A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Arizona

Guidelines for the Use of Controlled Substances for the Treatment of Chronic Pain

• The Arizona Medical Board ("Board") strongly urges physicians to view effective pain management as a high priority in all patients, including children and the elderly. Pain should be assessed and treated promptly, effectively, and for as long as pain persists. The medical management of pain should be based on up-to-date knowledge about pain, pain assessment, and pain treatment. Pain treatment may involve the use of several drug and nondrug treatment modalities, often in combination. For some types of pain, the use of drugs is emphasized and should be pursued vigorously; for other types, the use of drugs is better de-emphasized in favor of other therapeutic modalities. Physicians should have sufficient knowledge or consultation to make such judgments for their patients.
• Drugs, in particular the opioid analgesics, are considered the cornerstone of treatment for pain associated with trauma, surgery, medical procedures, and cancer. Physicians are referred to the US Agency for Health Care Policy and Research Clinical Practice Guidelines as a sound yet flexible approach to the management of these types of pain.
• The prescribing of opioid analgesics for other patients with intractable noncancer pain also may be beneficial, especially when efforts to remove the cause of pain or to treat it with other modalities have been unsuccessful. For the purposes of these guidelines, intractable pain is defined as the following:
• A pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts including, but not limited to, evaluation by the attending physician and surgeon and one or more physicians and surgeons specializing in the treatment of the area, system, or organs of the body perceived as the source of the pain.
• Therefore, these guidelines are an attempt to communicate to physicians who prescribe opioids for intractable pain not to fear disciplinary action from this Board for prescribing or administering controlled substances to a person in the course of treatment of intractable pain. In addition, physicians should use sound clinical judgment and should care for their patients according to the following principles of responsible professional practice.

Guidelines for Patient Care When Prescribing Controlled Substances for Chronic Pain

• Pain Assessment
  1. Medical history, including the presence of a recognized medical indication for the use of a controlled substance, the intensity and character of pain, and questions regarding substance abuse.
  2. Corroboration of medical history by reviewing patient's medical records and/or speaking with patient's former physicians. Patients frequently seek out a new prescribing physician after their previous prescribing physician has terminated them for noncompliance, substance abuse, and/or drug diversion.
  3. Psychosocial assessment, which may include but is not limited to:
     1. The patient's understanding of the medical diagnosis, expectations about pain relief and pain management methods, concerns regarding the use of controlled substances, and coping mechanisms for pain.
     2. Changes in mood which have occurred secondary to pain (ie, anxiety, depression).
     3. The meaning of pain to the patient and his/her family.
  4. Physical examination, including a neurologic evaluation and examination of the site of pain.
  5. Urine drug screen, testing for commonly abused street drugs as well as prescription pain drugs that are known abused or diverted drugs. Such screening will help identify drug abusers and drug diverters.
• Treatment Plan
  • A treatment plan should be developed for the management of chronic pain and should state objectives by which therapeutic success can be evaluated, including:
    1. Pain relief;
    2. Improved physical functioning;
    3. Proposed diagnostic evaluations (ie, blood tests; radiologic, psychological, and social studies such as computed axial tomography [CAT] and bone scans, magnetic resonance imaging [MRI], and neurophysiologic examinations such as electromyography); and
    4. Analysis of inclusion and exclusion criteria for opioid management. Inclusion criteria include a clear diagnosis consistent with symptoms has been made, all reasonable alternative therapies have been explored; the patient is reliable and communicates well, and there has been informed consent or a treatment agreement signed. Potential exclusion criteria include a history of chemical dependency, major psychiatric disorder, chaotic social situation, or a planned pregnancy.
• Informed Consent
  • The physician should advise the patient, guardian, or designated surrogate about the risks and benefits of the use of controlled substances. The patient should be counseled on the importance of regular visits, the impact of recreational drug use, the number of physicians and pharmacies used for prescriptions, taking medications as prescribed, and other issues.
  • The physician and the patient should enter into a pain treatment contract that specifically states the patient's required compliance with the treatment plan and what the consequences of noncompliance, misuse, and abuse will be. It is particularly important that patients understand that they will be discontinued from the prescribed controlled substances in a safe manner if they are found to be abusing or diverting drugs.
• Ongoing Assessment
  • The assessment and treatment of chronic pain mandates continuing evaluation, and if necessary, modification and/or discontinuation of opioid therapy. If clinical improvement does not occur, the physician should consider the appropriateness of continued opioid therapy and should consider a trial of alternative pharmacologic and nonpharmacologic modalities.
• Consultation
  • The physician should refer the patient as necessary for additional evaluation to achieve treatment objectives. Physicians should recognize patients requiring individual attention, in particular, patients whose living situations pose a risk for misuse or diversion of controlled substances. In addition, the prescription of controlled substances to patients with a history of substance abuse requires extra care, monitoring, and documentation, and may also require consultation with an addiction medicine specialist.
• Documentation
  • The physician must maintain adequate, accurate and timely records. "Adequate Records," pursuant to Arizona Revised Statute 32-1401(2), "means legible records containing, 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." Specific to patients with chronic pain, the documentation should include:
    1. The medical history and physical examination;
    2. Related evaluations and consultations, treatment plan, and objectives;
    3. Evidence of discussion regarding informed consent;
    4. Prescribed medications and treatments;
    5. Periodic reviews of treatments and patient response; and
    6. Any physician-patient agreements or contracts.
• Counting and Destroying Medication
  • The physician may desire to see and count a patient's medication to determine whether the patient is taking the medication as prescribed. The patient should display and count the medication in front of the physician. Under no circumstance should the physician touch a patient's controlled substances. If the medication must be destroyed, the patient should flush the medication down the toilet in the physician's presence. The physician should document this in the patient's chart.
• Postdated Prescriptions
  • Postdated prescriptions are illegal in the State of Arizona. Therefore, physicians may not issue postdated prescriptions.
• Referral of Patients With Active Substance Abuse Problems
  • Patients discovered to have an active substance abuse problem should be referred to either a detoxification and rehabilitation program or to an appropriate maintenance program for addicts.

