REPORT OF MEDICAL SOCIETY OF VIRGINIA
PAIN MANAGEMENT SUBCOMMITTEE
PREFACE TO THE MEDICAL SOCIETY OF VIRGINIA
PAIN MANAGEMENT SUBCOMMITTEE REPORT
Recently, there has been increasing interest on the part of physicians, regulatory
agencies, legislators, the public, and patients for the proper diagnosis, timely workup,
and state of the art treatment for acute, cancer, and non-cancer, chronic pain conditions.
While there is widespread agreement among health care providers concerning the treatment
of acute and cancer pain with opioids (also known as
narcotics)--as exemplified by Federal Clinical Practice Guidelines published by the Agency
for Health Care Policy and Research, U.S. Department of Health and Human Services--there
has been a lack of consensus, misunderstanding and hesitation among health care providers
(physicians, nurses, pharmacists), regulatory agencies, patients, and third party
providers concerning the use of these same agents in the management of chronic, non-cancer
Inadequate understanding about issues such as addiction, tolerance, physical dependence,
and abuse has lead to unfounded stigma against proper opioid prescription. Fears of legal
and regulatory sanctions or discipline from local, state, and federal authorities often
result in inappropriate and inadequate treatment of chronic pain patients. Undertreatment
or avoidance of appropriate opioid therapy increasingly has been reported by physicians,
patients, and other health care team
The discipline of pain medicine has produced a new awareness about the necessity of proper
diagnosis, history and physical examination, and treatment planning for the patient with
chronic pain. Unfortunately, the paucity of specially trained physicians in the field of
pain management often precludes patient access to specialized pain treatment facilities.
The treatment for these patients will appropriately fall within the realm of the primary
care or specialty physician. Until adequate guidelines are made for prescribers of opioids
for patients with chronic non-cancer pain, episodes of undertreatment of this deserving
population will continue.
As a result of the efforts and recommendations of the Governor's Joint Subcommittee
studying pain, the Medical Society of Virginia's House of Delegates, at the 1996 annual
meeting of its legislative body, recognized the lack of national consensus as well as the
need for parameters concerning the proper use of opioids for patients with intractable
pain of non-cancer origin within the Commonwealth of Virginia. The following guidelines
are presented with the hope that they will attenuate fears about professional discipline,
encourage adequate and proper treatment of chronic pain with all appropriate therapies,
and educate about and protect patients as well as the general public from unsafe or
inappropriate prescribing patterns or abuses.
The Society believes that physicians have an obligation to treat patients with intractable
pain and to lessen suffering and that opioids may be appropriately and safely prescribed
for many acute, cancer, and chronic pain conditions as long as acceptable protocols and
standards are closely followed. The Society feels that physicians should be encouraged to
prescribe, dispense, and administer opioids when there is demonstrated medical necessity
and proper indication for these agents without fear of discipline, excessive scrutiny, or
remunerative or restrictive legal penalties. These guidelines should not be interpreted as
absolute standards of care in the treatment of chronic pain patients, nor are they
absolute directives for clinical practice. Rather, they are guidelines by which, all
physicians may more safely and comfortably evaluate and treat this very problematic and
needy group of patients.
MEDICAL SOCIETY OF VIRGINIA 'S GUIDELINES FOR THE USE OF OPIOIDS IN THE
MANAGEMENT OF CHRONIC NON-CANCER PAIN
For the purposes of this document the following terms shall have the following
Addiction is a disease process involving use of opioid(s) wherein there is a loss of
control, compulsive use, and continued use despite adverse social, physical,
psychological, occupational, or economic consequences.
Substance abuse is the use of any substance(s) for non-therapeutic purposes; or use of
medication for purposes other than those for which it is prescribed.
Physical dependence is a physiologic state of adaptation to a specific opioid(s)
characterized by the emergence of a withdrawal syndrome during abstinence, which may be
relieved in total or in part by
re-administration of the substance. Physical dependence is a predictable sequelae of
regular, legitimate opioid or benzodiazepine use, and does not equate with addiction.
Tolerance is a state resulting from regular use of opioid(s) in which an increased dose of
the substance is needed to produce the desired effect. Tolerance may be a predictable
sequelae of opiate use and does not imply addiction.
Withdrawal syndrome is a specific constellation of signs and symptoms due to the abrupt
cessation of, or reduction in, a regularly administered dose of opioid(s).
Opioid withdrawal is characterized by three or more of the following symptoms that develop
within hours to several days after abrupt cessation of the substance: (a) dysphoric mood,
(b) nausea and vomiting, (c) muscle aches and abdominal cramps, (d) lacrimation or
rhinorrhea, (e) pupillary dilation, piloerection, or sweating, (f) diarrhea, (g) yawning,
(h) fever, (i) insomnia.
