Note: This report, written in response to Resolution 534 (A-06), reflects information on this subject as of June 2007.
Full text
This Council previously addressed barriers to pain management and the use of opioids in persistent noncancer pain, as well as the overall management of patients with neuropathic pain. The latter two reports also briefly reviewed the broader spectrum of pain care choices. A comprehensive and multi-modal review of pain management is beyond the scope of this report. In addition, most of the tension in the pain management community emanates from issues involving the use of controlled substances, so these are the focus of this report.
Policies (or standards) affecting pain management are derived from laws, regulations, and practice guidelines. Opioid analgesics are controlled substances because they have the potential for misuse and the development of addiction. Thus, their manufacture, distribution, prescribing, and dispensing are governed by a combination of international treaties, U.S. federal and state laws, and regulations intended to balance drug control with patient access to needed pain medicine.
This report evaluates different factors influencing pain management, as well as how various federal and state policies influence physician behavior in providing appropriate pain management. Only U.S. policies, laws, regulations, and government activities are discussed. This report does not specifically address clinical practice guidelines for pain management, the risk assessment of pain patients with a history of substance abuse, or interventions for patients with opioid dependence or a history of prescription drug misuse and addiction.
Methods
English-language reports on studies using human subjects were selected from a MEDLINE search of the literature from 1997 to March 2007 using the terms analgesics, opioid* or opioid-related disorders in combination with epidemiology; prevention & control*; prescriptions, drug/statistics & numerical data; government agencies, and substance abuse detections. Additional articles were identified by manual review of the references cited in these publications. Web sites of the American Pain Society (APS), American Academy of Pain Medicine (AAPM), National Institutes of Health, Drug Enforcement Administration (DEA), Federation of State Medical Boards (FSMB), the University of Wisconsin Pain & Policies Study Group also were searched for relevant articles.
Background
A number of issues underlie physician concerns and frame the debate on pain management. Over the last two decades, several important reports have established evidence-based clinical approaches, and identified barriers to adequate pain management.1-10 Widespread agreement exists that opioid analgesics are indispensable for relieving moderate to severe pain. Because opioids also are subject to diversion and misuse, their production and availability are strictly regulated under federal- and state-controlled substances laws. However, these controls and their enforcement should be balanced and not interfere with the availability of opioid analgesics for legitimate medical purposes. Providing access to pain relief for those in need, while simultaneously preventing the diversion and misuse of pain medications, requires “balance” in pain policy. To foster a balanced approach, the AMA and 21 other health organizations joined with the DEA in a joint statement of accountability in 2001.11 This statement noted that “both healthcare professionals, and law enforcement and regulatory personnel, share responsibility for ensuring that prescription pain medications are available to the patients who need them and for preventing these drugs from becoming a source of harm or abuse,” and that “preventing drug abuse is an important societal goal, but there is consensus, by law enforcement agencies, health care practitioners, and patient advocates alike, that it should not hinder patients’ ability to receive the care they need and deserve.”
As noted above, this Council has previously identified barriers to the appropriate management of patients with acute and persistent cancer pain, examined issues related to the use of opioids in patients with persistent noncancer pain, and addressed the diagnosis and treatment of neuropathic pain, including the use of opioids.12-14 The Board of Trustees (BOT) previously examined the feasibility of addressing physician’s concerns about the use of opioids in the treatment of intractable pain with legislative remedies.15,16 BOT Report 3 (A-06) “Promoting Pain Relief and Preventing Abuse of Controlled Substances” addressed some of the same issues contained in this report.17 The AMA has been active on the educational front as well, creating a successful 12-part Pain Management Continuing Medical Education program, available in both print and online format, and updated for 2007.
Factors relevant to pain management practices
Undertreatment of pain. As noted above, the publication of several important reports1-10 and clinical consensus guidelines18-20 have led to improved pain management, yet undertreatment of pain continues to be a significant problem, and persistent pain is often inadequately controlled. A substantial percentage of individuals (~75 million Americans) report suffering from acute and chronic noncancer pain that is not adequately relieved.21,22 Daily pain is prevalent among nursing home residents, and is often untreated, particularly among older and minority patients.23,24 Undertreatment is influenced by diverse factors including limited training in opioid prescribing and pain management, unfounded concerns about addiction and side effects, fear of regulatory oversight, and lack of access to pain specialists.
