment of the intractable pain or the condition underlying the intractable pain. The practitioner shall maintain a copy of any record or report of any practitioner on which the practitioner relied for purposes of meeting the requirements under this paragraph; [...] (C) If the practitioner believes or has reason to believe that the patient is suffering from addiction or drug abuse, the practitioner shall immediately consult with an addiction medicine specialist or other substance abuse professional to obtain formal assessment of addiction or drug abuse. [...] (2) The practitioner shall do all of the following:
(a) Document the recommendations of the consultation in the patient's record;
(b) Continue to actively monitor the patient for signs and symptoms of addiction, drug abuse or di-version; and
(c) Maintain a copy of any written report made by the addiction medicine specialist or substance abuse professional to whom referral for evaluation was made under this paragraph.
(3) Prescription drug therapy may be continued consistent with the recommendations of the consultation. If the consulting addiction medicine specialist or other substance abuse professional believes the patient to be suffering from addiction or drug abuse, prompt referral shall be made to one of the following:
(a) An addiction medicine specialist or substance abuse professional; or
(b) An addiction medicine or substance abuse treatment facility.
Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety: [...] • Reconsider having the patient evaluated by one or more other providers who specialize in the treatment of the area, system, or organ of the body perceived as the source of the pain.
Medical Board. 4731-21-02. (1) Patients shall be seen by the practitioner at appropriate periodic intervals to assess the efficacy of treatment, assure that prescription drug therapy remains indicated, evaluate the patient's progress toward treatment objectives and note any adverse drug effects. During each visit, attention shall be given to changes in the patient's ability to function or to the patient's quality of life as a result of prescription drug usage, as well as indications of possible addiction, drug abuse or diversion. Compliance with this paragraph of the rule shall be documented in the patient's medical record; (2) Some patients with intractable pain may be at risk of developing increasing prescription drug con-sumption without improvement in functional status. Subjective reports by the patient should be supported by objective data. Objective measures in the patient's condition are determined by an ongoing assessment of the patient's functional status, including the ability to engage in work or other gainful activities, the pain intensity and its interference with activities of daily living, quality of family life and social activities, and physical activity of the patient. Compliance with this paragraph of the rule shall be documented in the patient's medical record; (req) Medical Board. 4731-29-01. (A)(4) “Informed consent” means a process of communication between a patient and physician that results in the patient's signed authorization or agreement to undergo a specific medical intervention after all of the following subjects are discussed:
(a) The patient's diagnosis;
(b) The nature and purpose of the proposed treatment or procedure;
(c) The risks and benefits of a proposed treatment or procedure;
(d) Alternatives regardless of their costs or the extent to which the treatment options are covered by health insurance;
(e) The risks and benefits of the alternative treatment or procedure; and
(f) The risks and benefits of not receiving or undergoing a treatment or procedure. [...] (E) In providing supervision, direction, and control of individuals at a pain management clinic the physician owner shall establish and ensure compliance with the following: [...] (2) A requirement that providers obtain informed consent for each patient prior to the commencement of treatment. (req)
State Medical Board. 4731.052. (E) A physician shall not prescribe, personally furnish, or administer to a patient a controlled substance or product containing tramadol without taking into account the potential for abuse of the controlled substance or product, the possibility the controlled substance or product may lead to dependence, the possibility the pa-tient will obtain the controlled substance or product for a nontherapeutic use or distribute it to other persons, and the potential existence of an illicit market for the controlled substance or product. In addition, the physi-cian shall address with the patient the risks associated with protracted treatment with controlled substances or products containing tramadol, including informing the patient of the potential for dependence, tolerance, and addiction and the clinical or monitoring tools the physician may use if signs of addiction, drug abuse, or drug diversion are present. (req) Medical Board. 4731-21-02. (5) The practitioner shall ensure and document in the patient's record that the patient or other individual who has the authority to provide consent to treatment on behalf of that patient gives consent to treatment after being informed of the benefits and risks of receiving prescription drug therapy on a protracted basis or in amounts or combinations that may not be appropriate when treating other medical conditions, and after being informed of available treatment alternatives. (req)State Medical Board. 4731.052. (E) A physician shall not prescribe, personally furnish, or administer to a patient a controlled substance or product containing tramadol without taking into account the potential for abuse of the controlled substance or product, the possibility the controlled substance or product may lead to dependence, the possibility the pa-tient will obtain the controlled substance or product for a nontherapeutic use or distribute it to other persons, and the potential existence of an illicit market for the controlled substance or product. In addition, the physi-cian shall address with the patient the risks associated with protracted treatment with controlled substances or products containing tramadol, including informing the patient of the potential for dependence, tolerance, and addiction and the clinical or monitoring tools the physician may use if signs of addiction, drug abuse, or drug diversion are present. (req)Medical Board. 4731-29-01. (2) Each physician owner of a pain management clinic must meet one of the following requirements:
(a) Hold current subspecialty certification in pain management by the American board of medical specialties, or hold a current certificate of added qualification in pain management by the American osteopathic association bureau of osteopathic specialists; or
(b) Hold current subspecialty certification in hospice and palliative medicine by the American board of medical specialties, or hold a current certificate of added qualification in hospice and palliative medicine by the American osteopathic association bureau of osteopathic specialists; or
(c) Hold current board certification by the American board of pain medicine; or
(d) Hold current board certification by the American board of interventional pain physicians; or
(e) Meet both of the following:
(i) Hold current board certification in anesthesiology, psychiatry, neurology, physical medicine and rehabilitation, occupational medicine, or rheumatology by the American board of medical specialties or hold current primary certification in anesthesiology, psychiatry, neurology, physical medicine and rehabilitation, occupational medicine, or rheumatology by the American osteo-pathic association bureau of osteopathic specialists.
(ii) Demonstrate conformance with the minimal standards of care.
(3) To demonstrate conformance with the minimal standards of care pursuant to paragraph (B)(2)(e)(ii) of this rule:
(a) The physician shall provide to the medical board a copy of the application for a category III terminal distributor of dangerous drugs with a pain management clinic classification under section 4729.552 of the Revised Code.
(b) The copy of the application shall serve as a complaint which shall authorize the medical board to investigate the physician's practice pursuant to division (F) of section 4731.22 of the Revised Code.
Medical Board. 4731-21-02
(a) Addiction medicine specialist means a physician who is qualified by advanced formal training in addiction medicine or other substance abuse specialty, and includes a medical doctor or doctor of osteopathic medicine who is certified by a specialty examining board to so limit the whole or part of his or her practice.
(b) Substance abuse professional includes a psychologist licensed pursuant to Chapter 4732. of the Revised Code and certified as a clinical health psychologist, an independent chemical dependency counselor, or a chemical dependency counselor III. (req)
Medical Board. 4731-29-01. (B)(1) Each physician owner of a pain management clinic shall complete at least twenty hours of category I continuing medical education in pain medicine every two years, to include one or more courses addressing the potential for addiction. The courses completed in compliance with this rule shall be accepted to-ward meeting the category I requirement for certificate of registration renewal for the physician. [...] (C) Each physician who provides care at a pain management clinic shall complete at least twenty hours of category I continuing medical education in pain medicine every two years, to include one or more courses addressing the potential for addiction. The courses completed in compliance with this rule shall be accepted toward meeting the category I requirement for certificate of registration renewal for the physician. (req) Medical Board. 4731-21-03. The board encourages those practitioners who encounter patients with intractable pain in the usual course of their practices to complete continuing medical education related to the treatment of intractable pain, including coursework related to pharmacology, alternative methods of pain management and treatment, and addiction medicine. (rec)State Medical Board. 4731.052. (1) “Chronic pain” means pain that has persisted after reasonable medical efforts have been made to relieve the pain or cure its cause and that has continued, either continuously or episodically, for longer than three continuous months. “Chronic pain” does not include pain associated with a terminal condition or with a pro-gressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition. Medical Board. 4731-21-01. (G) “Intractable pain” means a state of pain that is determined, after reasonable medical efforts have been made to relieve the pain or cure its cause, to have a cause for which no treatment or cure is possible or for which none has been found. “Intractable pain” does not include pain experienced by a patient with a termi-nal condition. “Intractable pain” does not include the treatment of pain associated with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition. Medical Board. 4731-21-06. (A) A practitioner who treats pain by utilizing prescription drugs is not subject to disciplinary action pursuant to this chapter of the Administrative Code under the following circumstances:
(1) The treatment of pain for a patient with a terminal condition;
(2) The treatment of pain associated with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition; [...] (C) A medical doctor or doctor of osteopathic medicine who provides comfort care as described in division (E)(1) of section 2133.12 of the Revised Code to a patient with a terminal condition is not subject to discipli-nary action by the board under section 4731.22 of the Revised Code if the treatment of pain for a patient with a terminal condition is provided pursuant to the requirements of section 2133.11 of the Revised Code. Medical Board. 4731-29-01. (2) “Chronic pain” means pain that has persisted after reasonable medical efforts have been made to re-lieve the pain or cure its cause and that has continued, either continuously, or episodically, for longer than three continuous months. “Chronic pain” does not include pain associated with a terminal condition or with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition. (req)
Medical Board. 4731-21-02. (4) The practitioner shall document in the patient's medical record the medical necessity for utilizing more than one controlled substance in the management of a patient's intractable pain; and (5) The practitioner shall document in the patient's medical record the name and address of the patient to or for whom the prescription drugs were prescribed, dispensed, or administered, the dates on which pre-scription drugs were prescribed, dispensed, or administered, and the amounts and dosage forms of the prescription drugs prescribed, dispensed, or administered, including refills. (req) Medical Board. 4731-21-04. (B) Physical dependence and tolerance are normal physiological consequences of extended opioid therapy, and do not, in the absence of other indicators of drug abuse or addiction, require reduction or cessation of opioid therapy. Medical Board. 4731-21-06. (A) A practitioner who treats pain by utilizing prescription drugs is not subject to disciplinary action pursuant to this chapter of the Administrative Code under the following circumstances: (3) Treatment utilizing only drugs that do not exert their effects at the central nervous system level; and (4) Treatment utilizing only drugs that are not controlled substances and are classified as antidepressants.
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OhioGuidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. Health care providers are not obligated to use opioids when a favorable risk-benefit balance cannot be documented. Providers should first consider non-pharmacologic and non-opioid therapies. Providers should exercise the same caution with tramadol as with opioids and must take into account the medication’s potential for abuse, the possibility the patient will obtain the medication for a nontherapeutic use or distribute it to other persons, and the potential existence of an illicit market for the medication.
Providers must be vigilant to the wide range of potential adverse effects associated with long-term opioid therapy and misuse of extended-release formulations. That vigilance and detailed attention has to be present from the outset of prescribing and continue for the duration of treatment. Providers should avoid starting a patient on long-term opioid therapy when treating chronic pain. Providers should also avoid prescribing benzodiazepines with opioids as it may increase opioid toxicity, add to sleep apnea risk, and increase risk of overdose deaths and other potential adverse effects. (rec)
Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. The guidelines are points of reference intended to supplement and not replace the individual prescriber’s clinical judgment. The 80 mg MED is the maximum daily dose at which point the prescriber’s actions are triggered; however, this 80 mg MED trigger point is not an endorsement by any regulatory body or medical professional to utilize that dose or greater. [...] Providers can further minimize the potential for prescription drug abuse/misuse and help reduce the number of unintentional overdose deaths associated with pain medications by recognizing times to “press pause” in response to certain “trigger points.” This pause allows providers to reassess their compliance with accepted and prevailing standards of care. The 80 mg Morphine Equivalent Daily Dose (MED) “trigger point” is one such time.
Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety:
• Reestablish informed consent, including providing the patient with written information on the potential adverse effects of long-term opioid therapy.
• Review the patient’s functional status and documentation, including the 4A’s of chronic pain treatment
o Activities of daily living,
o Adverse effects,
o Analgesia; and
o Aberrant behavior
• Review the patient’s progress toward treatment objectives for the duration of treatment.
• Utilize OARRS as an additional check on patient compliance.
• Consider a patient pain treatment agreement that may include: more frequent office visits, different treatment options, drug screens, use of one pharmacy, use of one provider for the prescription of pain medications, and consequences for non-compliance with terms of the agreement.
• Reconsider having the patient evaluated by one or more other providers who specialize in the treatment of the area, system, or organ of the body perceived as the source of the pain.
The 80 MED “trigger point” is an opportunity to review the plan of treatment, the patient's response to treatment, and any modification to the plan of treatment that is necessary to achieve a favorable risk-benefit balance for the patient’s care. If opioid therapy is continued, further reassessment will be guided by clinical judgment and decision-making consistent with accepted and prevailing standards of care. The “trigger point” also provides an opportunity to further assess addiction risk or mental health concerns, possibly using Screening, Brief Intervention, and Referral to Treatment (SBIRT) tools, including referral to an addiction medicine specialist when appropriate. (req)
Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety:• Review the patient’s functional status and documentation, including the 4A’s of chronic pain treatment (rec)Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety:• Reestablish informed consent, including providing the patient with written information on the potential adverse effects of long-term opioid therapy. (rec)Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety: [...] • Consider a patient pain treatment agreement that may include: more frequent office visits, different treatment options, drug screens, use of one pharmacy, use of one provider for the prescription of pain medications, and consequences for non-compliance with terms of the agreement. (rec)Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) “Trigger Point” [Medical Board, Board of Nursing, Dental Board, Board of Pharmacy]. Providers treating chronic, non-terminal pain patients who have received opioids equal to or greater than 80 mg MED for longer than three continuous months should strongly consider doing the following to optimize therapy and help ensure patient safety: [...] • Utilize OARRS as an additional check on patient compliance. (rec)
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OklahomaOklahoma Statutes Annotated. § 2-551. (D) The Oklahoma State Board of Medical Licensure and Supervision and the Oklahoma State Board of Osteo-pathic Examiners shall issue policies, guidelines or rules that ensure that physicians who are engaged in the appropriate treatment of pain are not subject to disciplinary action, and the Boards shall consider policies and guidelines developed by national organizations with expertise in pain medicine or in a medical discipline for this purpose. (req) Oklahoma Statutes Annotated. § 2-551. (B) The State of Oklahoma recognizes that principles of quality medical practice dictate that the people of the State of Oklahoma 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 to reduce the morbidity, and costs associated with untreated or inappropriately treated pain. The State of Oklahoma encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, acute or chronic. It is especially important for patients who experience pain as a result of terminal illness. (C). If, in the judgment of the medical doctor or the doctor of osteopathic medicine, appropriate pain manage-ment warrants a high dosage of controlled dangerous drugs and the benefit of the relief expected outweighs the risk of the high dosage, the medical doctor or doctor of osteopathic medicine may administer such a dos-age, even if its use may increase the risk of death, so long as it is not also furnished for the purpose of causing, or the purpose of assisting in causing, death for any reason and so long as it falls within policies, guidelines and rules of the Oklahoma State Board of Medical Licensure and Supervision or the Oklahoma State Board of Osteopathic Examiners. (rec) o Activities of daily living,Oklahoma Statutes Annotated. § 2-551. (B) The State of Oklahoma recognizes that principles of quality medical practice dictate that the people of the State of Oklahoma 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 to reduce the morbidity, and costs associated with untreated or inappropriately treated pain. The State of Oklahoma encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, acute or chronic. It is especially important for patients who experience pain as a result of terminal illness. (C). If, in the judgment of the medical doctor or the doctor of osteopathic medicine, appropriate pain manage-ment warrants a high dosage of controlled dangerous drugs and the benefit of the relief expected outweighs the risk of the high dosage, the medical doctor or doctor of osteopathic medicine may administer such a dos-age, even if its use may increase the risk of death, so long as it is not also furnished for the purpose of causing, or the purpose of assisting in causing, death for any reason and so long as it falls within policies, guidelines and rules of the Oklahoma State Board of Medical Licensure and Supervision or the Oklahoma State Board of Osteopathic Examiners.
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OklahomaState Board of Medical Licensure and Supervision. No. 138. Use of Controlled Substances for the Treatment of Pain. Inappropriate pain treatment may result from physicians’ lack of knowledge about pain management. Fears of investigation or sanction by federal, state and local agencies may also result in inappropriate treatment of pain. Appropriate pain management is the treating physician’s responsibility. As such, the Board will consider the inappropriate treatment of pain to be a departure from standards of practice and will investigate such allegations, recognizing that some types of pain cannot be completely relieved, and taking into account whether the treatment is appropriate for the diagnosis. [...] Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. (rec)State Board of Medical Licensure and Supervision. No. 138. Use of Controlled Substances for the Treatment of Pain. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the physician. (rec)State Board of Medical Licensure and Supervision. No. 138. Use of Controlled Substances for the Treatment of Pain. The Oklahoma State Board of Medical Licensure and Supervision (Board) recognizes that principles of quality medical practice dictate that the people of the State of Oklahoma 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 to reduce the morbidity and costs associated with untreated or inappropriately treated pain. For the purposes of this policy, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment and the continued use of ineffective treatments. The diagnosis and treatment of pain is integral to the practice of medicine. The Board encourages physicians to view pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness. All physicians should become knowledgeable about assessing patients’ pain and effective methods of pain treatment, as well as statutory requirements for prescribing controlled substances. Accordingly, this policy has been developed to clarify the Board’s position on pain control, particularly as related to the use of controlled substances, to alleviate physician uncertainty and to encourage better pain management. (rec)State Board of Medical Licensure and Supervision. 435:10-7-11. (1) A medical history and physical examination must be obtained, evaluated and documented in the medical rec-ord. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. (req/rec) [...] (6) Medical records.Records should remain current and be maintained in an accessible manner, readily available for review. The physician should keep accurate and complete records to include:
(A) the medical history and physical examination (including vital signs),
(B) diagnostic, therapeutic and laboratory results,
(C) evaluations, consultations and follow-up evaluations,
(D) treatment objectives,
(E) discussion of risks and benefits,
(F) informed consent,
(G) treatments,
(H) medications (including date, type, dosage and quantity prescribed),
(I) instructions and agreements and
(J) periodic reviews.
(rec/req)
State Board of Medical Licensure and Supervision. 435:10-7-11. (2) 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. (rec) State Board of Medical Licensure and Supervision. 435:10-7-11. (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 with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, docu-mentation and consultation with or referral to an expert in the management of such patients. (rec) o Adverse effects,State Board of Medical Licensure and Supervision. 435:10-7-11. (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 sur-rogate or guardian if the patient is without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including:
(A) urine/serum medication levels screening when requested;
(B) number and frequency of all prescription refills; and
(C) reasons for which drug therapy may be discontinued (e.g. violation of agreement)
(rec)
State Board of Medical Licensure and Supervision. 435:10-7-11. (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 sur-rogate or guardian if the patient is without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including:
(A) urine/serum medication levels screening when requested;
(B) number and frequency of all prescription refills; and
(C) reasons for which drug therapy may be discontinued (e.g. violation of agreement)
(rec)
State Board of Medical Licensure and Supervision. No. 138. Use of Controlled Substances for the Treatment of Pain. […] the Board expects that physicians incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (req)State Board of Medical Licensure and Supervision. No. 138. Use of Controlled Substances for the Treatment of Pain. The Board recognizes 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. State Board of Medical Licensure and Supervision. No. 138. Use of Controlled Substances for the Treatment of Pain. All such prescribing must be based on clear documentation of unrelieved pain. [...] The Board will judge the validity of the physician’s treatment of the patient based on available documentation, rather than solely on the quantity and duration of medication administration. The goal is to control the patient’s pain while effectively addressing other aspects of the patient’s functioning, including physical, psychological, social and work-related factors. (req)
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OklahomaOpioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 1. Opioids should only be used for treatment of acute pain when the severity of the pain warrants that choice and after determining that other non-opioid pain medications or therapies will not provide adequate pain relief. (rec) [...] 1. Alternatives to opioid treatment should be tried, or previous attempts documented, before initiating opioid treatment. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 2. A comprehensive evaluation should be performed before initiating opioid treatment for chronic pain. For chronic pain patients transferring their care to new health care providers, new opioid prescriptions should generally not be written until the previous provider’s records have been reviewed or the previous health care provider has been notified of the transfer of care. [...] 3. The health care provider should screen for risk of abuse or addiction before initiating opioid treatment. [...] 8. Regular visits for evaluation of progress toward goals should be scheduled during the period when the dose of opioids is being adjusted (titration period). During the titration period, and until the patient is clinically stable and judged to be compliant with therapy, it is recommended that the health care provider check the Oklahoma PMP more frequently. [...] 9. Once a stable dose has been established (maintenance period), regular monitoring should be conducted at face- to-face visits during which treatment goals, analgesia, activity, adverse effects, and aberrant behaviors are monitored. The Oklahoma PMP should be queried at least once per year for patients receiving opioid treatment for chronic pain. (rec) 1. Health care providers treating chronic pain patients with opioids should maintain records, in accordance with state and federal law, documenting patient evaluation, treatment plan, discussion of risks and benefits, informed consent, treatments prescribed, results of treatment, and any aberrant behavior observed. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 5. When opioids are used for the treatment of chronic pain, a written treatment plan should be established that includes measurable goals for reduction of pain and improvement of function. One health care provider should coordinate a patient’s comprehensive pain care plan and provide all opioid prescriptions required for the plan. (rec) 1. Health care providers treating chronic pain patients with opioids should maintain records, in accordance with state and federal law, documenting patient evaluation, treatment plan, discussion of risks and benefits, informed consent, treatments prescribed, results of treatment, and any aberrant behavior observed. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 10. Continuing opioid treatment should be a deliberate decision that takes into consideration the risks and benefits o chronic opioid treatment for that patient. Patients and health care providers should periodically reassess the need for continued opioid treatment, weaning whenever possible, as part of the comprehensive pain care plan. A second opinion or consultation may be useful in making that decision. [...] 13. Health care providers should consider consultation for patients with complex pain conditions, serious co- morbidities and mental illness, a history or evidence of current drug addiction or abuse, or when the provider is not confident of his/her ability to manage the treatment. (rec)o Analgesia; andOpioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 1. Health care providers treating chronic pain patients with opioids should maintain records, in accordance with state and federal law, documenting patient evaluation, treatment plan, discussion of risks and benefits, informed consent, treatments prescribed, results of treatment, and any aberrant behavior observed. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 5. When opioids are used for the treatment of chronic pain, a written treatment plan should be established that includes measurable goals for reduction of pain and improvement of function. One health care provider should coordinate a patient’s comprehensive pain care plan and provide all opioid prescriptions required for the plan.Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 2. Providers should query the Oklahoma Prescription Monitoring Program (PMP) for patients presenting with acute pain, prior to prescribing an opioid medication. In circumstances where a patient’s pain is resulting from an objectively diagnosed disease process or injury, a provider may prudently opt not to review the Oklahoma PMP. (rec) 6. The use of opioids should be re-evaluated carefully, including assessing the potential for abuse, if persistent pain suggests the need to continue opioids beyond the anticipated time period of acute pain treatment for that condition. Health care providers should query the Oklahoma PMP as part of this re-evaluation process. (rec) [...] 4. Prior to the initial prescribing of opioid medications, health care providers should query the Oklahoma Prescription Monitoring Program (PMP). (rec) [...] The Oklahoma PMP should be queried at least once per year for patients receiving opioid treatment for chronic pain. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. 6. The patient should be informed of the risks, benefits, and terms for continuation of opioid treatment, ideally using a written and signed treatment agreement. (rec) [...] 10. Continuing opioid treatment should be a deliberate decision that takes into consideration the risks and benefits o chronic opioid treatment for that patient. Patients and health care providers should periodically reassess the need for continued opioid treatment, weaning whenever possible, as part of the comprehensive pain care plan. A second opinion or consultation may be useful in making that decision. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. When opioids are prescribed for treatment of acute pain, the patient should be counseled to store the medications securely and never to share with others. In order to prevent non-medical use of the medications, it is also recommended that patients dispose of medications when the pain has resolved. (rec) Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. They are not intended as standards of care or as templates for legislation, nor are they meant for patients in palliative care programs or with cancer pain. [...] 3. When opioids are prescribed for treatment of acute pain, the number of doses dispensed should be no more than the number of doses needed based on the usual duration of pain severe enough to require opioids for that condition.(rec)Oklahoma Prescribing Guidelines for Oklahamoa Health Care Providers in the Office-Based Setting. 11. Opioid treatment should be discontinued if adverse effects outweigh benefits or if aberrant, dangerous, or illegal behaviors are demonstrated. (rec)Opioid Prescribing Guidelines for Oklahoma Health Care Providers in the Office-Based Setting. They are not intended as standards of care or as templates for legislation… [...] 3. When opioids are prescribed for treatment of acute pain, the number of doses dispensed should be no more than the number of doses needed based on the usual duration of pain severe enough to require opioids for that condition. [...]5. Long duration-of-action opioids (e.g., methadone, buprenorphine, fentanyl, extended release oxycodone, and morphine) are rarely indicated for treatment of acute pain. [...] 7. Health care providers should generally not provide replacement prescriptions for opioids that have been lost, stolen, or destroyed. (rec) [...] 7. Opioids should be initiated as a short-term trial to assess the effects of opioid treatment on pain intensity, function, and quality of life. In most instances, the trial should begin with a short-acting opioid medication. (rec) 15. The administration of intravenous and intramuscular opioids for the relief of exacerbations of chronic pain is discouraged, except in special circumstances. (rec) 16. Long-acting opioids are associated with an increased risk of overdose death, and should only be prescribed by health care providers familiar with their indications, risks, and need for careful monitoring. (rec)
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OklahomaState Board of Osteopathic Examiners. 510:5-9-2. (1) To treat a patient's intractable pain, as long as the benefit of the expected relief outweighs the risk, even if the use of the drug increases the risk of death, so long as it is not furnished for the purpose of causing, or the purpose of assisting in causing death, the physician may prescribe or administer Schedule II, III, IV or V con-trolled dangerous substances or other pain relieving drugs in higher than normal dosages when, in that physician's judgment, the higher dosages are necessary to produce the desired therapeutic effect. (req) State Board of Osteopathic Examiners. 510:5-9-2. (2) The determination of intractable pain must include a complete medical history and physical examination which includes an assessment of the patient's pain, physical and psychological function, substance abuse his-tory, underlying or co-existing diseases or conditions and the presence of a recognized medical indication for the use of an analgesic. (req) State Board of Osteopathic Examiners. 510:5-9-2. (3) The treatment plan must state objectives by which treatment success can be evaluated, such as pain relief and or improved physical and psychological function, and must indicate what further diagnostic evaluations or other treatments are planned. The drug therapy must be tailored to the individual needs of each patient. (req)State Board of Osteopathic Examiners. 510:5-9-2. (5) The management of intractable pain in patients with a history of substance abuse requires extra care, monitoring, documentation and consultation with addiction medicine specialists, and may include the use of agreements between the physician and patient specifying rules for medication use and consequences for its misuse. (rec)o Aberrant behavior • Review the patient’s progress toward treatment objectives for the duration of treatment. (rec)State Board of Osteopathic Examiners. 510:5-9-2. This rule requires that diagnosis be documented, it requires that certain records be maintained, and it requires that the physician must discuss the risks and benefits with the patient or the patient's guardian. (req) [...] (6) The physician must discuss the risks and benefits of the use of controlled substances with the patient or the patient's guardian and obtain informed consent prior to proceeding if it substantially increases the risk of death. (req)State Board of Osteopathic Examiners. 510:5-9-1. The purpose of this subchapter is to provide guidelines and requirements for osteopathic physicians who pre-scribe for chronic, intractable pain. State Board of Osteopathic Examiners. 510:5-9-3. The violation of any provision of this subchapter shall constitute unprofessional conduct, for which an appli-cation for licensure or reinstatement may be denied and for which appropriate sanctions may be imposed. (req)
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OregonOregon Medical Board Statements of Philosophy. Pain management treatment must be evidence-based and individualized to the patient. Oregon statute protects providers from disciplinary action by the Board when prescribing or administering controlled substances as part of a treatment plan for pain with the goal of controlling the patient’s pain for the duration of the pain. However, prescribing controlled substances without a legitimate medical purpose is prohibited. (req) Oregon Medical Board Pain Management Policy Statement. Oregon statute protects providers from disciplinary action by the Board when prescribing or administering controlled substances as part of a treatment plan for pain with the goal of controlling the patient’s pain for the duration of the pain. However, prescribing controlled substances without a legitimate medical purpose is prohibited.Oregon Medical Board Statements of Philosophy. Providers have a responsibility to diagnose and manage chronic pain while maximizing the benefits and minimizing the potential adverse effects of treatment. Opioids are not always required or effective for the treatment of chronic pain, and they should be discontinued if the patient’s pain control or function does not improve with their use. [...] Opioids are most likely to be successful in reducing pain and restoring function when they are combined with other pain management approaches such as physical therapy and psychological techniques. (rec) Oregon Medical Board Pain Management Policy Statement. Skillful pain management techniques including oral, parenteral and, when available, regional pain management techniques, can achieve maximum patient comfort and may reduce the need for opioids. Patients with chronic pain require complex care and treatment decisions for multi-faceted problems. Providers have a responsibility to diagnose and manage chronic pain while maximizing the benefits and minimizing the potential adverse effects of treatment. Opioids are not always required or effective for the treatment of chronic pain, and they should be discontinued if the patient’s pain control or function does not improve with their use.(rec)Oregon Medical Board Statements of Philosophy. Opioids are most likely to be successful in reducing pain and restoring function when they are combined with other pain management approaches such as physical therapy and psychological techniques. (rec) Oregon Medical Board Pain Management Policy Statement. Opioids are most likely to be successful in reducing pain and restoring function when they are combined with other pain management approaches such as physical therapy and psychological techniques. (rec)Oregon Medical Board Statements of Philosophy. The OMB urges the skillful use of effective pain control for all patients. It is important for providers to be well-informed on relevant pain management techniques and hone their skills for the optimal treatment of their patients, taking into account the etiology of the pain. [...] Inadequately managed acute pain may result in chronic pain. [...] (rec) Oregon Medical Board Pain Management Policy Statement. The OMB urges the skillful use of effective pain control for all patients. It is important for providers to be well-informed on relevant pain management techniques and hone their skills for the optimal treatment of their patients, taking into account the etiology of the pain. [...] Inadequately managed acute pain may result in chronic pain. (rec)Oregon Medical Board. 847-015-0030. (2) Controlled substances may be prescribed for long term treatment of intractable pain. The attending physician records must contain the attending physician's examination, diagnosis and any other supporting diagnostic evaluations and other therapeutic trials, including records from previous providers. If there is a consulting physician, written documentation of his/her corroborating findings, diagnosis and recommendations shall be included in the record. (req) Oregon Medical Board Pain Management Policy Statement. When prescribing opioids for chronic pain, Oregon law requires practitioners to provide careful assessment and documentation of the medical condition causing pain as well as co-morbid medical and mental health conditions. Goals for treatment should be established with the patient before prescribing opioids. The provider’s assessment, diagnosis and discussion must be documented in the patient record. (req/rec)Oregon Medical Board Pain Management Policy Statement. The diagnosis, drugs used, goals, alternatives, and side effects must be included in a signed document demonstrating consent and understanding of the treatment plan and its risks. A sample document may be found here
. In addition to the signed informed consent document, a written patient-provider agreement is recommended for patients requiring opioids for chronic pain. In all cases of pain management, practitioners should maintain records to track prescriptions and coordinate care with other treating practitioners.
(req/rec)
Oregon Medical Board Pain Management Policy Statement. Providers are encouraged to treat pain within the scope of their practice and refer patients to the appropriate specialists when indicated. Oregon Medical Board. 847-015-0030. (3) Before initiating treatment of intractable pain with controlled substances or, when it is apparent that pain which is already being treated with controlled substances has now become intractable, the attending physician shall discuss with the patient the procedures, alternatives and risks associated with the prescribing or admin-istering controlled substances for long term management of pain. Following the discussion the patient will be given an opportunity to request further explanations. When the patient is satisfied with the explanation of the issues related to the prescribing of these drugs over long periods of time, the attending physician shall provide to the person and the person shall sign a written document outlining the issues discussed associated with the prescribed or administered controlled substances. (4) The material risk notice should include but not be limited to: [Goes on to list 1.5 pages of recommended disclosures]. (5) The material risk consent form will be maintained as a permanent component of the patient record as shall documentation of long term follow-up to demonstrate the continued need for this form of therapy. A dispens-ing record of the amount and dose of the prescribed or administered controlled substances shall be maintained as part of the patient record. (req/rec) Oregon Medical Board Pain Management Policy Statement. The diagnosis, drugs used, goals, alternatives, and side effects must be included in a signed document demonstrating consent and understanding of the treatment plan and its risks. A sample document may be found here
. In addition to the signed informed consent document, a written patient-provider agreement is recommended for patients requiring opioids for chronic pain. In all cases of pain management, practitioners should maintain records to track prescriptions and coordinate care with other treating practitioners.
(req/rec)
Oregon Medical Board Pain Management Policy Statement. The OMB recommends enrollment and participation in the Oregon Prescription Drug Monitoring Program (PDMP), a division of the Oregon Health Authority, to help guide treatment plans. The PDMP is a database that allows prescribers of controlled substances to access a patient’s name, the controlled substance prescribed, the dosage, and the name and contact information of the prescriber. (rec)Oregon Medical Board. 847-015-0030. (3) Before initiating treatment of intractable pain with controlled substances or, when it is apparent that pain which is already being treated with controlled substances has now become intractable, the attending physician shall discuss with the patient the procedures, alternatives and risks associated with the prescribing or admin-istering controlled substances for long term management of pain. Following the discussion the patient will be given an opportunity to request further explanations. When the patient is satisfied with the explanation of the issues related to the prescribing of these drugs over long periods of time, the attending physician shall provide to the person and the person shall sign a written document outlining the issues discussed associated with the prescribed or administered controlled substances. (4) The material risk notice should include but not be limited to: [Goes on to list 1.5 pages of recommended disclosures]. (5) The material risk consent form will be maintained as a permanent component of the patient record as shall documentation of long term follow-up to demonstrate the continued need for this form of therapy. A dispensing record of the amount and dose of the prescribed or administered controlled substances shall be maintained as part of the patient record. (req/rec)Oregon Medical Board Pain Management Policy Statement. Types of pain include, but are not limited to, acute post-operative or traumatic pain, chronic non-cancer pain, chronic pain caused by malignancies and pain associated with terminal illness. Oregon Medical Board Statements of Philosophy. The OMB believes that physicians should make every effort to relieve the pain and suffering of their terminally ill patients. Patients nearing the end of their lives should receive sufficient opioid dosages to produce comfort. The physician should acknowledge that the natural dying process usually involves declining blood pressures, decreasing respirations and altered levels of consciousness. Opioids should not be withheld on the basis of physiologic parameters when patients continue to experience pain.
Some physicians express concerns that the use of opioids in these patients may hasten death through pneumonia or respiratory depression. For these reasons, at times physicians may have limited the use of opioids in dying patients out of fear that they may be investigated for inappropriate prescribing or allegations of euthanasia.
The OMB is concerned that such fear on the part of physicians may result in inadequate pain control and unnecessary suffering in terminally ill patients. The OMB encourages physicians to employ skillful and compassionate pain control for patients near the end of life and believes that relief from suffering remains the physician’s primary obligation to these patients. (rec) Oregon Medical Board Pain Management Policy Statement. The OMB believes that physicians should make every effort to relieve the pain and suffering of their terminally ill patients. Patients nearing the end of their lives should receive sufficient opioid dosages to produce comfort. The physician should acknowledge that the natural dying process usually involves declining blood pressures, decreasing respirations and altered levels of consciousness. Opioids should not be withheld on the basis of physiologic parameters when patients continue to experience pain.
Some physicians express concerns that the use of opioids in these patients may hasten death through pneumonia or respiratory depression. For these reasons, at times physicians may have limited the use of opioids in dying patients out of fear that they may be investigated for inappropriate prescribing or allegations of euthanasia.
The OMB is concerned that such fear on the part of physicians may result in inadequate pain control and unnecessary suffering in terminally ill patients. The OMB encourages physicians to employ skillful and compassionate pain control for patients near the end of life and believes that relief from suffering remains the physician’s primary obligation to these patients.
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Rhode IslandHealth Department. 31-2-6:3.0. 3.9 (a) Medication is only one aspect of treating chronic pain. Chronic pain often requires a multidisciplinary approach and the patient will often benefit from appropriate consultation not just with pain management specialists, but other professionals who offer treatment for pain. Other professionals such as chiropractors, acupuncturists, behavioral health providers, physical therapists are examples of providers who can use their skills to help alleviate patient's chronic pain. (rec)Health Department. 31-2-6:3.0. 3.1 The practitioner shall obtain, evaluate and document the patient's health history and physical examination in the health record prior to treating for chronic pain. (req)Health Department. 31-2-6:3.0. 3.3 Prescribing opioids for an acute injury shall be for a reasonable duration consistent with community standards for the pain that is being treated. […] 3.9 (c) The consideration, and documentation of consideration, for consultation threshold for adults is one hundred twenty (120) milligrams morphine equivalent dose per day (MED) (oral). In the event a practitioner prescribes a dosage amount that meets or exceeds the consultation threshold of one hundred twenty (120) milligrams MED (orally) per day, a consideration of consultation with a Pain Medicine Physician is re-quired, and must be documented in the medical record. (req)Health Department. 31-2-6:3.0. The treatment agreement may include, at the practitioner's discretion, a request that toxicology screens be performed at random intervals at the practitioner's discretion. (rec)Health Department. 31-2-6:3.0. 3.2 Documentation in the medical record for chronic pain shall state the objectives that will be used to determine treatment success and shall include, at a minimum: (1) Any change in pain relief; (2) Any change in physical and psychosocial function; and (3) Additional diagnostic evaluations or other planned treatements. (req)Health Department. 31-2-6:3.0. 3.7 Periodic reviews, including an in-person visit, shall take place at intervals not to exceed twelve (12) months. During the periodic review, the practitioner shall determine: (1) Patient's adherence with any medication treatment plan; (2) If pain, function, or quality of life have improved or diminished using objective evidence; and (3) If continuation or modification of medications for pain management treatment is necessary based on the practitioner's evaluation of progress towards treatment objectives. The practitioner shall consider tapering, changing, or discontinuing treatment when: (1) Function or pain does not improve after a trial period; or (2) There is reason to believe there has been misuse, addiction, or diversion. (req/rec)Health Department. 31-2-6:3.0. 3.4 If prescribing opioids, the practitioner will advise patients specifically about adverse risks of taking alcohol or other psychoactive medications (e.g., sedatives and benzodiazepines), tolerance, dependence, addiction overdose or death if acute or long term use. For those patients in recovery from substance dependence, education shall be focused on relapse risk factors. This education will be communicated orally or in writing de-pending on patient preference and shall include as a minimum: (a) Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a secure location; and (b) Educate patient regarding safe disposal options for unused portion of a controlled substance. (req)Health Department. 31-2-6:3.0. 3.6 [and 3.12] (a) Chronic pain patients who receive opioid medication(s) shall have a written patient treatment agreement which shall become part of their medical record. This written agreement may be started at any point, at the practitioner's discretion, based on individual patient history and risk, however, no later than after ninety (90) days of treatment with an opioid medication. The written agreement shall be signed between, at a minimum, the practitioner and the patient (or their proxy). This written patient agreement for treatment may include, at the practitioner's discretion:
(1) The patient's agreement to take medications at the dose and frequency prescribed with a specific protocol for lost prescriptions and early refills;
(2) Reasons for which medication therapy may be discontinued, including but not limited to, violation of the written treatment agreement or lack of effectiveness;
(3) The requirement that all chronic pain management prescriptions are provided by a single practitioner or a limited agreed upon group of practitioners;
(4) The patient's agreement to not abuse alcohol or use other medically unauthorized substances or medications;
(5) Acknowledgment that a violation of the agreement may result in action as deemed appropriate by the prescribing practitioner such as a change in the treatment plan or referral to an addiction treatment program; and
(6) A request that toxicology screens be performed at random intervals at the practitioner's discretion.
(b) At their discretion, practitioners may have a written patient treatment agreement with any patient who receives opioid medication for any duration, based on individual patient history and risk. (req/rec)
Health Department. 31-2-6:3.0. 3.5 The prescription monitoring program (PMP) shall be reviewed prior to starting any opioid. (req) [...] 3.7 For patients the practitioner is maintaining on continuous opioid therapy for pain for six (6) months or longer, the practitioner shall review information from the prescription monitoring program (PMP) at least every twelve (12) months. Documentation of that review shall be noted in the patient's medical record. (req) [...] 3.13 A practitioner shall review the prescription monitoring program (PMP) prior to refilling or initiating opioid therapy with an intrathecal pump. (req)Health Department. 31-2-6:3.0. 3.4 If prescribing opioids, the practitioner will advise patients specifically about adverse risks of taking alcohol or other psychoactive medications (e.g., sedatives and benzodiazepines), tolerance, dependence, addiction overdose or death if acute or long term use. For those patients in recovery from substance dependence, education shall be focused on relapse risk factors. This education will be communicated orally or in writing de-pending on patient preference and shall include as a minimum: (a) Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a secure location; and (b) Educate patient regarding safe disposal options for unused portion of a controlled substance. (req) [...] 3.12 (b) For patients on long-acting opioids, including methadone, practitioners shall monitor use closely, espe-cially upon initiation and following any dose increases. Practitioners shall also document in the medical record that the following education has been given to the patient and the patient has had the opportunity to ask questions and understands the following risks:
(1) Serious life-threatening or even fatal respiratory depression may occur;
(2) Methadone treatment may initially not provide immediate pain relief, and patient needs to be aware of overdose potential if taken in excess of dose, as prescribed;
(3) Accidental consumption of long-acting opioids especially in children, can result in fatal overdose;
(4) Long-term opioid use can result in physical addiction to opiates and abrupt stopping of medication may cause withdrawal symptoms including, but not limited to: runny eyes, runny nose, insomnia, diarrhea, vomiting, restlessness, nausea, weakness, muscle aches, leg cramps and hot flushes. [...] 3.13 (b) A practitioner is responsible to educate the patient and document in the medical record about risks and benefits of an intrathecal pump as well as risk of withdrawal if the pump goes dry, or the pump malfunctions causing interruption of delivery of medication. (req)
Health Department. 31-2-6:6.0. All applicants and registrants shall provide effective controls and procedures to guard against theft and diver-sion of controlled substances. In determining whether an applicant or registrant has demonstrated maintenance of effective security controls pursuant to § 21-28-3.28 of the Act, the Director may consider, but not be limited to, the following factors: [goes on to list 2 pages of factors]. (req)Health Department. 31-2-6:3.0. 3.8 To qualify as a Pain Medicine or Addiction Medicine Physician, a physician shall meet one or more of the following qualifications:
(a) (1) Board certified or board eligible by an American Board of Medical Specialties (ABMS) approved board in physical medicine and rehabilitation, neurology, neurosurgery, rheumatology, addiction medicine or anesthesiology; or by the American Board of Pain Medicine (ABPM); or
(2) Board certified or board eligible by an American Osteopathic Association (AOA) approved board in physical medicine and rehabilitation, neurology and psychiatry, anesthesiology, or neuromusculoskeletal medicine; or
(b) Possess a subspecialty certificate in pain medicine by an ABMS-approved board; or
(c) Possess a certification of added qualification in pain management or pain medicine or a certification of special qualification in rheumatology by the AOA; or
(d) Completion of a minimum of three (3) years of clinical experience in a chronic pain management care setting; and.
(1) Successful completion of at least eighteen (18) continuing education hours in pain management dur-ing the past two (2) years; and
(2) At least thirty percent (30%) of the physician's current practice is the direct provision of pain man-agement care or is in a multi-disciplinary pain clinic. (req)
Health Department. 31-2-6:3.0. 3.12 (a) Effective 15 January 2017, all practitioners prescribing long-acting opioids shall have completed an ed-ucational program compliant with the ER/LA Opioid Analgesic REMS Educational requirements issued by the U.S. Food and Drug Administration (FDA). This may be from a continuing education program or from an accredited professional preparation education program including approved residency training programs. (req)This website (http://www.health.ri.gov/healthcare/medicine/about/safeopioidprescribing/) says: When appropriate, providers will follow the guidelines below regarding the use and prescribing of opioid pain medications for chronic intermittent, non-cancer related pain: [list of what prescribers should do re: physical exam, treatment plan, opioid trial, etc.] (req)Health Department. 31-2-6:3.0. 3.10 Periodically, a practitioner will require a patient to seek care from another practitioner for ongoing treatment. Referring practitioner shall facilitate a safe transition of care for any patient being referred to another practitioner. Safe transition shall include documented practitioner to practitioner contact regarding the patient and appropriate steps to prevent a disruption in the patient's continuity of care for pain management. (req)
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Rhode IslandGen.Laws 1956, § 5-37.4-3. (a) A practitioner may prescribe, administer, or dispense controlled substances not prohibited by law for a therapeutic purpose to a person diagnosed and treated by a practitioner for a condition resulting in intracta-ble pain, if this diagnosis and treatment has been documented in the practitioner's medical records. No practitioner shall be subject to disciplinary action by the board solely for prescribing, administering, or dispensing controlled substances when prescribed, administered, or dispensed for a therapeutic purpose for a person diagnosed and treated by a practitioner for a condition resulting in intractable pain, if this diagnosis and treat-ment has been documented in the practitioner's medical records. [...] (d) Drug dependency or the possibility of drug dependency in and of itself is not a reason to withhold or pro-hibit prescribing, administering, or dispensing controlled substances for the therapeutic purpose of treatment of a person for intractable pain, nor shall dependency relating solely to this prescribing, administering, or dispensing subject a practitioner to disciplinary action by the director. [...] (f) A practitioner may administer a controlled substance prescribed by a practitioner and not prohibited by law for a therapeutic purpose to a person diagnosed and treated by a practitioner for a condition resulting in intractable pain, if this diagnosis and treatment has been documented in the practitioner's medical records. No practitioner shall be subject to disciplinary action by the director solely for administering controlled sub-stances when prescribed or dispensed for a therapeutic purpose for a person diagnosed and treated by a prac-titioner for a condition resulting in intractable pain, if this diagnosis and treatment has been documented in the practitioner's medical records of the patient. (req)
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South CarolinaJoint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. These Revised Guidelines are designed to communicate to licensees that the Boards view pain management as an important area of patient care integral to the practice of medicine; that opioid analgesics may be necessary for the relief of certain pain conditions; and that prescribers will not be sanctioned solely for prescribing opioid analgesics of the dose prescribed for legitimate medical purposes. Further, the Revised Guidelines are intended to alleviate prescriber uncertainty and to encourage patient-centered care. These Revised Guidelines are intended to reinforce the exercise of sound clinical judgment while discouraging prescriptive behaviors that may lead to misuse or abuse of controlled substances, including opioids.

