Current through Register Vol. 50, No. 9, September 20, 2024
A. Requisite Prior Conditions. In utilizing
any controlled substance for the treatment of noncancer-related chronic or
intractable pain on a protracted basis, a physician shall comply with the
following rules.
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.
2. Medical Diagnosis.
A medical diagnosis shall be established and fully documented in the patient's
medical record, which indicates not only the presence of noncancer-related
chronic or intractable pain, but also the nature of the underlying disease and
pain mechanism if such are determinable.
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.
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.
B. Controlled Substance Therapy. Upon
completion and satisfaction of the conditions prescribed in
§6921 A, and upon a physician's judgment
that the prescription, dispensation, or administration of a controlled
substance is medically warranted, a physician shall adhere to the following
rules.
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.
2. Drug Screen. If a physician reasonably
believes that the 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.
3. Responsibility for Treatment. A single
physician shall take primary responsibility for the controlled substance
therapy employed by him in the treatment of a patient's noncancer-related
chronic or intractable pain.
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.
5. Medications Employed. A physician shall
document in the patient's medical record the medical necessity for the use of
more than one type or schedule of controlled substance employed in the
management of a patient's noncancer-related chronic or intractable
pain.
6. Treatment Records. A
physician shall document and maintain in the patient's medical record, accurate
and complete records of history, physical and other examinations and
evaluations, consultations, laboratory and diagnostic reports, treatment plans
and objectives, controlled substance and other medication therapy, informed
consents, periodic assessments, and reviews and the results of all other
attempts at analgesia which he has employed alternative to controlled substance
therapy.
7. Documentation of
Controlled Substance Therapy. At a minimum, a physician shall document in the
patient's medical record the date, quantity, dosage, route, frequency of
administration, the number of controlled substance refills authorized, as well
as the frequency of visits to obtain refills.
C. Termination of Controlled Substance
Therapy. Evidence or behavioral indications of substance abuse or diversion of
controlled substances shall be followed by tapering and discontinuation of
controlled substance therapy. Such therapy shall be reinitiated only after
referral to and written concurrence of the medical necessity of continued
controlled substance therapy by an addiction medicine specialist, a pain
management specialist, a psychiatrist, or other substance abuse specialist
based upon his physical examination of the patient and a review of the
referring physician's medical record of the patient.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
37:1270(A)(1),
37:1270(B)(6), and 37:1285(B).
