APPENDIX: Guidelines for the Use of Opioids in the Treatment of
Chronic, Non-Cancer Pain
THE MEDICAL SOCIETY OF VIRGINIA: Report of the MSV Pain Management Subcommittee
PREFACE
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 pain.
Inadequate understanding about issues such as addiction, tolerance,
physical dependence, and abuse has led 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
members.
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 lesson 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.