A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: North Carolina

Project Lazarus and Related Materials

• Project Lazarus is the first program of its kind in the South, the first prescription naloxone program to target pharmaceutical opioids, and the first time naloxone has been incorporated into pain management. Information about the project is hosted on the North Carolina Medical Board's Web site http://www.ncmedboard.org/HomeFrame.aspx

North Carolina Medical Practice Act

• This is a voluminous act and should be read by the physician in its entirety. It is available at: http://www.ncmedboard.org/Clients/NCBOM/Public/PublicMedia/mpa2.pdf

Position Statements of the North Carolina Medical Board

• The North Carolina Medical Board has several position statements -- some general and some specific to pain management. Portions of key position statements are shown below. Read the entire statement before addressing the need for changes to your current medical practice.

Position Statement: What Are the Position Statements of the Board and to Whom Do They Apply?

• In North Carolina, position statements are interpretive statements that attempt to define or explain the meaning of laws or rules that govern the practice of physicians,* physician assistants, and nurse practitioners in North Carolina, usually relating to discipline. They also set forth criteria or guidelines used by the Board's staff in investigations and in the prosecution or settlement of cases.

Position Statement: The Physician-Patient Relationship

• This position statement sets out the physician's duties to patients. It states a physician may not neglect a patient nor fail for any reason to prescribe the full care that patient requires in accordance with the standards of acceptable medical practice. In North Carolina, it is unethical for a physician to allow financial incentives or contractual ties of any kind to adversely affect his or her medical judgment or patient care. The full position statement is available at: http://www.ncmedboard.org/Clients/NCBOM/Public/NewsandForum/phypat.htm

Position Statement: Medical Record Documentation

• North Carolina takes the position that physicians and physician extenders should maintain accurate patient care records of history, physical findings, assessments of findings, and the plan for treatment. The Board recommends the Problem Oriented Medical Record method known as SOAP (developed by Lawrence Weed). NOTE: This is not the SAOPP R used in the pain community for risk assessment. Read the entire position statement at: http://www.ncmedboard.org/Clients/NCBOM/Public/NewsandForum/recdoc.htm

Position Statement: Contact With Patients Before Prescribing

• In North Carolina, it is inappropriate to prescribe drugs to an individual the prescriber has not personally examined, except in the circumstances listed below. The North Carolina Board recommends that before a physician prescribes a drug, he or she should "make an informed medical judgment based on the circumstances of the situation and on his or her training and experience." An appropriate history and physical examination is required, along with a diagnosis and a therapeutic plan, which may include medications. The entire process must be documented appropriately. Exceptions to the personal examination requirement include:
  1. admission orders for a newly hospitalized patient,
  2. prescribing for a patient of another physician for whom the prescriber is taking call, or
  3. continuing medication on a short-term basis for a new patient prior to the patient's first appointment.
  Established patients may not require a new history and physical examination for each new prescription, depending on good medical practice. Finally, in North Carolina it is inappropriate and unprofessional to prescribe drugs to individuals the physician has never met based solely on answers to a set of questions, as is common with Internet or toll-free telephone prescribing.

Position Statement: Writing of Prescriptions

• Prescriptions should be written in ink or indelible pencil or typewritten or electronically printed and should be signed by the practitioner at the time of issuance. Quantities should be indicated in both numbers AND words for example, 30 (thirty). Such prescriptions must not be written on presigned prescription blanks. Each prescription for a Drug Enforcement Agency (DEA) controlled substance (2, 2N, 3, 3N, 4, and 5) should be written on a separate prescription blank. Multiple medications may appear on a single prescription blank only when none are DEA-controlled. No prescriptions should be issued for a patient in the absence of a documented physician-patient relationship. No prescription should be issued by a practitioner for his or her personal use. (See Position Statement entitled "Self-Treatment and Treatment of Family Members and Others With Whom Significant Emotional Relationships Exist.") The practice of presigning prescriptions is unacceptable to the Board. It is the responsibility of those who prescribe controlled substances to fully comply with applicable federal and state laws and regulations. Links to these laws and regulations may be found on the Board's Web site (www.ncmedboard.org)

Position Statement: Self-Treatment and Treatment of Family Members and Others With Whom Significant Emotional Relationships Exist

• Except for minor illnesses and emergencies, physicians should not treat, medically or surgically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. When a minor illness or emergency requires self-treatment or treatment of a family member or other person with whom the physician has a significant emotional relationship, the physician must prepare and keep a proper written record of that treatment, including but not limited to prescriptions written and the medical indications for them. Record keeping is too frequently neglected when physicians manage such cases. The Board expects physicians to delegate the medical and surgical care of themselves, their families, and those with whom they have significant emotional relationships to one or more of their colleagues to ensure that appropriate and objective care is provided and to avoid misunderstandings related to their prescribing practices.

