A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Oregon

Oregon Intractable Pain Treatment Act

Definitions

1. "Controlled substance" has the meaning given that term under ORS 475.005.
2. "Healthcare professional" means a person licensed by a health professional regulatory board who is practicing within the scope of practice of that licensure and who is authorized to prescribe or administer controlled substances.
3. "Health professional regulatory board" has the meaning given that term in ORS 676.440.

Administration of Controlled Substances for Pain Allowed; Exceptions

1. Notwithstanding any other provision of this chapter and notwithstanding ORS 678.010 to 678.410 and ORS chapters 679 and 689, a healthcare professional may prescribe or administer controlled substances to a person in the course of treating that person for a diagnosed condition causing pain.
2. A healthcare professional shall not be subject to disciplinary action by a health professional regulatory board for prescribing or administering controlled substances in the course of treatment of a person for pain with the goal of controlling the patient's pain for the duration of the pain.
3. Subsections (1) and (2) of this section do not apply to:
   1. A healthcare professional's treatment of a person for chemical dependency resulting from the use of controlled substances;
   2. The prescription or administration of controlled substances to a person the healthcare professional knows to be using the controlled substances for nontherapeutic purposes;
   3. The prescription or administration of controlled substances for the purpose of terminating the life of a person having pain, except as allowed under ORS 127.800 to 127.897; or
   4. The prescription or administration of a substance that is not a controlled substance approved by the United States Food and Drug Administration for pain relief.
4. Subsection (2) of this section does not exempt the governing body of any hospital or other medical facility from the requirements of ORS 441.055.

Discipline

ORS 677.474 does not prohibit a health professional regulatory board from placing on probation or denying, revoking, limiting, or suspending the license of any healthcare professional who does any of the following:

1. Prescribes or administers a controlled substance or treatment that is nontherapeutic in nature or nontherapeutic as administered or prescribed or that is administered or prescribed for a nontherapeutic purpose.
2. Fails to keep a complete and accurate record of controlled substance purchases, dispensing, and disposal as required by the Comprehensive Drug Abuse Prevention and Control Act of 1970, other federal law, or ORS 475.005 to 475.285 and 475.840 to 475.980.
3. Prescribes controlled substances without a legitimate medical purpose.
4. Prescribes, administers, or dispenses controlled substances in a manner detrimental to the best interest of the public.
5. Prescribes, administers, or dispenses a controlled substance in a manner prohibited under ORS 475.005 to 475.285 or 475.840 to 475.980.
6. Falsifies prescription information, including, but not limited to, the identity of the recipient.

Oregon Medical Board Statement of Philosophy on Pain Management

The Oregon Medical Board (OMB) urges the use of effective pain control for all patients, irrespective of the cause of their pain. This includes, but is not limited to, pain derived from malignancies, acute pain resulting from injuries, acute illnesses or invasive procedures, and chronic pain of diverse etiology. Management of pain is considered to be within the scope of practice of most physicians. It is the expectation of the Board that physicians will be knowledgeable or become knowledgeable in treatment of pain for problems that are within their scope of practice.

Physicians choose not to provide pain care to patients for the following reasons: 1) concern about causing addiction; 2) lack of knowledge about pain management techniques and pain medication pharmacology; 3) fear of scrutiny and discipline by regulatory agencies; 4) challenges in determining the appropriate treatment; 5) inadequate compensation. The Board does not consider any of the reasons above to be legitimate excuses for a physician to exclude treatment of pain from their clinical practice. The Board expects that physicians will treat pain within the scope of their practice or refer when appropriate.

The treatment of acute pain caused by injuries, acute illnesses, or interventional procedures requires aggressive management and frequent feedback from the patient regarding the adequacy of the pain control prescribed. The potential for addiction is very low when short courses of opioids are used to treat acute, self -limited pain. Skillful pain management techniques, including oral, parenteral, and when available, regional pain management techniques can achieve maximum patient comfort and may reduce the total amount of opioids required. The OMB encourages physicians to become well informed in acute pain management and to hone their skills in the latest techniques for control of these acute, self-limited episodes of pain.

Management of the patient with a chronic pain syndrome requires different techniques but a similar degree of skill. In 1995, the Oregon Legislative Assembly passed ORS 677.470-485, commonly referred to as the Intractable Pain Act. This act allows a physician to prescribe or administer controlled substances to a patient diagnosed with a condition causing intractable pain without fear of sanction from the Oregon Medical Board, so long as that physician complies with the provisions of this statute. Both this statute and its facilitating Oregon Administrative Rule (847-030-0015), as revised in 2004, assure that patients with chronic pain syndromes: (1) receive careful assessment, documentation, and management of the pain; (2) are informed of the risk of taking the controlled substances used in the course of their treatment; and 3) acknowledge receipt of this information by signing the approved material risk form. Although the 2003 Legislature amended the Act to remove a stipulation that all patients with chronic pain receive an "evaluation by one or more physicians specializing in the treatment of the body area, system, or organ perceived as the source of the pain," the OMB notes that the accepted standard of care includes such consultations (evaluations) when the diagnosis or appropriate treatment is uncertain or when the current treatment is not producing expected results.

