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.

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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.