Some populations with pain (eg, cancer patients) should receive opioids as first-line agents for moderate to severe pain. Less than 50 percent of patients with metastatic cancer receive adequate pain relief, and ~40 percent suffer moderate to severe pain in the last 3 days of life.25,26 Remarkably, even children dying of cancer often experience substantial suffering in the last months of life.27 Such factors contributed to requirements by the Joint Commission to document and monitor pain, which have contributed to improved pain management in the hospital environment.
Opioid prescribing patterns. Opioid prescriptions have increased substantially over the last 15 years because of increased attention to better management of persistent pain, cancer pain, and end-of-life care.28,29 The extent to which the increase in opioid prescriptions reflects more aggressive and better pain management practices versus inappropriate prescribing is not known. Substantial geographic variations exist, and prescriber demographics have shifted for some products, with primary care physicians now responsible for a larger fraction of prescriptions for certain opioid analgesic products.30,31 Nevertheless, a subgroup of patients with chronic noncancer pain may benefit from long-term therapy with opioid analgesics. The size of this subgroup and its characteristics remains controversial. Unfortunately, the increased availability and clinical use of opioid analgesics has been temporally associated with indicators of increased nonmedical use or abuse.29,32,33
Some indicators of nonmedical use, misuse, and addiction are increasing. Several entities track indicators of prescription drug misuse and addiction, but relatively few provide any information on the sources of diversion. Various survey data indicate that the prevalence of nonmedical use or unauthorized use of opioid analgesics has risen appreciably over the last 15 years, notably among adolescents and young adults. The percentage of 12th-graders who report lifetime use of “narcotics other than heroin” doubled from 1991 to 2004, but has since remained relatively stable at ~13.5 percent. The percentage of 12th-graders who report annual use of such products declined somewhat from a peak of 9.5 percent in 2004 to 9.0 percent in 2006.33
In 2005, 2.5 million persons aged 12 years or older used “psychotherapeutics” nonmedically for the first time according to the National Survey on Drug Use and Health (NSDUH).32 This includes psychostimulants and sedatives, as well as opioid analgesics. However, NSDUH showed a decline from 2002 to 2005 among youths aged 12 to 17 years for past-month nonmedical use of prescription drugs. The rates of current use of illicit drugs are higher in young adults aged 18 to 25 years than in younger or older subjects. Past-month nonmedical use of prescription drugs in this group increased from 5.4 percent in 2002 to 6.3 percent in 2005, primarily due to an increase in prescription pain reliever use. In 2005, ~1.5 million persons aged 12 years and older were diagnosable with opioid abuse or dependence—this includes a substance use disorder related to heroin or prescription opioids. Information from the Treatment Episode Data Set (TEDS) indicates a quadrupling of admissions for opioid treatment during the period 1995 to 2005.34 TEDS is an administrative data system providing descriptive information about the national flow of admissions to providers of substance abuse treatment.
Most youth who admit to nonmedical use acquire prescription drugs from peers or family members; a smaller number purchase them illegally, and far fewer obtain them from a physician in the course of a legitimate patient-physician encounter.35,36 Theft is a major contributor to the diversion of prescription-type opioid drugs, and in some cases, these products can be obtained illegally from Internet sources.37
The actual percentage of patients who meet the criteria for opioid dependence after receiving opioids for legitimate pain management is generally considered to be quite small (0.7 percent-two percent),38,39 but views on this continue to evolve. Patients with persistent noncancer pain who regularly use or misuse opioid analgesics tend to be younger, with a previous history of substance abuse, or concurrent anxiety or mood disorders.38,39-41 Thus, diagnosis of psychiatric disorders is important when considering patients for long-term opioid therapy. Nevertheless, the relationship between chronic pain and depression is highly complex. Individuals with major depression are more likely to have chronic pain and vice versa, and both conditions may need to be treated separately.
Differential diagnosis of aberrant drug taking attitudes and addiction is not straightforward, as many aberrant behaviors are ambiguous. Nevertheless, patients with a history of abuse or addiction may still be appropriate candidates for opioid therapy, but require a special skill set on the part of the treating physician.