These Revised Guidelines serve to protect South Carolinians’ access to pain care while combating prescription drug misuse, abuse, diversion and addiction. Prescribers must be held to a safe and best clinical practice. The Federal Controlled Substances Act defines a “lawful prescription” as one that is issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice. The use of opioids for other than legitimate medical purposes poses a threat to the individual and to the public health, thus imposing on prescribers a responsibility to minimize potential for misuse, abuse and diversion of opioids and all other controlled substances. (req)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. 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. [...] Persistent, intractable pain, like all chronic illnesses, is managed optimally with a bio- psychosocial model and not with opio-centric practices of the past. A continuum of care in choosing possible opioid and nonopioid alternatives is preferred, depending on the clinical situation and prescriber discretion as to safe and appropriate treatment. [...] Section I. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and nonpharmacologic modalities according to the judgment of the prescriber. [...] Section II. (A) Consideration and utilization of a multimodal approach to patient care is essential. A prescriber treating a patient seeking care for pain should have knowledge of all available treatment options, including, but not limited to: physical therapy; non-opioid medications; injections; surgical options; cognitive and behavioral methods; rehabilitation approaches; and complementary treatments. These should be explored and documented as part of a routine evaluation. Early treatment with non-pharmacologic interventions including physical therapy, exercise, and cognitive behavioral techniques, should be employed whenever possible. First line pharmacotherapy should be the appropriate use of non-opioid analgesics, including over the counter medication, non- steroidal anti-inflammatory drugs, and acetaminophen. Other treatment modalities, including minor intervention such as anesthetic and steroid joint injections, cutaneous stimulation, topical anesthetics, and local therapies employing heat, massage, and manipulations, should be considered before using opiates. (rec) [...] The prescriber should avoid opiate dose escalation without adequate attention to risks or alternative treatments. The prescriber should be mindful that not all pain can be alleviated through the use of opioids. Clinicians should avoid over-reliance on opioids as the primary or only treatment modality, including using opioid dose escalation as the only response to a complaint of inadequate pain relief. The prescriber should be continuously attentive to the use of opiates in the presence of other comorbidities, such as mental illness, respiratory disorders and sleep apnea, and a pre-existing substance use disorder. The prescriber should dispel any mistaken expectation that complete eradication of pain is an attainable goal when a reasonable level of discomfort is the best clinical outcome a patient may achieve. (rec)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Persistent, intractable pain, like all chronic illnesses, is managed optimally with a bio- psychosocial model and not with opio-centric practices of the past. A continuum of care in choosing possible opioid and nonopioid alternatives is preferred, depending on the clinical situation and prescriber discretion as to safe and appropriate treatment. (rec)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. These Revised Guidelines are designed to communicate to licensees that the Boards view pain management as an important area of patient care integral to the practice of medicine; that opioid analgesics may be necessary for the relief of certain pain conditions; and that prescribers will not be sanctioned solely for prescribing opioid analgesics of the dose prescribed for legitimate medical purposes. Further, the Revised Guidelines are intended to alleviate prescriber uncertainty and to encourage patient-centered care. These Revised Guidelines are intended to reinforce the exercise of sound clinical judgment while discouraging prescriptive behaviors that may lead to misuse or abuse of controlled substances, including opioids. [...] The Boards recognize that principles of quality medical practice dictate that South Carolinians have access to appropriate and effective pain relief. (req)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section I. It will be considered the standard of care to assess and evaluate the current status of pain treatment prior to initiating new treatment or adjusting current treatment. The registration and utilization of SC PMP/SCRIPTS program (SCRIPTS), which provides both a current and historical survey of narcotic, sedative and controlled substance use, is considered mandatory for prescribers to provide safe, adequate pain treatment. Drug screening is strongly recommended, when indicated. Prescribers are responsible for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. The Boards regulating prescribers will consider prescribing, ordering, dispensing or administering controlled substances for pain to be for a legitimate medical purpose if based upon documented, sound clinical judgment. All such prescribing must be based on clear documentation of unrelieved pain. To be within the usual course of professional practice, a practitioner-patient relationship must exist and the prescription should be based on a diagnosis and documentation of unrelieved pain. Compliance with applicable state and federal law is required. (reqs and recs) [...] Section II. (A) A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. [...] Every prescriber who treats patients for pain must maintain accurate and complete medical records. The medical record should include the following:
Copies of the signed consent and/or treatment agreement as appropriate for level of treatment;
The patient’s medical history;
Results of the physical examination and all laboratory tests;
Results of the risk assessment, including results of any screening instruments used;
A description of the treatment provided, including all medications prescribed or administered (including date, type, dose, and quantity.);
SCRIPTS data;
Instructions to the patient, including discussions of risks and benefits with the patient and any significant others;
Results of ongoing monitoring of patient progress in terms of pain management and physical, functional and psychosocial improvement;
Notes on evaluation by and consultations with specialists;
Any other information used to support the initiation, continuation, revision or termination of treatment and the steps taken in response to any aberrant medication use behaviors. These may include actual copies of, or references to, medical records of past hospitalizations or treatments by other providers; Authorization for release of medical information to other treatment providers; and All prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record. The name, telephone number, and address of the patient’s pharmacy should also be recorded in an accessible manner so as to be readily available for review.

