Prescribing Controlled Substances Reconsidered
Eric A. Voth, M.D., FACP, Chairman, The Institute on Global Drug Policy

Abstract:

Pain management is an important and emerging field of medicine. Appropriately prescribing and managing controlled substances for pain is unfortunately fraught with risk of litigation, regulatory intervention, manipulation by drug abusers, and misunderstanding by the public. Chronic pain is a pervasive and widespread phenomenon which must be adequately treated while at the same time minimizing diversion and abuse of powerful but effective substances. This article outlines useful recommendations for the appropriate use of controlled substances in pain management, and it also defines a legal standard of care.

As the field of pain management has evolved, so have the complexities surrounding the choices of therapy, the abuse and diversion of controlled pain medications, and the disciplinary environment which seeks to protect the public from inappropriate prescribing and drug diversion. Since this author’s first discussion of prescribing controlled substances in 1991 (1), volumes have been written on the management of both cancer and chronic non-cancer pain (2).

Unfortunately, prescription narcotic abuse is a significant problem. While 4.8 percent of individuals over 12 years of age used prescription pain relievers non-medically in the prior year of the survey (3), 11.9 percent of individuals age 18 to 25 used the drugs non-medically. Fortunately, use has been reasonably stable from 2002 to 2005. Cicero has examined abuse patterns and determined that the most frequently abused products are either oxycodone or hydrocodone-based medications (4) as well as buprenorphine and methadone (5).

Counterbalancing the concerns over the abuse of controlled pain medicines is the fact that pain continues to be largely under-treated. Recent work has characterized the global impact of the undertreatment of pain as a function of negative attitudes toward pain, legal barriers, financial constraints, and poor access to care. Taylor et al (6) relate that 80% of patients globally do not receive adequate pain treatment.

An evolution of the disciplinary arena has resulted in the recognition that there exists an appropriate framework for prescribing and managing chronic pain. (7). Such guidelines were largely based upon the definitions outlined by pain specialists as they grappled with the complexity of pain management. (8,9). Unfortunately, such guidelines are nebulous enough that they are open for abuse from either a lenient or restrictive perspective. What is very important, however, is that respected authorities have defined the problem and stated clearly that the use of controlled substances is appropriate in the treatment of chronic pain.

Despite progress and changes in position on the part of the regulatory environment, the level of understanding of the management of chronic pain on the part of disciplinary boards still lags behind the medical pain treatment community. By 2004, two-thirds of regulators considered long-term use of opioid pain medications to patients for non-cancer pain to be lawful as compared to only 33% in 1997. Of equal importance is the fact that only 21% considered the use of opioids in patients with a prior substance abuse history as legal in 2004 compared to 6% in 1997 and only 1% in 1991 (10).

Central to the entire discussion of pain management and appropriate or legal prescribing is the notion of addiction vs. dependence vs. abuse. Part of the problem arises in the lack of a uniform vernacular and nomenclature. Indeed, there is variance between such nomenclatures as the WHO, the DSM-IV, and general medical vernacular (Atluri S, Boswell MV, Hansen HC, Trescot AM, Singh V, Jordan AE. Guidelines for the Use of Controlled Substances in the Management of Chronic Pain. Pain Provider 2003;6:233-257).

To better understand these issues, we need to establish a working definition of terms. For purposes of clarification, the terms practitioner and provider are used synonymously. We do recognize that there are a host of specialties that will prescribe for chronic pain, including those with mid-level training (provider assistants and ARNPs).  Physical dependence will develop in many patients simply as the result of sustained exposure to opiate pain medication or other habituating medication. Such dependence is often accompanied by tolerance, which may necessitate increases in dosing of narcotics in some patients for them to continue to experience analgesic qualities. Such increases in required dose may be a sign of impending problems with the medications. However, the acceptance of the term pseudoaddiction has helped explain such a phenomenon when patients push for higher doses of medication as the result of legitimate pain needs in the absence of abuse.  Practitioners need to question whether dose adjustments and perceived manipulations are more the result of under-treated pain than true misbehavior.

Withdrawal is virtually always seen in a patient who has had sustained narcotic dosing and abruptly stops the medication. Such patients may incorrectly be labeled as “addicts” rather than individuals suffering a normal physiological response to the abrupt discontinuation of habituating medications. This may be the result of inadvertent discontinuation such as hospitalization or may result from an intentional discontinuation of the medicine by either the patient or practitioner.

Addiction (also termed drug dependence or chemical dependence) is a vexing term. This terminology brings to bear the issue of misbehavior and manipulation. It encompasses illegal behaviors along with loss of control and compulsion to use. Certainly, awareness of such “aberrant” behaviors on the part of practitioners is paramount to deciding whether to continue to provide medications. Sadly, prescribing controlled substances may require the provider to be suspicious of patients. Most providers are trained to believe patients’ histories, giving them the benefit of the doubt. The cold war adage “trust but verify” is a useful stance to adopt.