Law enforcement actions. Drug law enforcement actions, and the perception of them, create fear of regulatory or legal scrutiny among physicians. By their nature, law enforcement agencies focus on diversion and inappropriate opioid prescribing, without considering the potential detrimental effects of their actions or pronouncements on medically appropriate use. On the surface, analysis of actual enforcement actions by the DEA or state medical boards suggests that the number of physicians subject to prosecution or disciplinary actions is small, compared with the total number of DEA registrants. Generally, these physicians have committed egregious offenses, or clearly lacked documentation to support their prescribing practices.43,44 However, the number of investigations is substantially higher, and the number of high-volume opioid prescribers is small. One analysis estimated that ~15 percent of pain specialists may be subject to investigation.45 Thus, the actual risk of scrutiny for these physicians is substantially higher, and statistics based only on enforcement actions do not measure the impact of media attention and personal knowledge of other investigations on prescribing behavior.46 In one survey, 40 percent of pain management physicians indicated that regulatory, not medical concerns dissuaded them from prescribing opioids for patients with persistent noncancer pain.47
Development of tolerance and physical dependence. Tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not the same as addiction.48 A consensus document developed by the AAPM, APS, and the American Society of Addiction Medicine (ASAM) articulates the differences.49 However, misunderstanding of these phenomena continues to influence prescribing decisions and patient acceptance. Although tolerance does occur, significant increases in dosage for patients suffering from cancer pain generally are associated with a change in disease status. The development of tolerance does not preclude clinical effectiveness; its development can be lessened by using a rotation of different opioid compounds, and wide inter-individual variations exist in clinical response. Thus, overstatement and misunderstanding of the risks of addiction or side effects likely contribute to undertreatment of pain, even in the absence of concerns about regulatory scrutiny.
Federal policies impacting pain management
Food and Drug Administration (FDA). The FDA regulates the approval of prescription drugs for marketing based on safety and efficacy, including their potential for misuse and addiction, and shares responsibility with the DEA for assigning a drug to a controlled substance schedule (see below). The FDA also provides oversight of risk management strategies and educational activities that pharmaceutical companies may implement to address the risks associated with certain prescription drugs, including opioid analgesics. To date, FDA policies and activities have not generally served to restrict appropriate pain management.
Drug Enforcement Administration. Among other duties and authority, the DEA carries out the mandates of the Controlled Substances Act (CSA) to prevent, detect, and investigate the diversion of controlled substances by legitimate handlers, and to ensure an adequate and uninterrupted supply to meet legitimate medical needs. The CSA is not intended to interfere with medical practice or with the availability of controlled substances for legitimate medical purposes. Physicians retain authority under the CSA to prescribe, dispense, or administer controlled substances for the treatment of pain within acceptable medical standards. The CSA recognizes the essential medical purpose of opioid analgesics and other controlled substances, noting that these “drugs have a useful and legitimate medical purpose and are necessary to maintain the health and general welfare of the American people" (21 U.S.C. § 801(1)).
Under the CSA, the requirement for a prescription for a controlled substance is that it must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice (21 C.F.R. § 1306.04(a)). However, the CSA does not define "legitimate medical purpose" nor does it set forth standards of medical practice. These practices are defined by the medical community in concert with the development of clinical guidelines, performance measures, and standards of care. The Act also instructs manufacturers that are registered to “produce an adequate and uninterrupted supply of these substances” 21 U.S.C. §823a(1). The DEA has further noted that “the quantity of drug prescribed and frequency of prescriptions filled are not alone indications of fraud or improper prescribing especially if the patient is being treated with opioids for pain management.” Thus, language contained in the CSA contains many elements essential to a balanced pain policy.
However, despite provisions for balance in the language of the CSA, other actions and pronouncements by the DEA may have the opposite effect. The developments surrounding the DEA’s action to issue an Interim Policy Statement (IPS) and withdraw its support of a publication entitled: “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel (FAQ)” were previously discussed in BOT Report 3, A-06.17 The sudden withdrawal of the FAQs without notice or sufficient explanation raised concern in the pain management community. The FAQs were intended, in part, to educate health care practitioners, law enforcement, and regulatory personnel who might be misinformed about pain management, opioid use and misuse, and addiction.