Good records demonstrate that a medically necessary service was provided to the patient. Even if the outcome is less than optimal, thorough records protect both the prescriber and the patient. (req)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) Risks associated with opioids increase with escalating doses. When a patient is prescribed 80 Morphine Equivalent Dose (MED) for longer than three continuous months, it is recommended that the prescriber: re-establish informed consent; review the patient’s functional status, including daily activities, analgesia, aberrant behavior, and adverse effects, as it relates to progress toward treatment objectives established at the onset of opioid therapy; consult SCRIPTS to verify compliance; re-establish office visit intervals; review frequency of drug screens; and review and execute a new treatment agreement. Relevant information from SCRIPTS should become part of the patient’s medical record. (rec) [...] Section IV. Patients prescribed more than 80 mg MED are at an increased risk of death from respiratory depression. These patients require closer monitoring and other respiratory depressants, such as alcohol and benzodiazepines, should be avoided. The Board recognizes that a prescription of Naloxone may be appropriate in certain situations involving patients who are prescribed high dose opioids or are more vulnerable to the risk of opioid overdose due to co-morbidities or other factors. Whether Naloxone is medically necessary for a particular patient is within the discretion of the patient’s primary opioid prescriber. (rec)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section I. Drug screening is strongly recommended, when indicated. (rec) […] Section II. (A) A toxicology screen, such as a urine drug screen, is a useful tool in the assessment of risks associated with prescribing higher dose opioids and should be utilized prior to prescribing opioids for treatment of chronic pain. It may reveal the use of controlled medications other than those prescribed, such as opioids or benzodiazepines, or the use of illicit drugs. (rec) [...] Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs. Drug testing is an important monitoring tool because self-reports of medication use and behavioral observations are not always reliable. Urine may be the preferred biologic specimen for testing because of its ease of collection and storage and the cost-effectiveness of such testing. When testing is conducted as part of a pain treatment plan, forensic standards are generally not employed. Sample collection may not need to be observed and chain-of-custody protocols are not customarily followed. Initial testing may be done using class-specific immunoassay point-of-care or laboratory-based test. These tests do not typically identify a particular specific drug within a class. However, the tests are available as panels and immunoassays for specific drugs can be included. It is important that the clinician formulate these panels to include the specific medications being prescribed, and, if possible, the drugs commonly abused in the local community. If necessary, initial testing can be followed with more specific techniques, including gas chromatography/mass spectrometry (GC/MS) or other chromatographic tests. It is important to identify the specific drug, not just the class of the drug, when drug testing a pain patient.

