A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Massachusetts

The Massachusetts Board of Registration in Medicine (Board) references the Model Policy for the Use of Controlled Substances for the Treatment of Pain on its Web site. The Board's Prescribing Practices Policy and Guidelines can be found at http://www.massmedboard.org/regs/pdf/prescribe2.pdf.

Management of Pain

Pain is one of the most common reasons people consult a physician, yet it frequently is inadequately treated, leading to enormous social cost in the form of lost productivity, needless suffering, and excessive healthcare expenditures. --American Pain Society

The Use of Opioids for the Treatment of Chronic Pain

The Board does not wish to discourage physicians from prescribing strong analgesics to relieve the suffering of patients who are in severe pain, both acute and chronic. Opiates and opioids have legitimate clinical usefulness, and physicians should not hesitate to prescribe them when they are indicated for the comfort and well-being of patients who require relief that cannot be provided by nonopiate analgesics and alternative forms of therapy.

When faced with a patient who has acute or chronic pain, physicians should complete a history and physical examination that addresses the nature of the patient's pain and includes an assessment of the patient's risk for addiction. Physicians should consider and explore appropriate alternatives to drug therapy and referral to an established pain clinic. Neuropathic pain is usually not relieved by the use of narcotic analgesics and physicians should look for drugs that have been shown to be effective for that particular symptom.

The treatment plan should be individualized to the patient. The medical record should include documented, careful informed consent and possibly a written agreement signed by the patient. Periodic reassessment and review of the treatment plan should be well documented.

The Board also recognizes that there is a distinction between prescribing solely to maintain a dependency and prescribing to patients with chronic pain who are tolerant to the pain medications they require. Tolerance and physical dependence will probably develop in all patients with the sustained use of narcotic and analgesic drugs. When patients are receiving these drugs for the treatment of legitimate pain, this is rarely a problem.

Beyond these basic principles of pain management, the Board has specifically endorsed the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain that were developed and adopted as policy by the House of Delegates of the Federation of State Medical Boards of the United States in May 1998.

The Board has more recently adopted as policy the updated Federation of State Medical Boards Model Policy, which is available at http://www.massmedboard.org/regs/pdf/use_controlled_substances.pdf

Model Policy for the Use of Controlled Substances for the Treatment of Pain of the Federation of State Medical Boards of the United States, Inc.

The recommendations contained herein were adopted as policy by the House of Delegates of the Federation of State Medical Boards of the United States, Inc., May 2004.

Introduction

The Federation of State Medical Boards (the Federation) is committed to assisting state medical boards in protecting the public and improving the quality and integrity of healthcare in the United States. In 1997, the Federation undertook an initiative to develop model guidelines and to encourage state medical boards and other healthcare regulatory agencies to adopt policies that encourage adequate treatment, including use of opioids when appropriate for patients with pain. The Federation thanks the Robert Wood Johnson Foundation for awarding a grant in support of the original project and the American Academy of Pain Medicine; the American Pain Society; the American Society of Law, Medicine, & Ethics; and the University of Wisconsin Pain & Policy Studies Group for their contributions.

Since adoption in April 1998, the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain have been widely distributed to state medical boards, medical professional organizations, other healthcare regulatory boards, patient advocacy groups, pharmaceutical companies, state and federal regulatory agencies, and practicing physicians and other healthcare providers. The Model Guidelines have been endorsed by the American Academy of Pain Medicine, the US Drug Enforcement Administration (DEA), the American Pain Society, and the National Association of State Controlled Substances Authorities. Many states have adopted pain policy using all or part of the Model Guidelines.

Despite increasing concern in recent years regarding the abuse and diversion of controlled substances, pain policies have improved as a result of the efforts of medical, pharmacy, and nursing regulatory boards that have committed to improving the quality of and access to appropriate pain care.

Notwithstanding progress to date in establishing state pain policies recognizing the legitimate uses of opioid analgesics, there is a significant body of evidence suggesting that both acute and chronic pain continue to be undertreated. Many patients who are terminally ill unnecessarily experience moderate to severe pain in the last weeks of life. The undertreatment of pain is recognized as a serious public health problem that results in a decrease in patients' functional status and quality of life and may be attributed to a myriad of social, economic, political, legal, and educational factors, including inconsistencies and restrictions in state pain policies. Circumstances that contribute to the prevalence of undertreated pain include: (1) lack of knowledge of medical standards, current research, and clinical guidelines for appropriate pain treatment; (2) the perception that prescribing adequate amounts of controlled substances will result in unnecessary scrutiny by regulatory authorities; (3) misunderstanding of addiction and dependence; and (4) lack of understanding of regulatory policies and processes. Adding to this problem is the reality that the successful implementation of state medical board pain policy varies among jurisdictions.