Statements contained in the IPS led to renewed concerns by physicians about the DEA’s real intentions. For example, the IPS declared that it was illegal for a physician to prepare multiple prescriptions on the same day with instructions to fill on different dates (serial prescriptions),49 although this has been a longstanding practice for selected patients. In the IPS, the DEA also admonished physicians to increase their vigilance in prescribing abusable drugs, particularly for patients with known or suspected risk of abuse, implying that physicians currently have the means to accurately assess all patients for abuse risk. Moreover, the DEA declared that the government ‘‘can investigate merely on suspicion that the law is being violated, or even just because it wants assurances that it is not.” Eventually, on September 6, 2006, the DEA took a step to improve the clinical practice environment for pain management by issuing a notice of proposed rulemaking that would allow an individual practitioner to issue multiple, but postdated prescriptions for a 90-day supply, assuming certain criteria were fulfilled.50 This proposal has not been finalized, and other issues raised by the IPS remain in need of clarification.
Other federal agencies. Other federal agencies: (1) set policies, priorities, and objectives for the nation’s drug control programs (Office of National Drug Control Policy); (2) administer grants, and collect and evaluate data related to drug abuse (Substance Abuse and Mental Health Services Administration); and (3) support research on the health aspects of drug abuse and addiction, and provide information to the public on drug abuse (National Institute on Drug Abuse). These activities assist in informing the public and professional debate on these issues.
State policies
States are responsible for regulating medical and pharmacy practice. State medical practice laws generally delegate the responsibility of regulating physicians to state medical boards, which license physicians and grant them prescribing privileges. In addition to the federal requirements noted above, the prescribing, dispensing, and administering of controlled substances is regulated by states. In general, state pain policies are more “unbalanced” than federal policies, at least in terms of their language, in focusing on law enforcement over adequate pain management.52
Federation of State Medical Boards (FSMB) model policy. Initially released in 1998, the FSMB Model Guidelines for the Use of Controlled Substances for the Treatment of Pain were updated in 2004 and renamed “Model Policy.” The Policy statement provides model language that may be used by states to clarify their positions on the use of controlled substances to treat pain, help to alleviate physician uncertainty, and encourage better pain management. The 2004 update, in part, reflected continuing concerns about the undertreatment of pain.48 The Model Policy recognizes that pain management is an integral part of quality medical practice; controlled substances are an essential part of pain management; tolerance and physical dependence are not synonymous with addiction; and physicians should not fear regulatory sanctions for appropriately prescribing controlled substances for pain. With respect to the latter, the Model Policy states…“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....”
Many state medical boards have rewritten pain policies since the Model Guidelines were first published. According to an analysis conducted by the Pain and Policies Study Group at the University of Wisconsin, a total of 28 states had adopted either the FSMB’s Model Guidelines or Policy in whole or in part.53 At least 19 states evidenced positive policy changes between 2003 and 2006 based on adoption of policies encouraging pain management or palliative care or adoption of pain-specific statutes (see the Appendix for a list of criteria identified by the study group as either positive or negative influences). Despite these improvements, 21 states still have policies that characterize opioids as a treatment of last resort.
Prescription drug monitoring programs. Another way to address prescription drug diversion and misuse at the state level is through the institution of prescription drug monitoring programs. Current programs utilize electronic data transfer, either singly or in combination with special government-issued prescription forms for controlled substances. A few electronic systems operate proactively, routinely analyzing prescription data (trend analysis) to identify individuals, physicians, or pharmacies with unusual patterns of use. Most monitoring programs are passive, being used only for specific requests or searches that satisfy specific criteria.
As of February 2007, 24 states had implemented systems to monitor the prescription and sale of controlled substances, and legislation was pending in another 11 states.54 Many of these programs were developed in response to the federal National All Schedules Prescription Electronic Reporting Act (NASPER). NASPER created a program to offer individual states federal funding for the establishment of state prescription monitoring programs that could help detect individuals who “doctor shop” to obtain controlled substances. One analysis suggests that these types of programs reduce overall opioid prescribing.55
The use of special prescription forms clearly leads to a decline in prescribing for monitored drugs, and sometimes substitution of a less suitable agent.56-58 Thus, current but limited evidence suggests prescription drug monitoring programs reduce opioid prescribing and, therefore, indirectly reduce prescription drug misuse and addiction. The extent to which such programs may have the unintended effect of promoting the undertreatment of pain with opioid medications is not known.
Summary and conclusion
The actions and pronouncements of the DEA, the features of state-based pain policies, and the development of state-based prescription drug monitoring programs represent the most significant influences on physician prescribing of opioid analgesics and pain management. Further research and policy evaluation and development, as well as better communication, cooperation, and education of all stakeholders, are needed to prevent or overcome barriers to patients receiving adequate pain management, and to determine why pain management is not adequate. Improvement in state-based pain policies should be a continuing priority.
