A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: District of Columbia

District of Columbia Municipal Regulations for Medicine

Standards for the Use of Controlled Substances for the Treatment of Pain

The full text of the Standards is available at: http://hpla.doh.dc.gov/hpla/frames.asp?doc=/hpla/lib/hpla/medicine/updated_regs_6_30_2008.pdf, section 4614.

• Prescriptions

  A licensed physician shall prescribe, order, administer, or dispense controlled substances for pain only for a legitimate medical purpose based on accepted scientific knowledge of the treatment of pain or based on sound clinical grounds. All such prescribing shall be based on clear documentation of unrelieved pain and in compliance with applicable District or federal law.

• Treatment

  A licensed physician should use up-to-date treatment modalities to improve the quality of life for patients with pain as well as to reduce the morbidity and costs incurred by patients associated with untreated or inappropriately treated pain. For purposes of this section, "inappropriately treated pain" includes the following:

  1. Nontreatment;
  2. Undertreatment;
  3. Overtreatment; and
  4. The continued use of ineffective treatments.
• Evaluation

  A licensed physician must perform an evaluation of the patient by taking a complete medical history and performing a physical examination. The medical history and physical examination must be documented in the medical record. The medical record must contain a description of the following:

  1. The nature and intensity of the patient's pain;
  2. The patient's current and past treatments for pain;
  3. The patient's underlying or coexisting diseases or conditions;
  4. The effect of the pain on the patient's physical and psychological function;
  5. A history of the patient's substance abuse if applicable; and
  6. The presence of one or more recognized medical indications in the patient for the use of a controlled substance.
• Treatment Plan

  A licensed physician must maintain a written treatment plan which states the objectives used to determine treatment success, such as pain relief and improved physical and psychosocial function.

  The treatment plan should indicate whether any further diagnostic evaluations or other treatments are planned.

  The physician should adjust drug therapy to the individual medical needs of each patient after treatment begins.

  The physician should consider other treatment modalities or a rehabilitation program if necessary depending on the cause of the pain and the extent to which the pain is associated with physical and psychosocial impairment.

• High-risk Patients

  The physician should discuss the risks and benefits of the use of controlled substances with the patient, person(s) designated by the patient, or with the patient's surrogate or guardian if the patient is incompetent.

  If the patient is determined to be at high risk for medication abuse or has a history of substance abuse, the physician should use a written agreement between the physician and the patient outlining the patient's responsibilities, including, but not limited to:

  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, such as violation of an agreement.

  The physician must do the following:

  1. Review the course of treatment and any new information about the cause of the pain at reasonable intervals based on the individual circumstances of the patient;
  2. Continue or modify the pain therapy depending on the physician's evaluation of the patient's progress;
  3. Reevaluate the appropriateness of continued treatment if treatment goals are not being achieved despite medication adjustments; and
  4. Monitor the patient's compliance with medication usage and related treatment plans.
• Referrals

  The physician should refer the patient as necessary to another physician for additional evaluation and treatment to achieve treatment objectives. Special attention must be given to those patients with pain who are at risk for misusing their medications and those whose living arrangements pose a risk for medication misuse or diversion.

  The physician should consult with or refer to an expert for the management of the following types of patients:
  1. Patients with a history of substance abuse; or
  2. Patients with comorbid psychiatric disorders that require extra care, monitoring, and documentation.
• Tolerance/Dependence

  The physician should recognize that tolerance and physical dependence are normal consequences of the sustained use of opioid analgesics and are not the same as addiction.

• Medical Records

  The physician must keep accurate and complete records that include, but are not limited to:

  1. The medical history and physical examination, including history of drug
  abuse or dependence, as appropriate;
  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.

The physician must maintain current records in an accessible manner readily available for review.

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Author Information

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

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