NEW ORLEANS — Get educated about state and federal regulations and policies on the prescription of controlled substances, advised David Joranson, director of the Pain and Policy Studies Group at the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center in Madison.
Mr. Joranson, who spoke at the annual meeting of the American Academy of Pain Medicine, said that understanding current regulations is critical to avoiding unnecessary fears over the risk of sanctions from prescribing pain medication.
In recent years there has been increasing agreement reached between pain medicine specialists, law enforcement, and regulators, he said. For example, from 2003 to 2006, 19 states either repealed or added language to their state's controlled substances prescribing policies to take a more balanced approach—recognizing opioids are necessary but also pose risks and need to be controlled. “The state policies are becoming more balanced,” he said.
Importantly, 39 states have adopted a policy aimed at directly addressing physicians' concerns about regulatory scrutiny, he added.
Nearly 10 years ago, the Federation of State Medical Boards made it clear that physicians should recognize that tolerance and physical dependence are the normal consequences of the sustained use of opioid analgesics and are not synonymous with addiction. As a result, many state medical board guidelines now reflect that statement, Mr. Joranson said.
Last year, at the federal level the Drug Enforcement Administration issued a statement that nearly every prescription issued in the United States is for a legitimate medical purpose and that the amount of dosage units per prescription will never be a basis for investigation for the overwhelming majority of physicians. “Here again it looks like we're pretty much on the same page,” he said.
Research findings indicated, however, that physicians may not be paying attention to this policy shift. In a study published in the Journal of Family Practice in 2001, investigators from the University of California, San Francisco/Stanford Collaborative Research Network surveyed 230 primary care physicians on pain treatment, the use of opioids, and their familiarity with state prescribing and documentation guidelines.
Specifically, the investigation focused on whether physicians were aware of guidelines on prescribing opioids for chronic nonmalignant pain that were issued by the Medical Board of California in 1994. The guidelines were aimed in part at reducing physicians' fear of regulatory scrutiny. The guidelines were mailed to all licensed physicians in the state three times between 1994 and 1996.
Of the 161 physicians who completed the survey, only 39% remembered reading the guidelines 1 year after the third mailing. And 40% of respondents said that fear of legal investigation influenced their opioid prescribing habits. “It can be an uphill battle to get physicians to pay attention to policy,” Mr. Joranson said.
Despite the growing areas of agreement on proper pain prescriptions, there are still some areas surrounding prescribing of controlled substances that need to be worked out, he said. For example, prescribing opioids to pain patients who may have a substance abuse problem is an area where law enforcement and physicians have the potential to clash. More dialogue is needed between the pain medicine community and DEA on this issue, he said.
In addition, some groups mistakenly believe that physicians and patients are the main source of drug diversion, he said.
Although it's likely that the majority of regulatory and law enforcement actions against physicians for prescribing of controlled substances are appropriate, there have been exceptions, he said. Some physicians have been charged and later acquitted in court; others have been convicted only to have their cases overturned later. These cases need to be investigated to figure out what went wrong, he added.