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Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain – July 2013

The goal of this Model Policy is to provide state medical boards with an updated guideline for assessing physicians’ management of pain, so as to determine whether opioid analgesics are used in a manner that is both medically appropriate and in compliance with applicable state and federal laws and regulations.

Section II: Guidelines

The Board has adopted the following criteria for use in evaluating a physician’s management of a patient with pain, including the physician’s prescribing of opioid analgesics:

Understanding Pain: The diagnosis and treatment of pain is integral to the practice of medicine.(…)

Patient Evaluation and Risk Stratification: The medical record should document the presence of one or more recognized medical indications for prescribing an opioid analgesic and reflect an appropriately detailed patient evaluation.(…)

Development of a Treatment Plan and Goal: The treatment plan and goals should be established as early as possible in the treatment process and revisited regularly, so as to provide clear-cut, individualized objectives to guide the choice of therapies. (…)

Informed Consent and Treatment Agreement: The decision to initiate opioid therapy should be a shared decision between the physician and the patient. (…)

Initiating an Opioid Trial: Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, non-malignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 days) and with specified evaluation points.(…)

Ongoing Monitoring and Adapting the Treatment Plan: The physician should regularly review the patient’s progress, including any new information about the etiology of the pain or the patient’s overall health and level of function. (…)

Periodic Drug Testing: Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs. (…)

Consultation and Referral: The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed. (…)

Discontinuing Opioid Therapy: Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate. (…)

Medical Records: Every physician who treats patients for chronic pain must maintain accurate and complete medical records.

Compliance with Controlled Substance Laws and Regulations: To prescribe, dispense or administer controlled substances, the physician must be registered with the DEA, licensed by the state in which he or she practices, and comply with applicable federal and state regulations

Section III: definitions

For the purposes of this Model Policy, the following terms are defined as shown.

Addiction: A longstanding definition of addiction is that it is “a primary, chronic, neurobiologic disease, whose development and manifestations are influenced by genetic, psychosocial, and environmental factors”. Addiction often is said to be characterized by behaviors that include impaired control over drug use, craving, compulsive use, and continued use despite harm. A newer definition, adopted by the American Society of Addiction Medicine in 2011, describes addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death”.