MONTANA

Statement of the prescribing and filling of controlled substances in the treatment of chronic pain.

The Montana Board of Medical Examiners, Montana Board of Nursing and Montana Board of Pharmacy recognize that pain has historically been under treated due to an exaggerated fear of patient addiction and diversion of pain medication with corresponding fear of legal consequences, and a lack of current knowledge concerning pain management. Untreated chronic pain can lead to clinical exacerbations, increased suffering and eventual disability. Patient requests for more pain medication can often be interpreted as drug seeking behavior, when inadequately treated pain is actually the cause.

Improper prescribing and dispensing of opioids will continue to be a concern of the Montana Board of Medical Examiners, Board of Nursing, and Board of Pharmacy. However, appropriate prescribing of opioid analgesics should be encouraged by all of those involved in patient care. Both the physician or other healthcare provider and the pharmacist share responsibility for appropriate prescribing and dispensing of opioid pain medication. If a prescription for controlled substances is not written for a legitimate medical purpose, the pharmacist shares a corresponding responsibility and liability in filling that prescription while having reason to know that it was not issued for a legitimate medical purpose. If a pharmacist has suspicion of the inappropriateness of a pain medication, he or she should contact the practitioner concerning this issue. The Board of Medical Examiners has established a policy for appropriate treatment of chronic pain, which is outlined below. With the use of these guidelines and appropriate communication between practitioners and pharmacists, inappropriate use of opioid pain medications will be minimized.

Treatment of chronic pain is multifactorial and treatment with modalities other than opioids should usually be utilized before opioids are prescribed. The use of alternative types of treatment should be considered periodically to reassess the necessity of continued opioid use. The following guidelines have been provided in the form of a policy letter from the Board of Medical Examiners to providers in the state.

The Board of Medical Examiners recommendations:

• Thorough history and physical examination. Included in the history is assessment of the etiology of pain, physical and psychological function of the patient, substance abuse history, other treatments that have been attempted to control the patient’s level of pain, identification of underlying or co-existing diseases or conditions and, as much as possible, statements by all treating physicians that the patient’s pain is intractable and not controlled by other than the use of opioid analgesics.
  
• Treatment plan. A thoroughly documented, written treatment plan should be established and should include how treatment success will be evaluated, such as pain relief and improved physical or psychological functioning. Several treatment modalities should be utilized in most cases and should be done concurrently with the use of opiates. Periodic review by the physician should be accomplished to determine that there are no other appropriate treatment methods that would then be of additional benefit to the patient.
  
• Informed consent. The physician should discuss the risks and benefits of the use of controlled substances with the patient and/or guardian. This should be accomplished on an ongoing basis, not just at the initiation of treatment.
  
• Appropriate referral. If treatment objectives are not being realized or if patients appear to be at risk for misuse of medications, referral should be made to appropriate specialists including addiction medicine specialists and chronic pain specialists.
  
• Documentation. All the above recommendations and guidelines should be recorded accurately and completely in the patient’s medical record.

  A pharmacist evaluating a controlled substance prescription should consider the following points:

  • Are you able to verify the identity of the prescriber and the patient?
    
  • What is the physical condition and demeanor of the patient with respect to the drug being prescribed? Is the prescribed drug therapeutically appropriate to the patient’s diagnosis?
    
  • Does the patient live within the general area of the pharmacy? If not, is the distance great enough to make it unlikely the patient would travel so far to fill a legitimate prescription?
    
  • Does the drug prescribed have a pattern of abuse, and does the patient have any known history of drug abuse or misuse that might contraindicate the use of this drug?
    
  • Is the prescription consistent with the prescribing patterns of the practitioner, including the type and amount of drug prescribed? Does the practitioner write for a greater than usual percentage of controlled substances? Are you aware of any prior disciplinary or criminal action involving the practitioner?
    
  • Are the drugs prescribed consistent with the practitioner’s specialty and scope of practice? Does the prescription contain an unusual combination of drugs, or drugs that antagonize one another?
    
  • Does the quantity of drug prescribed and refills authorized differ appreciably from recognized and accepted prescribing practices?

  Studies have shown that the abuse potential of opioids is generally low in healthy volunteers who do not abuse drugs. Practitioners are encouraged to reverse the trend of under treatment of pain, yet remain aware of the dangers of diversion and nonmedical use of controlled substances. It is imperative that pharmacists and prescribers continue to strive for open and clear lines of communication regarding their patient’s use and possible misuse of medications. The Boards of Medical Examiners, Nursing and Pharmacy seek to ensure that no Montana resident will needlessly suffer due to under treated pain, and encourage both prescribers and pharmacists to do their part by responsibly prescribing and dispensing opioids.