A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Kansas

Kansas Legislature Pain Patient's Quality of Care Act

• The legislature finds and declares that pain is a significant health problem, and that the diagnosis and treatment of pain is complex and can involve several therapeutic modalities. The treatment of pain may require the use of controlled substances in appropriate circumstances. To promote the public health, safety, and welfare, the state has a duty to restrict the inappropriate use of controlled substances while supporting a physician's or other health care provider's ability to provide appropriate pain treatment consistent with patient needs and sound clinical judgment.

Kansas Board of Healing Arts Guidelines for the Use of Controlled Substances for the Treatment of Pain

• The Kansas Board of Healing Arts recognizes that principles of quality medical practice dictate that the people of the State of Kansas have access to appropriate and effective pain relief. The appropriate application of up-to-date knowledge and treatment modalities can serve to improve the quality of life for those patients who have pain as well as reduce the morbidity and costs associated with untreated or inappropriately treated pain. The Board encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially important for patients who experience pain as a result of terminal illness. All physicians should become knowledgeable about effective methods of pain treatment.

Definitions

• "Pain" is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
• "Chronic pain" is 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.
• "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" 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.
• "Physical dependence" on a controlled substance is a physiologic state of neuroadaptation that 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.
• "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.
• "Pseudoaddiction" is a pattern of drug-seeking behavior of patients with pain who are receiving inadequate pain management and can be mistaken for addiction.
• The Board has adopted the following guidelines when evaluating the use of controlled substances for pain control:
  • Evaluation of the Patient. 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 one 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 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 incompetent. The patient should receive prescriptions from one physician and one pharmacy where possible. If the patient is determined to be at high risk for medication abuse or to have a history of substance abuse, the physician may employ 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
    • Reasons for which drug therapy may be discontinued (ie, violation of agreement)
    • Periodic Review. At reasonable intervals based on the individual circumstances of the patient, the physician should review the course of treatment and any new information about the cause of the pain. Continuation or modification of therapy should depend on the physician's evaluation of progress toward stated treatment objectives, such as improvement in patient's pain intensity and improved physical and/or psychosocial functioning (ie, ability to work, need for healthcare resources, activities of daily living, and quality of social life). If treatment goals are not being achieved despite medication adjustments, the physician should reevaluate the appropriateness of continued treatment. The physician should monitor patient compliance in medication usage and related treatment plans.
• Medical Records. The physician should comply with and meet the requirements of KAR 100-24-1 in the maintenance of an adequate record for each patient.
  KAR 100-24-1 states:
  • K.A.R. 100-24-1. Adequacy; minimal requirements.
    1. Each licensee of the Board shall maintain an adequate record for each patient for whom the licensee performs a professional service.
    2. Each patient record shall meet these requirements:
       1. be legible;
       2. contain only those terms and abbreviations that are or should be comprehensible to similar licensees;
       3. contain adequate identification of the patient;
       4. indicate the dates any professional service was provided;
       5. contain pertinent and significant information concerning the patient's condition;
       6. reflect what examinations, vital signs, and tests were obtained, performed, or ordered and the findings and results of each;
       7. indicate the initial diagnosis and the patient's initial reason for seeking the licensee's services;
       8. indicate the medications prescribed, dispensed, or administered and the quantity and strength of each;
       9. reflect the treatment performed or recommended;
       10. document the patient's progress during the course of treatment provided by the licensee; and
       11. include all patient records received from other healthcare providers, if those records formed the basis for a treatment decision by the licensee.
    3. Each entry shall be authenticated by the person making the entry unless the entire patient record is maintained in the licensee's own handwriting.
    4. Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form. The final form shall accurately reflect the care and services rendered to the patient.
    5. For purposes of implementing the healing arts act and this regulation, an electronic patient record shall be deemed a written patient record if the electronic record is authenticated by the licensee.
• 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.

