Section II: Guidelines
The Board has adopted the following criteria when evaluating the physician’s treatment of pain, including the use of controlled substances:
Evaluation of the Patient - A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance.
Treatment Plan - The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment.
Informed Consent and Agreement for Treatment - The physician should discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and
patient outlining patient responsibilities, including
urine/serum medication levels screening when requested;
number and frequency of all prescription refills; and
reasons for which drug therapy may be discontinued (e.g., violation of agreement); and
the North Carolina Controlled Substance Reporting Service can be accessed and its results used to make treatment decisions.
Periodic Review - The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician’s evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient’s decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient’s response to treatment. If the patient’s progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. Reviewing the North Carolina Controlled Substance Reporting Service should be considered if inappropriate medication usage is suspected and intermittently on all patients.
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 patients with pain who are at risk for medication misuse, abuse 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.
Medical Records - The physician should keep accurate and complete records to include
the medical history and physical examination,
diagnostic, therapeutic and laboratory results,
evaluations and consultations,
discussion of risks and benefits,
medications (including date, type, dosage and quantity prescribed),
instructions and agreements and
periodic reviews including potential review of the North Carolina Controlled Substance Reporting Service.
Records should remain current and be maintained in an accessible manner and readily available for review.
Compliance With Controlled Substances Laws and Regulations- To prescribe, dispense or administer controlled substances, the physician must be licensed in the state and comply with applicable federal and state regulations. Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration and any relevant documents issued by the state of North Carolina for specific rules governing controlled substances as well as applicable state regulations.
Section III: Definitions
For the purposes of these guidelines, the following terms are defined as follows:
Acute Pain- Acute pain is the normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus and typically is associated with invasive procedures, trauma and disease. It is generally time-limited.
Addiction- Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use, and continued use despite harm. Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and are not the same as addiction.
Chronic Pain- Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.
Pain- An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Physical Dependence- Physical dependence is a state of adaptation that is manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence, by itself, does not equate with addiction.
Pseudoaddiction- The iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction. The relief seeking behaviors resolve upon institution of effective analgesic therapy.
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.
Tolerance- Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction.Physicians need not label patients and call patients names .... at least not straight away to our face. Patients would be well advised to use the resources available for them and do not presume that every pain patient is faking or malingering.
Case in point: Sick, pre-surgical patients (such as myself) have elderly widowed moms that we care for and we must schedule even medical trips (in my case from NC to Cleveland) to coordinate with other family members. That means I suffer with pain and disability longer before I can have surgery.
I don't seek accolades and I certainly don't expect criticism.
I am not a martyr. But I am also certainly not a malingerer.
I just ask that that physicians please refrain from treating patients in situations like mine as drug seekers without any factual basis. I trust physicians when I make the appointment and write a check for the co-pay.
Abandoning me and mistreating me hurts my feelings and makes it more difficult for me to trust the next doctor.