Physicians should make every effort to relieve the pain of their terminally ill and dying patients. The OMB believes this effort is the physician's primary obligation to these patients. Pain control in terminally ill/dying patients may require doses of opioids well above the usual amounts administered intermittently or continually. The natural dying process may involve declining blood pressures, decreasing respirations, and altered levels of consciousness. When these patients continue to experience pain, opioids should not be withheld based on physiologic parameters or from fear of hastening death.

Appropriate management of all of these types of pain is the treating physician's responsibility. Although there is often a significant amount of latitude regarding the amount of medication required for control of the pain, the Board considers under treatment as well as over treatment to be below the standard of care.

Oregon Medical Board Administrative Rules Addressing Intractable Pain

847-015-0030
Written Notice Disclosing the Material Risks Associated With Prescribed or Administered Controlled Substances for the Treatment of "Intractable Pain"

1. Controlled substances may be prescribed for long-term treatment of "intractable pain," ORS 677.475 (1). The attending physician records must contain the attending physician's examination, diagnosis, and any other supporting diagnostic evaluations and other therapeutic trials, including records from previous providers. If there is a consulting physician, written documentation of his or her corroborating findings, diagnosis, and recommendations shall be included in the record.
2. Before initiating treatment of "intractable pain" with controlled substances, the attending physician shall discuss with the patient the material risks associated with the prescribed or administered controlled substances. Following the discussion, the patient may request further explanation prior to signing the material risks notice. Following completion of the discussion, the attending physician shall provide to the person and the person shall sign a written notice of the material risks associated with the prescribed or administered controlled substances to be prescribed, ORS 677.485.
3. The material risk notice should include but not be limited to:
   1. The diagnosis;
   2. The controlled substance and/or group of controlled substances to be used;
   3. Anticipated therapeutic results;
   4. Alternatives to controlled substance therapy; and
   5. Potential side effects (if applicable):
      1. General;
      2. Central nervous system;
      3. Gastrointestinal;
      4. Respiratory;
      5. Dermatologic, and
      6. Other.
   6. Allergy potential;
   7. Interaction/potentiation of other medications;
   8. Potential for dose escalation/tolerance;
   9. Withdrawal precautions;
   10. Potential for dependence and addiction;
   11. Potential for impairment of judgment and/or motor skills;
   12. Satisfaction with or desire for more explanation; and
   13. Patient signature (dated).
4. The material risk consent form will be maintained as a permanent component of the patient record, as shall documentation of long-term follow-up to demonstrate the continued need for this form of therapy, ORS 677.480(1)(3). A dispensing record of the amount and dose of the prescribed or administered controlled substances shall be maintained as part of the patient record.

Oregon Pharmacy Board Policy Statement on the Use of Controlled Substances in the Treatment of Pain

Healthcare leaders and patient advocates have come together in a legislatively mandated pain commission to work toward providing well-managed and adequate pain control to the citizens of Oregon. Involvement with The Oregon Pain Commission has prompted the Board of Pharmacy to take a leadership role in promoting the effective management of pain for the state's citizens. The mission of the Oregon Board of Pharmacy is to promote, preserve, and protect the public health, safety, and welfare by regulating the practice of pharmacy and the distribution of drugs within and into the state. As a part of that endeavor, the Board strives to ensure that all Oregonians have access to appropriate pain relief. Appropriate and effective pain therapies, including the use of controlled substance medications, can greatly improve a patient's quality of life and reduce unnecessary morbidity and cost associated with inadequate treatment of pain.

Inadequate pain control, in some cases, may result from a lack of knowledge or understanding of proper pain management by healthcare professionals and patients. Undertreatment of pain can also be the result of fear or misunderstanding of the position of regulatory boards or law enforcement agencies regarding the use of controlled substances in the treatment and management of pain. This statement is intended to clarify the Board of Pharmacy's position regarding pain management in the practice of pharmacy.

The Oregon Board of Pharmacy recognizes that the use of controlled substances, including opioid analgesics, is often essential for the treatment and management of both acute and chronic pain of any origin. A pharmacist involved in the care of a patient undergoing treatment for pain should not fear disciplinary action from the Board for dispensing controlled substances, including opioid analgesics, for a legitimate medical purpose as defined in the state of Oregon. Pharmacists' involvement with pain management in the usual course of their professional practice should be based on accepted scientific knowledge and sound clinical judgment.

The Board of Pharmacy also recognizes that controlled substances, by their nature, carry with them a risk for abuse or misuse. All healthcare professionals must remain alert that these drugs are subject to abuse and that some people will seek them for inappropriate uses. Care must be taken to balance this risk with the desired outcome of effective pain control for all who are in need.

Dispensing of controlled substances for the treatment of pain must be based on a valid prescription issued within currently accepted standards. All pharmacists are encouraged to increase their knowledge of current medical standards for the treatment of pain and develop effective strategies for delivering pharmaceutical care to patients with pain. Pharmacists should actively participate on the healthcare team by providing expertise to the patient, physician, nurse, and hospice provider or other caregiver. As a member of the healthcare team, pharmacists can contribute to positive therapeutic outcomes for patients with pain and can reduce the potential for drug abuse. Detailed documentation of the patient's medical condition and clinical response to treatment provides the strongest foundation for providing optimal patient care.

The Board acknowledges the review of position statements from the Iowa, Michigan, Wisconsin, and Texas Boards of Pharmacy as well as the Oregon Board of Nursing and the Oregon Board of Medical Examiners and the Oregon Pain Commission in developing this Position Statement on the Treatment and Management of Pain.