A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Mississippi

Mississippi General Materials Relating to Pain Management

This summary provides basic information, link to key Web sites with specific materials at www.legalsideofpain.com. There are many additional relevant materials from the State of Mississippi. Legal counsel or legal experts should be consulted if there are any questions. Full text of the material below can be found at: http://www.msbml.state.ms.us/July12007RegBook.pdf.

Patient Record

A physician who prescribes, dispenses, or administers a controlled substance must maintain a complete record of his or her examination, evaluation, and treatment of the patient, which must include documentation of the diagnosis and reason for prescribing, dispensing, or administering any controlled substance; the name, dose, strength, quantity of the controlled substance, and the date that the controlled substance was prescribed, dispensed, or administered.

No physician shall prescribe, administer, or dispense any controlled substance or other drug having addiction-forming or addiction-sustaining liability without a good faith prior examination and medical indication.

• What Constitutes a Good Faith Examination?
  • A determination as to whether a "good faith prior examination and medical indication therefore" exists depends on the facts and circumstances in each case.
  • Standards of proper medical practice require that, on any encounter with a patient, a physician must take 3 steps to establish a proper diagnosis and regimen of treatment:
    1. Take and record an appropriate medical history;
    2. Carry out an appropriate physical examination; and
    3. Record the results.
  • A determination of proper medical indication also requires a careful examination of the nature of the drug and all circumstances surrounding dispensing of the drug.
• Examples of Good Faith Factors.
  • Some of the factors used in determining the existence of good faith may include, but are not limited to: (a) a physician permitting a patient to name the drug desired; (b) a physician dispensing drugs to a patient who has no medical need when the physician knows or should know that the patient is addicted to drugs; (c) a physician writing prescriptions for repeated refills over relatively short periods of time or the issuance of prescriptions at a time when the patient should not have been finished taking the same medication from a prior prescription had the prescription directions been properly followed or the correct dosage taken; (d) general remarks of the physician indicating his or her experience with nontherapeutic uses of the drug; (e) a physician prescribing contraindicated medication such as amphetamines and depressants in a manner that results in therapeutic conflicts.

Use of Controlled Substances for Chronic (Nonterminal) Pain.

Mississippi uses the following definitions relating to the use of controlled medications to treat pain:

• Chronic Pain. Chronic pain is a pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts, including but not limited to, evaluation by the attending physician and one or more physicians specializing in the treatment of the area, system, or organ of the body perceived as the source of the pain. Further, if a patient is receiving controlled substances for the treatment of pain for a prolonged period of time (more than 6 months), the patient will be considered for the purposes of this regulation to have de facto chronic pain and is subject to the same requirements of this regulation.
• Terminal Disease Pain. Terminal disease pain should not be confused with chronic pain. For the purpose of this section, terminal disease pain is pain arising from a medical condition for which there is no possible cure and as a result of which the patient is expected to live no more than six (6) months.
• Acute Pain. 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 therapies, including controlled substances as defined by the US Drug Enforcement Administration.
• Addiction. Addiction is a neurobehavorial 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. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy for pain and should not be considered addiction.
• Physical Dependence. Physical dependence is a physiologic state of neuroadaptation to a substance characterized by the emergence of a withdrawal syndrome if the use of the substance is stopped or decreased abruptly, or if an antagonist is administered. Withdrawal may be relieved by re-administration of the substance. Physical dependence is a normal physiologic consequence of extended opioid therapy for pain and should not be considered addiction.
• 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 the same effect or a reduced effect is observed with a constant dose. Tolerance occurs to different degrees for various drug effects, including sedation, analgesia, and constipation. Analgesic tolerance is the need to increase the dose of opioid to achieve the same level of analgesia. Such tolerance may or may not be evident during treatment and does not equate with addiction.

Opioid Administration

A physician may administer, dispense, or prescribe opioid medications for the purpose of relieving chronic pain, provided the following conditions are met:

• Before initiating treatment, the physician shall conduct an appropriate risk/benefit analysis by reviewing his or her own records of prior treatment or review the records of prior treatment that another treating physician has provided to the physician, to determine that there is an indicated need for long-term controlled substance therapy. Such a determination shall take into account the specifics of each patient's diagnosis, past treatments, and suitability for long-term controlled substance use either alone or in combination with other indicated modalities for the treatment of chronic pain. This must be clearly entered into the patient medical record and should include consultation and referral reports to determine the underlying disease or cause of the chronic pain.
• Documentation in the patient record should include a complete medical history and results of physical examination indicating the presence of one or more recognized medical indications for the use of controlled substances.
• The patient record should include documentation of a written treatment plan that contains both stated objectives as a measure of successful treatment and planned diagnostic evaluations such as psychiatric evaluation or other treatments. The plan should also contain an informed consent agreement for treatment that details relative risks and benefits of the treatment course. This should also include specific requirements of the patient, such as using one physician and pharmacy if possible and urine/serum medication level monitoring when requested.
• Periodic review and documentation of the treatment course is conducted at reasonable intervals (no more than every 6 months) with modification of therapy dependent on the physician's evaluation of progress toward the stated treatment objectives. This should include referrals and consultations as necessary to achieve those objectives.
• It is illegal to administer, dispense, or prescribe a controlled substance or other drug having addiction-forming and addiction-sustaining liability if that action is nontherapeutic in nature or nontherapeutic in the manner the controlled substance or other drug is administered, dispensed, or prescribed.
• If a patient is taking controlled medications in any manner other than in strict compliance with the physician's instructions, the physician is prohibited from continuing to prescribe them to the patient. Mississippi views the following patient actions as coming within the scope of this rule:
  1. Doctor shoppers: Patients who obtain controlled substances or other abusable drugs from more than one physician, and
  2. Those who request early refills: Patients who have obtained or attempted to obtain new prescriptions for controlled substances or other abusable drugs before a prior prescription should have been consumed according to the treating physician's directions.
• This prohibition does not apply if a patient has legitimately increased a dose of pain medication because of an acute exacerbation of his or her condition but has maintained a therapeutic dose level. The treating physician must document in the patient record that such increase in dose level was for a recognized indication and was within appropriate therapeutic dose ranges. Repetitive or continuing escalations should be a reason for concern, and the physician should reevaluate the patient's current treatment plan.

Treating Persons Addicted to Drugs for Pain in Mississippi

• The state prohibits physicians from prescribing any controlled substance or other drug having addiction-forming or addiction-sustaining liability to a patient who is addicted to drugs for the purpose of detoxification treatment or maintenance treatment.
• The state also prohibits physicians from administering or dispensing any narcotic controlled substance for the purpose of detoxification treatment or maintenance treatment unless the physician is properly registered. However, a physician may administer narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral for treatment. Not more than one (1) day's medication may be administered to the person or for the person's use at one time. Such emergency treatment may be carried out for not more than three (3) days. A physician may administer or dispense narcotic controlled substances in a hospital to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction.

Prescription Guidelines: Controlled Substances

• It is the ultimate responsibility of the physician to determine the type, dosage form, frequency of application, and number of refills of any controlled substances prescribed to a patient. This responsibility must never be delegated to nonphysician personnel. Properly certified individuals may act within the scope of their license and, within the scope of their licensing, make preliminary or tentative determination and recommendation to the physician based on assessments and evaluations carried out by the nonphysician personnel, but in all such cases the recommendation of the nonphysician must be reviewed and approved by a physician, who must personally issue the prescription.
• All prescriptions for controlled substances must be written in strict compliance with state and federal laws.
• Table 1 provides an overview of prescribing rules for schedule II through V medications.
• Materials Relating to Controlled Substances in General.
  • All state materials should be read for complete statements about each item.
  • All prescriptions for controlled substances must be written in strict compliance with state laws, which contain requirements for prescription format, use of prescription blanks, and substantive requirements relating to individual drug schedules and other items;
  • On all prescriptions for controlled substances wherein refills are permitted, physicians shall indicate the appropriate refills, not to exceed five (5), or mark "none";
  • Each physician shall ensure that the complete name and address of the patient to whom the physician is prescribing the controlled substance appears on the prescription;
  • A physician shall not permit any prescription for controlled substances to be signed by any nonphysician in the place of or on behalf of the physician;
  • A physician shall not presign blank prescription pads or order forms under any circumstances; and
  • A physician shall not use blank prescription pads or order forms on which the signature of the physician has been electronically, mechanically, or photostatically reproduced.

