Book Text

History and Physical Examination
The physician must conduct a complete history and physical exam of the patient prior to the initiation of opioids. At a minimum the medical record must contain documentation of the following history from the chronic pain patient:

Current and past medical, surgical, and pain history including any past interventions and treatments for the particular pain condition being treated.
Psychiatric history and current treatment.
History of substance abuse and treatment.

Pertinent physical examination and appropriate diagnostic testing.
Documentation of current and prior medication management for the pain condition, including types of pain medications, frequency with which medications are/were taken, history of prescribers (if possible), reactions to medications, and reasons for failure of medications.
Social/work history.

Assessment
A justification for initiation and maintenance of opioid therapy must include at a minimum the following initial workup of the patient:

The working diagnosis (or diagnoses) and diagnostic techniques. The original differential diagnosis may be modified to one or more diagnoses.
Medical indications for the treatment of the patient with opioid therapy. These should include, for example, previously tried (but unsuccessful) modalities/medication regimens, diverse reactions to prior treatments, and other rationale for the approach to be utilized.
Updates on the patient's status including physical examination data must be periodically reviewed, revised, and entered in the patient's record.

Treatment Plan and Objectives
The physician must keep detailed records on all patients, which at a minimum include:

A documented treatment plan.
Types of medication(s) prescribed, reason(s) for selection, dose, schedule administered, and quantity.
Measurable objectives such as:

social functioning and changes therein due to opioid therapy.
activities of daily living and changes therein due to opioid therapy.
adequacy of pain control using standard pain rating scale(s) or at least statements of the patient's satisfaction with the degree of pain control.

Informed Consent and Written Agreement for Opioid Treatment
Written documentation of both physician and patient responsibilities must include:

Urine/serum medication levels screening (including checks for non-prescribed medications/substances) when requested.
Number and frequency of all prescription refills.
Reason(s) for which opioid therapy may be discontinued (e.g., violation of written agreement item[s]).

Periodic Review
Intermittent review and comparison of previous documentation with the current medical records are necessary to determine if continued opioid treatment is the best option for a patient. Each of the following must be documented at every office visit:

Medication side effects.
Review of the diagnosis and treatment plan.
Assessment of compliance (e.g., counting pills, keeping record of number of medication refills, frequency of refills, and disposal of unused medications/prescriptions).
Unannounced urine/serum drug screens and indicated laboratory testing, when appropriate.

Consultation
Most chronic non-cancer patients, like their cancer pain counterparts, can be adequately and safely managed by most physicians without regard for specialty. However, the treating physician must be cognizant of the availability of pain management specialists to whom the complex patient may be referred. The physician must be willing to refer the patient to a physician or a center with more expertise when indicated or when difficult issues arise. Consultations must be documented. The purpose of this referral should not necessarily be to prescribe the patient opioids.
Medical Records
Accurate medical records must be kept, including, but not limited to, documentation of:

All patient office visits and other consultations obtained.
All prescriptions written including date, type(s) of medication, and number (quantity) prescribed.