Although the number of prescriptions for opioid analgesics has increased substantially over the last 15 years, undertreatment of pain continues to be a problem. This is suggested specifically by the extant undertreatment of cancer pain. However, many physicians still lack comfort in the clinical use of opioid analgesics, particularly for patients with persistent noncancer pain. This is related to a number of factors, including limited training in opioid prescribing; uncertainty about the long-term effectiveness of opioid analgesics in these patients; excessive concerns about the side effects of opioid drugs and the potential for such drugs to lead to instances of misuse or cases of addiction; lack of sufficient methods to detect diversion and misuse; and concern about regulatory/criminal scrutiny by federal or state law enforcement officials.
Unfortunately, there are clear indications that the unauthorized use of prescription opioids has increased, as well as cases of diagnosable opioid addiction. In response to increasing prescription drug diversion and misuse, law enforcement has worked to limit access to these controlled substances, including opioid medications, in the hope of reducing their diversion; however, such actions can have the unintended consequence of exacerbating the problem of undertreatment of pain. Clinicians have a responsibility to use sensible approaches to prescribing controlled substances, and in maintaining appropriate vigilance to minimize opioid diversion and misuse. Pre-teens, adolescents, and young adults remain populations at particular risk for nonmedical opioid use and misuse, as are pain patients with comorbid psychiatric disorders. These populations should be the target of more intensive drug abuse prevention initiatives. Research is needed to identify the sources of diversion of opioid analgesics so that appropriate public health or law enforcement interventions can be devised.
Several questions must be addressed to better inform balanced pain management policies, including:
Who is involved in unauthorized/nonmedical use of opioid analgesics?
What are the sources of the prescription drugs that are diverted and misused?
What is the relationship between increased numbers of opioid prescriptions and rates of opioid addiction?
What are the consequences of lack of adequate epidemiological or clinical knowledge about prescription drug use, misuse, and addiction on physician prescribing and the appropriate use of opioid analgesics for pain patients?
A sustained cooperative effort is needed that is directed toward health professionals and law enforcement officials, and that involves the DEA and other relevant stakeholders. The goal should be to improve the regulatory environment for pain management, clarifying regulatory policies and demonstrating a mutual commitment to a balanced approach to drug diversion and pain management. Additionally, with the expansion of state-based prescription drug monitoring programs, the impact of such programs on medical care, including appropriate pain management, should be evaluated.
Recommendations (adopted AMA policy and directive)
The following statements, recommended by Council on Science and Public Health, were adopted by the AMA House of Delegates as AMA policy and directive at the 2006 AMA Annual Meeting:
1. States should examine their pain policies and seek to improve them, based on the Federation of State Medical Boards Model Policy and/or criteria established by the Wisconsin Pain & Policies Study Group. (Policy)
2. The impact of state-based prescription drug monitoring programs on medical care, including appropriate pain management, should be evaluated. (Policy)
3. The AMA urges the Drug Enforcement Administration to work with physician organizations and other relevant stakeholders to reconstruct a document similar to “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel” to serve as a legitimate resource for physicians, regulators, and law enforcement personnel. (Directive)
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References
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29. Gilson AM, Ryan KM, Joranson DE, Dahl JL. A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. J Pain Symptom Manage. 2004;28:176-188.
30. Curtis LH, Stoddard J, Radeva JI, et al. Geographic variations in the prescription of schedule II opioid analgesics among outpatients in the United States. Health Serv Res. 2006;41(3 Pt 1):837-855.
31. Zerzan JT, Morden NE, Soumerai S, et al. Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996-2002. Med Care. 2006;44:1005-1010.
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34. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Treatment Episode Data Set (TEDS). Available at: http://webapp.icpsr.umich.edu/cocoon/SAMHDA-STUDY/04626.xml. Accessed March 27, 2007.
35. McCabe SE, Boyd CJ. Sources of prescription drugs for illicit use. Addict Behav. 2005;30:1342-1350.
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37. Joranson DE, Gilson AM. Drug crime is a source of abused pain medications in the United States. J Pain Symptom Manage. 2005;30:299-301.
38. Pletcher MJ, Kertesz SG, Sifdney S, Kiefe CI, Hulley SB. Incidence and antecedents of nonmedical prescription opioid use in four US communities. The Coronary Artery Risk Development in Young Adults (CARDIA) prospective cohort study. Drug Alcohol Depend. 2006;85:171-176.
