A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Maryland

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

History and Physical Examination. It is improper to prescribe any medication for any patient without first taking the steps essential to evaluation. This is particularly true of patients with chronic pain because other treatment modalities may be beneficial and because it is important to recognize the addicted person who may complain of pain as a means to maintain a habit. Prescribing narcotics without a documented evaluation always represents substandard care.

Treatment Plan. Just as treatment for diabetes or hypertension has a specific objective, so should treatment for chronic pain. Frequently, the pain cannot be completely relieved, but the use of analgesic drugs may lead to an improved sense of well-being, better sleep, or even a return to work. The goal of analgesic therapy should be documented and the patient's progress measured against this goal.

Informed Consent. Because long-term narcotic use will usually result in habituation and tolerance (note the old language used by this Board) the physician should discuss these risks with the patient. Alternatives should be offered, if they exist, and the discussion should be documented.

Periodic Review. The course of treatment should be reviewed periodically to determine whether therapeutic goals are being met. Modification of treatment or its discontinuation should be considered, based on the patient's progress (or lack thereof) toward goals. Any new information about the cause of the pain or its treatment should be evaluated and documented.

Consultation. The complexity of chronic pain frequently requires evaluation by consultants who may suggest alternatives or additions to therapy. This may be particularly true for the patient who is at risk for drug misuse.

Records. Adequate documentation is the key to management of patients with pain and is the key to protecting the physician from legal or Board action. Documentation should be sufficient to allow another practitioner to understand and follow through with treatment.

Take time to familiarize yourself with federal and local laws regulating the use of controlled substances for pain. The US Drug Enforcement Administration publishes a Practitioner's Manual, which is available at their Web site at http://www.deadiversion.usdoj.gov, and Maryland laws are available through the Board. The Board hopes that physicians will use these guidelines to help them manage patients with chronic pain without fear of regulatory scrutiny. At the same time, the Board maintains its commitment to prevent the diversion and abuse of opioids.