Standard of care:
The term “standard of care” is often used synonymously in medical practice and medical institutions with the term “best practices.”  It is often connoted to mean “the” way to manage a medical situation. In a medico-legal or regulatory environment, however, a distinctly different situation exists. Unfortunately, there has been a surge in medical malpractice cases aimed at the standard of care in pain management. It is therefore important to explore this issue in detail.

In the legal realm, the “standard of care” represents a spectrum of behaviors and practices which range from best practices to those which are barely acceptable. Standard of care is generally regarded as the appropriate application of adequate training or practices which competent and reasonable providers consider appropriate and adequate. This is obviously a broad spectrum, and therefore there exists a hesitancy in defining a standard of care. One excellent summary of pain management even makes the statement, “these guidelines do not represent ‘standard of care’ ” (2).

Defining the standard of care:
Defining a deviation from the “standard of care” becomes a difficult task as it relates to pain management. Some practitioner behaviors are clear deviations from the standard of care while others are more difficult to ascertain. The provider who comes under scrutiny for prescribing might be termed a “misprescribing” provider. The misprescribing provider has been characterized previously as either Dated, Duped, Disabled, or Dishonest (1).

The most glaring examples of deviations of standard of care involve intentional diversion or abuse of controlled substances such as criminal or unethical behaviors. Examples of the “dishonest” provider would include knowingly selling drugs or providing prescriptions to patients for cash, sexual favors, or street drugs with the clear intent that they are to be abused. Undercover police investigations are often required to identify such behavior.

Persistent significant personal use or prescribing for family members of opiate pain medications or sedatives, particularly in doses exceeding reasonable therapeutic ranges by the “disabled” provider, is also inappropriate. States’ regulations vary as to personal prescribing, but in general, it is legally dangerous to prescribe opiate pain medicine or related narcotics for oneself or family members on a prolonged basis. This is to be contrasted with the rare or occasional prescription for narcotic cough medicines, pain medicine, or sedatives for family members. Some states may prohibit this as well.

It is also a clear deviation from the standard of care as well as ethical boundaries to prescribe narcotics or sedatives for sex partners, or certainly in any manner where the drugs are being traded for sexual or monetary favors.

The “dated” provider tends to be out of touch with the medical literature and accepted practices for dealing with pain. Such a provider may not use alternatives to narcotic treatments for pain out of a lack of awareness or a lack of availability of other modalities. While this type of provider might receive leniency or requirement for retraining from a regulatory agency, they are still exposed to litigation risks.

The greatest risk for the practitioner is falling into the trap of being “duped” by drug seeking or drug abusing patients. These providers are usually competent and compassionate physicians who seek to provide relief to patients who appear to be in misery. Many of the interventions which are considered best practices are targeted at preventing these types of situations.

Examples of best practices in pain management would include, but not be limited to, exhaustive and rigorous documentation, use of standardized scoring and assessment tools, monitoring with drug screening, pain contracts or agreements, monitoring pharmacy records, detailed review of past medical records, and criminal background checks. While these are useful and beneficial tools, they are quite time-consuming and often cumbersome to implement. Such interventions might be implemented in patients who are high-risk for abuse or manipulation (2).

History and Physical examination:
It is the documentation of history and physical findings that is the most important item that litigant attorneys, regulatory agencies, or enforcement agencies examine when trying to determine a deviation from standard of care. The best practice for documentation of history would include obtaining an extensive and thorough history of present illness and evaluating past medical history that corroborates the pain picture.

Elements of such a history include careful description of the history and source of pain, the character of the pain, variations throughout the day, benefits, detractors, and irritants. The use of a standardized pain scoring measure such as the Mankowsky grading scale which ranks pain intensity from 1-10, gives a good sense of the status of the pain. Other important items would include medication habits, past or current trouble with alcohol or other drugs, evidence of overt manipulation, inconsistencies in history or symptoms, and rigorous attention to behaviors or activities which alter pain for the better or worse. Every refill or pain-related contact with the patient would repeat the scoring and a thorough discussion of the status of pain. 

This level of documentation is certainly an excellent goal, but it is simply too time intensive to accomplish for every patient in today’s medical practice environment. While a “best practices” approach is optimal, practicing within the standard of care would dictate that there is at least some reasonable interval for follow-up and documentation of the status of the patient. That may be weekly for the unstable or worrisome patient, or it may be 6 months for the stable and reliable patient. If the patient care takes place in the primary care setting, an intrinsic difficulty is mixing other primary care issues and failing to address and document adequately regarding the pain status.

It is neither reasonable nor feasible for all pain management to take place in specialized practices. Indeed, most pain management takes place in primary care settings. It is not a deviation of the standard of care for a practitioner other than a pain specialist to care for pain. That being said, the provider must have some understanding of pain and the ability to evaluate and appropriately render treatment. Strong consideration should be given to referring unstable, poorly controlled cases or cases that are perceived to be problematic to either pain specialists or those who might have expertise with a specific system.