In April 2003, the Federation membership called for an update to its Model Guidelines to assure currency and adequate attention to the undertreatment of pain. The goal of the revised model policy is to provide state medical boards with an updated template regarding the appropriate management of pain in compliance with applicable state and federal laws and regulations. The revised policy notes that the state medical board will consider inappropriate treatment, including the undertreatment of pain, a departure from an acceptable standard of practice. The title of the policy has been changed from Model Guidelines to Model Policy to better reflect the practical use of the document. The Model Policy is designed to communicate certain messages to licensees: that the state medical board views pain management as being important and integral to the practice of medicine; that opioid analgesics may be necessary for the relief of pain; that the use of opioids for other than legitimate medical purposes poses a threat to the individual and society; that physicians have a responsibility to minimize the potential for the abuse and diversion of controlled substances; and that physicians will not be sanctioned solely for prescribing opioid analgesics for legitimate medical purposes. This policy is not meant to constrain or dictate medical decision-making.

Through this initiative, the Federation aims to achieve more consistent policy in promotion of adequate pain management and education of the medical community about treating pain within the bounds of professional practice and without fear of regulatory scrutiny. In promulgating this Model Policy, the Federation strives to encourage the legitimate medical uses of controlled substances for the treatment of pain while stressing the need to safeguard against abuse and diversion.

State medical boards are encouraged, in cooperation with their state's attorney general, to evaluate their state pain policies, rules, and regulations to identify any regulatory restrictions or barriers that may impede the effective use of opioids to relieve pain. Accordingly, this Model Policy has been revised to emphasize the professional and ethical responsibility of the physician to assess patients' pain as well as to update references and definitions of key terms used in pain management.

The Model Policy is not intended to establish clinical practice guidelines nor is it intended to be inconsistent with controlled substance laws and regulations.

1. As of January 2004, 22 of 70 state medical boards have policy, rules, regulations, or statutes reflecting the Federation's Model Guidelines for the Use of Controlled Substances for the Treatment of Pain and two (2) states have formally endorsed the Model Guidelines.
2. SUPPORT Study Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;274:1591-1598.
3. Gilson AM, Joranson DE, Mauer MA. Improving medical board policies: influence of a model. J Law Medicine Ethics. 2003;31:128.

Model Policy for the Use of Controlled Substances for the Treatment of Pain Adopted by the Massachusetts Board of Registration in Medicine, December 15, 2004

Section I: Preamble

The Massachusetts Board of Registration in Medicine recognizes that principles of quality medical practice dictate that the people of the Commonwealth of Massachusetts 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 patients with pain as well as reduce the morbidity and costs associated with untreated or inappropriately treated pain. For the purposes of this policy, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments.

The diagnosis and treatment of pain is integral to the practice of medicine. The Board encourages physicians to view pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness. All physicians should become knowledgeable about assessing patients' pain and effective methods of pain treatment, as well as statutory requirements for prescribing controlled substances. Accordingly, this policy has been developed to clarify the Board's position on pain control, particularly as related to the use of controlled substances, to alleviate physician uncertainty and to encourage better pain management.

Inappropriate pain treatment may result from physicians' lack of knowledge about pain management. Fears of investigation or sanction by federal, state, and local agencies may also result in inappropriate treatment of pain. Appropriate pain management is the treating physician's responsibility. As such, the Board will consider the inappropriate treatment of pain to be a departure from standards of practice and will investigate such allegations, recognizing that some types of pain cannot be completely relieved, and taking into account whether the treatment is appropriate for the diagnosis.

The Board recognizes that controlled substances, including opioid analgesics, may be essential in the treatment of acute pain resulting from trauma or surgery and chronic pain, whether from cancer or noncancer origins. The Board will refer to current clinical practice guidelines and expert review in approaching cases involving management of pain. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and nonpharmacologic modalities according to the judgment of the physician. Pain should be assessed and treated promptly, and the quantity and frequency of doses should be adjusted according to the intensity and duration of the pain and treatment outcomes. Physicians should recognize that tolerance and physical dependence are normal consequences of the sustained use of opioid analgesics and are not the same as addiction.

