A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Iowa

Summary

The Iowa Medical Board has a rule called "standards of practice -- prescribing or administering controlled substances for the treatment of patients with chronic, nonmalignant pain." The rule can be found at: http://medicalboard.iowa.gov/PDF_Files/painrules.pdf The Iowa Pharmacy Board has a similar policy statement.

The Medical Board's Rule

The Iowa Board of Medicine's rule establishes standards of practice for the management of chronic, nonmalignant pain. The purpose of the rule is to assist physicians who prescribe and administer drugs to provide relief and eliminate suffering in patients with chronic, nonmalignant pain as defined in this rule.

Key Definitions From the Medical Board's Rule

Some of the key definitions from the Medical Board's rule include:

Agency for Healthcare Research and Quality or AHRQ means the agency within the US Department of Health and Human Services that is responsible for establishing clinical practice guidelines on various aspects of medical practice.

Chronic, nonmalignant pain (ie, not caused by cancer) means persistent or episodic pain of a duration or intensity that adversely affects the functioning or well-being of a patient when (1) no relief or cure for the cause of pain is possible; (2) no relief or cure for the cause of pain has been found; or (3) relief or cure for the cause of pain through other medical procedures would adversely affect the well-being of the patient.

Key Components of the Rule

Physicians can safely and effectively use opioid analgesics to control pain in certain patients. Inappropriate prescribing of controlled substances can lead to, or accelerate, drug abuse and diversion. All physicians must base their medical management of pain on a thorough knowledge of pain assessment, pain treatment, and concern for the patient.

Treatment of Acute Pain and Cancer Pain. Physicians may refer to the Clinical Practice Guidelines published by the AHRQ for counsel on the proper treatment of acute pain and chronic pain associated with cancer. The AHRQ Clinical Practice Guidelines provide a sound, compassionate, and flexible approach to the management of pain in these patients.

Treatment of Chronic, Nonmalignant Pain. The basic premise underlying this rule is that various drugs, particularly opioid analgesics, may be useful for treating patients with chronic, nonmalignant pain in a safe, effective, and efficient manner when other efforts, including those by other practitioners or the patient, have failed to remove or effectively treat the pain. The Board strongly recommends that physicians who have reservations about the use of drugs in the treatment of chronic, nonmalignant pain consult materials published by the American Academy of Pain Medicine, the American Society of Addiction Medicine, and the American Pain Society.

Effective Chronic, Nonmalignant Pain Management

The physician must exercise sound clinical judgment by establishing an effective pain management plan, using the following points to guide patient care.

Patient Evaluation. The physician must conduct a physical examination and obtain a comprehensive medical history prior to initiation of treatment. The evaluation must include an assessment of the pain and of physical and psychological function; results of diagnostic studies; a list of previous interventions, including medication history; substance abuse history; and any underlying or coexisting conditions. The physician may want to consult with or refer the patient to a physician with expertise in pain medicine, addiction medicine, or substance abuse counseling. Referral to a physician who specializes in the treatment of the area, system, or organ perceived to be the source of the pain may also be warranted, depending on the expertise of the treating physician and the complexity of the presenting patient. Interdisciplinary evaluation is strongly encouraged.

Treatment Plan. The physician should establish a comprehensive treatment plan that tailors drug therapy to the individual needs of the patient. To ensure proper evaluation of the success of the treatment, the plan should clearly state the objectives of the treatment, for example, pain relief or improved physical or psychosocial functioning. The treatment plan should also indicate whether any further diagnostic evaluations or treatments are planned and their purposes. The treatment plan should also identify any other treatment modalities and rehabilitation programs used.

Informed Consent. The physician should document discussions about the risks and benefits of controlled substances with the patient or the person representing the patient.

Periodic Review. The physician should periodically review the course of the patient's drug treatment and the cause of the pain. Modification or continuation of drug therapy by the physician depends on evaluation of the patient's progress toward the objectives established in the treatment plan.

Consultation/Referral. If the patient is not meeting the objectives of the treatment plan, or if there is evidence of diversion or a pattern of abuse, the physician must consider consultation with, or referral to, a physician with expertise in pain medicine, addiction medicine, or substance abuse counseling.

Documentation. The physician must keep accurate, timely, and complete records that are in compliance with the Board's rule.

Physician-Patient Agreements. Physicians treating patients at risk for substance abuse should consider establishing physician-patient agreements that specify the rules for medication use and the consequences for misuse. In preparing agreements, a physician must evaluate each patient's case on its own merits, taking into account the nature of the risks to the patient and the potential benefits of treatment.

Termination of Care. If the physician encounters evidence of diversion or a repeated pattern of substance abuse, the physician should consider terminating patient care. The physician may also consider monitoring the patient more closely or discontinuing the use of opioids with the patient but not necessarily terminating overall patient care, depending on the circumstances of the individual patient's case.

New Drug Enforcement Administration Regulation Regarding Multiple Schedule II Controlled Substance Prescriptions

On December 19, 2007, the Drug Enforcement Administration rule on the issuance of multiple prescriptions for schedule II controlled substances pursuant to specific requirements became final. The Iowa Board of Medicine has stated that there is nothing in Iowa law that would prohibit the practice authorized by the federal rule. Therefore, the authority included in the federal rule became effective for Iowa prescribers on December 19, 2007.