Prescribers should be knowledgeable about the specific drug tests they order. They should be aware of the limitation, sensitivity and specificity of the tests they order and take care to order tests appropriately. When a drug test is ordered, it is important to specify that it include the opioid being prescribed. Because of the complexities involved in interpreting drug test results appropriately, it is advisable to confirm significant or unexpected results with the testing laboratory's toxicologist or a clinical pathologist.

Test results that suggest illicit or prescribed medication misuse should be discussed with the patient. Results of drug testing and subsequent discussion with the patient should be documented in the medical record. (rec)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) The decision to initiate opioid therapy for treatment of chronic pain should be the prescriber and patient’s joint decision. This decision may extend to another person responsible for the patient’s care (Caretaker). Once the joint decision to prescribe is made, a treatment plan and goals should be established as early as possible in the treatment process and revisited regularly. The prescriber should discuss the risks and benefits of the treatment plan, including any proposed use of opioid analgesics, with the patient and any Caretaker or other person(s) designated by the patient. If opioids are prescribed, the patient and any Caretaker should be counseled on safe ways to store and dispose of medications.

Appropriate goals of pain treatment include: reasonable attainable improvement in pain and activity; improvement in pain-associated problems such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Individualized goals for pain relief and improved physical, functional and psychosocial activity should be set to help guide the choice and response to treatment. The treatment plan should contain information supporting the selection of pharmacologic and non pharmacologic control of pain and achievement of specific physical, functional and psychosocial activity goals. The plan should document any further diagnostic evaluations, consultations or referrals, and/or additional therapies that have been considered, including any follow up plans. A prescriber may reduce risks of abuse, misuse, diversion, and/or unintentional overdose by incorporating a schedule for reassessment and re-evaluation in the treatment plan, as discussed in Periodic Review herein below. (rec)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) When opioids are identified as the best treatment option for complex or high-risk patients, specialists in psychology, psychiatry, and addiction management should be consulted, if possible. (rec) [...] Prescribers should reconsider a referral to one or more other providers specializing in the treatment of the area, system or organ of the body perceived to be the source of the patient’s pain. This may include consultation with a pain specialist if the prescriber is not a pain specialist. (rec) [...] The treating prescriber should seek a consultation with or refer the patient to a pain, psychiatric, addiction, or other mental health specialist as needed. A patient who has a history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment.

Prescribers who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction, including those available in licensed opioid treatment programs (OTPs) and those offered by an appropriately credentialed and experienced physician through office-based opioid treatment (OBOT), so as to make appropriate referrals when needed. (rec)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) As stated previously, review of SCRIPTS data at the time of clinical exam and prescription writing of opiates is the standard of care. The prescriber should regularly review the patient’s progress, including any new information about the etiology of the pain or the patient’s overall health and level of activities. When possible, collateral information about the patient’s response to opioid therapy, including the medication’s affect on physical, functional, and psychosocial activities, as well as signs of adverse effects, such as sedation or other impairment, should be obtained from family members or other close contacts. The prescriber should regularly review SCRIPTS data. The patient should be seen more frequently while the treatment plan is being initiated and when the opioid dose is being adjusted. As the patient is stabilized in the treatment regimen, follow up visits may be scheduled less frequently.

Continuation, modification or termination of opioid therapy for pain should be contingent on the prescriber’s evaluation of the patient’s progress toward treatment goals and assessments of substantial risks or adverse events. A satisfactory response to treatment would be indicated by a reduced level of pain and improved physical, functional, and psychosocial activities. Use of measurement tools to assess the patient’s level of pain, activity, and quality of life can be helpful in documenting therapeutic outcomes.

Risks associated with opioids increase with escalating doses. When a patient is prescribed 80 Morphine Equivalent Dose (MED) for longer than three continuous months, it is recommended that the prescriber: re-establish informed consent; review the patient’s functional status, including daily activities, analgesia, aberrant behavior, and adverse effects, as it relates to progress toward treatment objectives established at the onset of opioid therapy; consult SCRIPTS to verify compliance; re-establish office visit intervals; review frequency of drug screens; and review and execute a new treatment agreement. Relevant information from SCRIPTS should become part of the patient’s medical record.

The prescriber should avoid opiate dose escalation without adequate attention to risks or alternative treatments. The prescriber should be mindful that not all pain can be alleviated through the use of opioids. Clinicians should avoid over-reliance on opioids as the primary or only treatment modality, including using opioid dose escalation as the only response to a complaint of inadequate pain relief. The prescriber should be continuously attentive to the use of opiates in the presence of other comorbidities, such as mental illness, respiratory disorders and sleep apnea, and a pre-existing substance use disorder. The prescriber should dispel any mistaken expectation that complete eradication of pain is an attainable goal when a reasonable level of discomfort is the best clinical outcome a patient may achieve.

Prescribers should reconsider a referral to one or more other providers specializing in the treatment of the area, system or organ of the body perceived to be the source of the patient’s pain. This may include consultation with a pain specialist if the prescriber is not a pain specialist. (rec)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) Use of a written informed consent, memorializing the joint decision to prescribe, and a treatment agreement, memorializing the treatment plan and goals, is the standard of care. They may be combined into one document for convenience. Informed consent should always be considered for higher dose or ongoing acute or chronic pain opiate prescribing.
Informed consent documents typically address:
The potential risks and anticipated benefits of chronic opioid therapy;
Potential short and long term side effects of the medication, such as constipation and cognitive impairment;
The likelihood that tolerance to and physical dependence on the medication will develop;
The risk of drug interactions and over-sedation, including the increased risk of using opiates in disease and conditions such as obesity and sleep apnea;
The risk of impaired motor skills affecting driving and other tasks; The risk of opioid misuse, dependence, addiction and overdose; The limited evidence of the benefit of long-term opioid therapy;
The prescriber’s policies and expectations, including the number and frequency of prescription refills, early refills, and replacement of lost or stolen medications; and
Specific reasons for which drug therapy may be changed or discontinued, including violation of the policies and agreements spelled out in the treatment agreement. (req)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) Use of a written informed consent, memorializing the joint decision to prescribe, and a treatment agreement, memorializing the treatment plan and goals, is the standard of care. They may be combined into one document for convenience. (req)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. ...the Boards urge prescribers to incorporate safeguards into their practices to minimize the risks of misuse, abuse and diversion of opioid analgesics and other controlled substances. The consensus is that utilization of SCRIPTS prior to prescribing opiates is the best safeguard against these risks and the best practice for prescribers. Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section I. The registration and utilization of SC PMP/SCRIPTS program (SCRIPTS), which provides both a current and historical survey of narcotic, sedative and controlled substance use, is considered mandatory for prescribers to provide safe, adequate pain treatment. (req) [...] Section II. (A) SCRIPTS utilization should be part of every patient’s initial evaluation and subsequent monitoring program and is considered the standard of care. Failure to utilize SCRIPTS to assess risk of opiate/sedative prescribing may be considered misconduct by the responsible regulatory board, depending upon the clinical situation. Prescribers should register with SCRIPTS and become familiar with analyzing and using SCRIPTS data. Information from the SCRIPTS should be used to help confirm each patient’s compliance with treatment plans and opiate medication agreements. Relevant information from the SCRIPTS should become part of the patient’s medical record. (rec/req) [...] As stated previously, review of SCRIPTS data at the time of clinical exam and prescription writing of opiates is the standard of care. [...] The prescriber should regularly review SCRIPTS data. Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) The prescriber should discuss the risks and benefits of the treatment plan, including any proposed use of opioid analgesics, with the patient and any Caretaker or other person(s) designated by the patient. (rec) Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. The use of opioids for other than legitimate medical purposes poses a threat to the individual and to the public health, thus imposing on prescribers a responsibility to minimize potential for misuse, abuse and diversion of opioids and all other controlled substances.

Prescribers must recognize that inappropriate prescribing of controlled substances may contribute to drug misuse and diversion by individuals who seek opioids for other than legitimate medical purposes. Inappropriate treatment can result from a mistaken belief on the part of patients and their prescribers that complete eradication of pain is an attainable goal that can be achieved without disabling adverse effects. Accordingly, the Boards urge prescribers to incorporate safeguards into their practices to minimize the risks of misuse, abuse and diversion of opioid analgesics and other controlled substances. The consensus is that utilization of SCRIPTS prior to prescribing opiates is the best safeguard against these risks and the best practice for prescribers. (rec) Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) If opioids are prescribed, the patient and any Caretaker should be counseled on safe ways to store and dispose of medications. (rec) [...] Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require an immediate response. Failure to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempt, arrest and incarceration or death. For this reason, prescribers who prescribe chronic opioid therapy should be knowledgeable about substance use disorders and be able to distinguish substance use disorder from physical dependence on opiates. Detection of opioid diversion is one of the most difficult duties a prescriber has. The combination of periodic, unscheduled and random pill counting and a concomitant UDS with a confirmation is an effective way to ascertain whether a patient is diverting.

Warning signs that a patient may be seeking opioid medications for reasons other than legitimate pain relief include: [Goes on to list 1.5 pages of warning signs]
S.C. Code Ann. 40-47-40 (2) For renewal of an active permanent license biennially, documented evidence of at least one of the following options during the renewal period is required: (a) (a) forty hours of Category I continuing medical education sponsored by the American Medical Association, American Osteopathic Association, or another organization approved by the board as having acceptable standards for courses it sponsors, at least thirty hours of which must be related directly to the licensee's practice area, and at least two (2) hours of which may be related to approved procedures of prescribing and monitoring controlled substances listed in Schedules II, III, and IV of the schedules provided for in Sections 44-53-210, 44- 53-230, 44-53-250, and 44-53-270, and must be received from a statewide organization recognized by the Accreditation Council for Continuing Medical Education to recognize and accredit organizations in South Carolina offering continuing medical education or from a statewide organization approved to provide continuing medical education by its national organization which is accredited by the Accreditation Council for Continuing Medical Education. Each renewal form submitted pursuant to Section 40-47-41 must include a certificate of participation with the prescribing and monitoring education requirement issued by the organization from which the education was received; (req)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. These Revised Guidelines apply to the treatment of both acute and chronic pain with opioid analgesics, as well as clinical strategies to improve appropriate, safe prescribing of controlled substances and treatments. The use of opiates in end of life and palliative care may present unique benefits and risks not fully addressed herein. However, concepts presented will be relevant and generally applicable to the use of opiates for end of life and palliative care. (rec)Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) The prescriber and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate. Opioids should be tapered or discontinued when a patient’s pain is poorly controlled on appropriate doses of medication or if when opioid treatment produces no improvement in physical, functional, or psychosocial activity. Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, deteriorating physical, functional or psychosocial activities or significant aberrant medication use.

If opioid therapy is discontinued in the setting of appropriate use, but inadequate response, and the patient has become physically dependent, they should be provided with a safely structured tapering regimen. In the setting of abuse or addiction, when it is necessary to discontinue opioids quickly because of safety, withdrawal can be managed either by the prescriber or by referring the patient to an addiction specialist. The termination of opioid therapy should not mark the end of treatment, which should continue with other modalities, either through direct care or referral to other health care specialists, as appropriate. The discontinuation of opioid therapy where continuation is not clinically indicated does not constitute patient abandonment. (rec)
Joint Revised Pain Management Guidelines approved by the S.C. Boards of Medical Examiners, Dentristry, and Nursing. Section II. (A) Initiating an Opioid Trial. Safer alternative treatments should be considered before initiating opioid therapy. When the decision to use an opiate has been made, it should be presented to the patient as a therapeutic trial to test for a defined period of time, usually no more than ninety (90) days, and with specified evaluation points. The prescriber should explain that progress will be carefully monitored for benefit and harm in terms of the effect of opioids on the patient's level of pain, physical function and psychosocial activities. Attention will be focused on adverse events and risks to safety. Prescribers should develop and implement appropriate safe practices for patients identified as at risk for misuse, abuse, diversion, and/or overdose. At risk patients should be candidates for abuse deterrent formulations of the prescribed opioid. (rec)