The Massachusetts Board of Registration in Medicine is obligated under the laws of the Commonwealth to protect the public health and safety. The Board recognizes that the use of opioid analgesics for other than legitimate medical purposes poses a threat to the individual and to society and that the inappropriate prescribing of controlled substances, including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate medical use. Accordingly, the Board expects that physicians will incorporate safeguards into their practices to minimize the potential for abuse and diversion of controlled substances.

Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing, or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. The Board will consider prescribing, ordering, dispensing, or administering controlled substances for pain to be for a legitimate medical purpose if based on sound clinical judgment. All such prescribing must be based on clear documentation of unrelieved pain. To be within the usual course of professional practice, a physician-patient relationship must exist and the prescribing should be based on a diagnosis and documentation of unrelieved pain. Compliance with applicable state or federal law is required.

The Board will judge the validity of the physician's treatment of the patient based on available documentation rather than solely on the quantity and duration of medication administration. The goal is to control the patient's pain while effectively addressing other aspects of the patient's functioning, including physical, psychological, social, and work-related factors.

Allegations of inappropriate pain management will be evaluated on an individual basis. The Board will not take disciplinary action against a physician for deviating from this policy when contemporaneous medical records document reasonable cause for deviation. The physician's conduct will be evaluated to a great extent by the outcome of pain treatment, recognizing that some types of pain cannot be completely relieved, and by taking into account whether the drug used is appropriate for the diagnosis, as well as any improvement in patient functioning and/or quality of life.

Section II: Guidelines

The Board has adopted the following criteria when evaluating the physician's treatment of pain, including the use of controlled substances:

Evaluation of the Patient. A medical history and physical examination must be obtained, evaluated, and documented in the medical record. 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 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).

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. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in 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. Special attention should be given 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:

1. The medical history and physical examination;
2. Diagnostic, therapeutic, and laboratory results;
3. Evaluations and consultations;
4. Treatment objectives;
5. Discussion of risks and benefits;,
6. Informed consent;
7. Treatments;
8. Medications (including date, type, dosage and quantity prescribed);
9. Instructions and agreements; and
10. Periodic reviews.

Records should remain current and be maintained in an accessible manner and 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 are referred to the Physicians Manual of the US Drug Enforcement Administration (and any relevant documents issued by the state medical board) for specific rules governing controlled substances as well as applicable state regulations.

Section III: Definitions

For the purposes of these guidelines, the following terms are defined as follows:

Acute Pain. Acute pain is the normal, predicted physiologic response to a noxious chemical, thermal, or mechanical stimulus and typically is associated with invasive procedures, trauma, and disease. It is generally time-limited.

Addiction. Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use, and continued use despite harm. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy for pain and are not the same as addiction.

Chronic Pain. Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.

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 is a state of adaptation that is manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence, by itself, does not equate with addiction.

Pseudoaddiction. The iatrogenic syndrome resulting from the misinterpretation of relief-seeking behaviors as though they are drug-seeking behaviors commonly seen with addiction. Relief-seeking behaviors resolve when effective analgesic therapy is instituted.

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 a specific effect or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction.

Prescriptions

The following are excerpts from the Massachusetts Board of Registration in Medicine Prescribing Practices Policy and Guidelines. The entire document can be found at: http://www.massmedboard.org/regs/pdf/prescribe2.pdf

Prescriptions Must Be Issued in the Usual Course of Professional Practice and for a Legitimate Medical Purpose. A prescription for a controlled substance to be valid shall be issued for a legitimate medical purpose by a practitioner acting in the usual course of his professional practice… An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription within the meaning and intent [of this act]. M.G.L. c. 94C, § 19(a)

This statutory language sets forth the minimum requirements that must be met for a prescription to be valid in the Commonwealth. In sum, the standard of conduct proposed by Chapter 94C can be broken down into 2 requirements. To be valid, a prescription must be:

• Issued for a legitimate medical purpose; and
• Issued by a practitioner in the usual course of his or her professional practice.