Compliance With Laws and Regulations

• Prescribing Controlled Substances
  • To prescribe controlled substances, physicians must comply with all applicable laws, including the following:
    1. Possess a valid current license to practice medicine in the State of Arizona; and
    2. Possess a valid and current controlled substances Drug Enforcement Administration registration for the schedules being prescribed.
• Dispensing Controlled Substances
  • To dispense controlled substances, physicians must comply with all applicable laws, including the following:
    1. Possess a valid current license to practice medicine in the State of Arizona;
    2. Possess a valid and current controlled substances Drug Enforcement Administration registration for the schedules being prescribed;
    3. Comply with Arizona Revised Statutes 32-1491, et seq. and A.A.C. R4-16-201 through R4-16-205; and
    4. Comply with 22 CFR 1306.07(a) if controlled substances are dispensed for detoxification.

FAQs: The Arizona Medical Board and Chronic Pain Management

• Does the Arizona Medical Board have published Guidelines for Treatment of Chronic Pain that are readily accessible to Arizona physicians?
  
  Yes. The Arizona Medical Board has published these Guidelines since the early 1990s. The Guidelines were originally available in print, and have been available online for as long as there has been an Arizona Medical Board Web site. The direct link for the Guidelines is http://azmd.gov/pain_management/Guidelines.pdf
• Are the Arizona Medical Board's Guidelines for Treatment of Chronic Pain consistent with modern principles of chronic pain management?
  
  Yes. The Board's published position mirrors current state-of-the-art pain management principles as identified in the Federation of State Board's Model Policy and in the Consensus Statement published by the American Pain Society and the American Academy of Pain Medicine. The American Pain Society and American Academy of Pain Medicine are mainstream national organizations dedicated to advocacy for pain physicians and their patients.
• What is the purpose of the Guidelines for Treatment of Chronic Pain set forth by the Arizona Medical Board?
  
  The Guidelines explicitly state that these "are provided to encourage physicians to view pain management as a part of quality medical practice for all patients with pain...The guidelines demonstrate the Board's desire to encourage physicians to administer controlled substances in the course of treating pain without fear of disciplinary action from this Board when such treatment is provided with the accepted community standard of care."
• Do the Guidelines for Treatment of Chronic Pain mandate frequent office visits, opioid agreements, specialist consultation, and/or urine drug screens when prescribing opioids for chronic nonmalignant pain?
  
  No. Although a clinician may choose to use one or more of these tools at his or her discretion, none of these are mandated in the Guidelines for routine use when prescribing opioids for chronic pain.
• Are there cases in which frequent office visits, opioid agreements, specialist consultation, and/or urine drug screens are strongly indicated when prescribing opioids for chronic pain?
  
  Yes. As with many medical problems in addition to chronic pain (for example diabetes, coronary artery disease, seizure disorder), a patient with poorly controlled symptoms, who has a history of noncompliance with medications, and/or who is at high risk for medication-related complications may require closer monitoring, more frequent office visits, specialist consultations, and/or more sophisticated laboratory testing than a patient who is stable and at low risk for complications. As with other medical problems, the Board expects the physician to recognize and follow up on escalating symptoms or unusual behavior patterns that suggest poorly controlled pain, noncompliance, and/or high risk for complications (including substance abuse, addiction and/or diversion).

[ CLOSE WINDOW ]

Author Information

David Brushwood, RPh, JD, Professor, University of Florida College of Pharmacy, Gainesville

Disclosure: David B. Brushwood, RPh, JD, has disclosed no relevant financial relationships.