The OMB urges the skillful use of effective pain control for all patients. It is important for providers to be well-informed on relevant pain management techniques and hone their skills for the optimal treatment of their patients, taking into account the etiology of the pain. Types of pain include, but are not limited to, acute post-operative or traumatic pain, chronic non-cancer pain, chronic pain caused by malignancies and pain associated with terminal illness. Providers are encouraged to treat pain within the scope of their practice and refer patients to the appropriate specialists when indicated.
Effective treatment of acute pain promotes recovery and return to normal function. The potential for addiction is low when short courses of opioids are used to treat acute pain and discontinued as the patient recovers. Inadequately managed acute pain may result in chronic pain. Patients who are not recovering as expected must be carefully assessed. Skillful pain management techniques including oral, parenteral and, when available, regional pain management techniques, can achieve maximum patient comfort and may reduce the need for opioids.
Patients with chronic pain require complex care and treatment decisions for multi-faceted problems. Providers have a responsibility to diagnose and manage chronic pain while maximizing the benefits and minimizing the potential adverse effects of treatment. Opioids are not always required or effective for the treatment of chronic pain, and they should be discontinued if the patient’s pain control or function does not improve with their use.
Pain management treatment must be evidence-based and individualized to the patient. Oregon statute protects providers from disciplinary action by the Board when prescribing or administering controlled substances as part of a treatment plan for pain with the goal of controlling the patient’s pain for the duration of the pain. However, prescribing controlled substances without a legitimate medical purpose is prohibited.
Patient safety should be a key factor in determining a treatment plan for pain management. When the provider prescribes opioids as part of the treatment plan, the provider must consider drug safety, efficacy and treatment goals for the patient. Safe opioid prescribing requires knowledge of the pharmacology of various opioid classes, and of potential drug interactions. Opioids are most likely to be successful in reducing pain and restoring function when they are combined with other pain management approaches such as physical therapy and psychological techniques.
When prescribing opioids for chronic pain, Oregon law requires practitioners to provide careful assessment and documentation of the medical condition causing pain as well as co-morbid medical and mental health conditions. Goals for treatment should be established with the patient before prescribing opioids. The provider’s assessment, diagnosis and discussion must be documented in the patient record. The diagnosis, drugs used, goals, alternatives, and side effects must be included in a signed document demonstrating consent and understanding of the treatment plan and its risks. A sample document may be found at www.oregon.gov/OMB/pdfforms/materialrisknotice.pdf. In additon to the signed informed consent document, a written patient-provider agreement is recommended for patients requiring opiods for chronic pain. In all cases of pain management, practitioners should maintain records to track prescriptions and coordinate care with other treating practitioners.
The OMB recommends enrollment and participation in the Oregon Prescription Drug Monitoring Program (PDMP), a division of the Oregon Health Authority, to help guide treatment plans. The PDMP is a database that allows prescribers of controlled substances to access a patient’s name, the controlled substance prescribed, the dosage, and the name and contact information of the prescriber.
The OMB believes that physicians should make every effort to relieve the pain and suffering of their terminally ill patients. Patients nearing the end of their lives should receive sufficient opioid dosages to produce comfort. The physician should acknowledge that the natural dying process usually involves declining blood pressures, decreasing respirations and altered levels of consciousness. Opioids should not be withheld on the basis of physiologic parameters when patients continue to experience pain.
Some physicians express concerns that the use of opioids in these patients may hasten death through pneumonia or respiratory depression. For these reasons, at times physicians may have limited the use of opioids in dying patients out of fear that they may be investigated for inappropriate prescribing or allegations of euthanasia.
The OMB is concerned that such fear on the part of physicians may result in inadequate pain control and unnecessary suffering in terminally ill patients. The OMB encourages physicians to employ skillful and compassionate pain control for patients near the end of life and believes that relief from suffering remains the physician’s primary obligation to these patients.
- Adopted April 16, 1999
- Amended July 9, 2004
- Amended April 8, 2011
- Amended January 10, 2013