Protect Yourself! What Physicians Must Do When
Prescribing Opiods
Recent media attention problems related to OxyContin prescriptions brings to light the many issues relative on medication management that physicians face. With a desire and obligation to appropriately treat their patients, physicians must confront their concerns about patients’ addictive potential, about diversion of drugs to illegal markets, and about their own liability.
The importance of psychological and substance abuse evaluations
Stephen G. Gelfand, MD, FACP, FACR, suggests that the recent problems related to the misuse and abuse of oxycodone are in part due to physicians’ inattention to certain statements in the narcotic guidelines established by the Federation of State Medical Boards of the United States, Inc. (FSMB).1 In 1998 the FSMB adopted model guidelines for the medical use of controlled substances in pain management2 all or part of which have since been adopted or endorsed by many state medical boards.3 The FSMB guidelines were written to address the issues behind inadequate pain control and inconsistencies between state medical boards’ guidelines.
Gelfand, who practices at Carolina Rheumatology Associates in Myrtle Beach, SC, specifically points to the guidelines that include recommendations on the importance of psychological and substance abuse evaluations, referral for other treatments depending on the etiology of the pain and extent of psychosocial impairment, and referral to an expert for patients with comorbid psychiatric disorders.
Gelfand suggests that, because chronic pain and psychological distress are closely associated, opioid treatments have been expanded to patients with chronic pain of central affective origin. He notes that this group of patients is closely associated with a wide range of psychological distress, and these patients are especially at risk for the dangers of opioid therapy. He points out that this is particularly true in geographical areas where insufficient attention is given to psychosocial factors, which can both generate and amplify pain.
Gelfand stresses the importance of evaluating each patient in context, using good clinical judgment. He urges physicians to determine whether their patients’ chronic pain originates from peripheral or central mechanisms and stresses adherence to the narcotic guidelines for adequate psychosocial evaluation prior to prescribing opioids. He suggests diagnosis and care for chronic pain patients should be multimodal and include such disciplines as clinical psychology, psychiatry, stress management, health education, and physical or occupational therapy.
One solution does not fit all
While opioid analgesics have been used to treat pain for thousands of years, they are not appropriate for everyone. While following federal and state regulations and their state medical board’s narcotic guidelines, physicians must carefully select those patients who will receive controlled substances. As Gelfand points out, psychological assessments are an important part of the process. Psychological testing can help detect psychiatric disorders and addictive potential, and provide physicians with additional objective documentation to support their treatment decisions.
See “Ten Tips for Staying Out of Trouble” for more information.
1 Gelfand, Stephen G. (2002). The Pitfalls of Opioids for Chronic Nonmalignant Pain of Central Origin. Medscape Rheumatology, 4(1). Available at www.medscape.com/viewarticle/425468_print. Accessed June 18, 2003.
2 Federation of State Medical Boards of the United States (1998). Model Guidelines for the Use of Controlled Substances for the Treatment of Pain. Available at www.fsmb.org. Accessed June 20, 2003.
3 Gilson, A.M., Joranson, D.E., Maurer, M.A. (2003). Improving state medical board pain policies: Influence of a Model. Journal of Law, Medicine & Ethics, 31(1), 119-129. Available at www.medsch.wisc.edu/painpolicy/publicat/03jlme/index.htm. Accessed June 20, 2003.
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“The P-3® (Pain Patient Profile) assessment provides me and my partners the clinical information needed to assist in medication management, not only in decisions regarding psychotropic medication, but analgesic medication as well.”
“Once we have objectively established baseline functioning with the P-3 test, we then institute pharmacologic treatment and follow up with additional P-3 administrations for comparison purposes. This gives us needed information on response to treatment of pain as well as associated psychological functioning.”
“The P-3 test is the clear choice for physicians treating patients in pain. Where else can the physician get so much objective information on the need and benefits of both analgesic and psychotropic medication in one simple and quickly-administered test?”
John R. Satterthwaite, MD
Carolinas Centers for Pain
Greenville, South Carolina
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Summer 2003
