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The Board strongly urges physicians to view effective pain management
as a high priority in all patients, including children and the elderly.
Pain should be assessed and treated promptly, effectively and for as long
as pain persists. The medical management of pain should be based on up-to-date
knowledge about pain, pain assessment and pain treatment. Pain treatment
may involve the use of several drug and non-drug treatment modalities,
often in combination. For some types of pain the use of drugs is emphasized
and should be pursued vigorously; for other types, the use of drugs is
better de-emphasized in favor of other therapeutic modalities. Physicians
should have sufficient knowledge or consultation to make such judgements
for their patients.
Drugs, in particular the opioid analgesics, are considered the cornerstone
of treatment for pain associated with trauma, surgery, medical procedures
and cancer. Physicians are referred to the U.S. Agency for Health Care
Policy and Research Clinical Practice Guidelines as a sound yet flexible
approach to the management of these types of pain.
The prescribing of opioid analgesics for other patients with intractable
non-cancer pain also may be beneficial, especially when efforts to remove
the cause of pain or to treat it with other modalities have been unsuccessful.
For the purposes of these guidelines, intractable pain is defined as:
"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 surgeon and one or more physicians and surgeons
specializing in the treatment of the area, system, or organs of the body
perceived as the source of the pain."
Therefore, these guidelines are an attempt to communicate to physicians
who prescribe opioids for intractable pain not to fear disciplinary action
from this Board for prescribing or administering controlled substances
in the course of treatment of a person for intractable pain. Also, physicians
should use sound clinical judgement, and care for their patients according
to the following principles of responsible professional practice:
STATUTORY
ABILITY TO DEVELOP GUIDELINES
Pursuant to Arizona Revised Statutes §32-1403(A)(3), the Board
may develop and recommend standards governing the profession in Arizona.
In developing these guidelines, the Board reviewed 18 guidelines developed
by other states and agencies. 1
GUIDELINES
FOR PATIENT CARE WHEN PRESCRIBING CONTROLLED SUBSTANCES FOR CHRONIC PAIN
A) Pain Assessment
Pain assessment should occur during initial evaluation, after each new
report of pain, at appropriate intervals after each pharmacological intervention,
and at regular intervals during treatment. Unless a patient is terminally
ill and death is imminent (in which case the diagnosis is usually evident
and diagnostic evaluations may be of little value and discomforting to
the patient), the evaluation should include:
1. Medical history, including the presence of a recognized medical indication
for the use of a controlled substances, the intensity and character of
pain, and questions regarding substance abuse;
2. Psycho-social assessment, which may include but is not limited to:
a. The patient’s understanding of the medical diagnosis, expectations
about pain relief and pain management methods, concerns regarding the use
of controlled substances, and coping mechanisms for pain;
b. Changes in mood which have occurred secondary to pain (i.e., anxiety,
depression); and
c. The meaning of pain to the patient and his/her family.
3. Physical examination, including a neurologic evaluation and examination
of the site of pain.
B) Treatment Plan
A treatment plan should be developed for the management of chronic pain
and state objectives by which therapeutic success can be evaluated, including:
1. Pain relief;
2. Improved physical functioning;
3. Proposed diagnostic evaluations (i.e., blood tests, radiologic,
psychological and social studies such as CAT and bone scans, MRI and neurophysiologic
examinations such as electromyography); and
4. Analysis of inclusion and exclusion criteria for opioid management:
Inclusion criteria include: a clear diagnosis has been made, consistent
with symptoms; the exploration of all reasonable alternative therapies
have been explored; the patient is reliable and communicates well; and
there has been informed consent or a treatment agreement signed. Potential
exclusion criteria include a history of chemical dependency, major psychiatric
disorder, chaotic social situation, or a planned pregnancy.
C) Informed Consent
The physician should advise the patient, guardian, or designated surrogate
of the risks and benefits of the use of controlled substances. The patient
should be counseled on the importance of regular visits, the impact of
recreational drug use, the number of physicians and pharmacies used for
prescriptions, taking medications as prescribed, etc.
D) Ongoing Assessment
The assessment and treatment of chronic pain mandates continuing evaluation,
and if necessary, modification and/or discontinuation of opioid therapy.
If clinical improvement does not occur, the physician should consider the
appropriateness of continued opioid therapy, and consider a trial of alternative
pharmacologic and nonpharmacologic modalities.
E) Consultation
The physician should refer patients as necessary for additional evaluation
to achieve treatment objectives. Physicians should recognize patients requiring
individual attention, in particular, patients whose living situations pose
a risk for misuse or diversion of controlled substances. In addition, the
prescription of controlled substances to patients with a history of substance
abuse requires extra care, monitoring, and documentation, and may also
require consultation with an addiction medicine specialist. The physician
may also consider the use of physician-patient agreements or contracts
that specify the rules for medication use and the consequences of misuse
or abuse.
F) Documentation
The physician must maintain adequate, accurate and timely records regarding
items A-E from above. "Adequate Records," pursuant to A.R.S. §32-1401(2),
"means legible records containing, at a minimum, sufficient information
to identify the patient, support the diagnosis, justify the treatment,
adequately document the results, indicate advice and cautionary warnings
provided to the patient, and provide sufficient information for another
practitioner to assume continuity of the patient’s care at any point in
the treatment." Specific to chronic pain patients, the documentation should
include:
1. The medical history and physical examination;
2. Related evaluations and consultations, treatment plan and objectives;
3. Evidence of discussion regarding informed consent;
4. Prescribed medications and treatments;
5. Periodic reviews of treatments and patient response; and
6. Any physician-patient agreements or contracts.
COMPLIANCE
WITH LAWS AND REGULATIONS
To prescribe controlled substances, physicians must comply with all
applicable laws, including the following:
1. Possess a valid current license to practice medicine in the State
of Arizona;
2. Possess a valid and current controlled substances Drug Enforcement
Administration registration for the schedules being prescribed;
3. If drugs are dispensed from the office, comply with Arizona Revised
Statutes §32-1491 et. Seq., and AAC R4-16-201 through R4-16-205.
4. If controlled substances are provided for detoxification, comply
with 22 CFR 1306.07(a).
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