A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Virginia

Summary

Virginia's Board of Licensure in Medicine has adopted a position statement on the Use of Controlled Substances for Treatment of Pain. Virginia also has one of the best "law" handbooks for physicians in the country. All Virginia physicians should read the Virginia law book and stay current with federal and state materials on the use of controlled medications. Virginia physicians will also find the Virginia Board of Pharmacy Web site helpful.

Definitions

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 opioid therapy, among other therapies.

Addiction. Addiction is a neurobehavioral 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. Addiction may also be referred to by terms such as "drug dependence" and "psychological dependence." Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy for pain and should not be considered addiction.

Chronic Pain. A pain state that is persistent and in which the cause of the pain cannot be removed or otherwise treated. Chronic pain may be associated with a long-term incurable or intractable medical condition or disease.

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 on a controlled substance is a physiologic state of neuroadaptation that is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or if an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself, does not equate with addiction.

Pseudoaddiction. Pattern of drug-seeking behavior of patients with pain who are receiving inadequate pain management. This pattern can be mistaken for 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.

Virginia Guidelines

Evaluation of the Patient. The physician must obtain, evaluate, and document a medical history and physical examination. The physician 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 physician should also document the presence of one or more recognized medical indications for the use of a controlled substance.

Treatment Plan. The physician should use a written treatment plan stating the 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. The patient's decreased pain, increased level of function, or improved quality of life may indicate a satisfactory response to treatment. The physician should monitor objective evidence of improved or diminished function and consider information from family members or other caregivers when determining the patient's response to treatment. If the patient's progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities.

Consultation. The physician should be willing to refer the patient as necessary for additional evaluation and treatment to achieve treatment objectives. The physician should give special attention 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 the following:

• Medical history and physical examination;
• Diagnostic, therapeutic and laboratory results;
• Evaluations and consultations;
• Treatment objectives;
• Discussion of risks and benefits;
• Informed consent;
• Treatments;
• Medications (including date, type, dosage and quantity prescribed);
• Instructions and agreements; and
• Periodic reviews.

Records should remain current and be maintained in an accessible manner and 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 should review the Drug Enforcement Administration's Practitioner's Manual and any relevant documents issued by the state medical board for specific rules governing controlled substances as well as applicable state regulations.