39. Huang B, Dawson DA, Stinson FS, et al. Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders in the United States: results of the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:1062-1073.
40. Dowling K, Storr CL, Chilcoat HD. Potential influences on initiation and persistence of extramedical prescription pain reliever use in the US population. Clin J Pain. 2006;22:776-783.
41. Weaver M, Schnoll S. Addiction issues in the prescribing opioids for chronic nonmalignant pain. J Addiction Med. 2007;1:2-10.
42. Sullivan MD, Edlund MJ, Zhang L, Unutzer J, Wells K. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med. 2006;166:2087-2093.
43. Richard J, Riedenberg MM. The risk of disciplinary action by state medical boards against physicians prescribing opioids. J Pain Symptom Manage. 2005;29:206-212.
44. Jung B, Reidenberg MM. The risk of the Drug Enforcement Administration against physician prescribing opioids for pain. Pain Med. 2006;7:353-357.
45. Passik SD, Kirch KL. Fear and loathing in the pain clinic. Pain Med. 2006;7:363-364.
46. Bolen J. DEA, administrative action statistics, and pain management: it is time to get real. Pain Med. 2006;7:358-359.
47. Joranson DE, Gilson AM, Dahl JL, et al. Pain management, controlled substances, and state medical board policy: a decade of change. J Pain Symptom Manage. 2002;23:138-147.
48. Federation of State Medical Boards of the United States Inc. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Dallas, TX: Federation of State Medical Boards of the United States Inc.; 2004. Available at: http://www.fsmb.org.
49. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain. Glenview, IL: AAPM, APS, ASAM; 2001. Available at: http://www.ampainsoc.org/advocacy/opioids2.htm.
50. Drug Enforcement Administration. Dispensing of Controlled Substances for the Treatment of Pain. Interim Policy Statement. Fed Reg. 2004;69:67170-67172.
51. Drug Enforcement Administration. Issuance of Multiple Prescriptions for Schedule II Controlled Substances. Notice of Proposed Rulemaking. Fed Reg. 2006;71:52724-52726.
52. Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card. Madison, Wisconsin: University of Wisconsin; 2006.
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56. Fishman SM, Papazian JS, Gonzales S, Riches P. Regulating opioid prescribing through balanced prescription monitoring programs. Pain Med. 2004;5:255-257.
57. Simoni-Wastila L, Ross-Degnan D, Mah C, et al. A retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in Medicaid patients with chronic psychiatric and neurologic disorders. Clin Therap. 2004;26:322-336.
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Appendix.
Criteria for Evaluating State Pain Policies52
Criteria that identify provisions that may enhance pain management
1. Controlled substances are recognized as necessary for public health
2. Pain management is recognized as part of general medical practice
3. Medical use of opioids is recognized as legitimate professional practice
4. Pain management is encouraged
5. Practitioners’ concerns about regulatory scrutiny are addressed
6. Prescription amount alone is recognized as insufficient to determine legitimacy of
prescribing
7. Physical dependence or analgesic tolerance are not confused with “addiction”
8. Other provisions that may enhance pain management
Category A: Issues related to healthcare professionals
Category B: Issues related to patients
Category C: Regulatory or policy issues
Criteria that identify provisions that may impede pain management
9. Opioids are considered a treatment of last resort
10. Medical use of opioids is implied to be outside legitimate professional practice
11. Physical dependence or analgesic tolerance are confused with “addiction”
12. Medical decisions are restricted
Category A: Restrictions based on patient characteristics
Category B: Mandated consultation
Category C: Restrictions regarding quantity prescribed or dispensed
Category D: Undue prescription limitations
13. Length of prescription validity is restricted
14. Practitioners are subject to undue prescription requirements
15. Other provisions that may impede pain management
16. Provisions that are ambiguous
Category A: Arbitrary standards for legitimate prescribing
Category B: Unclear intent leading to possible misinterpretation
Category C: Conflicting or inconsistent policies or provisions
Resolution 543 introduced by the Arizona Delegation at the 2006 Annual Meeting and referred to the Board of Trustees, asks:
That the American Medical Association (AMA) work with all agencies and government bodies associated with setting pain standards, in cooperation with relevant medical specialty societies, to urge coordination of pain standards.
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