A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Montana

Montana Municipal Regulations for Medicine

Statement on the Use of Controlled Substances in the Treatment of Intractable Pain

The full text of the statement can be found at http://mt.gov/dli/bsd/license/bsd_boards/med_board/pdf/chronic_pain.pdf.

• The Montana Board of Medical Examiners continues to be concerned about the use of controlled substances by individuals who seek them for their mood-altering and addictive potential rather than for legitimate medical reasons. However, the Board is also concerned about adequate pain management.
• The Board recognizes that pain from whatever cause is often undertreated. The Board is aware that there are a number of factors that continue to interfere with effective pain management. These include exaggerated fears of opioid side effects, including addiction, fear of legal consequences when controlled substances are used, low priority of proper pain management in our healthcare system, and the lack of integration of current knowledge concerning pain management into medical education and clinical practice.
• The Board seeks to assure that no Montanan requiring narcotics for pain relief is denied them because of a physician's real or perceived fear that the Board of Medical Examiners will take disciplinary action based solely on the use of narcotics to relieve pain. Although improper use of narcotics, like any improper medical care, will continue to be a concern of the Board, the Board is aware that treatment of malignant and especially nonmalignant pain is a very difficult task. The Board does not want to be a hindrance to the proper use of opioid analgesics. Treatment of chronic pain is multifactorial, and certainly treatment with modalities other than opioid analgesics should be used, usually before long-term opioids are prescribed. Use of new or alternative types of treatment should always be considered for intractable pain periodically, in attempts to either cease opioid medications or reduce their use.
• The proper use of opioid analgesics for chronic pain must involve certain elements that are consistent with any quality medical care. The following guidelines will help assure the proper use of these medications for chronic pain and minimize improper use. These guidelines have been provided in the form of a policy letter from the Board of Medical Examiners to providers in the state.

Guidelines for Prescribing Opioid Analgesics for Chronic Pain

• Thorough History and Physical Examination. Included in the history is an assessment of the cause of the pain, the physical and psychological function of the patient, substance abuse history, other treatments that have been attempted to control the patient's level of pain, identification of underlying or coexisting diseases or conditions, and as much as possible, statements by all treating physicians that the patient's pain is intractable and cannot be controlled by other than the use of opioid analgesics.
• Treatment Plan. A thoroughly documented, written treatment plan should be established and should include how treatment success will be evaluated, such as pain relief and improved physical or psychological functioning. Several treatment modalities should be used in most cases and should be administered concurrently with opiates. Periodic review by the physician should be accomplished to determine whether other appropriate treatment methods would be of additional benefit to the patient.
• Informed Consent. The physician should discuss the risks and benefits of the use of controlled substances with the patient and/or guardian. This discussion should be ongoing, not only at the initiation of treatment.
• Appropriate Referral. If treatment objectives are not being realized or if patients appear to be at risk for misuse of medications, referral should be made to appropriate specialists, including specialists in addiction medicine and chronic pain.

• Documentation. All the above recommendations and guidelines should be recorded accurately and completely in the patient's medical record.

  The Montana Board of Medical Examiners hopes that the above statements and guidelines will help reverse the trend of undertreatment of intractable pain, and that the guidelines will facilitate the more appropriate use of controlled substances by duly licensed practitioners with prescriptive authority in the State of Montana.

Statement of the Prescribing and Filling of Controlled Substances in the Treatment of Chronic Pain

• The Montana Board of Medical Examiners, Montana Board of Nursing and Montana Board of Pharmacy recognize that pain has historically been undertreated because of an exaggerated fear of patient addiction and diversion of pain medication with corresponding fear of legal consequences and a lack of current knowledge concerning pain management. Untreated chronic pain can lead to clinical exacerbations, increased suffering and eventual disability. Patient requests for more pain medication can often be interpreted as drug-seeking behavior, when inadequately treated pain is actually the cause.
• Improper prescribing and dispensing of opioids will continue to be a concern of the Montana Board of Medical Examiners, Board of Nursing, and the Board of Pharmacy. However, appropriate prescribing of opioid analgesics should be encouraged by all those involved in patient care. Both the physician or other healthcare provider and the pharmacist share responsibility for appropriate prescribing of opioid pain medication. The Board of Medical Examiners has established a policy for appropriate treatment of chronic pain, which is outlined below. With use of these guidelines and appropriate communication between practitioners and pharmacists, inappropriate use of opioid pain medications will be minimized. If a pharmacist has suspicion of the inappropriateness of a pain medication, he or she should contact the practitioner concerning this issue. A pharmacist evaluating a controlled substance prescription should consider the following points:
  • Are you able to verify the identity of the prescriber and the patient?
  • What is the physical condition and demeanor of the patient with respect to the drug being prescribed? Is the prescribed drug therapeutically appropriate to the patient's diagnosis?
  • Does the patient live within the general area of the pharmacy? If not, is the distance great enough to make it unlikely the patient would travel so far to fill a legitimate prescription?
  • Does the drug prescribed have a pattern of abuse, and does the patient have any known history of drug abuse or misuse that might contraindicate the use of this drug?
  • Is the prescription consistent with the prescribing patterns of the practitioner, including the type and amount of drug prescribed? Does the practitioner write for a greater than usual percentage of controlled substances? Are you aware of any prior disciplinary or criminal action involving the practitioner?
  • Are the drugs prescribed consistent with the practitioner's specialty and scope of practice?
  • Does the prescription contain an unusual combination of drugs, or drugs that antagonize one another?
  • Does the quantity of drug prescribed and refills authorized differ appreciably from recognized and accepted prescribing practices?
• Studies have shown that the abuse potential of opioids is generally low in healthy volunteers who do not abuse drugs. Practitioners are encouraged to reverse the trend of undertreatment of pain yet should remain aware of the dangers of diversion and nonmedical use of controlled substances. It is imperative that pharmacists and prescribers continue to strive for open and clear lines of communication regarding their patients' use and possible misuse of medications.
• The Boards of Medical Examiners, Nursing, and Pharmacy seek to assure that no Montana resident will needlessly suffer because of undertreated pain and the Boards encourage prescribers and pharmacists to do their part by responsibly prescribing and dispensing opioid medications.

[ 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.