The lowest dose possible should be given to an opioid naive patient at the beginning of opioid therapy and titrated to effect while monitoring for complication. Opioid therapy should begin with a short acting drug and rotate to a long acting/extended release, if indicated. A decision to continue opioid therapy beyond the trial period should reflect a careful evaluation of benefits, adverse events, and potential risks. (rec) [...] Section IV. Chronic pain shall not be treated by the use of controlled substances through telemedicine. (req)
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TennesseeDivision of Pain Management Clinics. 1200-34-01-.07 (2)(a) The medical director shall ensure that each health care provider employed by or working at a certified pain management clinic shall maintain complete and accurate medical records of patient consultation, examination, diagnosis, and treatment, which shall include, but not be limited to the following:
1. patient medical history;
2. physical examination;
3. diagnostic, therapeutic, and laboratory results;
4. evaluations and consultations;
5. treatment objectives;
6. documentation of informed consent and discussion of risks and benefits of treatment provided;
7. treatments and treatment options;
8. medications prescribed (including date, type, dosage and quantity prescribed);
9. instructions and agreements;
10. periodic reviews;
11. reason for prescribing or dispensing more than a seventy-two (72) hour dose of controlled sub-stances for the treatment of chronic nonmalignant pain;
12. a notation indicating whether the controlled substance monitoring database had been accessed for a particular patient;
13. copies of records, reports, or other documentation obtained from other health care providers;
14. results of urine drug screens to be performed as clinically indicated, but at a minimum upon each new admission and once every six (6) months thereafter. (req) Board of Medical Examiners. 63-6-214. (1) Except as provided in paragraph (2), it shall be a prima facie violation of T.C.A. 63-6-214 (b) (1), (4), and (12) for a physician to prescribe or dispense any drug to any individual, whether in person or by electronic means or over the Internet or over telephone lines, unless the physician has first done and appropriately documented, for the person to whom a prescription is to be issued or drugs dispensed, all of the following: (a) Performed an appropriate history and physical examination; and (b) Made a diagnosis based upon the examinations and all diagnostic and laboratory tests consistent with good medical care; and (c) Formulated a therapeutic plan, and discussed it, along with the basis for it and the risks and benefits of various treatments options, a part of which might be the prescription or dispensing drug, with the patient; and (d) Insured availability of the physician or coverage for the patient for appropriate follow-up care. (req)
Division of Health Related Boards. Pain Management Clinics. § 63-1-309. If any practitioner providing services at a pain management clinic prescribes more than a seventy-two-hour dose of controlled substances for the treatment of chronic nonmalignant pain, the practitioner must document in the patient's record the reason for prescribing that quantity. (req)Division of Pain Management Clinics. 1200-34-01-.07. (1)(a) The medical director of a pain management clinic shall: […] 7. establish quality assurance policies and procedures, which, at a minimum, include, but are not limited to: […] (ii) a written drug screening policy and compliance plan for patients to include random urine drug screening as clinically indicated, but at a minimum, upon each new admission and once every six (6) months thereafter; (iii) use of substance abuse risk assessment tools upon new patient admission and periodic review or re-assessment; [...] (v) medication counts for any controlled substances prescribed by the clinic to the clinic's patients; (req)Division of Pain Management Clinics. 1200-34-01-.07. (2)(a) The medical director of a pain management clinic shall: […] 7. establish quality assurance policies and procedures, which, at a minimum, include, but are not limited to: […] (vii) health care provider access to and review of patient information contained in the controlled substance monitoring database in accordance with T.C.A. §§ 53-10-301 - 53-10-309, as clinically indicated, but at a minimum upon each new admission and once every six (6) months thereafter; (req)Division of Health Related Boards. Pain Management Clinics. § 63-1-310. (a) A pain management clinic may accept only a check or credit card in payment for services provided at the clinic, except as provided in subsection (b). (b) A payment may be made in cash for a co-pay, coinsurance or deductible when the remainder of the charge for the services will be submitted to the patient's insurance plan for reimbursement. (req) Division of Pain Management Clinics. 1200-34-01-.07. (a) The medical director of a pain management clinic shall: […] 7. establish quality assurance policies and procedures, which, at a minimum, include, but are not limited to: […] (ii) a written drug screening policy and compliance plan for patients to include random urine drug screening as clinically indicated, but at a minimum, upon each new admission and once every six (6) months thereafter; (iii) use of substance abuse risk assessment tools upon new patient admission and periodic review or re-assessment; [...] (v) medication counts for any controlled substances prescribed by the clinic to the clinic's patients;(req)Division of Pain Management Clinics. 1200-34-01-.09. (1) Each physician serving as the medical director at a clinic shall meet at least one (1) of the following re-quirements:
(a) Successful completion of a residency program in physical medicine and rehabilitation, anesthesiology, addiction medicine, neurology, neurosurgery, family practice, preventive medicine, internal medicine, surgery, orthopedics or psychiatry approved by the Accreditation Council for Graduate Medical Educa-tion (ACGME) or American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS);
(b) Board certification in physical medicine and rehabilitation, anesthesiology, addiction medicine, neu-rology, neurosurgery, family practice, preventive medicine, internal medicine, surgery, orthopedics or psychiatry approved by the ACGME or AOABOS;
(c) Subspecialty certification in pain management, hospice and palliative medicine, geriatric medicine, rheumatology, hematology, medical oncology, gynecologic oncology, infectious disease, pediatric he-matology-oncology, or pediatric rheumatology recognized by the ABMS or AOABOS with a certificate of added qualification from the Bureau of Osteopathic Specialists;
(d) Board certification by the American Board of Pain Medicine;
(e) Board certification by the American Board of Interventional Pain Physicians; or
(f) Completion of forty (40) hours of in-person, live-participatory AMA Category I or AOABOS Category I CME coursework in pain management completed within three (3) years prior to implementation of this rule or prior to serving as medical director for the clinic, whichever event is most recent. The coursework shall address the following areas:
1. the goals of treating both short term and ongoing pain treatment;
2. controlled substance prescribing rules, including controlled substance agreements;
3. drug screening or testing, including usefulness and limitations;
4. the use of controlled substances in treating short-term and ongoing pain syndromes, including use-fulness and limitations;
5. evidence-based non-controlled pharmacological pain treatments;
6. evidence-based non-pharmacological pain treatments;
7. a complete pain medicine history and physical examination;
8. appropriate progress note keeping;
9. comorbidities with pain disorders, including psychiatric and addictive disorders;
10. substance abuse and misuse including alcohol and diversion, and prevention of same;
11. risk management;
12. medical ethics. (req)
Division of Pain Management Clinics. 1200-34-01-.09. Each health care provider providing pain management services at a clinic shall complete ten (10) hours in continuing education courses during each health care provider's licensure renewal cycle which shall be a part of the continuing education requirements established by each of the health care provider's respec-tive boards. The ten (10) continuing education hours shall address at least one or more of the following topics related to pain management:
(a) prescribing controlled substances;
(b) drug screening or testing;
(c) pharmacological and non-pharmacological pain management;
(d) completing a pain management focused history and physical examination and maintaining appropri-ate progress notes;
(e) comorbidities with pain syndromes; and
(f) substance abuse and misuse including diversion, prevention of same, and risk assessment for abuse. (req)
Division of Health Rleated Boards. Pain Management Clinics. § 63-1-313. (a) Notwithstanding any provision of this title or title 53, chapters 10 and 11 to the contrary, no pain man-agement clinic or medical doctor, osteopathic physician, advanced practice nurse with certificates of fitness to prescribe, or physician assistant working at a pain management clinic shall be permitted to dispense con-trolled substances; provided, however, that this subsection (a) shall not prohibit a medical doctor, osteopathic physician, advanced practice nurse with certificates of fitness to prescribe, or physician assistant working at a pain management clinic from providing to that practitioner's patient, without charge, a sample of a schedule IV or schedule V controlled substance in a quantity limited to an amount that is adequate to treat the patient for a maximum of seventy-two (72) hours or a sample of a non-narcotic schedule V controlled substance in a quantity limited to an amount that is adequate to treat the patient for a maximum of fourteen (14) days. (req)
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TexasOccupations Code § 107.051. Notwithstanding any other law, a physician may prescribe or administer a dangerous drug or controlled substance to a person in the course of the physician's treatment of the person for intractable pain. Occupations Code § 107.052. This chapter does not authorize a physician to prescribe or administer to a person a dangerous drug or controlled substance: (1) for a purpose that is not a legitimate medical purpose as defined by the board; and (2) if the physician knows or should know the person is using drugs for a nontherapeutic purpose. (req)
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TexasTexas Medical Board § 170.1. Physicians should be able to treat their patients' pain using sound clinical judgment without fear that the board will pursue disciplinary action. […] (2) The regulatory atmosphere must support a physician's ability to treat pain, no matter how difficult the case, using whatever tools are most appropriate. Drugs, including opiates, are essential tools for the treatment of pain. [...] (5) Physicians should not fear board action if they provide proper pain treatment. The board will not look solely at the quantity or duration of drug therapy. Proper pain treatment is not a matter of how much drug therapy is used, as long as that therapy is based on sound clinical judgment. Sound clinical judgment results from evidence-based medicine and/or the use of generally accepted standards. (rec)Texas Medical Board § 170.1. The treatment of pain is a vital part of the practice of medicine. Patients look to physicians not only to cure disease, but also to try to relieve their pain. […] (1) Pain is a medical condition that every physician sees regularly. It is an integral part of the practice of medicine. Patients deserve to have medical treatment for their pain, whether the pain is acute or chronic, mild or severe. The goal of pain management is to treat the patient's pain in relation to overall health, including physical function, psychological, social, and work-related factors. (req)Texas Medical Board § 170.3. (a)(1) A physician is responsible for obtaining a medical history and a physical examination that includes a problem-focused exam specific to the chief presenting complaint of the patient. The medical record shall document the medical history and physical examination. In the case of chronic pain, the medical record should document: (i) the nature and intensity of the pain, (ii) current and past treatments for pain, (iii) underlying or coexisting diseases and conditions, (iv) the effect of the pain on physical and psychological function, (v) any history and potential for substance abuse, and (vi) the presence of one or more recognized medical indications for the use of a dangerous or scheduled drug. (req)Texas Medical Board § 195.4. (f) Standards to Ensure Quality of Patient Care. The medical director of a pain management clinic shall: […] (4) establish quality assurance procedures to include at a minimum: [...] (C) a written drug screening policy and compliance plan for patients receiving chronic opioids; (req)Texas Medical Board § 170.3. (a)(2) Treatment plan for chronic pain. The physician is responsible for a written treatment plan that is documented in the medical records. The medical record should include: (A) How the medication relates to the chief presenting complaint of chronic pain; (B) dosage and frequency of any drugs prescribed, (C) further testing and diagnostic evalua-tions to be ordered, (D) other treatments that are planned or considered, (E) periodic reviews planned, and (F) objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function. (rec). Texas Medical Board § 170.3. (a)(7) Medical records. The medical records shall document the physician's rationale for the treatment plan and the prescription of drugs for the chief complaint of chronic pain and show that the physician has followed these guidelines. [(req)]. Specifically the records should include: (A) the medical history and the physical examination; (B) diagnostic, therapeutic and laboratory results; (C) evaluations and consultations; (D) treatment objectives; (E) discussion of risks and benefits; (F) informed consent; (G) treatments; (H) medications (including date, type, dosage and quantity prescribed); (I) instructions and agreements; and (J) periodic reviews. (rec).Texas Medical Board § 170.3. (a)(6) Consultation and Referral. The physician should refer a patient with chronic pain for further evaluation and treatment as necessary. Patients who are at-risk for abuse or addiction require special attention. Patients with chronic pain and histories of substance abuse or with co-morbid psychiatric disorders require even more care. A consult with or referral to an expert in the management of such patients should be considered in their treatment. (rec)Texas Medical Board § 170.3. (a)(5) Periodic review of the treatment of chronic pain.
(A) The physician should see the patient for periodic review at reasonable intervals in view of the individual circumstances of the patient. (rec)
(B) Periodic review should assess progress toward reaching treatment objectives, taking into consideration the history of medication usage, as well as any new information about the etiology of the pain. (rec)
(C) Each periodic visit shall be documented in the medical records. (req)
(D) Contemporaneous to the periodic reviews, the physician should note in the medical records any adjustment in the treatment plan based on the individual medical needs of the patient. (rec)
(E) A physician should continue or modify the use of dangerous and scheduled drugs for pain management based on an evaluation of progress toward treatment objectives. (i) Progress or the lack of progress in relieving pain should be documented in the patient's record. (ii) Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, and/or improved quality of life. (iii) Objective evidence of improved or diminished function should be monitored. Information from family members or other caregivers should be considered in determining the patient's response to treatment. (iv) If the patient's progress is unsatisfactory, the physician should reassess the current treatment plan and consider the use of other therapeutic modalities. (rec)
Texas Medical Board § 170.3. (a)(3) Informed consent. It is the physician's responsibility to discuss the risks and benefits of the use of controlled substances for the treatment of chronic pain with the patient, persons designated by the patient, or with the patient's surrogate or guardian if the patient is without medical decision-making capacity. This discussion should be documented by either a written signed document maintained in the records or a contemporaneous notation included in the medical records. Discussion of risks and benefits should include an explana-tion of the: (A) diagnosis; (B) treatment plan; (C) anticipated therapeutic results, including the realistic expectations for sustained pain relief and improved functioning and possibilities for lack of pain relief (D) therapies in addition to or instead of drug therapy, including physical therapy or psychological techniques; (E) potential side effects and how to manage them; (F) adverse effects, including the potential for dependence, addiction, tolerance, and withdrawal; and (G) potential for impairment of judgment and motor skills. (rec)Texas Medical Board § 170.3. (a)(4) Agreement for treatment of chronic pain. A proper patient-physician relationship for treatment of chronic pain requires the physician to establish and inform the patient of the physician's expectations that are necessary for patient compliance. If the treatment plan includes extended drug therapy, the physician should consider the use of a written pain management agreement between the physician and the patient outlining patient responsibilities, including the following provisions: (A) the physician may require laboratory tests for drug levels upon request; (B) the physician may limit the number and frequency of prescription refills; (C) only one physician will prescribe dangerous and scheduled drugs; (D) only one pharmacy will be used for prescriptions, and (E) reasons for which drug therapy may be discontinued (e.g. violation of agreement). (rec)Texas Medical Board § 170.3. (a)(3) Informed consent. It is the physician's responsibility to discuss the risks and benefits of the use of controlled substances for the treatment of chronic pain with the patient, persons designated by the patient, or with the patient's surrogate or guardian if the patient is without medical decision-making capacity. This discussion should be documented by either a written signed document maintained in the records or a contemporaneous notation included in the medical records. Discussion of risks and benefits should include an explana-tion of the: (A) diagnosis; (B) treatment plan; (C) anticipated therapeutic results, including the realistic expectations for sustained pain relief and improved functioning and possibilities for lack of pain relief (D) therapies in addition to or instead of drug therapy, including physical therapy or psychological techniques; (E) potential side effects and how to manage them; (F) adverse effects, including the potential for dependence, addiction, tolerance, and withdrawal; and (G) potential for impairment of judgment and motor skills. (rec)Texas Medical Board § 195.4. (e) Personnel Requirements. The medical director of a pain management clinic must, on an annual basis, ensure that all personnel are properly licensed, if applicable, trained to include 10 hours of continuing medical education (CME) related to pain management, and qualified for employment consistent with § 195.2(b)(1) of this title. (f) Standards to Ensure Quality of Patient Care. The medical director of a pain management clinic shall: [...] (4) establish quality assurance procedures to include at a minimum: (A) a practice quality plan that requires the medical director to complete as part of the 48 credits of CME completed every 24 months as a prerequisite for registration of the physician's permit, at least 10 hours of CME in the area of pain management from formal courses that are: (i) designated for AMA Category 1 credit by a CME sponsor accredited by the Accreditation Council for Continuing Medical Education or a state medical society recognized by the Committee for Review and Recognition of the Accreditation Council for Continuing Medical Education; or (ii) designated for AOA Category 1-A credit required for osteopathic physicians by an accredited CME sponsor approved by the American Osteopathic Association; [...] (req)Texas Medical Board § 170.1. (3) The board is charged by the Legislature with the responsibility to assure that drugs are used in a therapeutic manner. A license to practice medicine gives a physician legal authority to prescribe drugs for pain. The physician has a duty to use that authority to help, and not to harm patients and the public. (4) Harm can result when a physician does not use sound clinical judgment in using drug therapy. If the physician fails to apply sufficient drug therapy, the patient will likely suffer continued pain and may demonstrate relief-seeking behavior, known as pseudoaddiction. On the other hand, non-therapeutic drug therapy may lead to or contribute to abuse, addiction, and/or diversion of drugs. As with everything in the practice of medicine, physicians must be well informed of and carefully assess the risks and the benefits as they apply to each case. (6) A physician can demonstrate sound clinical judgment by recording the physician's rationale for the treatment plan and maintaining medical records that are legible, complete, accurate and current for each patient. (7) The extent of medical records should be reasonable for each case. A treatment plan for acute, episodic pain may note only the dosage and frequency of drugs prescribed and that no further treatment is planned. (8) Treatment of chronic pain requires a reasonably detailed and documented plan to assure that the treatment is monitored. An explanation of the physician's rationale is especially required for cases in which treatment with scheduled drugs is difficult to relate to the patient's objective physical, radiographic, or laboratory findings. (9) The intent of these guidelines is not to impose regulatory burdens on the practice of medicine. Rather, these guidelines are intended to set forth those items expected to be done by any reasonable physician involved in the treatment of pain. The use of the word “shall” in these guidelines is used to identify those items a physician is required to perform in all such cases. The word “should” and the phrase “it is the responsibility of the physi-cian” in these guidelines are used to identify those actions that a prudent physician will either do and document in the treatment of pain or be able to provide a thoughtful explanation as to why the physician did not do so. Texas Medical Board § 170.3. (b) It is not the board's policy to take disciplinary action against a physician solely for not adhering strictly to these guidelines if the physician's rationale for the treatment indicates sound clinical judgment documented in the medical records. Each case of prescribing for pain will be evaluated on an individual basis. The physician's conduct will be evaluated by considering: (1) the treatment objectives, including any improvement in functioning, (2) whether the drug used is pharmacologically recognized to be appropriate for the diagnosis as determined by a consensus of medical practitioners in the State or by recognized experts in the field for which the drug is being used, (3) the patient's individual needs, and (4) that some types of pain cannot be completely relieved. (rec)
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VermontVermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. A. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met. The Board considers the use of opioids for pain management to be for a legitimate medical purpose when based on sound clinical judgment and current best clinical practices, appropriately documented, and of demonstrable benefit to the patient. To be within the usual course of professional practice, a legitimate physician-patient relationship must exist and the prescribing or administration of medications should be appropriate to the identified diagnosis, should be accompanied by careful follow-up monitoring of the patient’s response to treatment as well as his or her safe use of the prescribed medication, and should demonstrate that the therapy has been adjusted as needed [7,38,43]. There should be documentation of appropriate referrals as necessary [36-37]. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. E. Safer alternative treatments should be considered before initiating opioid therapy for chronic, non- malignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 days) and with specified evaluation points. The physician should explain that progress will be carefully monitored for both benefit and harm in terms of the effects of opioids on the patient’s level of pain, function, and quality of life, as well as to identify any adverse events or risks to safety [51]. When initiating opioid therapy, the lowest dose possible should be given to an opioid naïve patient and titrated to effect. It is generally suggested to begin opioid therapy with a short acting opioid and consider rotating to a long-acting/extended release opioid only if indicated. Vermont law now requires checking VPMS in certain circumstances before a prescription for controlled substances is written, including when initiating treatment of chronic pain with opioids, as further discussed in the following section.
A decision to continue opioid therapy beyond the trial period should reflect a careful evaluation of benefits versus adverse events [29] and/or potential risks. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. The Board recognizes that principles of high-quality medical practice dictate that the people of the State of Vermont have access to appropriate, safe and effective pain management. The application of up-to-date knowledge and treatment modalities can help to restore function and thus improve the quality of life of patients who suffer from pain, particularly chronic pain [4,8,26]. [...] For the purposes of this policy, inappropriate treatment of pain includes non-treatment, inadequate treatment, overtreatment, and continued use of ineffective treatments. (rec)Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. B. The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic [7] and reflect an appropriately detailed patient evaluation [38]. Such an evaluation should be completed before a decision is made as to whether to prescribe an opioid analgesic.
The nature and extent of the evaluation depends on the type of pain and the context in which it occurs. For example, [GOES ON FOR TWO PAGES OF RECOMMENDATIONS] (rec) [...] Section II. J. Every physician who treats patients for chronic pain must maintain accurate, complete, and legible medical records. Information that should appear in the medical record includes the following [22- 23,38,43-44]:
• Copies of the signed informed consent and treatment agreement.
• The patient’s medical history.
• Results of the physical examination and all laboratory tests.
• Results of the risk assessment, including results of any screening instruments used.
• A description of the treatments provided, including all medications prescribed or administered (including the date, type, dose and quantity).
• Instructions to the patient, including discussions of risks and benefits with the patient and any significant others.
• Results of ongoing monitoring of patient progress (or lack of progress) in terms of pain management and functional improvement.
• Notes on evaluations by and consultations with specialists or other providers, and notation by the receiving provider of response to the information and recommendations.
• Any other information used to support the initiation, continuation, revision, or termination of treatment and the steps taken in response to any aberrant medication use behaviors [21- 23,30,38,45,68].
These may include actual copies of, or references to, medical records of past hospitalizations or treatments by other providers.
• Authorization for release of information to other treatment providers.
The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record [25]. The name, telephone number, and address of the patient’s pharmacy also should be recorded to facilitate contact as needed [23]. Records should be up-to-date and maintained in an accessible manner so as to be readily available for review [25].
Good records demonstrate that a service was provided to the patient and establish that the service provided was medically necessary. Even if the outcome is less than optimal, thorough records protect the physician as well as the patient [23,38,45,68]. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. G. Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs [53-54]. Drug testing is an important monitoring tool because self-reports of medication use are not always reliable and behavioral observations may detect some problems but not others [55-59]. Patients being treated for addiction should be tested as frequently as necessary to ensure therapeutic adherence. Use of testing should not be limited to instances in which the provider perceives a problem; the regular use of testing as a universal precaution will avoid having the request for a test become a confrontation that affects the physician-patient relationship. [TWO MORE PAGES OF RECOMMENDATIONS] (rec)Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. A. The diagnosis and treatment of pain is integral to the practice of medicine [4,34-37]. In order to cautiously prescribe opioids, physicians must understand the relevant pharmacologic and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient. Such an approach should be employed in the care of every patient who receives chronic opioid therapy [4,8]. (rec) [...] Section II. C. The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain-associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications [4,8]. Effective means of achieving these goals vary widely, depending on the type and causes of the patient’s pain, other concurrent issues, and the preferences of the physician and the patient.
The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear-cut, individualized objectives to guide the choice of therapies [38]. The treatment plan should contain information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and nonpharmacologic. It also should specify the objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function [14,36,47]. Ongoing documentation of treatment should reference the treatment plan, as appropriate.
The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered [21-23,45]. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. H. The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed [37-38]. For example, a patient who has a history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment, if available [31,66].
Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office-based opioid treatment [OBOT]), so as to make appropriate referrals when needed [23,31,37,39]. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. F. The physician should regularly review the patient’s progress, including any new information about the etiology of the pain or the patient’s overall health and level of function [35,49-50]. When possible, collateral information about the patient’s response to opioid therapy should be obtained from family members or other close contacts.