Acute pain is the normal, predicted physiological response to an adverse (noxious)
chemical, thermal, or mechanical stimulus. Acute pain is generally time limited and is
historically responsive to opioid therapy, among other therapies.
Chronic pain is persistent or episodic pain of a duration or intensity that adversely
affects the function or well-being of the patient, attributable to any non malignant
ASSESSMENT, DOCUMENTATION, AND TREATMENT
A. History and Physical Examination: The physician must conduct a complete history and
physical exam of the patient prior to the initiation of opioids. At a minimum the medical
record must contain
documentation of the following history from the chronic pain patient:
1. Current and past medical, surgical, and pain history including any past
interventions and treatments for the particular pain condition being treated.
2. Psychiatric history and current treatment
3. History of substance abuse and treatment.
4. Pertinent physical examination and appropriate diagnostic testing.
5. Documentation of current and prior medication management for the pain condition,
including types of pain medications, frequency with which medications are/were taken,
history of prescribers (if possible), reactions to medications, and reasons for failure of
6. Social work history.
B . Assessment: A justification for initiation and maintenance of opioid therapy must
include at a minimum the following initial workup of the patient:
1. The working diagnosis (or diagnoses) and diagnostic techniques. The original
differential diagnosis may be modified to one or more diagnoses.
2. Medical indications for the treatment of the patient with opioid therapy. These should
include, for example, previously tried (but unsuccessful) modalities/medication regimens,
diverse reactions to prior treatments, and other rationale for the approach to be
3. Updates on the patient's status including physical examination data must be
periodically reviewed, revised, and entered in the patient's record.
C. Treatment Plan and Objectives: The physician must keep detailed records on all
patients, which at a minimum include:
1. A documented treatment plan.
2. Types of medication(s) prescribed, reason(s) for selection, dose, schedule
administered, and quantity.
3. Measurable objectives such as:
a. social functioning and changes therein due to opioid
b. activities of daily living and changes therein due to
c. adequacy of pain control using standard pain rating
scale(s) or at least statements of the patient's satisfaction with the degree of pain
D. Informed Consent and Written Agreement for Opioid Treatment: Written documentation of
both physician and patient responsibilities must include:
1. Risks and complications associated with treatment using opioids
2. Use of a single prescriber for all pain related medications.
3. Use of a single pharmacy, if possible.
4. Monitoring compliance of treatment:
a. Urine/serum medication levels screening (including checks for non-prescribed
medications/substances) when requested.
b. Number and frequency of all prescription refills.
c. Reason(s) for which opioid therapy may be discontinued (e.g. violation of written
E. Periodic Review: Intermittent review and comparison of previous documentation with the
current medical records are necessary to determine if continued opioid treatment is the
best option for a
patient. Each of the following must be documented at every office visit:
1. Efficacy of Treatment
a. Subjective pain rating (e.g. 0-10 verbal assessment of
b. Functional changes.
i. Improvement in ability to perform activities of daily
ii. Improvement in home, work, community, or social life.
2. Medication side effects.
3. Review of the diagnosis and treatment plan.
4. Assessment of compliance (e.g. counting pills, keeping record of number of medication
refills, frequency of refills, and disposal of unused medications/prescriptions).
5. Unannounced urine/serum drug screens and indicated laboratory testing, when
F . Consultation: Most chronic non-cancer patients, like their cancer pain counterparts
can be adequately and safely managed by most physicians without regard for specialty.
However, the treating physician must be cognizant of the availability of pain management
specialists to whom the complex patient may be referred. The physician must be willing to
refer the patient to a physician or a center with more expertise when indicated or when
difficult issues arise. Consultations must be
documented. The purpose of this referral should not necessarily be to prescribe the
G . Medical Records: Accurate medical records must be kept, including, but not limited to
a. All patient office visits and other consultations obtained .
b. All prescriptions written including date, type(s) of medication, and number
c. All therapeutic and diagnostic procedures performed.
d. All laboratory results.
e. All written patient instructions and written agreements.
SUMMARY AND CONCLUDING REMARKS
The treatment of patients with chronic, non-cancer pain should not be limited to pain
specialists only. Because of complex social, regulatory, ethical, and legal issues
surrounding the use of opioids in these patients, the physician who elects to help treat
these patients may find it useful to utilize the guidelines and examples outlined in this
document. While these guidelines do not define standard of care, it is the hope of the
Medical Society of Virginia, working in close conjunction with the Virginia Board of
Medicine, and the Commonwealth of Virginia's Joint Subcommittee to Study the
Commonwealth's Current Laws and Policies Related to Chronic, Acute, and Cancer Pain
Management, that physicians who do treat this very difficult and deserving patient
population will find significant clinical benefit from this document and will be
enlightened by the suggestions offered herein.