Expert Article Library

Pain Medication Guidelines and Standards of Care

by Robert J. Friedman, MD

Pain Medication prescribing has historically been an unsettled area with little consensus. There has been controversy between the concepts of those who oppose widespread opioid prescriptions for patients suffering from chronic pain, and the idea that all persons with severe chronic pain should have relatively unrestricted access. The prudent path is somewhere in between, and finding the appropriate balance is an ongoing process.

Opioid ("narcotic') pain medications are only one of several treatment options available for chronic pain. Yet prescription of these medications is the standard of care for cancer pain, and there is now a general consensus that they have an appropriate place in the management of severe non-malignant (non-cancer) pain. This latter includes chronic back pain and pain due to nerve injury, for example. The medications can be life-saving for some people, help them function, and used appropriately, often have an acceptable degree of side effects. On the other hand, the dangers of misused opioid medications are notorious. Fatal overdoses can easily occur when the drugs are misused or fall into the wrong hands. Side effects can interfere with everyday function or cause other medical problems. The disease of addiction can be fed when opioids are prescribed without appropriate precautions. And these drugs are actively sought by persons who wish to sell or abuse them.

Guidelines for opioid pain medication management in chronic nonmalignant pain have been issued by professional societies such as the American Academy of Pain Medicine. Somtimes determining the standard of care has been problematic because of the evolving changes in consensus statements and the rules proliferated by state medical boards. For the most part, the changes in these administrative rules have been positive, reflecting recommendations of the Pain & Policy Studies Group at the University of Wisconsin and others.

Diversion of opioid medications has recently brought "pain clinics" to the front pages of newspapers. Owners of some Florida medical clinics have taken advantage of regulations that allow them to employ doctors merely to prescribe pain medications. People have traveled from out of state to get these prescriptions. And the many recent deaths due to misused prescription drugs have raised public consciousness of this widespread affliction.

For the foreseeable future, there will be a prominent role of opioids in chronic pain management. It will be impossible to completely prevent the misuse and diversion of these drugs. What is needed is an optimization of the rules and processes governing their prescription and use. Generally this can be achieved by striking a balance between making these drugs available and rendering that misuse less likely. For doctors, this means prescribing when appropriate but evaluating patients properly and taking reasonable precautions to ensure appropriate use by patients. For patients, this means understanding the risks and guarding the drugs from diversion. For state professional boards, it is necessary to maintain guidelines and to monitor prescription by their licensees. State and federal regulators such as the DEA need to focus on preventing diversion and abuse while acknowledging the legitimate medical uses of these drugs.