In addition to the need to consider information from the patient and close contacts, physicians must make use of the state prescription monitoring system. Vermont law now requires all providers who prescribe or dispense any Schedule II, III, or IV drugs to register to use VPMS. It also requires consultation of VPMS in specified circumstances2:
• At least annually for ongoing opioid chronic pain treatment;
• When first prescribing opioids for long-term, chronic pain treatment expected to last for 90 days or more;
• The first time prescribing a Schedule II, III, or IV opioid for chronic pain; and
• Before writing a replacement prescription for any Schedule II, III, or IV controlled substance. Replacement refers to the issuance of a prescription to replace medication reported by the patient as lost or stolen. (The Board notes that Vermont law also requires that a replacement prescription be marked “REPLACEMENT” and documented in the chart as a replacement prescription.)

The law also tasks the Commissioner of Health with creating rules relating to those requirements, including consideration of additional situations that trigger a required check of VPMS; the rules are not published as of the date of this policy, but will be posted on the Board webpage. If a provider fails to follow the requirements of the statute and any applicable rules, there may be both a violation of Vermont law relating to the practice of medicine, which is one form of unprofessional conduct, and such failure may be a factor in evaluating whether the standard of care was met.

The patient should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted [44-51]. As the patient is stabilized in the treatment regimen, follow-up visits may be scheduled less frequently. (However, if the patient is seen less than monthly and an opioid is prescribed, arrangements must be made for the patient to obtain a refill or new prescription when needed.)

At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the “5As” of chronic pain management; these involve a determination of whether the patient is experiencing a reduction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of Aberrant substance- related behaviors, and mood of the individual (Affect) [38,52]. Validated brief assessment tools that measure pain and function, such as the three-question “Pain, Enjoyment and General Activity” (PEG) scale [47] or other validated assessment tools, may be helpful and time effective.

Continuation, modification or termination of opioid therapy for pain should be contingent on the physician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion [21-23,45]. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life [29]. Information from family members or other caregivers should be considered in evaluating the patient’s response to treatment [14,35-36]. Use of measurement tools to assess the patient’s level of pain, function, and quality of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes [14,49]. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. D. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity [32,35]. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications [3,37].

Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is highly recommended [21-23,35,38]. The failure to use a treatment contract in a given case does not per se constitute unprofessional conduct, but in the absence of a treatment agreement contract, documentation in the patient’s chart should meet the same goals and support a conclusion that the standard of care was met.

Informed consent documents typically address:
• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short- and long-term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over-sedation.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long-term opioid therapy.
• The physician’s prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician’s policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement).
[...]
Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. D. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity [32,35]. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications [3,37].

Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is highly recommended [21-23,35,38]. The failure to use a treatment contract in a given case does not per se constitute unprofessional conduct, but in the absence of a treatment agreement contract, documentation in the patient’s chart should meet the same goals and support a conclusion that the standard of care was met.
[...] Treatment agreements outline the joint responsibilities of physician and patient [35-37] and are indicated for opioid or other medications that may be abused. They typically discuss:
• The goals of treatment, in terms of pain management, restoration of function, and safety.
• The patient’s responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication).
• The patient’s responsibility to obtain his or her prescribed opioids from only one physician or practice.
• The patient’s agreement to periodic drug testing (as of blood, urine, hair, or saliva).
• The physician’s responsibility to be available or to have a covering physician available to care for unforeseen problems and to prescribe scheduled refills.

Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. B. The Board may use a variety of sources to determine the appropriateness of treatment including prescribing information obtained from the Vermont Prescription Monitoring System (VPMS).1 [...] 1 It is a recognized goal for the future that states cooperate on interstate and regional basis to share Prescription Monitoring Program information. If and when that occurs, the expectation for use of VPMS will be expanded to include use of available information from other states. [...] Section II. E. Vermont law now requires checking VPMS in certain circumstances before a prescription for controlled substances is written, including when initiating treatment of chronic pain with opioids, as further discussed in the following section. (req) [...] Section II. F. In addition to the need to consider information from the patient and close contacts, physicians must make use of the state prescription monitoring system. Vermont law now requires all providers who prescribe or dispense any Schedule II, III, or IV drugs to register to use VPMS. It also requires consultation of VPMS in specified circumstances2:
• At least annually for ongoing opioid chronic pain treatment;
• When first prescribing opioids for long-term, chronic pain treatment expected to last for 90 days or more;
• The first time prescribing a Schedule II, III, or IV opioid for chronic pain; and
• Before writing a replacement prescription for any Schedule II, III, or IV controlled substance. Replacement refers to the issuance of a prescription to replace medication reported by the patient as lost or stolen. (The Board notes that Vermont law also requires that a replacement prescription be marked “REPLACEMENT” and documented in the chart as a replacement prescription.)

The law also tasks the Commissioner of Health with creating rules relating to those requirements, including consideration of additional situations that trigger a required check of VPMS; the rules are not published as of the date of this policy, but will be posted on the Board webpage. If a provider fails to follow the requirements of the statute and any applicable rules, there may be both a violation of Vermont law relating to the practice of medicine, which is one form of unprofessional conduct, and such failure may be a factor in evaluating whether the standard of care was met. (req)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. B. ...the Board expects physicians to incorporate safeguards into their practices to minimize the risk of misuse and diversion of opioid analgesics and other controlled substances [19-23,38,45-46]. [...] Section II. G. Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require a firm, immediate response3 [22-23,38,46]. Indeed, failure to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempts, arrests and incarceration, or even death [23,65-67]. For this reason, physicians who prescribe chronic opioid therapy should be knowledgeable in the diagnosis of substance use disorders and able to distinguish such disorders from physical dependence—which is expected in chronic therapy with opioids and many sedatives. (req)Vermont Board of Medical Practice's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. (K) Physicians licensed by the Board who have a DEA registration number must include at least 1 hour AMA PRA Category 1 CreditTM CME on safe prescribing in every two-year licensing period, as required by Vermont law and the Board’s Rules for CME. (req)Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. By its terms, this policy pertains only to treatment of chronic pain. Many of the expectations that apply to treatment for chronic pain do not apply strictly to treatment of acute pain, or to use of controlled substances other than opioids. Also, as a policy targeting use of opioids for chronic pain, it is not directed at palliative, end-of-life care. However, some of the statutory and regulatory requirements noted in the guidelines do apply more broadly and physicians need to be mindful of that. For instance, any provider who writes a prescription for any DEA Schedule II, III, or IV substance must be registered for VPMS. Furthermore, all controlled substances carry some risk of misuse, abuse, and diversion. Thus, you are encouraged to consider whether some of the practices set forth here may be of benefit in prescribing situations that are not specifically covered by this policy. (req)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. I. Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate [46].
If opioid therapy is continued, the treatment plan may need to be adjusted to reflect the patient’s changing physical status and needs, as well as to support safe and appropriate medication use [22-23].
Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient’s quality of life despite reasonable titration, deteriorating function, or significant aberrant medication use [38, 45].
If opioid therapy is discontinued, the patient who has become physically dependent should be provided with a safely structured tapering and withdrawal regimen. Withdrawal can be managed either by the prescribing physician (who may want to consult with an addiction specialist) or by referring the patient to an addiction specialist [63]. The termination of opioid therapy should not mark the end of treatment, which should continue with other modalities, either through direct care or referral to other health care specialists, as appropriate [21-23].
Additionally, providers should not continue opioid treatment unless the patient has received a benefit, including demonstrated functional improvement. (rec)
Vermont Board of Medical Practice, Use of Opioid Analgesics in the Treatment of Chronic Pain. This is a policy that provides guidelines. On its own, the policy will not be the basis for an allegation of unprofessional conduct. It is offered to assist providers. However, parts of the policy reflect Vermont and federal laws and regulations that must be followed. [...] In addition, the policy reflects the Board’s understanding of the standard of care at the time the policy is adopted. Thus, failure to follow the guidance may put a provider at risk of failing to meet the standard of care, which could lead to an allegation of unprofessional conduct under 26 V.S.A. § 1354(a)(22) or 26 V.S.A. § 1354(b). [...] Unless indicated otherwise expressly or by context, all references in this document to “physician” should be read to include other licensees of the Board who may prescribe DEA scheduled controlled substances, which includes podiatrists, physician assistants, and residents who hold a limited training license. [...] The Board will judge the validity of the physician’s treatment of a patient on the basis of available documentation, rather than solely on the quantity and duration of medication administered. [...] Section II. L. The Board recommends that physicians ensure that their practices establish systems and processes to help practice effectively, safely, and in accordance with this policy. Consistent processes and training of staff will allow for better care, deter misuse and diversion, and protect the patient and the physician. Examples of systems follow:
• The law and regulations surrounding VPMS allow for use of delegates to perform checks. It is not necessary for the physician to check the system, so the Board encourages establishment of a process that provides for office staff to get the needed information from VPMS for the provider.
• Another recommendation is to issue prescriptions for controlled substances for a duration that is a multiple of 7, up to 28 days (and adjusted for holidays) to reduce the incidents of prescriptions running out on weekends, and thereby reduce the need for a physician who does not know the patient as well, but who is on call, to write a prescription. [...] Section III. Definitions. Universal Precautions: The concept of universal precautions is borrowed from an infectious disease model of the same name to underscore its comparability to practices in other areas of medicine. The concept recognizes that all patients have a level of risk that can only be estimated initially, with the estimate modified over time as more information is obtained. The 10 essential steps of universal precautions can be summarized as follows [38]:
1. Make a diagnosis with an appropriate differential.
2. Conduct a patient assessment, including risk for substance use disorders.
3. Discuss the proposed treatment plan with the patient and obtain informed consent.
4. Have a written treatment agreement that sets forth the expectations and obligations of both the patient and the treating physician.
5. Initiate an appropriate trial of opioid therapy, with or without adjunctive medications.
6. Perform regular assessments of pain and function.
7. Reassess the patient’s pain score and level of function.
8. Regularly evaluate the patient in terms of the “5 A’s”: Analgesia, Activity, Adverse effects, Aberrant behaviors, and Affect.
9. Periodically review the pain diagnosis and any comorbid conditions, including substance use disorders, and adjust the treatment regimen accordingly.
10. Keep careful and complete records of the initial evaluation and each follow-up visit.
By acknowledging the fact that there are no signs that invariably point to substance use disorder [41], the universal precautions encourage a consistent and respectful approach to the assessment and management of pain patients, thereby minimizing stigma, improving patient care, and reducing overall risk [38]. (rec)
64
VirginiaVirginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met. The Board considers the use of opioids for pain management to be for a legitimate medical purpose when based on sound clinical judgment and current best clinical practices, appropriately documented, and of demonstrable benefit to the patient. To be within the usual course of professional practice, a legitimate physician-patient relationship must exist and the prescribing or administration of medications should be appropriate to the identified diagnosis, should be accompanied by careful follow-up monitoring of the patient’s response to treatment as well as his or her safe use of the prescribed medication, and should demonstrate that the therapy has been adjusted as needed [7,38,43]. There should be documentation of appropriate referrals as necessary [36-37]. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, non- malignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 days) and with specified evaluation points. The physician should explain that progress will be carefully monitored for both benefit and harm in terms of the effects of opioids on the patient’s level of pain, function, and quality of life, as well as to identify any adverse events or risks to safety [51]. When initiating opioid therapy, the lowest dose possible should be given to an opioid naïve patient and titrated to effect. It is generally suggested to begin opioid therapy with a short acting opioid and consider rotating to a long-acting/extended release opioid only if indicated. Vermont law now requires checking VPMS in certain circumstances before a prescription for controlled substances is written, including when initiating treatment of chronic pain with opioids, as further discussed in the following section.
A decision to continue opioid therapy beyond the trial period should reflect a careful evaluation of benefits versus adverse events [29] and/or potential risks. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The Board recognizes that principles of high-quality medical practice dictate that the people of the State of Vermont have access to appropriate, safe and effective pain management. The application of up-to-date knowledge and treatment modalities can help to restore function and thus improve the quality of life of patients who suffer from pain, particularly chronic pain [4,8,26]. [...] For the purposes of this policy, inappropriate treatment of pain includes non-treatment, inadequate treatment, overtreatment, and continued use of ineffective treatments. (rec)Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic [7] and reflect an appropriately detailed patient evaluation [38]. Such an evaluation should be completed before a decision is made as to whether to prescribe an opioid analgesic.
The nature and extent of the evaluation depends on the type of pain and the context in which it occurs. For example, [GOES ON FOR TWO PAGES OF RECOMMENDATIONS] (rec) [...] Every physician who treats patients for chronic pain must maintain accurate, complete, and legible medical records. Information that should appear in the medical record includes the following [22- 23,38,43-44]:
• Copies of the signed informed consent and treatment agreement.
• The patient’s medical history.
• Results of the physical examination and all laboratory tests.
• Results of the risk assessment, including results of any screening instruments used.
• A description of the treatments provided, including all medications prescribed or administered (including the date, type, dose and quantity).
• Instructions to the patient, including discussions of risks and benefits with the patient and any significant others.
• Results of ongoing monitoring of patient progress (or lack of progress) in terms of pain management and functional improvement.
• Notes on evaluations by and consultations with specialists or other providers, and notation by the receiving provider of response to the information and recommendations.
• Any other information used to support the initiation, continuation, revision, or termination of treatment and the steps taken in response to any aberrant medication use behaviors [21- 23,30,38,45,68].
These may include actual copies of, or references to, medical records of past hospitalizations or treatments by other providers.
• Authorization for release of information to other treatment providers.
The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record [25]. The name, telephone number, and address of the patient’s pharmacy also should be recorded to facilitate contact as needed [23]. Records should be up-to-date and maintained in an accessible manner so as to be readily available for review [25].
Good records demonstrate that a service was provided to the patient and establish that the service provided was medically necessary. Even if the outcome is less than optimal, thorough records protect the physician as well as the patient [23,38,45,68].
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs [53-54]. Drug testing is an important monitoring tool because self-reports of medication use are not always reliable and behavioral observations may detect some problems but not others [55-59]. Patients being treated for addiction should be tested as frequently as necessary to ensure therapeutic adherence. Use of testing should not be limited to instances in which the provider perceives a problem; the regular use of testing as a universal precaution will avoid having the request for a test become a confrontation that affects the physician-patient relationship. [TWO MORE PAGES OF RECOMMENDATIONS] (rec)Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The diagnosis and treatment of pain is integral to the practice of medicine [4,34-37]. In order to cautiously prescribe opioids, physicians must understand the relevant pharmacologic and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient. Such an approach should be employed in the care of every patient who receives chronic opioid therapy [4,8]. (rec) [...] The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain-associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications [4,8]. Effective means of achieving these goals vary widely, depending on the type and causes of the patient’s pain, other concurrent issues, and the preferences of the physician and the patient.
The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear-cut, individualized objectives to guide the choice of therapies [38]. The treatment plan should contain information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and nonpharmacologic. It also should specify the objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function [14,36,47]. Ongoing documentation of treatment should reference the treatment plan, as appropriate.
The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered [21-23,45]. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The treating pbysician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed [37-38]. For example, a patient who has a his­ tory of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment, if available [31,66].

Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTP,]) and those offered by an appropriately credentialed and experienced physician through office-based opioid treatment [OBOTJ), so as to make appro­ priate referrals when needed [23,31,37,39]. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient's overall health and level of function [35,49-50]. When possible, collateral information about the patient's response to opioid therapy should be obtained from family members or other close contacts, and the state POMP. The parienr should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted [44-51]. As the patient is stabilized in the treatment regimen, follow-up visits may be scheduled less frequently. (However, if the patient is seen less than monthly and an opioid is prescribed, arrangements must be made for the patient co obtain a refill or new prescription when needed.)
At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the "5As" of chronic pain management; these involve a determination of whether the patient is experiencing a re­ duction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of Aberrant substance-related behaviors, and mood of the individual {Affect) [38,52]. Validated brief assessment tools that measure pain and function, such as the th ree­ question "Pain, Enjoyment and General Activity" (PEG) scale [47] or other validated assessment tools, may be helpful and time effective.
Continuation, modification or termination of opioid therapy for pain should be contingent on the physician's evaluation of (I) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion [21-23,45]. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved qualii:y oflife [29]. Infor­ mation from family members or other caregivers should be considered in evaluating the patient's response to treatment [14,35-36). Use of measurement tools to assess rhe parient's level of pain, function, and qualiry of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes [14,49]. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity [32,35]. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications [3,37].

Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is highly recommended [21-23,35,38]. The failure to use a treatment contract in a given case does not per se constitute unprofessional conduct, but in the absence of a treatment agreement contract, documentation in the patient’s chart should meet the same goals and support a conclusion that the standard of care was met.

Informed consent documents typically address:
• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short- and long-term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over-sedation.
• The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long-term opioid therapy.
• The physician’s prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician’s policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement).
[...]
Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity [32,35]. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications [3,37].

Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is highly recommended [21-23,35,38]. The failure to use a treatment contract in a given case does not per se constitute unprofessional conduct, but in the absence of a treatment agreement contract, documentation in the patient’s chart should meet the same goals and support a conclusion that the standard of care was met.
[...] Treatment agreements outline the joint responsibilities of physician and patient [35-37] and are indicated for opioid or other medications that may be abused. They typically discuss:
• The goals of treatment, in terms of pain management, restoration of function, and safety.
• The patient’s responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication).
• The patient’s responsibility to obtain his or her prescribed opioids from only one physician or practice.
• The patient’s agreement to periodic drug testing (as of blood, urine, hair, or saliva).
• The physician’s responsibility to be available or to have a covering physician available to care for unforeseen problems and to prescribe scheduled refills.

