The Ohio Board of Medicine has reviewed the following policies of other organizations and has concluded that these are sound policies that delineate appropriate guidelines for practitioners:
Federation of State Medical Boards, Model Policy for the Use of Controlled Substances for the Treatment of Pain.
National Consensus Project for Quality Palliative Care, Clinical Practice Guidelines for Quality Palliative Care.
Federation of State Medical Boards, Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office.
The Ohio Board of Medicine has adopted rules for the treatment of intractable pain.
"Pain" means an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
"Intractable pain" means a state of pain that is determined, after reasonable medical efforts have been made to relieve the pain or cure its cause, to have a cause for which no treatment or cure is possible or for which none has been found. Intractable pain does not include the treatment of pain associated with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition.
"Physical dependence" means a physiologic state of adaptation to a specific drug or medication characterized by the development of a withdrawal syndrome following abrupt cessation or a drug or on administration of an agonist.
"Tolerance" means decreasing response to the same dosage of a prescription drug over time as a result of physiologic adaptation to that drug.
"Addiction" means a compulsive disorder in which an individual becomes preoccupied with obtaining and using a substance, despite adverse social, psychological, and/or physical consequences, and the continued use of which results in a decreased quality of life. Physical dependence alone is not evidence of addiction.
"Drug abuse" means a maladaptive or inappropriate use or overuse of a medication.
Physical dependence and tolerance by themselves to not indicate addiction.
Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy and do not, in the absence of drug abuse or addiction, require reduction or cessation of drug therapy.
Initial treatment requires complete medical, pain, alcohol, and substance abuse histories; assessment of the impact of pain on physical and psychological functions; review of previous diagnostic studies and previously utilized therapies; an assessment of coexisting illnesses, diseases, or conditions; and an appropriate physical examination. The medical diagnosis must be documented that indicates the existence of intractable pain along with the signs, symptoms, and causes of the pain. An individual treatment plan is required to be documented specifying the medical justification for the treatment of intractable pain with prescription drugs on a protracted basis, the intended role of prescription drug therapy within the overall plan, and other medically reasonable treatment for relief of the intractable pain that has been offered or attempted without adequate or reasonable success. The response to the treatment must be documented along with modifications to the treatment plan. The diagnosis of intractable pain can be made only after having the patient evaluated by one or more other practitioners who specialize in the treatment of the anatomic area, system, or organ of the body perceived as the source of pain. The practitioner is to maintain a copy of the report of the evaluation. The evaluation is not required if the patient has been evaluated and treated within an anatomic area, system, or organ perceived to be the source of pain, and the treating practitioner is satisfied that he or she can rely on the evaluation to meet the requirements of the board rules. The practitioner is required to obtain and maintain a copy of the records or report on which he or she relied to meet the requirements of an evaluation by a specialist. An informed consent must be retained in the medical record informing the patient about the risks and benefits of receiving prescription drug therapy and about available alternatives.
Practitioners must see patients at appropriate periodic intervals to assess the efficacy of treatment, assure that prescription drug therapy remains indicated, evaluate patients' progress, and note any adverse drug effects. There must be an assessment of functional status, and of pain intensity and its interference with activities of daily living, quality of life, and social activities. If there is evidence or behavioral indication of drug abuse, the practitioner may obtain a drug screen. It is within the practitioner's discretion to decide the nature of the screen and which type of drugs to be screened. Results of the screening must be documented in the patient's medical record.
The practitioner must obtain an immediate consultation with an addiction medicine or substance abuse specialist if the practitioner believes or has reason to believe that the patient has an addiction or is abusing drugs.
A practitioner who treats pain by using prescription drugs is not subject to disciplinary action pursuant to Ohio law under the following circumstances:
The treatment of pain for a patient with a terminal condition.
The treatment of pain associated with a progressive disease that, in the normal course of progression, may reasonably be expected to result in a terminal condition.
Treatment using only drugs that do not exert their effects at the central nervous system level.
Treatment using only drugs that are not controlled substances and are classified as antidepressants.
A practitioner who treats intractable pain by using prescription drugs is not subject to disciplinary action solely because the practitioner treated the intractable pain with prescription drugs. The practitioner is subject to disciplinary action only if the prescription drugs are not used in accordance with the requirements for the treatment of intractable pain.
The Ohio Bureau of Worker's Compensation has determined that the use of prescription medication for the treatment of chronic intractable pain is acceptable in Ohio on a protracted basis or in amounts or combinations that may not be appropriate when treating other medical conditions, so long as the treating physician complies with the State Medical Board of Ohio Administrative Rules.
No prescription may be dispensed for the first time beyond 6 months from the date it was issued or refilled beyond 1 year from the date it was issued.
All prescriptions must specify the number of times or the period of time for which the prescription may be refilled. A prescription marked "Refill PRN" or some similar designation is not considered a valid refill authorization.
A physician may not self-prescribe or self-administer controlled substances.
Accepted and prevailing standards of care require that a physician maintain detached professional judgment when using controlled substances in the treatment of family members. A physician shall use controlled substances when treating a family member only in an emergency situation, which shall be documented in the patient's record. "Family member" means a spouse, parent, child, sibling, or other individual in relation to whom a physician's personal or emotional involvement may render that physician unable to exercise detached professional judgment in reaching diagnostic or therapeutic decisions.