Current through Register Vol. 35, No. 18, September 24, 2024
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.
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.
B. The
prescribing, ordering, administering or dispensing of controlled substances to
meet the individual needs of the patient for management of chronic pain is
appropriate if prescribed, ordered, administered or dispensed in compliance
with the following.
(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.
(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.
(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 treatment 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,
consultation, referral or use of other treatment modalities.
(4) The practitioner shall discuss the risks
and benefits of using controlled substances with the patient or surrogate or
guardian, and shall document this discussion in the record.
(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.
(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 practice in the area of chronic pain control; such
professionals need not be those who specialize in pain control.
(7) When prescribing opioids for chronic
pain, practitioners shall require urine drug testing when starting opioid
therapy and shall use urine drug testing at least every six months to assess
for prescribed medications as well as other controlled prescription drugs and
illicit drugs.
(8) 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.
D. The board
will evaluate the quality of care on the following basis: appropriate diagnosis
and evaluation; appropriate medical indication for the treatment prescribed;
documented change or persistence of the recognized medical indication; and,
follow-up evaluation with appropriate continuity of care. The board will judge
the validity of prescribing based on the practitioner'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.
E. The board will review
both over-prescription and under-prescription of pain medications using the
same standard of patient protection.
F. A practitioner who appropriately
prescribes controlled substances and who follows this section would be
considered to be in compliance with this rule and not be subject to discipline
by the board, unless there is some violation of the Medical Practice Act or
board rules.