Informed consent documents and treatment agreements can be part of one document for the sake of convenience. (rec)
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. The Board may use a variety of sources to determine the appropriateness of treatment including prescribing information obtained from the State Prescription Drug Monitoring Program. [...] If possible, the patient evaluation should include information from family members and/or significant orhers [22-23,49-50]. Where available, the state prescription drug monitoring program (POMP) should be consulted to determine whether the patient is receiving prescriptions from any other physicians, and the results obtained from the PDMP should be documented in the patient record (34]. (rec)Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. ...the Board expects physicians to incorporate safeguards into their practices to minimize the risk of misuse and diversion of opioid analgesics and other controlled substances [19-23,38,45-46]. [...] Documented drug diversion or prescription forgery, obvious impairment, and abusive or assaultive behaviors require a firm, immediate response3 [22-23,38,46]. Indeed, failure to respond can place the patient and others at significant risk of adverse consequences, including accidental overdose, suicide attempts, arrests and incarceration, or even death [23,65-67]. For this reason, physicians who prescribe chronic opioid therapy should be knowledgeable in the diagnosis of substance use disorders and able to distinguish such disorders from physical dependence—which is expected in chronic therapy with opioids and many sedatives. (req)Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate [46].
If opioid therapy is continued, the treatment plan may need to be adjusted to reflect the patient’s changing physical status and needs, as well as to support safe and appropriate medication use [22-23].
Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient’s quality of life despite reasonable titration, deteriorating function, or significant aberrant medication use [38, 45].
If opioid therapy is discontinued, the patient who has become physically dependent should be provided with a safely structured tapering and withdrawal regimen. Withdrawal can be managed either by the prescribing physician (who may want to consult with an addiction specialist) or by referring the patient to an addiction specialist [63]. The termination of opioid therapy should not mark the end of treatment, which should continue with other modalities, either through direct care or referral to other health care specialists, as appropriate [21-23].
Additionally, providers should not continue opioid treatment unless the patient has received a benefit, including demonstrated functional improvement.
Virginia Board of Medical Practice, Guidance on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Universal Precautions: The concept of universal precautions is borrowed from an infectious disease model of the same name to underscore its comparability to practices in other areas of medicine. The concept recognizes that all patients have a level of risk that can only be estimated initially, with the estimate modified over time as mo re information is obtained. The 10 essential steps of universal precautions can be summarized as follows [38]:
1. Make a diagnosis with an appropriate differential.
2. Conduct a patient assessment, including risk for substance use disorders.
3. Discuss the proposed treatment plan with the patient and obtain informed consent.
4. Have a written treatment agreement that sets forth the expectations and obligations of both the patient and the treating physician.
5. Initiate an appropriate trial of opioid therapy, with or without adjunctive medications.
6. Perform regular assessments of pain and function.
7. Reassess the patient's pain score and level of function.
8. Regularly evaluate the patient in terms of the "5 its": Analgesia, Activity, Adverse effects, Aberrant behaviors, and Affect.
9. Periodically review the pain diagnosis and any comorbid conditions, including substance use disorders, and adjust the treatment regimen accordingly.
10. Keep careful and complete records of the initial evaluation and each follow-up visit.
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WashingtonWashington Dept. of Health. 246-919-850. Physicians should not fear disciplinary action from the commission for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. The commission will consider prescribing, ordering, dispensing or adminis-tering controlled substances for pain to be for a legitimate medical purpose if based on sound clinical judg-ment. All such prescribing must be based on clear documentation of unrelieved pain. To be within the usual course of professional practice, a physician-patient relationship must exist and the prescribing should be based on a diagnosis and documentation of unrelieved pain. Compliance with applicable state or federal law is required.

The commission will judge the validity of the physician's treatment of the patient based on available docu-mentation, rather than solely on the quantity and duration of medication administration. The goal is to control the patient's pain while effectively addressing other aspects of the patient's functioning, including physical, psychological, social, and work-related factors.

These rules are designed to assist practitioners in providing appropriate medical care for patients. They are not inflexible rules or rigid practice requirements and are not intended, nor should they be used, to establish a legal standard of care outside the context of the medical quality assurance committee's jurisdiction. (rec)
Washington Dept. of Health. 246-919-854. 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. (rec)Washington Dept. of Health. 246-919-850. The Washington state medical quality assurance commission (commission) recognizes that principles of quality medical practice dictate that the people of the state of Washington 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 as-sociated with untreated or inappropriately treated pain. For the purposes of this rule, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments.

The diagnosis and treatment of pain is integral to the practice of medicine. The commission encourages physicians to view pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness. All physicians should become knowledgeable about assessing patients' pain and effective methods of pain treatment, as well as statutory requirements for prescribing controlled substances. Accordingly, this rule has been developed to clarify the commission's position on pain control, particularly as related to the use of controlled sub-stances, to alleviate physician uncertainty and to encourage better pain management. (rec)
Washington Dept. of Health. 246-919-853. The physician shall obtain, evaluate, and document the patient's health history and physical examination in the health record prior to treating for chronic noncancer pain. (req). The patient's health history shall include: (a) Current and past treatments for pain; (b) Comorbidities; and (c) Any substance abuse. (req). The patient's health history should include: (a) A review of any available prescription monitoring program or emergency department-based infor-mation exchange; and (b) Any relevant information from a pharmacist provided to a physician. (rec). The initial patient evaluation shall include: (a) Physical examination; (b) The nature and intensity of the pain; (c) The effect of the pain on physical and psychological function; (d) Medications including indication(s), date, type, dosage, and quantity prescribed; (e) A risk screening of the patient for potential comorbidities and risk factors using an appropriate screening tool. (req). The screening should address: (i) History of addiction; (ii) Abuse or aberrant behavior regarding opioid use; (iii) Psychiatric conditions; (iv) Regular concomitant use of benzodiazepines, alcohol, or other central nervous system medications; (v) Poorly controlled depression or anxiety; (vi) Evidence or risk of significant adverse events, including falls or fractures; (vii) Receipt of opioids from more than one prescribing practitioner or practitioner group; (viii) Repeated visits to emergency departments seeking opioids; (ix) History of sleep apnea or other respiratory risk factors; (x) Possible or current pregnancy; and (xi) History of allergies or intolerances. (rec). The initial patient evaluation should include: (a) Any available diagnostic, therapeutic, and laboratory results; and (b) Any available consultations. (rec).
Washington Dept. of Health. 246-919-860. The mandatory consultation threshold for adults is one hundred twenty milligrams morphine equivalent dose (MED)(oral). In the event a physician prescribes a dosage amount that meets or exceeds the consultation threshold of one hundred twenty milligrams MED (orally) per day, a consultation with a pain management specialist as described in WAC 246-919-863 is required, unless the consultation is exempted under WAC 246-919-861 or 246-919-862. (req)Washington Dept. of Health. 246-919-854. The written treatment plan shall state the objectives that will be used to determine treatment success and shall include, at a minimum: (a) Any change in pain relief; (b) Any change in physical and psychosocial function; and (c) Additional diagnostic evaluations or other planned treatments. (req). Washington Dept. of Health. 246-919-860. (1) The physician shall consider, and document the consideration, referring the patient for additional evaluation and treatment as needed to achieve treatment objectives. Special attention should be given to those chronic noncancer pain patients who are under eighteen years of age, or who are at risk for medication misuse, abuse, or diversion. The management of pain in patients with a history of substance abuse or with comor-bid psychiatric disorders may require extra care, monitoring, documentation, and consultation with, or referral to, an expert in the management of such patients. (req). (2) The mandatory consultation threshold for adults is one hundred twenty milligrams morphine equivalent dose (MED)(oral). In the event a physician prescribes a dosage amount that meets or exceeds the consultation threshold of one hundred twenty milligrams MED (orally) per day, a consultation with a pain management specialist as described in WAC 246-919-863 is required, unless the consultation is exempted under WAC 246-919-861 or 246-919-862. Great caution should be used when prescribing opioids to children with chronic noncancer pain and appropriate referrals to a specialist is encouraged.
(a) The mandatory consultation shall consist of at least one of the following: (i) An office visit with the patient and the pain management specialist; (ii) A telephone consultation between the pain management specialist and the physician; (iii) An electronic consultation between the pain management specialist and the physician; or (iv) An audio-visual evaluation conducted by the pain management specialist remotely, where the patient is present with either the physician or a licensed health care practitioner designated by the physician or the pain management specialist.
(b) A physician shall document each mandatory consultation with the pain management specialist. Any written record of the consultation by the pain management specialist shall be maintained as a patient record by the specialist. If the specialist provides a written record of the consultation to the physician, the physician shall maintain it as part of the patient record. (req) Washington Dep. of Health. 246-919-861. A physician is not required to consult with a pain management specialist as described in WAC 246-919-863 when he or she has documented adherence to all standards of practice as defined in WAC 246-919-850 through 246-919-863 and when any one or more of the following conditions apply: (1) The patient is following a tapering schedule; (2) The patient requires treatment for acute pain which may or may not include hospitalization, requiring a temporary escalation in opioid dosage, with expected return to or below their baseline dosage level; or (3) The physician documents reasonable attempts to obtain a consultation with a pain management specialist and the circumstances justifying prescribing above one hundred twenty milligrams morphine equivalent dose (MED) per day without first obtaining a consultation; or (4) The physician documents the patient's pain and function is stable and the patient is on a nonescalating dosage of opioids. Washington Dept. of Health. 246-919-862. The physician is exempt from the consultation requirement in WAC 246-919-860 if one or more of the following qualifications are met: (1) The physician is a pain management specialist under WAC 246-919-863; or (2) The physician has successfully completed, within the last two years, a minimum of twelve (Category I) continuing education hours on chronic pain management with at least two of these hours dedicated to long acting opioids; or (3) The physician is a pain management practitioner working in a multidisciplinary chronic pain treatment center, or a multidisciplinary academic research facility; or (4) The physician has a minimum three years of clinical experience in a chronic pain management setting, and at least thirty percent of his or her current practice is the direct provision of pain management care.
Washington Dept. of Health. 246-919-854. After treatment begins the physician should adjust drug therapy to the individual health needs of the patient. (rec). Washington Dept. of Health. 246-919-857. The physician shall periodically review the course of treatment for chronic noncancer pain, the patient's state of health, and any new information about the etiology of the pain. Generally, periodic reviews shall take place at least every six months. However, for treatment of stable patients with chronic noncancer pain involving nonescalating daily dosages of forty milligrams of a morphine equivalent dose (MED) or less, periodic re-views shall take place at least annually. (req). During the periodic review, the physician shall determine: (a) Patient's compliance with any medication treatment plan; (b) If pain, function, or quality of life have improved or diminished using objective evidence, considering any available information from family members or other caregivers; and (c) If continuation or modification of medications for pain management treatment is necessary based on the physician's evaluation of progress towards treatment objectives. (req). The physician shall assess the appropriateness of continued use of the current treatment plan if the patient's progress or compliance with current treatment plan is unsatisfactory. The physician shall consider tapering, changing, or discontinuing treatment when: (a) Function or pain does not improve after a trial period; (b) There is evidence of significant adverse effects; (c) Other treatment modalities are indicated; or (d) There is evidence of misuse, addiction, or diversion. (req). Washington Dept. of Health. 246-919-856. Chronic noncancer pain patients should receive all chronic pain management prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse, or has a history of substance abuse, or psychiatric comorbidities, the prescribing physician shall use a written agreement for treatment with the patient outlining patient responsibilities. This written agreement for treatment shall include: (1) The patient's agreement to provide biological samples for urine/serum medical level screening when re-quested by the physician; (2) The patient's agreement to take medications at the dose and frequency prescribed with a specific protocol for lost prescriptions and early refills; (3) Reasons for which drug therapy may be discontinued (e.g., violation of agreement); (4) The requirement that all chronic pain management prescriptions are provided by a single prescriber or multidisciplinary pain clinic and dispensed by a single pharmacy or pharmacy system; (5) The patient's agreement to not abuse alcohol or use other medically unauthorized substances; (6) A written authorization for: (a) The physician to release the agreement for treatment to local emergency departments, urgent care fa-cilities, and pharmacies; and (b) Other practitioners to report violations of the agreement back to the physician; (7) A written authorization that the physician may notify the proper authorities if he or she has reason to be-lieve the patient has engaged in illegal activity; (8) Acknowledgment that a violation of the agreement may result in a tapering or discontinuation of the prescription; (9) Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a se-cure location; and (10) Acknowledgment that if the patient violates the terms of the agreement, the violation and the physician's response to the violation will be documented, as well as the rationale for changes in the treatment plan. (req). Washington Dep. of Health. 246-919-859. If a patient has signed a written agreement for treatment and has provided a written authorization to release the agreement under WAC 246-919-856(6) to episodic care practitioners, then the episodic care practitioner should report known violations of the agreement back to the patient's treatment practitioner who provided the agreement for treatment. (rec). Washington Dept. of Health. 246-919-857. (3) The physician should periodically review information from any available prescription monitoring program or emergency department-based information exchange. (rec). Washington Dept. of Health. 246-919-857. (1) When evaluating patients for episodic care, such as emergency or urgent care, the physician should review any available prescription monitoring program, emergency department-based information exchange, or other tracking system.Washington Dept. of Health. 246-919-855. The physician shall discuss the risks and benefits of treatment options with the patient, persons designated by the patient, or with the patient's surrogate or guardian if the patient is without health care decision-making capacity. (req)Washington Dept. of Health. 246-919-854. The physician shall advise the patient that it is the patient's responsibility to safeguard all medications and keep them in a secure location. (req).Washington Dept. of Health. 246-919-862. The physician is exempt from the consultation requirement in WAC 246-919-860 if one or more of the fol-lowing qualifications are met: (1) The physician is a pain management specialist under WAC 246-919-863; or (2) The physician has successfully completed, within the last two years, a minimum of twelve (Category I) continuing education hours on chronic pain management with at least two of these hours dedicated to long acting opioids; or (3) The physician is a pain management practitioner working in a multidisciplinary chronic pain treatment center, or a multidisciplinary academic research facility; or (4) The physician has a minimum three years of clinical experience in a chronic pain management setting, and at least thirty percent of his or her current practice is the direct provision of pain management care. Washington Dept. of Health. 246-919-863. A pain management specialist shall meet one or more of the following qualifications: (1) If a physician or osteopathic physician: (a) Board certified or board eligible by an American Board of Medical Specialties-approved board (ABMS) or by the American Osteopathic Association (AOA) in physical medicine and rehabilitation, rehabilitation medicine, neurology, rheumatology, or anesthesiology; or (b) Has a subspecialty certificate in pain medicine by an ABMS-approved board; or (c) Has a certification of added qualification in pain management by the AOA; or (d) A minimum of three years of clinical experience in a chronic pain management care setting; and (i) Credentialed in pain management by an entity approved by the Washington state medical quality assurance commission for physicians or the Washington state board of osteopathic medicine and surgery for osteopathic physicians; and (ii) Successful completion of a minimum of at least eighteen continuing education hours in pain management during the past two years for physicians or three years for osteopathic physicians; and (iii) At least thirty percent of the physician's or osteopathic physician's current practice is the direct provision of pain management care or is in a multidisciplinary pain clinic. (req). [Note: There are separate requirements for dentists and podiatrists.]Washington Dept. of Health. 246-919-858. Long-acting opioids, including methadone, should only be prescribed by a physician who is familiar with its risks and use, and who is prepared to conduct the necessary careful monitoring. Special attention should be given to patients who are initiating such treatment. The physician prescribing long-acting opioids or methadone should have a one-time (lifetime) completion of at least four hours of continuing education relating to this topic. (rec).Washington Dept. of Health. 246-919-850. These rules govern the use of opioids in the treatment of patients for chronic noncancer pain. (req)Washington Dept. of Health. 246-919-851. The rules adopted under WAC 246-919-850 through 246-919-863 do not apply: (1) To the provision of palliative, hospice, or other end-of-life care; or (2) To the management of acute pain caused by an injury or surgical procedure. Washington Dept. of Health. 246-919-854. The physician shall include indications for medication use on the prescription and require photo identifica-tion of the person picking up the prescription in order to fill. (req). Washington Dept. of Health. 246-919-857. (4) The physician should periodically review any relevant information from a pharmacist provided to the physician. (rec). Washington Dept. of Health. 246-919-859. (2) Episodic care practitioners should avoid providing opioids for chronic pain management. However, if opioids are provided, the practitioner should limit the use of opioids for a chronic noncancer pain patient to the minimum amount necessary to control the pain until the patient can receive care from a primary care prac-titioner. (3) Prescriptions for opioids written by an episodic care practitioner shall include indications for use or the International Classification of Diseases (ICD) code and shall be written to require photo identification of the person picking up the prescription in order to fill.
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West VirginiaManagement of Pain Act. § 30-3A-2. A physician is not subject to disciplinary sanctions by a licensing board or criminal punishment by the state for prescribing, administering or dispensing pain-relieving controlled substances for the purpose of alleviating or controlling pain if: [...] (2) In the case of a patient who is not dying and is experiencing pain, the physician discharges his or her professional obligation to relieve the patient's pain, if the physician can demonstrate by reference to an accepted guideline that his or her practice substantially complied with that accepted guideline. Evidence of substantial compliance with an accepted guideline may be rebutted only by the testimony of a clinical expert. Evidence of noncompliance with an accepted guideline is not sufficient alone to support disciplinary or criminal action. (b) A registered nurse is not subject to disciplinary sanctions by a licensing board or criminal punishment by the state for administering pain-relieving controlled substances to alleviate or control pain, if administered in accordance with the orders of a licensed physician. (c) A registered pharmacist is not subject to disciplinary sanctions by a licensing board or criminal punish-ment by the state for dispensing a prescription for a pain-relieving controlled substance to alleviate or control pain, if dispensed in accordance with the orders of a licensed physician. (req)
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West VirginiaWV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met. (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. The medical management of pain should reflect current knowledge of evidence-based or best clinical practices for the use of pharmacologic and nonpharmacologic modalities, including the use of opioid analgesics and non-opioid therapies. Such prescribing must be based on careful assessment of the patient and his or her pain (see the discussion on risk stratification, below). Pain should be assessed and treated promptly, and the selection of therapeutic modalities (including the quantity and frequency of medication doses) should be adjusted according to the nature of the pain, the patient's response to treatment, and the patient's risk level relative to the use of medications with abuse potential. (rec) WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, non-malignant pain. (rec)
WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. The Board recognizes that principles of high-quality medical practice dictate that the people of the State of West Virginia have access to appropriate, safe and effective pain management. The application of up-to-date knowledge and treatment modalities can help to restore function and thus improve the quality of life of patients who suffer from pain, particularly chronic pain. This policy has been developed to articulate the Board's position on the use of controlled substances for pain, particularly the use of opioid analgesics and with special attention to the management of chronic pain. The policy thus is intended to encourage physicians to be knowledgeable about best clinical practices as regards the prescribing of opioids and be aware of associated risks. For the purposes of this policy, inappropriate treatment of pain includes non­treatment, inadequate treatment, overtreatment, and continued use of ineffective treatments. (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic and reflect an appropriately detailed patient evaluation . Such an evaluation should be completed before a decision is made as to whether to prescribe an opioid analgesic. [FOLLOWED BY NEARLY 2 PAGES OF EVALUATION "SHOULDS" modeled on FSMB guidelines] (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs. Drug testing is an important monitoring tool because self-reports of medication use is not always reliable and behavioral observations may detect some problems but not others. Patients being treated for addiction should be tested as frequently as necessary to ensure therapeutic adherence, but for patients being treated for pain, clinical judgment trumps recommendations for frequency of testing.

