Joint Policy Statement of the Boards of Healing
Arts,
Nursing and Pharmacy on the Use of Controlled Substances for the
Treatment of Pain
Section I: Preamble
The Kansas Legislature created the Board of Healing Arts, the Board
of Nursing, and the Board of Pharmacy to protect the public health,
safety and welfare. Protection of the public necessitates reasonable
regulation of health care providers who order, administer, or dispense
drugs. The boards adopt this statement to help assure health care
providers and patients and their families that it is the policy
of this state to encourage competent comprehensive care for the
treatment of pain. Guidelines by individual boards are appropriate
to address issues related to particular professions.
The appropriate application of current knowledge and treatment modalities
improves the quality of life for those patients who suffer from
pain, and reduces the morbidity and costs associated with pain that
is inappropriately treated. All health care providers who treat
patients in pain, whether acute or chronic, and whether as a result
of terminal illness or non-life-threatening injury or disease, should
become knowledgeable about effective methods of pain treatment.
The management of pain should include the use of both pharmacologic
and non-pharmacologic modalities.
Inappropriate treatment of pain is a serious problem in the United
States. Inappropriate treatment of pain includes nontreatment, undertreatment,
overtreatment, and ineffective treatment. All persons who are experiencing
pain should expect the appropriate assessment and management of
pain while retaining the right to refuse treatment. A person's report
of pain is the optimal standard upon which all pain management interventions
are based. The goal of pain management is to reduce the individual's
pain to the lowest level possible, while simultaneously increasing
the individual's level of functioning to the greatest extent possible.
The exact nature of these goals is determined jointly by the patient
and the health care provider.
Prescribing, administering or dispensing controlled substances,
including opioid analgesics, to treat pain is considered a legitimate
medical purpose if based upon sound clinical grounds. Health care
providers authorized by law to prescribe, administer or dispense
drugs, including controlled substances, should recognize that tolerance
and physical dependence are normal consequences of sustained use
of opioid analgesics and are not synonymous with addiction.
A board is under a duty to make an inquiry when it receives information
contending that a health care provider treated pain inappropriately.
Proper investigation is necessary in order to obtain relevant information.
A health care provider should not construe any request for information
as a presumption of misconduct. Prior to the filing of any allegations,
the results of the investigation will be evaluated by the health
care provider's peers who are familiar with this policy statement.
Health care providers who competently treat pain should not fear
disciplinary action from their licensing board.
The following guidelines are not intended to define complete or
best practice, but rather to communicate what the boards consider
to be within the boundaries of professional practice. This policy
statement is not intended to interfere with any healthcare provider's
professional duty to exercise that degree of learning and skill
ordinarily possessed by competent members of the healthcare provider's
profession.
Section II: Principles
The boards approve the following principles when evaluating the
use of controlled substances for pain control:
-
Assessment of the Patient
Pain should be assessed and reassessed as clinically indicated.
Interdisciplinary communications regarding a patient's report
of pain should include adoption of a standardized scale for
assessing pain.
-
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 drug therapy plan should
be adjusted to the individual medical needs of each patient.
The nurse's skill is best utilized when an order for drug administration
uses dosage and frequency parameters that allow the nurse to
adjust (titrate) medication dosage. 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. If, in a healthcare
provider's sound professional judgement, pain should not be
treated as requested by the patient, the healthcare provider
should inform the patient of the basis for the treatment decisions
and document the substance of this communication.
-
Informed Consent
The physician retains the ultimate responsibility for obtaining
informed consent to treatment from the patient. All health care
providers share the role of effectively communicating with the
patient so that the patient is apprised of the risks and benefits
of using controlled substances to treat pain.
-
Agreement for Treatment of High-Risk Patients
If the patient is determined to be at high risk for medication
abuse or to have a history of substance abuse, the health care
provider should consider requiring a written agreement by the
patient outlining patient responsibilities, including:
-
Submitting to screening of urine/serum medication levels
when requested;
-
Limiting prescription refills only to a specified number
and frequency;
-
Requesting or receiving prescription orders from only one
health care provider;
-
Using only one pharmacy for filling prescriptions; and
-
Acknowledging reasons for which the drug therapy may be
discontinued (i.e., violation of agreement).
-
Periodic Review
At reasonable intervals based on the individual circumstances
of the patient, the course of treatment and any new information
about the etiology of the pain should be evaluated. Communication
among health care providers is essential to review of the medical
plan of care. The health care providers involved with the management
of pain should evaluate progress toward meeting treatment objectives
in light of improvement in patient's pain intensity and improved
physical or psychosocial function, i.e., ability to work, need
of health care resources, activities of daily living and quality
of social life. If treatment goals are not being achieved despite
medication adjustments, the health care provider's should reevaluate
the appropriateness of continued treatment.
-
Consultation
The health care provider 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 pain patients who are at risk for misusing their
medications and those whose living arrangement poses a risk
for medication misuse or diversion. The management of pain in
patients with a history of substance abuse or with a co-morbid
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 medical record should document the nature and intensity
of the pain and contain pertinent information concerning the
patient's health history, including treatment for pain or other
underlying or coexisting conditions. The medical record also
should document the presence of one or more recognized medical
indications for the use of a controlled substance.
- Compliance With Controlled Substances Laws and Regulations
To prescribe, dispense or administer controlled substances within
this state, the health care provider must be licensed according
to the laws of this state and comply with applicable federal and
state laws.
Section III: Definitions
For the purposes of these guidelines, the following terms are defined
as follows:
Acute pain is the normal, predicted physiological response to
an adverse chemical, thermal or mechanical stimulus and is associated
with surgery, trauma and acute illness. It is generally time-limited
and is responsive to opioid therapy, among other therapies.
Addiction is a neuro-behavioral syndrome with genetic and environmental
influences that results in psychological dependence on the use of
substances for their psychic effects and is characterized by compulsive
use despite harm. Addiction may also be referred to as "psychological
dependence." Physical dependence and tolerance are normal physiological
consequences of extended opioid therapy for pain and should not
be considered addiction. Addiction must be distinguished from pseudoaddiciton,
which is a pattern of drug-seeking behavior of pain patients who
are receiving inadequate pain management that can be mistaken for
addiction.
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 not equate
with addiction.
Chronic pain is a pain state which is persistent beyond the usual
course of an acute disease or a reasonable time for an injury to
heal, or that is associated with a chronic pathologic process that
causes continuous pain or pain that recurs at intervals for months
or years.
Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms of
such damage.
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.
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 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.
APPROVALS
The foregoing Joint Policy Statement was approved, upon a motion
duly made, seconded and adopted by a majority of the Kansas Board
of Healing Arts, on the 1st day of June, 2002.
Lance E. Malmstrom, D.C.
President
The foregoing Joint Policy Statement was approved, upon a motion
duly made, seconded and adopted by a majority of the Kansas Board
of Nursing, on the 17th day of July, 2002.
Karen Gilpin, R.N.
President.
The foregoing Joint Policy Statement was approved, upon a motion
duly made, seconded and adopted by a majority of the Kansas Board
of Pharmacy, on the 10th day of June, 2002.
Max Heidrick, RPh
President
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