A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Kentucky

Summary

Kentucky has an old guideline and a new version that somewhat tracks the Federation of State Medical Boards' Model Policy on the Use of Controlled Medications for the Treatment of Pain. Kentucky also has several policy and position statements, including one on the use of benzodiazepines. All Kentucky-licensed physicians should read these materials very carefully and check the Kentucky Board of Medical Licensure (KBML) Web site for updates.

Kentucky Guidelines for Using Controlled Medications for Pain Management

The full text of the guidelines can be found at: http://media.kentucky.com/smedia/2008/08/01/19/UseofCSsinPainTreatment.source.prod_affiliate.79.pdf

The KBML states that physicians should not fear disciplinary action from the Board for prescribing controlled substances for a legitimate medical purpose and in the usual course of professional practice. KBML will consider the prescribing of controlled substances for pain a legitimate medical purpose, if such prescribing is based on accepted scientific knowledge of pain treatment, and if it is based on sound clinical grounds. Documentation must be clear and in compliance with applicable federal and state laws.

KBML states it will not discipline physicians who do not strictly follow these guidelines so long as the physician can demonstrate good cause for the deviation. Instead, KBML states it will look to the treatment outcome and will take into account whether the drug used was medically and/or pharmacologically recognized to be appropriate for the diagnosis; the patient's individual needs, including improvement in functioning; and a recognition that some types of pain cannot be completely relieved. According to the KBML, the goal of pain management is to control the patient's pain for its duration and to do so in a manner that balances the patient's functioning, including physical, psychological, social and work-related factors.

KBML does not intend for these guidelines to define complete or best practice, but rather the intention is to communicate what the Board considers to be within acceptable boundaries of professional practice when prescribing for recurrent or persistent chronic pain. KBML believes the prescribing guidelines for acute pain to be less stringent, but, in principle, the same.

Evaluation of the Patient. The physician must conduct and document a complete medical history and physical examination. The physician should document a family history with particular reference to any history of a first-degree relative with chemical dependence problems. 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 any substance abuse. The medical record also should document the presence of one or more recognized medical indication(s) for the use of a controlled substance.

By definition, pain is a subjective statement of a patient's perception of actual or potential tissue damage. The physician should establish the distinction between pain and suffering. A patient may suffer because of pain, but the person may have other reasons for suffering as well. The physician should assess a patient's overall condition at the initial evaluation and thereafter. It is the goal of the physician to assist in the relief of suffering no matter the cause. Financial, emotional, mental, physical, and spiritual factors may contribute to the patient's distress. Relief of the underlying reasons for suffering as well as the pain will lead to optimal treatment and use of controlled substances.

Before beginning treatment with controlled drugs, the physician must determine, through actual clinical trial or through patient records and history, that nonaddictive medication regimens have been inadequate or are unacceptable for solid clinical reasons. Speaking with the patient's significant other or conducting a family conference can be helpful if there is any doubt regarding the patient's integrity. Physicians should also consider using the Kentucky All Schedule Prescription Electronic Reporting (KASPER Report) initially to aid in documenting the patient's history of drug use.

Treatment Plan. The physician should use a written treatment plan stating objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function. The physician should also document in the treatment plan whether he or she plans any further diagnostic evaluations, consultations, or other treatments. 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 Consents and Treatment Agreements. The physician should discuss the risks and benefits of the use of controlled substances with the patient or his or her surrogate, including the risk for tolerance and drug dependence. If the patient is determined to be at high risk for medication abuse or to have a history of substance abuse, the physician may use a written agreement between physician and patient outlining patient responsibilities, including:

• There must be only one prescribing doctor and one designated pharmacy;
• The patient will undergo urine/serum drug screening when requested;
• There will be no early refills and no medications called in. If medications are lost or stolen, a police report may be required before additional prescriptions are considered; and
• Documentation of the reasons for which drug therapy may be discontinued, such as violation of a documented doctor-patient 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 reduction in patient's pain intensity and improved physical and/or psychosocial function (ie, ability to work), need for healthcare resources, activities of daily living, and quality of social life. If the patient is not achieving treatment goals 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. The physician should consider using periodic requests for a KASPER Report.

Consultation. The physician should be willing to refer the patient as clinically indicated for additional evaluation and to further achieve treatment objectives. Special attention should be given to those patients with pain who are at risk for misuse of their medications and those whose living arrangement pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a coexisting 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 risk, benefits, and limitations of treatments;
• Treatments;
• Medications (including date, type, dosage, and quantity prescribed);
• Instructions and agreements; and
• Periodic reviews.

Records should remain current and should be maintained in an accessible manner readily available for review.

The physician should not keep initial or periodic KASPER Report(s) as part of the patient's records and should not release these reports to the patient or to a third party.

Compliance With Controlled Substances Laws and Regulations. To prescribe, dispense, or administer controlled substances, the physician must have an active license in the state and comply with applicable federal and state regulations. Physicians should studiously avoid prescribing scheduled drugs for themselves or for immediate family or staff, in accordance with the American Medical Association's Code of Medical Ethics and the Kentucky Medical Practice Act.

The KBML states that it wishes to encourage physicians to use adequate medications to treat their patients with serious pain complaints without undue fear of legal or licensure repercussions. Concurrently, the Board strives to prevent, as much as possible, drug diversion and inappropriate prescribing practice.