The Board discussed these standards in depth in the disciplinary case In the Matter of Arthur E. Baer, MD, Adjudicatory Case No. 205, Final Decision and Order (July 14, 1978). The following summarizes the standards established in the Baer decision:

1. Legitimate Medical Purpose. The general standard for whether a prescription is issued for a legitimate medical purpose is often regarded as a question of whether the physician was acting in good faith in issuing the prescription. Several indications of the lack of good faith are furnished by case law. They are as follows:

   1. Failure to follow at least minimum professional procedures (see discussion below of the requirement that a prescription be issued by a practitioner in the usual course of his or her professional practice);
   2. The physician permitting the patient to name the drug he or she desires;
   3. The physician expressing concern during a patient encounter about how and where a prescription would be filled in a manner that does not indicate a good faith concern for the patient;
   4. Repeated refills over relatively short periods;
   5. General remarks of the physician indicating his or her experience with nontherapeutic uses of the drug and of drug enforcement actions and procedures;
   6. Failure to schedule appropriate additional appointments for return visits and other factors, indicating a lack of interest in follow-up care; and
   7. Conversations and other circumstances that demonstrate that the physician knew that the drugs were not to be used for a therapeutic or medical purpose.

   Physicians should remember that these are merely indications of a lack of good faith that state or federal authorities might look for in scrutinizing a physician's prescribing practices.

2. In the Usual Course of a Practitioner's Practice. To satisfy the requirement that a prescription be issued by a practitioner in the usual course of his or her professional practice, there must be a physician-patient relationship that is for the purpose of maintaining the patient's well-being, and the physician must conform to certain minimum norms and standards for the care of patients.

   A minimum standard of proper medical practice requires that the physician establish a proper diagnosis and regimen of treatment. At a minimum, on first encounter with a patient, a physician must:

   • Take and record an appropriate medical history; and
   • Carry out an appropriate physical and/or mental status examination and record the results.

   The paramount importance of a complete medical history is well established. The importance of the physical examination in making a correct diagnosis and establishing a course of treatment is also well documented.

   The observance of these procedures as a function of the "usual course of professional practice" is of particular importance when controlled substances are to play a part in the course of treatment. It is the responsibility of the physician to prescribe drugs with proper regard for their action and potential dangers. Such procedures not only ensure that the patient obtains correct treatment but they may also prevent adverse reactions to drugs, which are a common cause of morbidity, and less commonly, of mortality.

   Failure to obtain an appropriate medical history and conduct an appropriate examination may not only have serious consequences for the patient, but it can also lead to difficulties for the physician as well, including malpractice claims and Board investigations. Careless diagnosis is as serious as careless treatment and frequently leads to allegations of misconduct. Physicians who have been disciplined by the Board for prescription practice violations have written prescriptions for potentially dangerous controlled substances without conducting any physical examinations or after conducting only cursory examinations.

   Beyond documenting appropriate medical histories and physical examinations, physicians must maintain medical records that are detailed enough in nature that the physician's clinical reasoning is implicit in his or her documentation. Treatment plans should be explicitly recorded. All patient visits and telephone calls relating to treatment should be documented. Prescriptions should be documented, and changes in medications or dosage should be explained. These are, of course, just some of the rudiments of complete medical records.

DEA Prescription Guidelines

The DEA has issued these general guidelines for prescribers of controlled substances (ie, schedules II-V). These guidelines have been endorsed by the American Medical Association. The Board endorses these general guidelines.

1. Controlled substances have legitimate clinical usefulness, and the prescriber should not hesitate to consider prescribing them when they are indicated for the comfort and well-being of patients.
2. Prescribing controlled substances for legitimate medical uses requires special caution because of their potential for abuse and dependence.
3. Good judgment should be exercised in administering and prescribing controlled substances so that diversion to illicit uses is avoided and the development of drug dependence is minimized or prevented.
4. Physicians should guard against contributing to drug abuse through injudicious prescription-writing practices or by acquiescing to the unwarranted demands of some patients.
5. Each prescriber should examine his or her individual prescribing practices to ensure that all prescriptions for controlled substances are written with caution.
6. Physicians should make a specific effort to ensure that patients are not obtaining multiple prescription orders from different prescribers.

Further Prescription Guidelines

The following more specific guidelines include DEA guidelines and Massachusetts law and are based on principles the Board articulated in the Baer decision and other Board decisions.

