Why Did Arizona Repeal
their Pain Guidelines?
In 1996 I was fighting
for my right to pain relief. an article was published in the Kingman Miner
about my fight for pain meds. In 1997 Arizona Medical Board published their
first guidelines for treating chronic pain.
Substantive Policy
Statement or SPS #7 was published in
November 1997 as guidelines for physicians on how to treat chronic pain with
opioids without getting in trouble. SPS #7 was revised in May 1999, and then
revised again in June 2003.
Then in December 2014
for some reason it was repealed. All guidance for physicians on how not to get
in trouble with the Arizona Medical Board or DEA for treating patients with
opioid medications was gone...
Why Did Arizona Repeal
their Pain Guidelines?
Regulations and Laws
Physicians Need Guidance
on how to treat pain without fear
Substantive Policy
Statement #7 that was published
in November 1997 revised in May 1999, and June 2003. Then in December 2014 for
some reason the Arizona Medical Board repealed SPS #7 removing all guidance for
physicians on the treatment of chronic pain with controlled substances.
AZ Medical Board Substantive Policy Statement #7
Use of Controlled Substances for the Treatment
of Chronic Pain
This substantive policy statement is advisory only. A substantive policy
statement does not include internal procedural documents that only affect the
internal procedures of the agency and does not impose additional requirements
or penalties on regulated parties or include confidential information or rules
made in accordance with the Arizona administrative procedure act. If you
believe that this substantive policy statement does impose additional
requirements or penalties on regulated parties you may petition the agency
under Arizona Revised Statutes section 41-1033 for a review of the statement.
ARIZONA MEDICAL BOARD
9545 East Doubletree Ranch Road, Scottsdale, Arizona 85258
GUIDELINES FOR THE USE OF CONTROLLED SUBSTANCES FOR THE
TREATMENT OF CHRONIC PAIN (SPS 7)
The Arizona Medical Board (“Board”) strongly urges physicians to view effective
pain management as a high priority in all patients, including children and the
elderly. Pain should be assessed and treated promptly, effectively and for as
long as pain persists. The medical management of pain should be based on
up-to-date knowledge about pain, pain assessment and pain treatment. Pain
treatment may involve the use of several drug and nondrug treatment modalities,
often in combination. For some types of pain the use of drugs is emphasized and
should be pursued vigorously; for other types, the use of drugs is better
de-emphasized in favor of other therapeutic modalities. Physicians should have
sufficient knowledge or consultation to make such judgments for their patients.
Drugs, in particular the opioid analgesics, are considered the cornerstone of
treatment for pain associated with trauma, surgery, medical procedure and
cancer. Physicians are referred to the U.S. Agency for Health Care Policy and
Research Clinical Practice Guidelines as a sound yet flexible approach to the
management of these types of pain.
The prescribing of opioid analgesics for other patients with intractable
non-cancer pain also may be beneficial, especially when efforts to remove the
cause of pain or to treat it with other modalities have been unsuccessful. For
the purposes of these guidelines, intractable pain is defined as:
A pain state in which the cause of the pain cannot be removed or otherwise
treated and which in the generally accepted course of medical practice no
relief or cure of the cause of the pain is possible or none has been found
after reasonable efforts including, but not limited to, evaluation by the
attending physician and surgeon and one or more physicians and surgeons
specializing in the treatment of the area, system or organs of the body
perceived as the source of the pain.
Therefore, these guidelines are an attempt to communicate to physicians who
prescribe opioids for intractable pain not to fear disciplinary action from
this Board for prescribing or administering controlled substances in the course
of treatment of a person for intractable pain. Also, physicians should use
sound clinical judgment, and care for their patients according to the following
principles of responsible professional practice.
I. STATUTORY ABILITY TO DEVELOP GUIDELINES
Pursuant to Arizona Revised Statutes § 32-1403(A)(3), the Board may develop and
recommend standards governing the profession in Arizona.
II. GUIDELINES FOR PATIENT CARE WHEN PRESCRIBING CONTROLLED SUBSTANCES FOR
CHRONIC PAIN
A) Pain Assessment
Pain assessment should occur during initial evaluation, after each new report
of pain, at appropriate intervals after each pharmacological intervention, and
at regular intervals during treatment. Unless a patient is terminally ill and
death is imminent (in which case the diagnosis is usually evident and
diagnostic evaluations may be of little value and discomforting to the
patient), the evaluation should include:
1. Medical history, including the presence of a recognized medical indication
for the use of a controlled substance, the intensity and character of pain, and
questions regarding substance abuse;
2. Corroboration of medical history by reviewing patient’s medical records
and/or speaking with patient’s former physicians. Patients frequently seek out
a new prescribing physician after their previous prescribing physician has
terminated them for non-compliance, substance abuse, and/or drug diversion;
3. Psycho-social assessment, which may include but is not limited to:
a. The patient's understanding of the medical diagnosis, expectations about
pain relief and pain management methods, concerns regarding the use of
controlled substances, and coping mechanisms for pain;
b. Changes in mood which have occurred secondary to pain (i.e., anxiety,
depression); and
c. The meaning of pain to the patient and his/her family.
