Prescribing Controlled Substances for Pain
A statement by the Medical Board of California, 1997
On May 6 the Medical Board formally adopted the following statement on "Prescribing For Pain Management.". It is the first formal statement of its kind in the nation made by a licensing board. This statement was adopted after a year of testimony at hearings held by the Board's Task Force on Appropriate Prescribing and a day-long "Summit," sponsored by Governor Wilson, involving scores of experts from around the country.
At the Board's July 28-29 meeting the members will consider formal adoption of a set of guidelines based on this policy statement. The guidelines. once adopted, will be published in the October Action Report and other publications read by physicians.
The Task Force was established to look into "malprescribing," one of the fastest growing categories of physician discipline. The Board continues to be concerned that controlled substances are subject to abuse by individuals who seek them for their mood altering and other psychological effects, rather than for legitimate medical purposes.
The Board is also concerned about effective pain management and the appropriate medical use of controlled substances. During the Task Force's public meetings, the members heard testimony that some physicians avoid prescribing controlled substances, including the "triplicate" drugs, for patients with intractable pain for fear of discipline by the Board. The Task Force recommended that the Board take a pro-active approach to emphasize to all California physicians that it supports prescribing of opioid analgesics (narcotics) and other controlled substances when medically indicated for the treatment of pain, including intractable pain. After careful review of this matter, the Board concurs with the following statement.
This statement is consistent with good medical practice, protection of public health and consumer interests, with international treaties, federal and California law, including the California Intractable Pain Treatment Act.
The Pain Problem
While some progress is being made to improve pain and symptom management, the Board is concerned that a number of factors continue to interfere with effective pain management. These include the low priority of pain management in our health care system, incomplete integration of current knowledge into medical education and clinical practice, lack of knowledge among consumers about pain management, exaggerated fears of opioid side effects and addiction, and fear of legal consequences when controlled substances are used.
Pain Management Should
Be A High Priority In California
In addition to making this statement, the Board will take a number of steps to help make effective pain management a reality in California. The Board has provided information to all state physicians about new clinical practice guidelines for pain management that have been prepared by a panel of experts supported by the Agency for Health Care Policy and Research. The Board also co-sponsored and participated in the March 18, 1994 Pain Management and Appropriate Prescribing Summit in conjunction with the Department of Consumer Affairs on removing impediments to appropriate prescribing of controlled substances for effective pain management. Further, the Board will develop guidelines to help physicians avoid investigation if they appropriately prescribe controlled substances for pain management.
The Appropriate Role
Of Opioid Analgesics
The Board recognizes that opioid analgesics can also be useful in the treatment of patients with intractable non-malignant pain especially where efforts to remove the cause of pain or to treat it with other modalities have failed. The pain of such patients may have a number of different etiologies and may require several treatment modalities. In addition, the extent to which pain is associated with physical and psychosocial impairment varies greatly. Therefore, the selection of a patient for a trial of opioid therapy should be based upon a careful assessment of the pain as well as the disability experienced by the patient Continuation of opioid therapy should be based on the physician's evaluation of the results of treatment, including the degree of pain relief, changes in physical and psychological functioning, and appropriate utilization of health care resources. Physicians should not hesitate to obtain consultation from legitimate practitioners who specialize in pain management.
The Board recommends that physicians pay particular attention to those patients who misuse their prescriptions, particularly when the patient or family have a history of substance abuse that could complicate pain management The management of pain in such patients requires extra care and monitoring, as well as consultation with medical specialists whose area of expertise is substance abuse or pain management.
The Board believes that addiction should be placed into proper perspective. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy and are not the same as addiction. Addiction is a behavioral syndrome characterized by psychological dependence and aberrant drug related behaviors. Addicts compulsively use drugs for nonmedical purposes despite harmful effects; a person who is addicted may also be physically dependent or tolerant. Patients with chronic pain should not be considered addicts or habitues merely because they are being treated with opioids.
Controlled Substances And The Law
The Medical Board will work with the Drug Enforcement Administration, the Bureau of Narcotic Enforcement, the Office of the Attorney General, the Board of Pharmacy and its own investigators in an attempt to develop policy and guidelines based on the physician's diagnosis and treatment program rather than amounts of drugs prescribed.
Concerns about regulatory scrutiny should not make physicians who follow appropriate guidelines reluctant to prescribe or administer controlled substances, including Schedule 11 drugs, for patients with a legitimate medical need for them. A physician is not subject to Board action when prescribing in the regular course of his or her profession to one under the physician's treatment for a pathology or condition and where the prescription is issued after a good faith examination and where there is medical indication for the drug.
Good faith prescribing
requires an equally good faith history, physical examination and documentation.
The Board hopes to replace practitioners' perception of inappropriate regulatory scrutiny with recognition of the Board's commitment to enhance the quality of life of patients by improving pain management while, at the same time, preventing the diversion and abuse of controlled substances.
Originally appeared on www.druglibrary.org/schaffer/index.htm
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