National organization updates chronic pain management guidelines

By Frank Connor

Medical licensure boards and other state agencies in Massachusetts and Rhode Island are aggressively investigating chronic pain management regimens prescribed by physicians as part of an effort to combat patient misuse and abuse of opioids.

The boards take their cue in part from guidelines on opioid use issued by the Federation of State Medical Boards (FSMB). Following a comprehensive review of its longstanding policy on pain management, the FSMB recently updated the guidelines for the first time since 2004.

The FSMB – in collaboration with experts in pain management, pharmacology, psychiatry, public health, and medical regulation – examined new scientific research and public policy on opioids, with the goal of ensuring consistency between the updated model policy and emerging medical insights on pain management and the use of controlled substances.

While the FSMB’s guidelines are not binding as a legal standard of care, they are quite influential as a reference, and are well known to the Massachusetts Department of Public Health and Board of Registration in Registration, as well as the Rhode Island Department of Health, Board of Medical Licensure and Discipline, and Board of Pharmacy. Accordingly, for any physician who treats patients with chronic requiring use of opioid analgesics, a thorough understanding of these guidelines is a must.

The FSMB intends its guidelines (formally known as Model Policy for the Use of Opioid Analgesics in the Treatment of Chronic Pain) as a resource for state medical boards in educating licensed physicians concerning responsible prescribing of controlled substances. The overarching goal, according to the FSMB, is to promote public health by helping doctors to prescribe opioid analgesics in a manner that is both medically appropriate and in compliance with applicable state and federal laws and regulations.

The guidelines emphasize that physicians have a professional and ethical responsibility to assess and manage their patients’ chronic pain by, in part, considering the relative risks for misuse and addiction, monitoring aberrant behaviors, and intervening when appropriate.

Set forth below are a few red flags that, according to the Model Policy, state medical boards will likely view as a strong indicator of inappropriate management of chronic pain and/or a departure from accepted best clinical practices:

  • Inadequate attention to initial assessment to determine if opioids are clinically indicated and to determine risks associated with their use in a particular patient;
  • Inadequate monitoring during the use of opioids that can be potentially misused;
  • Inadequate attention to patient education and informed consent;
  • Unjustified dose escalation without adequate attention to risks or alternative treatments;
  • Excessive reliance on opioids, especially high dose opioids, for chronic pain management;
  • Not making use of available tools for risk mitigation.

The guidelines seek to balance legitimate prescriptions of opioids for pain management with the heightened awareness that some patients may not be good candidates for initial or continued use of controlled substances. In fact, the FSMB explicitly states that physicians “should not fear disciplinary action … for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice, when current best clinical practices are met.”

The challenge facing physicians is staying current on best clinical practices for prescribing opioids, with all of the attendant requirements for documentation, while still finding time to treat their patients and operate a financially viable practice.

Frank is a partner in the Providence office of Barton Gilman. His practice includes representing physicians facing investigations by medical boards of licensure.