Urine may be the preferred biologic specimen for testing because of its ease of collection and storage and the cost-effectiveness of such testing. When such testing is conducted as part of pain treatment, forensic standards are generally not necessary and not in place, so collection is not observed and chain-of-custody protocols are not followed. Initial testing may be done using class­ specific immunoassay drug panels (point-of-care or laboratory-based), which typically do not identify particular drugs within a class unless the immunoassay is specific for that drug. If necessary, this can be followed up with a more specific technique, such as gas chromatography/mass spectrometry (GC/MS) or other chromatographic tests to confirm the presence or absence of a specific drug or its metabolites. In drug testing in a pain practice, it is important to identify the specific drug not just the class of the drug.

Physicians need to be aware of the limitations of available tests (such as their limited sensitivity for many opioids) and take care to order tests appropriately. For example, when a drug test is ordered, it is important to specify that it include the opioid being prescribed. Because of the complexities involved in interpreting drug test results, it is advisable to confirm significant or unexpected results with the laboratory toxicologist or a clinical pathologist.

While immunoassay, point of care (POC) testing has its utility in the making of temporary and "on the spot" changes in clinical management, its limitations with regard to accuracy have recently been the subject of study. These limitations are such that the use of point of care testing for the making of more long term and permanent changes in management of people with the disease of addiction and other clinical situations may not be justified until the results of confirmatory testing with more accurate methods such as LC-MS/MS are obtained. A recent study on LC-MS/MS results following immunoassay POC testing in addiction treatment settings and found very high rates of "false negatives and positives".

Test results that suggest opioid misuse should be discussed with the patient. It is helpful to approach such a discussion in a positive, supportive fashion, so as to strengthen the physician­ patient relationship and encourage healthy behaviors (as well as behavioral change where that is
needed). Both the test results and subsequent discussion with the patient should be documented in the medical record. (rec)
WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. The diagnosis and treatment of pain is integral to the practice of medicine. In order to cautiously prescribe opioids, physicians must understand the relevant pharmacologic and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient. Such an approach should be employed in the care of every patient who receives chronic opioid therapy. [...] The goals of pain treatment include reasonably attainable improvement in pain and function; improvement in pain-associated symptoms such as sleep disturbance, depression, and anxiety; and avoidance of unnecessary or excessive use of medications. Effective means of achieving these goals vary widely, depending on the type and causes of the patient's pain, other concurrent issues, and the preferences of the physician and the patient. The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear-cut, individualized objectives to guide the choice of therapies. The treatment plan should contain information supporting the selection of therapies, both pharmacologic (including medications other than opioids) and nonpharmacologic. It also should specify the objectives that will be used to evaluate treatment progress, such as relief of pain and improved physical and psychosocial function. The plan should document any further diagnostic evaluations, consultations or referrals, or additional therapies that have been considered. (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed. For example, a patient who has a history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment, if available.

Physicians who prescribe chronic opioid therapy should be familiar with treatment options for opioid addiction (including those available in licensed opioid treatment programs [OTPs]) and those offered by an appropriately credentialed and experienced physician through office-based opioid treatment [OBOT]), so as to make appropriate referrals when needed. (rec)
WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient's overall health and level of function. When possible, collateral information about the patient's response to opioid therapy should be obtained from family members or other close contacts, and the state PDMP. The patient should be seen more frequently while the treatment plan is being initiated and the opioid dose adjusted. As the patient is stabilized in the treatment regimen, follow-up visits may be scheduled less frequently. (However, if the patient is seen less than monthly and an opioid is prescribed, arrangements must be made for the patient to obtain a refill or new prescription when needed.)

At each visit, the results of chronic opioid therapy should be monitored by assessing what have been called the "5As" of chronic pain management; these involve a determination of whether the patient is experiencing a reduction in pain (Analgesia), has demonstrated an improvement in level of function (Activity), whether there are significant Adverse effects, whether there is evidence of
Aberrant substance-related behaviors, and mood of the individual (Affect). Validated brief assessment tools that measure pain and function, such as the three-question "Pain, Enjoyment and General Activity" (PEG) scale [47] or other validated assessment tools, may be helpful and time effective.

Continuation, modification or termination of opioid therapy for pain should be contingent on the physician's evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion. A satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function, and/or improved quality of life. Information from family members or other caregivers should be considered in evaluating the patient's response to treatment. Use of measurement tools to assess the patient's level of pain, function, and quality of life (such as a visual analog or numerical scale) can be helpful in documenting therapeutic outcomes [14,49]. (rec)
WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. Use of a written informed consent and treatment agreement (sometimes referred to as a "treatment contract") is recommended. Informed consent documents typically address:
• The potential risks and anticipated benefits of chronic opioid therapy.
• Potential side effects (both short- and long-term) of the medication, such as constipation and cognitive impairment.
• The likelihood that tolerance to and physical dependence on the medication will develop.
• The risk of drug interactions and over-sedation.
•.The risk of impaired motor skills (affecting driving and other tasks).
• The risk of opioid misuse, dependence, addiction, and overdose.
• The limited evidence as to the benefit of long-term opioid therapy.
• The physician's prescribing policies and expectations, including the number and frequency of prescription refills, as well as the physician 's policy on early refills and replacement of lost or stolen medications.
• Specific reasons for which drug therapy may be changed or discontinued (including violation of the policies and agreements spelled out in the treatment agreement). (rec)
WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. Use of a written informed consent and treatment agreement (sometimes referred to as a "treatment contract") is recommended. […] Treatment agreements outline the joint responsibilities of physician and patient and are indicated for opioid or other abusable medications. They typically discuss:
• The goals of treatment, in terms of pain management, restoration of function, and safety.
• The patient's responsibility for safe medication use (e.g., by not using more medication than prescribed or using the opioid in combination with alcohol or other substances; storing medications in a secure location; and safe disposal of any unused medication).
• The patient 's responsibility to obtain his or her prescribed opioids from only one physician or practice.
• The patient's agreement to period ic drug testing (as of blood, urine, hair, or saliva).
• The physician's responsibility to be available or to have a covering physician available to care for unforeseen problems and to prescribe scheduled refills.
WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. The Board may use a variety of sources to determine the appropriateness of treatment including prescribing information obtained from the State Prescription Drug Monitoring Program. [...] When possible, collateral information about the patient's response to opioid therapy should be obtained from family members or other close contacts, and the state PDMP. (rec). WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. As noted earlier and where available, consulting the state's PDMP before prescribing opioids for pain and during ongoing use is highly recommended. A PDMP can be useful in monitoring compliance with the treatment agreement as well as identifying individuals obtaining controlled substances from multiple prescribers. (rec).WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. The decision to initiate opioid therapy should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the treatment plan (including any proposed use of opioid analgesics) with the patient, with persons designated by the patient, or with the patient's surrogate or guardian if the patient is without medical decision-making capacity. If opioids are prescribed, the patient (and possibly family members) should be counseled on safe ways to store and dispose of medications. (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. The Board also recognizes that individuals' use of opioid analgesics for other than legitimate medical purposes poses a significant threat to the health and safety of the individual as well as to the public health. The Board further recognizes that inappropriate prescribing of controlled substances by physicians may contribute to drug misuse and diversion by individuals who seek opioids for other than legitimate medical purposes. Accordingly, the Board expects physicians to incorporate safeguards into their practices to minimize the risk of misuse and diversion of opioid analgesics and other controlled substances. (req). WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. [After discussing UDT at length] Periodic pill counting is also a useful strategy to confirm medication adherence and to minimize diversion (e.g., selling, sharing or giving away medications). As noted earlier and where available, consulting the state's PDMP before prescribing opioids for pain and during ongoing use is highly recommended. A PDMP can be useful in monitoring compliance with the treatment agreement as well as identifying individuals obtaining controlled substances from multiple prescribers. (rec) WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section I. The Board recognizes that opioid analgesics are useful and can be essential in the treatment of acute pain that results from trauma or surgery, as well as in the management of certain types of chronic pain, whether due to cancer or non-cancer causes. WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, non-malignant pain. (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. If opioid therapy is discontinued, the patient who has become physically dependent should be provided with a safely structured tapering regimen. Withdrawal can be managed either by the prescribing physician or by referring the patient to an addiction specialist. The termination of opioid therapy should not mark the end of treatment, which should continue with other modalities, either through direct care or referral to other health care specialists, as appropriate. (rec)WV Board of Medicine's Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain. Section II. Providers should not continue opioid treatment unless the patient has received a benefit, including demonstrated functional improvement. (rec)
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West VirginiaChronic Pain Clinic Licensing Act. § 16-5H-4. (10)(B) The physician shall maintain a record of all of the following: (i) Medical history and physical examination of the individual; (ii) The diagnosis of chronic pain, including signs, symptoms and causes; (iii) The plan of treatment proposed, the patient's response to the treatment and any modification to the plan of treatment; (iv) The dates on which any medications were prescribed, dispensed or administered, the name and address of the individual to or for whom the medications were prescribed, dispensed or administered and the amounts and dosage forms for the drugs prescribed, dispensed or administered; and, (v) A copy of the report made by the physician to whom referral for evaluation was made. (10)(C) (C) A physician, physician assistant, certified registered nurse anesthetist or advanced nurse practitioner shall perform a physical examination of a patient on the same day that the physician initially prescribes, dispenses or administers a controlled substance to a patient and at least four times a year thereafter at a pain management clinic according to accepted and prevailing standards for medical care. (req). Chronic Pain Clinic Licensing Act. § 16-5H-4. (10)(A) When a physician diagnoses an individual as having chronic pain, the physician may treat the pain by man-aging it with medications in amounts or combinations that may not be appropriate when treating other medical conditions. The physician's diagnosis shall be made after having the individual evaluated by one or more other physicians who specialize in the treatment of the area, system or organ of the body perceived as the source of the pain unless the individual has been previously diagnosed as suffering from chronic pain and is referred to the pain management clinic by such diagnosing physician. The physician's diagnosis and treatment deci-sions shall be made according to accepted and prevailing standards for medical care. (req). Chronic Pain Clinic Licensing Act. § 16-5H-4. (7) A person may not dispense any medication, including a controlled substance, as defined by section one hundred one, article one, chapter sixty-a of this code, on the premises of a licensed pain management clinic unless he or she is a physician or pharmacist licensed in this state. Prior to dispensing or prescribing con-trolled substances, as defined by section one hundred one, article one, chapter sixty-a of this code, at a pain management clinic, the treating physician must access the Controlled Substances Monitoring Program data-base maintained by the Board of Pharmacy to ensure the patient is not seeking controlled substances from multiple sources. If the patient receives ongoing treatment, the physician shall also review the Controlled Substances Monitoring Program database at each patient examination or at least every ninety days. The results obtained from the Controlled Substances Monitoring Program database shall be maintained with the patient's medical records. [...] (9) A pain management clinic shall not dispense to any patient more than a seventy-two-hour supply of a controlled substance, as defined by section one hundred one, article one, chapter sixty-a of this code. (req). Chronic Pain Clinic Licensing Act. § 16-5H-4. (10)(B) A physician authorized to prescribe controlled substances who practices at a pain management clinic is re-sponsible for maintaining the control and security of his or her prescription blanks and any other method used for prescribing controlled substance pain medication. The physician shall comply with all state and fed-eral requirements for tamper-resistant prescription paper. In addition to any other requirements imposed by statute or rule, the physician shall notify the secretary in writing within twenty-four hours following any theft or loss of a prescription blank or breach of any other method for prescribing pain medication. (req). Chronic Pain Clinic Licensing Act. § 16-5H-4. Each pain management clinic shall designate a physician owner who shall practice at the clinic and who will be responsible for the operation of the clinic. […] The designated physician shall […] meet one of the following training requirements: (i) Complete a pain medicine fellowship that is accredited by the Accreditation Council for Graduate Medical Education or such other similar program as may be approved by the secretary; or (ii) Hold current board certification by the American Board of Pain Medicine or current board certification by the American Board of Anesthesiology or such other board certification as may be approved by the secretary. (req)Chronic Pain Clinic Licensing Act. § 16-5H-4. Upon satisfaction that an applicant has met all of the requirements of this article, the secretary may issue a license to operate a pain management clinic. An entity that obtains this license may possess, have custody or control of, and dispense drugs designated as Schedule II or Schedule III in sections two hundred six or two hundred eight, article two, chapter sixty-a of this code.
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WyomingWyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section I. Fears of investigation or sanction by federal, state and local agencies may also result in inappropriate treatment of pain. Appropriate pain management is the treating prescriber’s responsibility. As such, the Boards will consider the inappropriate treatment of pain to be a departure from standards of practice and will investigate such allegations, recognizing that some types of pain cannot be completely relieved, and taking into account whether the treatment is appropriate for the diagnosis. [...] Prescribers should not fear disciplinary action from the Boards for ordering, prescribing, dispensing or adminstering controlled substances, including opioid analgesics, for a legitimate purpose and in the course of professional practice. The Boards will consider prescribing, ordering, dispensing or administering controlled substances for pain to be for a legitimate purpose if based on sound clinical judgment. All such prescribing must be based on clear documentation of unrelieved pain. To be within the usual course of professional practice, a prescriber-patient relationship must exist and the prescribing should be based on a diagnosis and documentation of unrelieved pain. Compliance with applicable state or federal law is required. (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section I. The management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non- pharmacologic modalities according to the judgment of the prescriber. (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section I. The Wyoming state boards of Medicine, Nursing, Dental Examiners, Pharmacy, Podiatry, Optometry, and Veterinary Medicine ("the Boards") recognize that principles of quality health care practice dictate that the people of the State of Wyoming have access to appropriate 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. For the purposes of this policy, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments. The diagnosis and treatment of pain is integral to the provision of health care. The Boards encourage all prescribers to view pain management as a part of quality practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness. All prescribers should become knowledgeable about assessing patients’ pain and effective methods of pain treatment, as well as statutory and regulatory requirements for prescribing controlled substances.(rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (1) A patient history and physical exam must be otained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for 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 indications for the use of a controlled substance. (req)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (3) The treatment agreement should outline the patient's responsibilities regarding urine / serum medication levels screening when requested. (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (2) 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 prescriber 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. (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (5) The prescriber 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 with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (4) The prescriber should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on teh prescriber's evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient's response to treatment. If the patient's progress is unsatisfactory, the prescriber should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (3) The prescriber 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 without decision-making capacity. The patient should receive prescriptions from one prescriber and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the prescriber should strongly consider the use of a written agreement between prescriber and patient outlining patient responsibilities including, where appropriate: (a) urine/serum medication levels screening when requested; (b) number and frequency of all prescription refills; and, (c) reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (3) The prescriber 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 without decision-making capacity. The patient should receive prescriptions from one prescriber and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the prescriber should strongly consider the use of a written agreement between prescriber and patient outlining patient responsibilities including, where appropriate: (a) urine/serum medication levels screening when requested; (b) number and frequency of all prescription refills; and, (c) reasons for which drug therapy may be discontinued (e.g., violation of agreement). (rec)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section I. The Boards are obligated under the laws of the State of Wyoming to protect the public health and safety. The Boards recognize that the use of opioid analgesics for other than legitimate purposes poses a threat to the individual and society and that the inappropriate prescribing of controlled substances, including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate use. Accordingly, the Boards expect that prescribers will incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (req)Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section I. The Boards recognize 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. Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section I. The Boards will refer to current clinical practice guidelines appropriate to the prescriber’s profession and practice, as well as expert review, in approaching cases involving management of pain. The management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non- pharmacologic modalities according to the judgment of the prescriber. Pain should be assessed and treated promptly, and the quantity and frequency of doses should be adjusted according to the intensity, duration of the pain, and treatment outcomes. Prescribers should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not the same as addiction. [...] Allegations of inappropriate pain management will be evaluated on an individual basis. The Boards will not take disciplinary action against prescribers for deviating from this policy when contemporaneous medical records document reasonable cause for deviation. A prescriber’s conduct will be evaluated to a great extent by the outcome of pain treatment, recognizing that some types of pain cannot be completely relieved, and by taking into account whether the drug used is appropriate for the diagnosis, as well as improvement in patient functioning and/or quality of life. Wyoming Health Care Licensing Boards' Uniform Policy for the Use of Controlled Substances in the Treatment of Pain. Section II. (6) The prescriber should keep accurate and complete records to include
a. the patient’s history and physical examination,
b. diagnostic, therapeutic and laboratory results,
c. evaluations and consultations,
d. treatment objectives,
e. discussion of risks and benefits,
f. informed consent,
g. treatments,
h. medications (including date, type, dosage and quantity prescribed),
i. instructions and agreements, and
j. periodic reviews.
Records should remain current and be maintained in an accessible manner and readily available for review.
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