1. The Prescription Must Be Manually Signed When Written. The prescription order must be signed by the prescriber when it is written. A rubber stamp signature may not be used.
2. The Prescription Must Be Legible. The written prescription order should be precise and distinctly legible to enhance exact and effective communication between prescriber and dispenser.
3. Refills Must Be Indicated. The prescription order should indicate whether it may be refilled and, if so, the number of times or the duration for which refill is authorized. Unlike practice in other states, the term "PRN" (pro re nata) has no meaning with respect to refills in Massachusetts. If no refills are permitted, the physician should indicate "no refills" to prevent patients from adding refills in their own hand. Prescription orders for schedule III and IV drugs may be refilled if so authorized on the prescription order. However, prescriptions for schedule III and IV drugs may only be refilled up to 5 times within 6 months after the date of issue. The refilling of schedule II prescription orders is prohibited. Controlled substances that are prescribed without an indication for refills cannot be refilled without authorization by the prescriber.
4. Prescriptions Should Be Alteration-Proof. When prescribing a drug, the actual amount should be written out as well as given in numbers, with the number enclosed in parentheses or brackets to prevent the number from being altered. Prescribers should consider placing a number of check-off boxes on their prescription blanks to show the range of the prescribed amount, such as 1-25, 26-50, 51-100, and more than 100.
5. DEA Numbers Should Be Handwritten or Stamped. The Board discourages physicians from using prescription pads with a preprinted DEA registration number. Preprinting makes it easier for someone in possession of a stolen or forged prescription pad to write a falsified prescription. Physicians should consider using prescription pads with carbon copies or numbered prescription pads.
6. Write Indications on Prescription. The Board suggests that the indications be written directly on prescriptions for stronger drugs. Although this may not always be appropriate or necessary, including the indications on the prescription provides additional documentation of the physician's care.
7. Information on the Prescription Must Be Truthful. It is illegal for a prescription to be issued by a physician using the name of another physician or in the name of a person who is not the ultimate user of the drug. Problems of this nature usually arise when a physician is purposefully attempting to self-prescribe to conceal a chemical dependency. A physician should also be careful that his or her name is not being signed by colleagues on prescriptions and should be alert to the possibility that a patient might be obtaining drugs for ultimate use by other persons.
8. Separate Blanks Are Required for Separate Substances. A separate prescription blank must be used for each controlled substance prescribed. 105 CMR 721.035 states that practitioners who wish to prescribe more than one drug product with the same or different dispensing instructions shall place each prescription on a separate prescription form. More than one drug product may be prescribed on a single form in a hospital setting for the treatment of diseases specified on a list established by the Department of Public Health, provided that the prescription form sufficiently permits clear directions for use and interchange.
9. Beware of Fake Medical Records. Physicians should be aware that patients sometimes alter their prior medical records, acquired from another physician, to obtain drugs from a new physician. Physicians can avoid this problem by speaking with the previous physician to verify prior care claimed by the patient orally or through a medical record.
10. Put Identifying Information on Institutional Prescription Blanks. When institutional prescription blanks are used, the prescriber must print his or her name under his or her signature. The physician's address and DEA registration number (or hospital DEA number with assigned suffix) should also be on such blanks.
11. Predating and Postdating Are Prohibited. The date of issuance must appear on the prescription and no other date may appear. This means that predating or postdating prescriptions is prohibited. Keep in mind that a prescription does not have to be filled on the date it is issued. Schedule II prescriptions may be filled within 30 days of issuance. Schedule III and IV prescriptions are valid for 6 months. Schedules V and VI prescriptions may be filled for an unspecified period after the date of issuance.
12. Do Not Overprescribe. Physicians should prescribe no greater quantity of a drug than is needed until the next check-up. Physicians may prescribe no more than a 30-day supply of schedule II or III controlled substances on any single filling.
13. Patient Contact Must Be Maintained. The Board has interpreted "proper medical practice" to require that physicians remain in close contact with patients to whom they prescribe stronger drugs. In general, the Board believes that where a physician is prescribing controlled substances over a long period of time to a patient whose disease process is stable, proper medical practice requires that:
• The physician see the patient at least once every 6 months; or
• The physician write a note in his or her records explaining why it is impossible, impractical, or inappropriate to see the patient at least once every 6 months. Those occasions when it is all right to go more than 6 months without seeing a patient who is receiving controlled substances, even if a note is made in the record, should be extremely rare.

