I've had a very hard time getting this to the net, I'll tell you and I will tell you:
This is an agreement that was signed in May 1998, but I guess Gov't, Doctors, and Politicians like to play DRUG
WAR too much! So, here it is........abide by it, you wicked doctors out there!
(These are the Guidelines the DEA Agreed To in Dallas on March 17, 1998!)
THE FEDERATION OF STATE MEDICAL BOARDS
OF THE UNITED STATES, INC.
MODEL GUIDELINES FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN (Adopted May 2, 1998)
Section I: Preamble
The (name of board) recognizes that principles of quality medical practice dictate that the people of the State of (name
of state)
have access to appropriate and effective pain relief. The appropriate application of up-to-date knowledge and
treatment modalities can serve to
improve the quality of life for those patients who suffer from pain as well as to reduce
the morbidity and costs associated with untreated or
inappropriately treated pain. The Board encourages physicians to view
effective pain management as a part of quality medical practice for all
patients with pain, acute or chronic, and it is
especially important for patients who experience pain as a result of terminal illness. All physicians
should become knowledgeable
about effective methods of pain treatment as well as statutory requirements for prescribing controlled substances.
Inadequate pain control may result from physicians' lack of knowledge about pain management or an inadequate understanding
of addiction.
Fears of investigation or sanction by federal, state, and local regulatory agencies may also result in inappropriate
or inadequate treatment of
chronic pain patients. Accordingly, these guidelines have been developed to clarify the Board's
position on pain control, specifically as related
to the use of controlled substances, to alleviate physician uncertainty
and to encourage better pain management.
The Board recognizes that controlled substances, including opioid analgesics, may be essential in the treatment of acute
pain due to trauma or
surgery and chronic pain, whether due to cancer or non-cancer origins. Physicians are referred to
the U.S. Agency for Health Care and Research
Clinical Practice Guidelines for a sound approach to the management of acute1
and cancer-related pain.2
The medical management of pain should be based upon current knowledge and research and includes the use of both pharmacologic
and
non-pharmacologic modalities. Pain should be assessed and treated promptly and the quantity and frequency of doses
should be adjusted
according to the intensity and duration of the pain. Physicians should recognize that tolerance and
physical dependence are normal
consequences of sustained use of opioid analgesics and are not synonymous with addiction.
The (state medical board) is obligated under the laws of the State of (name of state) to protect the public health and
safety. The Board
recognizes that inappropriate prescribing of controlled substances, including opioid analgesics, may
lead to drug diversion and abuse by
individuals who seek them for other than legitimate medical use. Physicians should
be diligent in preventing the diversion of drugs for illegitimate
purposes.
Physicians should not fear disciplinary action from the Board or other state regulatory or enforcement agency for prescribing,
dispensing, or
administering controlled substances, including opioid analgesics, for a legitimate medical purpose and
in the usual course of professional
practice. The Board will consider prescribing, ordering, administering, or dispensing
controlled substances for pain to be for a legitimate
medical purpose if based on accepted scientific knowledge of the
treatment of pain or if based on sound clinical grounds. All such prescribing
must be based on clear documentation of
unrelieved pain and in compliance with applicable state or federal law.
Each case of prescribing for pain will be evaluated on an individual basis. The board will not take disciplinary action
against a physician for
failing to adhere strictly to the provisions of these guidelines, if good cause is shown for such
deviation. The physician's conduct will be
evaluated to a great extent by the treatment outcome, taking into account whether
the drug used is medically and/or pharmacologically
recognized to be appropriate for the diagnosis, the patient's individual
needs including any improvement in functioning, and recognizing that
some types of pain cannot be completely relieved.
The Board will judge the validity of prescribing based on the physician's treatment of the patient and on available documentation,
rather than on
the quantity and chronicity of prescribing. The goal is to control the patient's pain for its duration
while effectively addressing other aspects of
the patient's functioning, including physical, psychological, social and
work-related factors. The following guidelines are not intended to define
complete or best practice, but rather to communicate
what the Board considers to be within the boundaries of professional practice.
Section II: Guidelines
The Board has adopted the following guidelines when evaluating the use of controlled substances for pain control:
1. Evaluation of the Patient
A complete medical history and physical examination must be conducted 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 should also document the presence of one
or more recognized medical indications for the use of a controlled
substance.
2. 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.
3. 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 incompetent. The patient should receive
prescriptions from one physician and one
pharmacy where possible. If the patient is determined to be at high risk for
medication abuse or have a history of substance abuse, the physician
may employ the use of a written agreement between
physician and patient outlining patient responsibilities including (1) urine/serum medication
levels screening when
requested (2) number and frequency of all prescription refills and (3) reasons for which drug therapy may be discontinued
(i.e. violation of agreement).
4. Periodic Review
At reasonable intervals based upon the individual circumstance of the patient, the physician should review the course
of treatment and any new
information about the etiology of the pain. Continuation or modification of therapy should depend
on the physician's evaluation of progress toward
stated treatment objectives such as improvement in patient's pain intensity
and improved physical and/or psychosocial function, such as 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 physician should re-evaluate the appropriateness of continued treatment. The physician should monitor patient
compliance
in medication usage and related treatment plans.
5. 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 pain patients who are at risk for misusing their
medications and those whose living arrangement pose
a risk for medication misuse 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.
6. Medical Records
The physician should keep accurate and complete records to include (1) the medical history and physical examination (2)
diagnostic,
therapeutic and laboratory results (3) evaluations and consultations (4) treatment objectives (5) discussion
of risks and benefits (6) treatments
(7) medications [including date, type, dosage, and quantity prescribed] (8)
instructions and agreements and (9) periodic reviews. Records
should remain current and be maintained in an accessible
manner and readily available for review.
7. 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 medical board) 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 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: Addiction is a neurobehavioral 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 by terms
such as "drug dependence" and "psychological dependence." Physical dependence and tolerance
are normal physiological consequences of
extended opioid therapy for pain and should not be considered addiction.
Analgesic Tolerance: 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: A pain state which is persistent and in which the cause of the pain cannot be removed or otherwise treated.
Chronic pain may be
associated with a long-term incurable or intractable medical condition or disease.
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 on a controlled substance is a physiologic state of neuroadaptation 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.
Pseudoaddiction: Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that
can be mistaken for
addiction.
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 the same
effect or a reduced effect is observed with a constant dose.
"...some types of pain cannot be completely relieved." Dallas Agreement signed May 2 1998.
Here's where I'm at: Tolerance: 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.
I also have some of this going on:
Pseudoaddiction: Pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that
can be mistaken for
addiction. [...and HAS BEEN, still IS BEEN] [ALMOST 6 MONTHS OF HELL
ALREADY
I know THREE THINGS for sure!
I HURT!!!
I'M ANGRY!!!
THE PAIN IS NOT BEING SOLVED!!!
EVER HAVE YOUR KNEE POPPED OUT BACKWARDS?
I HAVE! I ALSO HAD/HAVE FOOTDROP!!!