A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Hawaii

Summary

Definitions

Abuse. Abuse means the misuse of a substance or the use of a substance to an extent deemed deleterious or detrimental to the user, to others, or to society.

Detoxification Treatment. Detoxification treatment means the dispensing, for a specific period of time, of a narcotic drug or narcotic drugs in decreasing doses to an individual to alleviate adverse physiologic or psychological effects incident to withdrawal from the continuous or sustained use of a narcotic drug and as a method of bringing the individual to a narcotic drug-free state within a specified period of time.

There are 2 types of detoxification treatments: short-term detoxification treatment and long-term detoxification treatment. Short-term detoxification treatment is for a period not in excess of 30 days, and long-term detoxification treatment is for a period more than 30 days but not in excess of 180 days.

Maintenance Treatment. Maintenance treatment means the dispensing of a narcotic drug in the treatment of an individual for dependence on heroin or other morphine-like drugs, for a period in excess of 21 days.

Key Prescription Requirements

Prescriptions for controlled substances shall be issued only as follows: (1) All prescriptions for controlled substances shall originate from within the state and be dated as of, and signed on, the day when the prescriptions were issued. Prescriptions must contain the first and last name and address of the patient and the drug name, strength, dosage form, quantity prescribed, and directions for use.

A practitioner may sign a prescription in the same manner as the practitioner would sign a check or legal document (eg, J.H. Smith or John H. Smith) and should use both words and figures (ie, indicate quantities both alphabetically and numerically: five [5]) to indicate the amount of controlled substance to be dispensed. Where an oral order is not permitted, prescriptions shall be written with ink or indelible pencil or typed, must be manually signed by the practitioner, and must include the name, address, telephone number, and registration number of the practitioner. The prescriptions may be prepared by a secretary or agent for the signature of the practitioner, but the prescribing practitioner is responsible.

A corresponding liability rests on a pharmacist who fills a prescription not prepared in the form prescribed by this section. A pharmacist may add a patient's missing address or change a patient's address on all controlled substance prescriptions after verifying the patient's identification and noting the identification number on the back of the prescription. The pharmacist may not make changes to the patient's name, the controlled substance being prescribed, the quantity of the prescription, the practitioner's Drug Enforcement Administration (DEA) number, or the practitioner's signature.

Hawaii Pain Management Guidelines

The Board of Medical Examiners may establish guidelines for physicians or osteopathic physicians with respect to patients' pain management. The guidelines apply to all patients with severe acute pain or severe chronic pain, regardless of the patient's prior or current chemical dependency or addiction, and may include standards and procedures for individuals who are chemically dependent. In 2006, the Hawaii Board of Medicine adopted its pain management guidelines, which are patterned after the guidelines established by the Federation of State Medical Boards.

Definitions Used in Hawaii Pain Management Guidelines

Acute Pain. Acute pain is the normal predicted physiologic response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness. It is generally time-limited and is responsive to opioid therapy, among other therapies.

Addiction. Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to by terms such as "drug dependence" and "psychological dependence." Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy for pain and should not be considered addiction.

Chronic Pain. A pain state that is persistent and in which the cause of the pain cannot be removed or otherwise treated. Chronic pain may be associated with a long-term incurable or intractable medical condition or disease.

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

Physical Dependence. Physical dependence on a controlled substance is a physiologic state of neuroadaptation, which is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or if an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself, does not equate with addiction.

Pseudoaddiction. Pattern of drug-seeking behavior of patients with pain who are receiving inadequate pain management. Pseudoaddiction can be mistaken for addiction.

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 the same effect or a reduced effect is observed with a constant dose.

Hawaii Guidelines

Evaluation of the Patient. The physician must obtain, evaluate, and document a medical history and physical examination. The physician 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 physician should also document the presence of one or more recognized medical indications for the use of a controlled substance.

Treatment Plan. The physician should use a written treatment plan stating the 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 physician 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 cause of the pain and the extent to which the pain is associated with physical and psychosocial impairment.

Informed Consent and Agreement for Treatment. The physician 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 one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician 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).

Terms of the Agreement. The following terms of agreement have been suggested by the Hawaii Board of Medicine.

1. Urine or blood sample upon request, which will be used to test for drugs of abuse or medication levels at the physician's discretion.
2. The physician may limit the number and frequency of prescription refills.
3. The physician may discontinue controlled substance therapy at his or her discretion and in certain circumstances (eg, significant violation of agreements or treatment plans by patients).
4. Physician-patient relationship may be discontinued under certain circumstances (eg, because of significant violations of agreements and treatment plans).
5. Medication refills will only be provided according to legitimate medical need and at mutually agreed intervals.
6. All therapies may be provided on a time-limited basis to determine potential effectiveness and may be discontinued if judged ineffective or detrimental to patient health.
7. Patients will be referred for addiction or behavioral health treatment when the patient's use of controlled substances is found to be connected to addiction (or possible addiction) and not pain

Periodic Review. The physician should periodically review the course of pain treatment and any new information about the cause of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician's evaluation of progress toward treatment objectives. The patient's decreased pain, increased level of function, or improved quality of life may indicate a satisfactory response to treatment. The physician should monitor objective evidence of improved or diminished function and consider information from family members or other caregivers when determining the patient's response to treatment. If the patient's progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities.

Consultation. The physician should be willing to refer the patient as necessary for additional evaluation and treatment to achieve treatment objectives. The physician should give special attention 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 physician should keep accurate and complete records to include the medical history and physical examination; diagnostic, therapeutic, and laboratory results; evaluations and consultations; treatment objectives; discussion of risks and benefits; informed consent; treatments; medications (including date, type, dosage, and quantity prescribed); instructions and agreements; and periodic reviews. Records should remain current and must be maintained in an accessible manner readily available for review.

Compliance With Controlled Substances Laws and Regulations. To prescribe, dispense, or administer controlled substances, the physician must be licensed in the state and comply with applicable federal and state regulations. Physicians should review the DEA's Practitioner's Manual and any relevant documents issued by the state medical board for specific rules governing controlled substances as well as applicable state regulations. The Practitioner's Manual can be found at: http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html.