Pain Management

The Oregon Medical Board urges effective, skillful treatment of pain for all patients.

Acute Pain
For acute pain, current standards recommend a multimodal approach, possibly including multiple classes of medications and appropriate application of local or regional nerve blocking agents. If opioids are prescribed, it is recommended to use the lowest effective dose of a single agent for a duration of less than 3 days. For most patients, this should be less than 50 Morphine Equivalent Dose (MED). In cases of more severe acute pain, limit the prescription to less than 7 days. If there is a compelling reason to re-prescribe , it should be well documented. Co-prescribing of benzodiazepines with opioids is to be avoided absent a documented compelling reason.

• See: Oregon Acute Opioid Prescribing Guidelines

Chronic Pain
The Board recognizes the complexity and difficulty in appropriately treating chronic pain. Addressing pain has been complicated in the not-too-distant past by well-meaning efforts to liberalize treatment of pain, including increased prescribing of opioids. Unfortunately, this has contributed to the opioid overdose crisis. Fortunately, there are now consensus statements from recognized authorities on the current standard of care. Specifically, from the United States Centers for Disease Control and Prevention and from the Oregon Pain Management Commission.

• See: Center for Disease Control (CDC) Guidelines for Prescribing Opioids for Chronic Pain, Oregon Pain Management Commission, and Oregon Pain Guidance Chronic Opioid Prescribing Guidelines

When the Board receives a complaint about potential overprescribing of controlled substances, it looks not only to these guidelines, but to the opinions of local expert consultants. While it is beyond the scope of a Statement of Philosophy to advise exact parameters, practitioners would do well to note the following guidelines.

Diagnoses and the treatment plan should be clearly documented. The effectiveness of the treatment, particularly as it relates to the patient's functional status, should be regularly assessed and documented. Assessments should be ongoing, real-time, not boilerplate repetitions. These are complex patients who deserve attention.

Prescribers should not go it alone. Consultants in specialty areas including pain management and mental and behavioral health are strongly advised. Recommendations from consultants should be reviewed, documented and acted upon.

The amount of prescribed opioid should be limited. When newly treating chronic pain, there is rarely a reason to exceed 50 morphine equivalent dose (MED) of opioid, and almost never a reason to exceed 90 MED.

Polypharmacy with opioids co-prescribed with benzodiazepines, muscle relaxants, gabapentinoids, and hypnotics should be avoided. If required, the medical decision making should be documented and, due to the attendant risks, the need regularly reassessed.

The Board recognizes not all patients can be tapered to MED less than 90, but such patients deserve thorough assessment and documentation and periodic referral to appropriate specialists for co-management. As much as possible, patients should be transitioned to Medication-Assisted Treatment (MAT) – buprenorphine-based treatment. Agonist/antagonist opioid medications have a far safer profile and are often found to be equivalent if not superior to pure agonists in treating  pain.

A Procedure, Alternatives, Risks, and Questions (PARQ) conference – a Material Risk Notification (MRN) – is essential. It needs to be documented. A signed agreement with the patient – a “pain contract" – is likewise essential. These should be readdressed and updated periodically, at least annually.

• Examples: Material Risk Notification and Patient Treatment Agreements

Prescribers should regularly check the Oregon PDMP (Physician Drug Monitoring Program) for possible multiple prescribers. It is strongly encouraged that licensees who are prescribing chronic opioids have mechanisms for office staff to perform and document the results of these checks at every refill.

Periodic urine drug screens are essential. Board consultants generally recommend a urine drug screen (UDS) be done annually, at minimum. Any patient on chronic long-term opioids needs to be assessed for compliance, regardless of the degree of trust the prescriber may have. Even patients with a long history of compliance may find their prescriptions being diverted by others. Prescribers need to appropriately address and attempt to remediate any discrepancies discovered when checking the PDMP or a urine drug screen.

Patients on chronic methadone can develop dangerous prolongation of the QT interval in their cardiac conduction. An annual electrocardiogram (EKG) has been considered standard.

Terminal Illness
The Board 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 Board is concerned that such fear on the part of physicians may result in inadequate pain control and unnecessary suffering in terminally ill patients. The Board 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

Evolving Standards
Finally, the Board knows the expectations of care can and do shift over time as the understanding of these complex situations shifts. While the Board makes every effort to update statements such as this, the final adjudication of an investigation of potential overprescribing will rest upon the recognized standards at the time.
 

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Under ORS 677.190(24) the Oregon Medical Board may may suspend or revoke a license to practice medicine for prescribing controlled substances without a legitimate medical purpose, or prescribing controlled substances without following accepted procedures for examination of patients, or prescribing controlled substances without following accepted procedures for record keeping.