Kansas State Board of Nursing Guideline for Pain Management

• Nursing Principles of Pain Management
  • The Kansas State Board of Nursing endorses the "Precepts of Pain Management" set forth by the Living Initiatives for End of Life Care (LIFE) Project and has drawn on the precepts to formulate nursing principles of pain management. They are as follows:
    • All persons who are experiencing pain have the right to have their pain relieved to the greatest extent possible. The nurse's goal is to reduce pain at least to a level specified by the recipient of care, while recognizing that all persons have the right to refuse treatment.
    • A person's perception of pain is the optimal standard upon which all pain management interventions are based.
    • A comprehensive nursing assessment includes the subjective description of pain, objective data, and the identified need for psychosocial/spiritual support.
    • Fear of addiction to opioids and other pain medications need not be a barrier to pain management. Nurses recognize and apply the following concepts:
      • Tolerance and physical dependence are consequences of sustained use of opioid analgesics and are not synonymous with addiction.
      • Pseudoaddiction is a pattern of drug-seeking behavior of persons with pain who are receiving inadequate pain management and may be mistaken for addiction
    • Persons with a history of substance abuse have the right to adequate pain relief, even if opioids must be used. Such persons require specialized care and treatment.
    • Continuity of care within and across healthcare settings is essential to effective pain management.
    • An interdisciplinary approach to pain management is optimal.
    • Nurses and other clinicians pursue the most effective modes of treatment to their maximal benefit. Research indicates that most persons experiencing pain can achieve optimal pain relief with simple, cost-effective modes of treatment.
    • Pain management continues even if the person becomes unresponsive.
    • Sedation is an acceptable means of controlling pain and discomfort when all other reasonable efforts have failed.
    • Assisted suicide and euthanasia are illegal in the State of Kansas and are not acceptable alternatives to optimal pain management.
• Nursing Functions of Pain Management
  • Nurses are responsible for maintaining the knowledge and skills necessary to coordinate optimal pain management. The nursing functions of appropriate pain management include:
    • Ensuring that the person or their legal representative actively participates in the treatment plan and understands the options available for pain relief and potential side effects.
    • Educating persons and their families in a culturally competent manner regarding pain management.
    • Educating staff members about pain assessment treatment and the common barriers to adequate pain management.
    • Using a standard scale to periodically assess and document a person's pain in accordance with institutional policies and procedures.
    • Developing and implementing a plan of care that prevents and alleviates pain as much as possible.
    • Administering medications and treatments as prescribed, using knowledge to maintain both safety and pain relief.
    • Initiating nonpharmacologic nursing interventions as indicated.
    • Serving as an advocate to assure effective pain management.
    • Communicating side effects or any reports of unrelieved pain to the prescriber and to appropriate team members.
    • Documenting pain assessment, intervention, evaluation, and changes to the plan of care in a clear and concise manner.

Joint Policy Statement of the Kansas Boards of Healing Arts, Nursing, and Pharmacy on the Use of Controlled Substances for the Treatment of Pain

• Prescribing, administering, or dispensing controlled substances, including opioid analgesics, to treat pain is considered a legitimate medical purpose if based on sound clinical grounds. Healthcare providers authorized by law to prescribe, administer, or dispense drugs, including controlled substances, should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.
• The Board is under a duty to make inquiry when it receives information contending that a healthcare provider treated pain inappropriately. Proper investigation is necessary to obtain relevant information. A healthcare provider should not construe any request for information as a presumption of misconduct. Prior to the filing of any allegations, the results of the investigation will be evaluated by the healthcare provider's peers who are familiar with this policy statement. Healthcare providers who competently treat pain should not fear disciplinary action from their licensing board.

Prescriptions

• Purpose of Issue
  • To be effective, a prescription for a controlled substance shall be issued for a legitimate medical purpose by a practitioner or midlevel practitioner acting in the usual course of professional practice. The responsibility for the proper prescribing and dispensing of controlled substances shall rest with the prescriber, but a corresponding responsibility shall rest with the pharmacist who fills the prescription.
  • A prescription shall not be issued so that a practitioner or midlevel practitioner may obtain controlled substances for the purpose of general dispensing to patients.
• Manner of Issuance of Prescriptions
  • Controlled substance prescriptions in schedules II through V shall not be issued on a prescription blank that is preprinted with the name of a proprietary preparation or with the strength, quantity, or directions.
  • All written prescriptions for controlled substances shall meet the following requirements:
    • Be dated and manually signed on the day issued
    • Bear the following information:
      • The full name, address, and registration number of the practitioner or midlevel practitioner
      • The name and address of the patient
      • The drug name, strength, dosage form, quantity prescribed, and directions for use
      • Be written with ink, indelible pencil, or typewriter

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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.