A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Alaska

Summary

Alaska is one of just a couple of states that lacks a formal medical board position statement on the use of controlled medications to treat pain. As demonstrated below, however, Alaska's Board of Nursing has adopted a guideline on the use of controlled medications to treat pain, and that guideline is modeled after the Federation of State Medical Boards' Model Policy Statement.

Record-Keeping Requirements

1. Be legible;
2. Contain only those terms and abbreviations that are or should be comprehensible to similar licensees;
3. Contain adequate patient identification;
4. Indicate the dates that professional services were provided to the patient;
5. Reflect what examinations, vital signs, and tests were obtained, performed, or ordered concerning the patient and the findings and results of each;
6. Indicate the chief complaint of the patient;
7. Indicate the licensee's diagnostic impressions of the patient;
8. Indicate the medications prescribed for, dispensed to, or administered to the patient and the quantity and strength of each medication;
9. Reflect the treatment provided to or recommended for the patient; and
10. Document the patient's progress during the course of treatment provided by the licensee.

Code of Ethics

The Alaska Medical Board has a rule that adopts the Principles of Medical Ethics of the American Medical Association.

Definition of Unprofessional Conduct

"Unprofessional conduct," as defined by the Alaska Medical Board in its Rules, includes:

…(8) delegating professional practice responsibilities that require a license or permit under AS 08.64 to a person who does not possess the appropriate education, training, or licensure to perform the responsibilities; (9) failing to prepare and maintain accurate, complete, and legible records in accordance with generally accepted standards of practice for each patient and to make those records available to the board and the board's representatives for inspection for investigation purposes; … (12) intentionally or negligently releasing or disclosing confidential patient information; this paragraph does not apply to disclosures required under state or federal law or when disclosure is necessary to prevent an imminent risk of harm to the patient or others; (13) offering, giving, soliciting, or receiving fees or other benefits, in whole or in part, to a person for bringing in or referring a patient; … (17J) unlawful distribution or possession for distribution of a controlled substance; for purposes of this subparagraph, "controlled substance" has the meaning given in AS 11.71.900; (18) using alcohol or other drugs (A) to the extent that the use interferes with professional practice functions of the licensee or endangers the safety of patients; or (B) that is illegal under state or federal law; … (27) providing treatment, rendering a diagnosis, or prescribing medications based solely on a patient-supplied history that a physician licensed in this state received by telephone, facsimile, or electronic format; …

Alaska's Medical Board Rules include a specific provision relating to the prescribing of controlled substances, which requires a physician to create and maintain a complete, clear, and legible written record of care that includes -- at a minimum -- (1) a patient history and evaluation sufficient to support a diagnosis; (2) a diagnosis and treatment plan for the diagnosis; (3) monitoring the patient for the primary condition that necessitates the drug, side effects of the drug, and results of the drug, as appropriate; and (4) a record of drugs prescribed, administered, or dispensed, including the type of drug, dose, and any authorized refills.

Nursing Board Pain Management Guideline

In 1996, the Alaska Board of Nursing published an Advisory Opinion adopting a Guideline on the Use of Controlled Medications to Treat Pain, which applies to advanced nurse practitioners. This guideline is based on the Federation of State Medical Boards' Model Guideline and those adopted by other boards. The main provisions of the Alaska Nursing Board Guideline are as follows.

Evaluation of the Patient

A medical history and physical examination must be obtained, evaluated, 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 also should document the presence of 1 or more recognized medical indications for the use of a controlled substance.

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 whether any further diagnostic evaluations or other treatments are planned. After treatment begins, the healthcare practitioner 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.

Informed Consent and Agreement for Treatment

The advanced nurse practitioner 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 without medical decision-making capacity. The patient should receive prescriptions from 1 advanced nurse practitioner and 1 pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the advanced nurse practitioner should consider the use of a written agreement between provider and patient outlining patient responsibilities, including urine/serum medication levels screening when requested, number and frequency of all prescription refills, and reasons for which drug therapy may be discontinued (eg, violation of agreement).