Position Statement: Policy for the Use of Controlled Substances for the Treatment of Pain

• Controlled substances, including opioid analgesics, may be an essential part of the treatment regimen. All prescribing of controlled substances must comply with applicable state and federal law.
• Guidelines for treatment include:
  1. complete patient evaluation, including pain history, physical examination, and risk assessment;
  2. establishment of a treatment plan;
  3. informed consent and treatment agreement; (d) periodic review; and
  4. consultation with specialists in various treatment modalities as appropriate.
  Deviation from these guidelines will be considered on an individual basis for appropriateness. The Board essentially follows the Federation of State Medical Board's Model Policy for the Use of Controlled Substances for the Treatment of Pain (4/04), which is available at http://www.fsmb.org/pdf/2004_grpol_controlled_substances.pdf
• 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 improvement in patient functioning and/or quality of life.
• Sources: (Adopted September 1996 as "Management of Chronic Non-Malignant Pain." Redone July 2005 based on the Federation of State Medical Board's "Model Policy for the Use of Controlled Substances for the Treatment of Pain," as amended by the Federation of State Medical Boards in 2004.)

Position Statement: End-of-Life Responsibilities and Palliative Care

• The North Carolina board has a position statement on End-of-Life Responsibilities and Palliative Care. It wants its physicians to assure patients and their families that they will receive competent, comprehensive palliative care at the end of their lives. The Board expects its physicians to be knowledgeable regarding effective and compassionate pain relief, and patients and their families should be assured that such relief will be provided.
• The Board will assume opioid use in such patients is appropriate if the responsible physician is familiar with and abides by acceptable medical guidelines regarding such use, is knowledgeable about effective and compassionate pain relief, and maintains an appropriate medical record that details a pain management plan. (See the Board's position statement on the Management of Chronic Non-Malignant Pain for an outline of what the Board expects of physicians in the management of pain.) Because the Board is aware of the inherent risks associated with effective pain relief in such situations, it will not interpret their occurrence as subject to discipline by the Board.
• To assist physicians in meeting these responsibilities, the Board recommends the following publications:
  • Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed (1996)
    Available at: http://whqlibdoc.who.int/publications/9241544821.pdf
  • Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee (1990)
    Available at: http://whqlibdoc.who.int/trs/WHO_TRS_804.pdf
  • Cancer Pain Relief and Palliative Care in Children (1998)
    Available at: http://whqlibdoc.who.int/publications/9241545127.pdf
  • Symptom Relief in Terminal Illness (1998)
    Published by the World Health Organization, Geneva, Switzerland.
  • Management of Cancer Pain (1994)
    Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.5
    Published by the Agency for Health Care Policy and Research, Rockville, MD.
  • Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 4th ed (1999)
    Published by the American Pain Society, Glenview, IL.
  • Hospice Care: A Physician's Guide (1998)
    Published by Hospice for the Carolinas, Raleigh
  • Oxford Textbook of Palliative Medicine, 3rd ed. (1993)
    Published by Oxford University Press, Oxford, UK
  • Sources: (Adopted 10/1999) *Steven A. Schroeder, MD, President, Robert Wood Johnson Foundation.

Related Statement: Joint Statement on Pain Management in End-of-Life Care

• Special attention must be given to the effective assessment of pain. The clinician should frankly but sensitively discuss with the patient and the family their concerns and choices at the end of life. The physician should make clear that, in some end-of-life care situations, there are inherent risks associated with effective pain relief. The Medical Board will assume opioid use in such patients is appropriate if the responsible physician is familiar with and abides by acceptable medical guidelines regarding such use, is knowledgeable about effective and compassionate pain relief, and maintains an appropriate medical record that details a pain management plan. Because the Board is aware of the inherent risks associated with effective pain relief in such situations, it will not interpret their occurrence as subject to discipline by the Board.
• North Carolina has no quantity restrictions on dispensing controlled substances, including those in schedule II.
• Federal and state rules also allow the fax transmittal of an original prescription for schedule II drugs for hospice patients.
• Pharmacy rules also allow the emergency refilling of prescriptions in schedules III, IV, and V. Although this does not apply to schedule II drugs, it can be useful in situations where the patient is using drugs such as Vicodin for pain or Xanax for anxiety.
• The nurse has the authority to adjust medication levels within the dosage and frequency ranges stipulated by the prescriber and according to the agency's established protocols. The nurse does not have the authority to change the medical pain management plan. Only the physician or other health professional with authority to prescribe may change the medical pain management plan. [10/99]

NOTE: This is a summary of the position statement and the user should read the entire document using the Medical Board's Web site.

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Author Information

Jennifer Bolen, JD, Founder, The Legal Side of Pain, Lenoir City, Tennessee

Disclosure: Jennifer Bolen, JD, has disclosed no relevant financial relationships.