4. Physical examination, including a neurologic evaluation and examination of
the site of pain.
5. Urine drug screen, testing for commonly abused street drugs as well as
prescription pain drugs that are known abused or diverted drugs. Such screening
will help identify drug abusers and drug diverters.
B) Treatment Plan
A treatment plan should be developed for the management of chronic pain and
state objectives by which therapeutic success can be evaluated, including:
1. Pain relief;
2. Improved physical functioning;
3. Proposed diagnostic evaluations (i.e., blood tests, radiologic,
psychological and social studies such as CAT and bone scans, MRI and
neurophysiologic examinations such as electromyography); and
4. Analysis of inclusion and exclusion criteria for opioid management:
Inclusion criteria includes a clear diagnosis consistent with symptoms, all
reasonable alternative therapies have been explored; the patient is reliable
and communicates well, there has been informed consent or a treatment agreement
signed; Potential exclusion criteria include a history of chemical dependency,
major psychiatric disorder, chaotic social situation, or a planned pregnancy.
C) Informed Consent
The physician should advise the patient, guardian, or designated surrogate of
the risks and benefits of the use of controlled substances. The patient should
be counseled on the importance of regular visits, the impact of recreational
drug use, the number of physicians and pharmacies used for prescriptions, taking
medications as prescribed, etc.
The physician and the patient should enter into a pain treatment contract that
specifically states the patient’s required compliance with the treatment plan
and what the consequences of non-compliance, misuse and abuse will be. It is
particularly important that patients understand that they will be discontinued
from the prescribed controlled substances, in a safe manner, should it be
revealed that they are abusing or diverting drugs.
D) Ongoing Assessment
The assessment and treatment of chronic pain mandates continuing evaluation,
and if necessary, modification and/or discontinuation of opioid therapy. If
clinical improvement does not occur, the physician should consider the
appropriateness of continued opioid therapy, and consider a trial of
alternative pharmacologic and nonpharmacologic modalities.
E) Consultation
The physician should refer the patient as necessary for additional evaluation
to achieve treatment objectives. Physicians should recognize patients requiring
individual attention, in particular, patients whose living situations pose a
risk for misuse or diversion of controlled substances. In addition, the
prescription of controlled substances to patients with a history of substance
abuse requires extra care, monitoring, and documentation, and may also require
consultation with an addiction medicine specialist.
F) Documentation
The physician must maintain adequate, accurate and timely records regarding
items A-E from above. "Adequate Records," pursuant to A.R.S. º32-1401(2),
"means legible records containing, at a minimum, sufficient information to
identify the patient, support the diagnosis, justify the treatment, adequately
document the results, indicate advice and cautionary warnings provided to the
patient, and provide sufficient information for another practitioner to assume
continuity of the patient's care at any point in the treatment." Specific
to chronic pain patients, the documentation should include:
1. The medical history and physical examination;
2. Related evaluations and consultations, treatment plan and objectives;
3. Evidence of discussion regarding informed consent;
4. Prescribed medications and treatments;
5. Periodic reviews of treatments and patient response; and
6. Any physician-patient agreements or contracts.
G. Counting and Destroying Medication
The physician may desire to see and count a patient’s medication to determine
if the patient is taking the medication as prescribed. The patient should
display and count the medication in front of the physician. Under no
circumstance should the physician touch a patient’s controlled substances. If
the medication must be destroyed, the patient should flush the medication down
the toilet in the physician’s presence. The physician should document this fact
in the patient’s chart.
H. Post-Dated Prescriptions
Post-dated prescriptions are illegal in the State of Arizona. Therefore,
physicians may not issue post-dated prescriptions.
I. Referral of Patients with Active Substance Abuse Problems
Patients discovered to have an active substance abuse problem should be
referred to either a detoxification and rehabilitation program or to an
appropriate maintenance program for addicts.
III. COMPLIANCE WITH LAWS AND REGULATIONS
A. Prescribing Controlled Substances
To prescribe controlled substances, physicians must comply with all applicable
laws, including the following:
1. Possess a valid current license to practice medicine in the State of
Arizona; and
2. Possess a valid and current controlled substances Drug Enforcement
Administration registration for the schedules being prescribed.
B. Dispensing Controlled Substances
To dispense controlled substances, physicians must comply with all applicable
laws, including the following:
1. Possess a valid current license to practice medicine in the State of
Arizona;
2. Possess a valid and current controlled substances Drug Enforcement
Administration registration for the schedules being prescribed;
3. Comply with Arizona Revised Statutes § 32-1491, et seq. and A.A.C. R4-16-201
through R4-16-205; and
4. Comply with 22 CFR 1306.07(a) if controlled substances are dispensed for
detoxification.