The Board strongly urges physicians to see patients who are using schedule II drugs as frequently as possible and suggests that these patients be clinically reevaluated at least every 4 months. At a minimum, the physician should speak with the patient or the patient's primary care physician by telephone before issuing a new schedule II prescription.

14. Make Reasonable Efforts to Coordinate Treatment. When a physician knows or has reason to believe that a patient is receiving treatment from another physician, the Board strongly encourages the physician to make reasonable efforts to coordinate treatment so that a patient is not independently receiving prescriptions for similar potentially dangerous controlled substances from more than one physician. It is the Board's position that when a primary care physician and a specialist are both treating a patient, it is the specialist who is obligated to inform the primary physician about any treatment rendered to a mutual patient.

    Physicians should also note that M.G.L. c. 94C, § 33(b) prohibits patients from obtaining controlled substances by deception or subterfuge through the nondisclosure of a material fact. Physicians should encourage all patients to disclose whether they are receiving drugs from another physician before prescribing additional drugs to them. At a minimum, a physician should ask whether a patient is seeing, or has recently seen, another physician and, if so, whether the other physician has prescribed medication for the patient. In the event that the patient is seeing another doctor, the physician, before prescribing schedule II and III drugs, may want to contact the other doctor to verify that the patient is not already being treated with drugs that would be incompatible with the prescription of certain controlled substances. Phone verification may be particularly appropriate where the patient is unfamiliar to the physician or the physician has reason to question the patient's candor. Such coordination of treatment may be critical to preventing serious drug interactions in addition to preventing drug addiction or diversion.

    When a physician consults with another doctor concerning a common patient, the conversation should be documented in the patient's medical records. It may be wise in some circumstances to write a note to the other doctor that says, "We are both treating patient A, and I am prescribing drugs X, Y, and Z."

15. Prescribing on Request May Be Improper. Physicians must exercise independent judgment when prescribing and not prescribe simply on demand. Patient requests for specific drugs, especially schedule II and III controlled substances, should be regarded as potential warning signals by the physician, particularly when the physician is not familiar with the patient or the patient's history. In such a situation, the physician should be especially cautious to ascertain that the patient is not seeking the drug for illegitimate uses. Obviously, the patient is often the best and only source of what alleviates his or her pain or other symptoms, and the Board does not wish to suggest that using the patient as a source of information is in any way improper.
16. Avoid Cursory Examinations. Patient examinations, particularly initial examinations, should be thorough and should include the taking of an appropriate medical history. As part of any initial examination, the physician or the staff should document the patient's social situation, as social factors often contribute to drug diversion. Because each patient is unique, there are no universal examination requirements that govern every patient visit. In general, the accepted standards of professional conduct should guide the physician when examining a patient.

17. Exercise Care When Covering for Other Physicians. The Board recognizes that covering and cross-covering for other physicians is part of good medical practice, and often the covering physician will write a prescription for a patient who the covering physician has neither seen nor examined. In these situations, the covering physician is acting in reliance on the treating physician's examination.

    As long as the covering physician's reliance is reasonable, this practice is perfectly permissible. The covering physician's reliance on another physician's examination will be presumed to be reasonable if the covering physician verifies the identity of the treating physician, discusses the patient's case with the treating physician, prescribes only that amount of medication necessary until the treating physician can again assume control of the patient's treatment, and documents his or her coverage accurately. Particular care must be taken when the covering physician is prescribing schedule II substances to a patient who the covering physician has not personally examined.

18. Record Accurately Examination Results and Prescriptions Written. The appearance of impropriety can result if a physician prescribes a controlled substance based on an examination that is not properly and accurately recorded. In addition, all prescriptions written should be accurately recorded in the patient's record.
19. Phone in First Prescription if Suspicious of New Patient. On a patient's initial visit, the physician may want to inquire what pharmacy the patient uses and call in the prescription personally if the physician has reason to be suspicious of the patient. This permits the physician to determine whether the patient is being truthful about actually using the pharmacy and may enable the physician to discover what other drugs, if any, the patient is being prescribed by other physicians.

[ CLOSE WINDOW ]

Author Information

David B. Brushwood, RPh, JD, Professor, University of Florida College of Pharmacy, Gainesville

Disclosure: David B. Brushwood, RPh, JD, has disclosed no relevant financial relationships.