Arizona Board of Osteopathic Examiners
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ARIZONA BOARD OF OSTEOPATHIC EXAMINERS |
| INTRODUCTION: |
| The Arizona State Board of Osteopathic Examiners in Medicine and Surgery recognizes that Principles of quality medical practice dictate that the people of the State Of Arizona have access to appropriate and effective pain relief. The appropriate application of up-to-date knowledge and treatment modalities can serve to improve the quality of life for those patients who suffer from pain as well as reduce the morbidity and costs associated with untreated or inappropriately treated pain. |
| The Board encourages physicians to view effective pain management as part of quality medical practice for all patients with pain, acute or chronic, and it is especially important for those patients who experience pain as a result of terminal illness. All physicians should become knowledgeable about effective methods of pain relief as well as statutory requirements for Prescribing controlled substances. |
| Physicians should not fear disciplinary action from the Board or other state regulatory or Enforcement agencies for prescribing, dispensing, or administering controlled substances, Including opioid analgesics in the usual course of professional practice. The Board will consider Prescribing, ordering, administering, or dispensing controlled substances for pain to be for a Legitimate medical purpose if based on accepted scientific knowledge of the treatment of pain or If based on sound clinical grounds. All such prescribing must be based on clear documentation of unrelieved pain and in compliance with applicable state and/or federal law. |
| The Board will judge the validity of prescribing based on the physician’s treatment of the patient and on the available documentation. 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. The following guidelines are not intended to define the complete or best practice, but rather to communicate what the Board considers to be with in the boundaries of professional practice. |
| PURPOSE: |
| The purpose of these guidelines regarding the prescribing of controlled substances for the treatment of pain is to establish criteria to be considered by the Board in consideration of allegations of unprofessional conduct. The Board’s objective is for these Guidelines to recognize but to not interfere with the medical use of controlled substances for pain relief, while continuing to address the issue of prescribing that may contribute to drug abuse and diversion. These guidelines are general recommendations. Each case involving the prescription of controlled substances for pain management will be judged on all factors related to that patient. These guidelines were created to provide the Board and the Licensed osteopathic medical community a basis in which to provide quality medical care to the citizens of the State of Arizona. |
| GUIDELINES: |
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The Board has adopted the following guidelines when evaluating the use of controlled substances for pain control. 1. Pain Assessment: A. Medical History |
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A comprehensive history should include a review of pertinent lab and diagnostic test that have already been performed.
The initial evaluation of the pain complaint should include characteristics such as intensity, character, frequency, location,
duration, and precipitating and relieving factors, underlying or co-existing diseases or conditions. It should also include a thorough analgesic medication history, including current and previous prescription medications, over-the-counter medications, natural remedies and illicit drug use. It should also include an evaluation of physical function. This should focus on pain associated disabilities, including activities of daily living. |
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B. Psycho-social Assessment Evaluation should also include assessment of the patient’s mood with particular concern regarding anxiety or depression. The physician should assess whether the patient understands the diagnosis. One should also evaluate the patient’s expectations about pain relief and pain management methods. The patient may have reservations about the use of controlled substances.The physician should question the patient about their coping mechanisms for pain. This also includes assessment of the patient’s social networks, including any dysfunctional family relationships. |
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C. Physical Exam Physical exams should focus on the neuromuscular system, search for neurological impairment, weakness, hyperalgesia, allodynia, or parathesias. One should assess the musculoskeletal system with attention to the palpation of tenderness, Inflammation, deformity, trigger points, and physical function. |
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2. Treatment Plan:
A. Pain Relief A treatment plan should be developed for the management of chronic pain. Consideration should also be given to different treatment modalities, such as a formal pain rehabilitation program, the use of behavioral strategies, the use of non-invasive techniques, or the use of medications. The assessment of pain should occur, not only during the initial exam, but also after each new reportive pain, at the appropriate intervals, after each pharmacological intervention and at regular intervals during treatment. B. Improved Physical Functioning A quantitative assessment of pain should be recorded by the use of a standard pain scale and pain log. Patients with chronic pain and their caregivers should be instructed on the use of the pain log with regular intervals for pain intensity, medication use, response to treatment, and associated activities. A qualitative assessment of the treatment plan should include the evaluation of the patient’s ability to function productively in society. |
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3. Informed Consent: Advise the chronic pain patient or guardian of the risks and the benefits of the use of controlled substances as well as alternatives to that treatment. They should be counseled on the importance of regular visits, the impact of recreational drug use, avoiding the use of multiple pharmacies and physicians for prescriptions and taking medication as directed. A contract should be signed outlining the patient’s responsibilities, if appropriate. |
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4. On-going Assessment: Patients with chronic pain should be re-assessed regularly. The frequency of follow-up should be a function of the pain syndrome and potential for adverse effects of treatment. The physician may consider discontinuing the use or modifying medications if the patient is experiencing side effects that are not tolerable, if clinical improvement does not occur, or if the physician notes non –compliance. The clinician should watch for signs of narcotic use for inappropriate indications like anxiety or depression. Requests for early refills should prompt an evaluation of tolerance to the medication, progression of disease or inappropriate behavioral factors. |
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5. Consultation and Referral – Optimal Treatment requires a team approach Psychiatrists, psychologists, pain management specialists are available and should be part of the treatment team specifically in the more complex patient. |
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6. Documentation: Documentation is essential for supporting the evaluation. The clinician should include the reason for prescribing controlled substances. The clinician should also document the overall pain management treatment plan, any consultations received, and a periodic review of the status of the patient. The clinician should also include medi8cations and treatments including the date, type, dosage and quantity prescribed. |
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7. Medical Record – in accordance with A.R.S.§ 32-1800 (2) and A.R.S. § 12-2291(4) Physician should develop and maintain complete records to include: br> Medical history and physical examination Diagnostic, therapeutic, and lab results; Evaluations and consultations; Treatment objectives; Discussion of risks and benefits; Treatment; Medication (include date, type, dose and quantity) Instructions and agreements; and Periodic reviews Records should be accessible and ready for review. |
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COMPLIANCE WITH LAWS AND REGULATIONS: Treating physician must possess a valid and current license to practice medicine in the State of Arizona. A. Possess a Valid and current controlled substances drug enforcement registration for the schedules being prescribed. B. If drugs are dispensed from the office, the physician must comply with the Arizona State Statutes. C. If controlled substances are provided for detoxification, the physician should comply with the Arizona State Statutes. |
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Definitions For the purpose of these guidelines, the following terms are defined as follows: |
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Acute Pain Acute pain is the normal, predicted physiological response to an adverse chemical, thermal, mechanical or neurological stimulus and is associated with surgery, trauma and acute illness. It is generally time-limited and is responsive to opioid therapy, among other therapies. |
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Addiction Addiction is a neurobehavioral syndrome with genetic and environmental influences that result in psychological dependence on the use of substances for the psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to by terms such as “drug dependence” and “psychological dependence.” Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction. |
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Analgesic Tolerance Analgesic tolerance is the need to increase the dose of opioid to achieve the same level of analgesia. Analgesic tolerance may or may not be evident during opioid treatment and does equate with addiction. |
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Chronic Pain A pain state which is persistent and in which the cause of the pain cannot be removed or otherwise treated. Chronic pain may be associated with long term incurable or intractable medical condition or disease. |
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Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. |
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Physical Dependence Physical dependence on a controlled substance is a physiologic state of neuro-adaptation which is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or if an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself does not equate with addiction. |
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Pseudo-addiction Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction. |
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Substance Abuse Substance abuse is the use of any substance(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed. |
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Tolerance Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect, or a reduced effect is observed with a constant dose. |