Current through Register Vol. 35, No. 18, September 24, 2024
The following regulations shall be used by the board to
determine whether an osteopathic physician's or osteopathic physician
assistant'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 should be recorded. Prescriptions for opioids shall include
indications for use. For chronic non-cancer pain patients treated with
controlled substance and 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 non-cancer 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 non-cancer pain, the patient's state of health, and any
new information about the etiology of the chronic non-cancer pain at least
every six months. In addition, a practitioner shall consult, when indicated by
the patient's condition, with a clinical pain expert. Consultation should occur
early in the course of long-term treatment and at reasonable intervals during
continued long-term treatment for assessment of benefit and need a minimum of
once every six months.
(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 abuse disorders shall include:
(1)
a contractual agreement;
(2)
appropriate consultation;
(3) urine
or hair or salivary or blood drug screening shall be considered 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 as a guiding principle.
F. Any physician or physician assistant that
prescribes opiate based pain medication, shall obtain at least six CME credits
in pain management over a three year period.
G. Any physician or physician assistant that
prescribes opiate based pain medication shall utilize the state based
prescription monitoring program at the initial office visit which results in a
prescription for an opiate based pain medication, and at least at every three
months intervals and at critical turning points in patient care.
H. 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 Osteopathic Medicine Act or
board rules.