Prescription Guidelines: All Medications

• Every written prescription delivered to a patient or delivered to any other person on behalf of a patient, must be manually signed on the date of issuance by the physician. This does not prohibit, however, the transmission of electronically telefaxed (but not e-mail) prescriptions for noncontrolled drugs to the pharmacy of the patient's choice. Such telefaxed prescriptions shall bear the signature of the prescribing physician and shall be issued in accordance with all other provisions of this section.
• Prescription drugs shall be dispensed only pursuant to a valid prescription or a valid order. A pharmacist shall not dispense a prescription that the pharmacist knows or should know is not a valid prescription.
• When filling a prescription or refilling a prescription that may be refilled, the pharmacist should exercise professional judgment in the matter. No prescription should be filled or refilled with greater frequency than the approximate interval of time that the dosage regimen ordered by the prescriber would indicate, unless extenuating circumstances are documented that would justify a shorter interval of time before the filling or refilling of the prescription.
• A prescription shall not be refilled after twelve (12) months from the date of issuance.
• No prescriptions for brand name or generic equivalents of nalbuphine HCl, carisoprodol, butalbital compounds, or tramadol HCl shall be telefaxed.
• A prescription shall no longer be valid after the occurrence of any one of the following events:
  • Thirty (30) days after the death of the issuing physician.
  • Thirty (30) days after the issuing physician has moved or otherwise changed the location of his or her practice so as to terminate the doctor/patient relationship. Termination of the doctor/patient relationship results when a patient is no longer able to seek personal consultation or treatment from the issuing physician.

Pharmacy Selection Rule

• A physician may own or operate a pharmacy if there is no resulting exploitation of patients. A physician shall not give a patient any prescriptions in code or enter into agreements with pharmacies or other suppliers regarding the filling of prescriptions by code. Patients are entitled to the same freedom of choice in selecting who will fill their prescription needs as they are in the choice of a physician. The prescription is a written direction for a therapeutic or corrective agent.
• A patient is entitled to a copy of the physician's prescription for drugs or other devices as required by the principles of medical ethics. The patient has a right to have the prescription filled wherever the patient wishes. Where medication is to be dispensed or a prescription, excluding refills, called in to a pharmacist for medication, a physician shall inform each patient of that patient's right to a written prescription and the right to have the prescription filled wherever the patient wishes.
• Violation of Regulations.
  • The prescribing, administering or dispensing of any controlled substance in violation of the above rules and regulations shall constitute the administering, dispensing, or prescribing of any narcotic drug or other drug having addiction-forming or addiction sustaining liability otherwise than in the course of legitimate professional practice, and violates Mississippi law.
  • The prescribing, administering, or dispensing of any legend drug or other medication in violation of the above rules and regulations shall constitute unprofessional conduct and dishonorable or unethical conduct likely to deceive, defraud, or harm the public and violates Mississippi law.

Ending the Physician-Patient Relationship

The full text of this information can be found at http://www.msbml.state.ms.us/July12008PoliciesBook.pdf.

• Once a physician-patient relationship has begun, the physician is under both an ethical and legal obligation to provide services as long as the patient needs them. There may be times, however, when a physician may no longer be able to provide care. It may be that the patient is noncompliant, unreasonably demanding, threatening, or otherwise contributing to a breakdown of the relationship. The decision to terminate the relationship must be made by the physician alone.
• Regardless of the situation, to avoid a claim of "patient abandonment," a physician must follow appropriate steps to terminate the physician-patient relationship. A physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable notice and sufficient opportunity to make other arrangements for care. A physician who does not terminate the relationship properly may be charged with unprofessional conduct.
• Appropriate steps to terminate the physician-patient relationship include:
  • Give the patient or patient's representative written notice, which may be by certified mail return receipt requested, or other reasonable proof. A copy of the letter should be included in the medical record.
  • Provide the patient with a brief and valid reason for terminating the relationship.
  • Agree to continue to provide care for a reasonable period of time (at least 30 days) to allow the patient to obtain care from another physician.
  • Provide recommendations to help the patient locate another physician of like specialty.
  • Offer to transfer records to the new physician upon signed authorization and include an authorization form with the letter.
  • A physician assistant or nurse practitioner may not independently terminate the physician-patient relationship.

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Author Information

Jennifer Bolen, JD, Founder, The Legal Side of Pain, Lenoir City, Tennessee http://www.legalsideofpain.com

Disclosure: Jennifer Bolen, JD, has disclosed that she has received grants for educational activities from King Pharmaceuticals and Cephalon. Ms. Bolen has also disclosed that she has served as an advisor or consultant to King Pharmaceuticals, Abbott Labs, PriCara, Calloway Labs, Millennium Labs, and Cephalon. Ms. Bolen has also disclosed that she serves as a speaker for King Pharmaceuticals, Abbott Labs, PriCara, Calloway Labs, Millennium Labs, and Cephalon.