Monday, June 22, 2015

OMB Policy Statement: Pain Management

The following is the Policy Statement Pain Management created by the Oregon Medical Board (OMB).  The OMB licenses doctors in Oregon.

"Pain Management
The OMB urges the skillful use of effective pain control for all patients.  It is important for providers to be well-informed on relevant pain management techniques and hone their skills for the optimal treatment of their patients, taking into account the etiology of the pain.  Types of pain include, but are not limited to, acute post-operative or traumatic pain, chronic non-cancer pain, chronic pain caused by malignancies and pain associated with terminal illness.  Providers are encouraged to treat pain within the scope of their practice and refer patients to the appropriate specialists when indicated.

Acute Pain

Effective treatment of acute pain promotes recovery and return to normal function.  The potential for addiction is low when short courses of opioids are used to treat acute pain and discontinued as the patient recovers.  Inadequately managed acute pain may result in chronic pain.  Patients who are not recovering as expected must be carefully assessed. Skillful pain management techniques including oral, parenteral and, when available, regional pain management techniques, can achieve maximum patient comfort and may reduce the need for opioids.

Chronic Pain

Patients with chronic pain require complex care and treatment decisions for multi-faceted problems. Providers have a responsibility to diagnose and manage chronic pain while maximizing the benefits and minimizing the potential adverse effects of treatment.  Opioids are not always required or effective for the treatment of chronic pain, and they should be discontinued if the patient’s pain control or function does not improve with their use.

Pain management treatment must be evidence-based and individualized to the patient. Oregon statute protects providers from disciplinary action by the Board when prescribing or administering controlled substances as part of a treatment plan for pain with the goal of controlling the patient’s pain for the duration of the pain.  However, prescribing controlled substances without a legitimate medical purpose is prohibited.

Patient safety should be a key factor in determining a treatment plan for pain management.  When the provider prescribes opioids as part of the treatment plan, the provider must consider drug safety, efficacy and treatment goals for the patient.  Safe opioid prescribing requires knowledge of the pharmacology of various opioid classes, and of potential drug interactions.  Opioids are most likely to be successful in reducing pain and restoring function when they are combined with other pain management approaches such as physical therapy and psychological techniques.

When prescribing opioids for chronic pain, Oregon law requires practitioners to provide careful assessment and documentation of the medical condition causing pain as well as co-morbid medical and mental health conditions.  Goals for treatment should be established with the patient before prescribing opioids. The provider’s assessment, diagnosis and discussion must be documented in the patient record.  The diagnosis, drugs used, goals, alternatives, and side effects must be included in a signed document demonstrating consent and understanding of the treatment plan and its risks.  A sample document may be found here​.   In addition to the signed informed consent document, a written patient-provider agreement is recommended for patients requiring opioids for chronic pain. In all cases of pain management, practitioners should maintain records to track prescriptions and coordinate care with other treating practitioners.

The OMB recommends enrollment and participation in the Oregon Prescription Drug Monitoring Program (PDMP), a division of the Oregon Health Authority, to help guide treatment plans.  The PDMP is a database that allows prescribers of controlled substances to access a patient’s name, the controlled substance prescribed, the dosage, and the name and contact information of the prescriber.

Terminal Illness

The OMB believes that physicians should make every effort to relieve the pain and suffering of their terminally ill patients. Patients nearing the end of their lives should receive sufficient opioid dosages to produce comfort.  The physician should acknowledge that the natural dying process usually involves declining blood pressures, decreasing respirations and altered levels of consciousness.  Opioids should not be withheld on the basis of physiologic parameters when patients continue to experience pain.

Some physicians express concerns that the use of opioids in these patients may hasten death through pneumonia or respiratory depression.  For these reasons, at times physicians may have limited the use of opioids in dying patients out of fear that they may be investigated for inappropriate prescribing or allegations of euthanasia.

The OMB is concerned that such fear on the part of physicians may result in inadequate pain control and unnecessary suffering in terminally ill patients.  The OMB encourages physicians to employ skillful and compassionate pain control for patients near the end of life and believes that relief from suffering remains the physician’s primary obligation to these patients.

- Adopted January 1993
- Amended April 1999
- Amended July 2004
- Amended April 2011
- Amended January 2013"

OMB Pain Management Policy Statement

Medical Marijuana & Opioid OMB Statement

The following statement is the current position of the Oregon Medical Board (OMB), which license doctors in this state.  It is clear that they do not prevent doctors from prescribing opioid pain medication to people who are also using marijuana.

"Medical Marijuana

The Oregon Medical Marijuana Program is administered by the Oregon Health Authority. The relevant Oregon Revised Statutes are 475.300 through 475.346 and the Oregon Administrative Rules are 333-0008-0000 through 333-008-0120. The Oregon Health Authority’s website on the Oregon Medical Marijuana Program provides additional program information and contact information.

The Oregon Medical Board does not oversee or otherwise regulate the Oregon Medical Marijuana Program.

The Board does not currently have a rule or a policy position on prescribing opioids to patients with a medical marijuana card.  While the Board’s consultants have included the use of marijuana among the list of contraindications for long-term opioid use, the Board has not prohibited the concurrent use of these drugs.

Prescribing practices do come to the Board’s attention, and every written complaint is investigated as required by statute.  The Board does not discipline physicians solely based on certifying patients for the use of medical marijuana, prescribing opioids to a known medical marijuana patient, or creating treatment plans that include the concurrent use of opioids and medical marijuana.  However, if an investigation into a complaint showed inappropriate practices or unprofessional conduct by any physician, the Board would take action for any violations of the Medical Practice Act that are found.

The Board will continue its attention to this evolving area of medicine.  Any updated policies created by the Board will be available on our website.  We appreciate the public interest in this important issue and its impact on the safety of Oregon patients"

Link to Oregon Medical Board (OMB) Statement