SPPM Note: The use of oral opioids in the treatment of  chronic benign pain has been a difficult and  controversial issue for  physicians who treat pain.   Dr. Scott's paper does an excellent job in covering how to safely prescribe oral opioids for these patients.

Using Oral Opioids for Noncancer Pain: How to Relieve Pain and Protect Your License.

On a daily basis, pain practitioners make patient care decisions that affect the lives of our patients. The choice of prescribing oral opioid agents for noncancer pain is one that affects not only your patient, but potentially your own livelihood as well.

Indeed, opioid analgesics are considered the cornerstone of treatment for pain associated with trauma, surgery, medical procedures, and cancer. Thus, there is little controversy regarding opioid prescriptions for these conditions. However, it is important to recognize that inappropriate prescribing of controlled substances, including the opioids, can lead to drug abuse and diversion. Inappropriate prescribing can also lead to ineffective management of pain, unnecessary suffering of patients, and increased health care costs.

Each of the following items listed below are essential items that a medical board will evaluate in determining whether a physician is prescribing opioids within standards of medical care.

1. Documentation of a History and Physical Examination

While this sounds so basic, it is often one of the most neglected. Your report should include an assessment of the pain, physical and psychological function, substance abuse history, and assessment of underlying or coexisting diseases or conditions. It should also include the presence of a recognized medical indication for the use of a controlled substance.

Documentation of the patient's pain level can be made by detailing the chronology and symptomatology of the presenting complaint. The data should include information about the onset, quality, intensity, distribution, duration, course, and affective components of the pain. Also include details about exacerbating and relieving factors. Additional symptoms (e.g., motor, sensory, and autonomic changes) should be noted. Information regarding previous diagnostic tests, results of previous therapies, and current therapies should be reviewed. This can be accomplished by having a prescreening questionnaire filled out before the appointment, as well as a template for questioning during the actual exam. Having the patient diagram the intensity and location of the pain on a pain homunculus at the initial visit can be very helpful.

The physical examination should include an appropriate, directed neurological and musculoskeletal evaluation, with attention to other systems as indicated. Not only the cause(s) of the pain, but also the effects of the pain, such as physical deconditioning, should be evaluated and recorded.

The psychosocial evaluation should include substance abuse history. Information about the presence of psychological symptoms (e.g., anxiety, depression, or anger), psychiatric disorders, personality traits or states, and coping mechanisms should be listed. Evidence of family, vocational, or legal issues, and involvement of rehabilitation agencies should be noted. The expectations of the patient, significant others, employer, attorney, and other agencies (e.g., Workers' compensation, Social Security Administration) also should be determined.

2. List your impression, differential diagnosis, and plan

Medical boards want to know if the opioid treatment fits the diagnosis. Be as specific as you can in listing your diagnosis, but don't be afraid to list a proper differential diagnosis.

The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. You are expected to tailor drug therapy to the individual medical needs of each patient. Document that these treatment and outcome goals were discussed with the patient.

3. Document informed consent for opioid use

You should discuss the specific risks, benefits, and alternatives for the use of opioids with your patient or their guardian. Discuss the appropriate way to document this discussion with a risk management specialist, such as your malpractice carrier.

Many physicians use an informed consent form, that in addition to detailing the risks, also has the patient agree to other stipulations, such as:

That only you will prescribe controlled substances for their painful conditions.

That they agree to use only one pharmacy.

That the patient must keep their current address on file with your office.

That no emergency refills for "lost " prescriptions will be given.

That random urine screening for substance use may be ordered.

4. See the patient regularly for follow-up

You should periodically review the course of opioid treatment of the patient and any new information about the etiology of the pain. Typically, no more than a thirty-day supply on opioids is written, and it is therefore reasonable to see the patient every month. Have the patient keep a pain diary, and record reports of side effects associated with pain management. Perform and document a focused physical exam. Include assessment of the patient's mental status when appropriate.

A medical board will want to see documentation that continuation or modification of opioid therapy was based on your evaluation of the patient's progress toward treatment objectives. If the patient has not improved after starting opioids, you should assess the appropriateness of continued opioid treatment and/or a trial of other modalities. Address the reason for any early medication refills-are you undertreating, is the patient tolerant, is the pain changing, or are there signs of addictive behavior.

Refer your patient to the appropriate specialist to help meet the diagnostic and treatment goals outlined in your treatment objectives. Be quick to refer patients to addiction medicine specialists if you have information to suspect they are at risk for misusing the opioids. Also be wary of those whose living arrangements pose a risk for medication misuse or diversion.

Some states, such as California, require that a patient be seen by at least two physicians if opioids are to be used. Documenting a curbside consult with a group partner can be a win/win scenario, as the partner has no additional liability, and you get the benefit of documenting a second opinion.

Document everything discussed. Keep copies of your phone conversations, and of each prescription you write.

Obtain copies of records from past treating physicians.

Obtain copies of appropriate studies and lab values.

Obtain reports from concurrent treating physicians.

Send copies of your reports to all of the patient's current treating physicians.

It goes without saying that you should follow the DEA and state rules when writing prescriptions. If you intend to dispense opioid medications from your office, be especially vigilant. The financial benefit may not be worth the risk if all documentation is not in order.

Use long-acting opioids for chronic pain. Short-acting "breakthrough" opioids should be needed no more than three times a day, if at all.

Use appropriate adjuvant analgesics such as antidepressants, membrane-stabilizing agents, and NSAIDs to limit opioid need.

Use blocks, TENS, physical therapy, psychological counseling, and biofeedback as appropriate to the diagnosis.

Some practitioners will attempt to decrease the opioid dose by 25% on occasion to see if the patient can maintain activities at that level.