Periodic Review

The advanced nurse practitioner should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on the practitioner's evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient's reduced pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored, and information from family members or other caregivers should be considered in determining the patient's response to treatment. If the patient's progress is unsatisfactory, the practitioner should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities.

Consultation

The advanced nurse practitioner 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 patients with pain who are at risk for medication misuse, abuse, 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.

Medical Records

The advanced nurse practitioner 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. Informed consent;
7. Treatments;
8. Medications, including date, type, dosage, and quantity prescribed;
9. Instructions and agreements; and
10. Periodic reviews.

Adequate records are legible and contain, at a minimum, sufficient information to identify the patient, support the diagnosis, justify the treatment, adequately document the results, indicate advice and cautionary warnings provided to the patient, and provide sufficient information for another practitioner to assume continuity of the patient's care at any point in the treatment. Records should remain current and be maintained in an accessible manner and readily available for review. "Coded" information, without definitions, does not constitute an acceptable record.

Compliance With Controlled Substances Laws and Regulations

To prescribe, dispense, or administer controlled substances, the advanced nurse practitioner must be licensed in the state and comply with applicable federal and state regulations. Practitioners are referred to the Physicians Manual of the US Drug Enforcement Administration for specific rules governing controlled substances as well as applicable state regulations.

The Alaska Board of Nursing's Advisory Opinion on the Pain Management Guideline includes the following definitions.

Acute pain. Acute pain is the normal, predicted physiologic response to a noxious chemical, thermal, or mechanical stimulus and typically is associated with invasive procedures, trauma, and disease. It is generally time-limited.

Addiction. Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use, and continued use despite harm. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy for pain and are not the same as addiction.

Chronic pain. Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.

Pain. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Physical dependence. Physical dependence is a state of adaptation that is manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence, by itself, does not equate with addiction.

Pseudoaddiction. Pseudoaddiction is a iatrogenic syndrome resulting from the misinterpretation of relief-seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction. The relief-seeking behaviors resolve upon institution of effective analgesic therapy.

Substance abuse. Substance abuse is the use of any substance(s) for nontherapeutic 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 a specific effect, or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction.

Relevant Basic Provisions of the Alaska Controlled Substances Act Include the Following

Controlled substances may only be prescribed, administered, dispensed, or distributed for a medical purpose. (The Alaska statute omits the word "legitimate" from the "medical purpose" requirement.)

Alaska Prescription Drug Monitoring Database

The Alaska Board of Pharmacy monitors the state's controlled substance prescription database. The purpose of the database is to contain data with regard to every prescription for a schedule IA, IIA, IIIA, IVA, or VA controlled substance under state law or a schedule I, II, III, IV, or V controlled substance under federal law dispensed in the state to a person other than those administered to a patient at a healthcare facility.

The database and the information contained within the database are confidential, are not public records, and are not subject to public disclosure. The Board may allow access to the database only to the following persons, and in accordance with the limitations provided and regulations of the board:

…(3) a licensed practitioner having authority to prescribe controlled substances, to the extent the information relates specifically to a current patient of the practitioner to whom the practitioner is prescribing or considering prescribing a controlled substance; (4) a licensed or registered pharmacist having authority to dispense controlled substances, to the extent the information relates specifically to a current patient to whom the pharmacist is dispensing or considering dispensing a controlled substance; (5) federal, state, and local law enforcement authorities may receive printouts of information contained in the database under a search warrant, subpoena, or order issued by a court establishing probable cause for the access and use of the information; and (6) an individual who is the recipient of a controlled substance prescription entered into the database may receive information contained in the database concerning the individual on providing evidence satisfactory to the board that the individual requesting the information is in fact the person about whom the data entry was made and on payment of a fee set by the board under AS 37.10.050 that does not exceed $10.