A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Nevada

Disciplinary Action

Standards of Practice

NAC 630.187 Adoption by Reference of Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.

1. The Board hereby adopts by reference the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain, May 1998, published by the Federation of State Medical Boards of the United States, Inc., and any subsequent revision of the publication that has been approved by the Board for use in this State. Each revision of the publication shall be deemed approved by the Board unless it disapproves of the revision within 60 days after the date of publication of the revision.
2. The most recent publication of the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain that has been approved by the Board will be available for inspection at the office of the Board of Medical Examiners, 1105 Terminal Way, Suite 301, Reno, Nevada, or may be obtained, free of charge, from the Federation of State Medical Boards of the United States, Inc., Federation Place, 400 Fuller Wiser Road, Suite 300, Euless, Texas 76039-3855, or from the Federation of State Medical Boards of the United States, Inc., at the Internet address http://www.fsmb.org. The Board shall:
   1. Review each revision of the publication to ensure its suitability for this State; and
   2. File a copy of each revision of the publication it approves with the Secretary of State and the State Library and Archives Administrator.

Model Policy for the Use of Controlled Substances for the Treatment of Pain 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 policy encouraging adequate treatment, including the 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 Drug Enforcement Administration, 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 because of the efforts of medical, pharmacy, and nursing regulatory boards 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, a significant body of evidence suggests 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 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

• Section I: Preamble. The (name of board) recognizes that principles of quality medical practice dictate that the people of the State of (name of state) 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 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 the 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 sustained use of opioid analgesics and are not the same as addiction.

  The (name of board) is obligated under the laws of the State of (name of state) 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 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 physicians to incorporate safeguards into their practice to minimize the potential for the 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 continuing the current treatment plan and should consider 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 should be maintained in an accessible manner 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 U.S. 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. The manual is available at: http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html
• Section III: Definitions. For the purpose of the guidelines, 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 that are commonly seen with addiction. The relief-seeking behaviors resolve upon institution of effective analgesic therapy.
  • 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.

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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.