A deviation from the standard of care relative to the use of specialists might hinge upon failure to obtain specialty consultation or advice in the face of persistent evidence of aberrant behaviors with widely fluctuating doses of medication, or without evidence of a clear explanation for such aberrant behaviors. A reasonable discussion of the decision to not refer could be an acceptable chart entry that might mitigate such a determination. Other mitigating issues would be lack of availability of specialists, lack of a clearly defined cause of pain, or rural locations where obtaining specialty input places an unnecessary burden on the patient to travel unreasonable distances.

Office notes need to be legible and demonstrate a reasonable flow of thought. It may be very difficult for expert witnesses or reviewers to sort out provider “short hand” notes, and this may work against the provider. The frequency of documentation is not well defined in the pain literature. The standard of care for adequacy of documentation depends largely upon the stability of the condition and treatment. Significant changes in dosage, changes in the reported nature of pain, changes in excuses, early refills, and other aberrant behavior need some discussion. Along this line, isolated or rare aberrant events might need minimal documentation.

It is also important to note that some lack of documentation does not necessarily tie directly to harmful outcomes. If there appears to be a reasonable initial indication for a narcotic, reasonable intervals of follow-up, generally acceptable doses, and no gross evidence of abuse on the part of the patient, then the chart probably meets the standard of care from a legal perspective.

Several other interventions exist that help constitute best practices. While these are very useful in building a case for a particular course of treatment, the lack of using them is not a deviation from the standard of care. These tools are very helpful in adding information that may help document the legitimacy of the patient behavior.

Assessment tools:
Several scoring tools exist that help in the determination of the status of pain. The intent of such tools is to use standardized scoring and description of the pain to help determine particularly the legitimacy of the pain history. Most of the assessments try to tie together the significant elements of documentation in a neat package. The Pain Assessment Documentation Tool is a reasonably short and easy tool that lends itself nicely to either a specialty or a primary care environment (11).

The DIRE score goes a step further by trying to predict troublesome patients. Essentially, the DIRE codifies the same type of decision-making processes that experienced pain providers go through as they make judgments of risk and legitimacy of patients. In so doing, risk is essentially quantified (12).

Pain agreements or contracts:
The use of pain agreements has become commonplace within the pain management community, but some controversy surrounds their use. It is inappropriate to suggest that a pain management “contract” is a bilateral, legally binding contract that requires the patient as well as the provider to perform in certain ways or be open to litigation. Some plaintiff attorneys have tried to litigate suggesting that if a provider continued to prescribe pain medication even though the patient had, for instance, failed a drug test that the provider was in violation of the contract.

Thus, the pain “agreement” is a better terminology that seeks to explain and document the expectations that the provider has of the pain patient. It also defines a possible set of circumstances that might result in termination of the patient if the patient is non-compliant. As with some of the other tools mentioned, the use of a pain agreement is a best practice. The pain agreement should generally be considered a one way agreement that if the patient performs within certain expectations that the provider may continue to prescribe pain medications.

One drawback of the pain agreement is the formal and almost adversarial structure that the signed agreement creates between the provider and the pain patient. The agreement does, however, clearly define some expectations of behavior of the patient.  Considering the litigation and regulatory environment that exists, it is still prudent to pursue the pain agreement (13,14).

Elements of the pain agreement may typically include but are not limited to a definition of the primary prescribing provider, the pharmacy to be used, adherence to dosing and prescribed interventions, the potential use of drug screens, perhaps a discussion of the toxicity or risks associated with narcotic therapy, and possibly other items that the provider may want covered. Plaintiff cases have sued pain specialists over the issues surrounding a lack of informed consent to administer narcotics. If carefully worded, a pain agreement can alleviate at least some of this risk.

The lack of use of a pain agreement or failure to terminate a patient based on  the patient’s violation of the agreement is insufficient to constitute a deviation of standard of care. Some plaintiff attorneys and regulatory agencies have interpreted the lack of termination of a patient who signs an agreement and then violates elements of the agreement as a deviation of the standard of care on the part of the provider. This is inappropriate (15).

At some point, repeated violations of a pain agreement may represent aberrant or manipulative behavior necessitating termination. However, this is an extremely variable situation and depends upon the judgment of the provider in the context of the overall case. Unless there is a clear and repeated pattern of ignoring significant elements of the pain agreement without a documented justification, this is not a deviation from the standard of care.

Pharmacy records:
The review of pharmacy records is useful in determining patient prescription patterns. Evidence of a patient filling prescriptions from multiple providers might constitute grounds to terminate a patient. However, the expectation of a single prescribing provider needs to be clearly articulated to the patient. Very manipulative or criminal patients may be well-organized enough to manage multiple pharmacy accounts that never become obvious to the primary prescribing provider.

Privacy rules would generally require that a release of information be obtained from the patient so that the provider can openly communicate with the pharmacy. It is also useful to send a letter of introduction to the pharmacy outlining who will be the primary prescribing provider.

Drug screening:
Drug screens can be useful in identifying the presence of unacceptable drugs such as marijuana, cocaine, or other drugs that should not be present. Drug screening can also confirm that prescribed medications are present. Of course, using drug screens entails a necessary level of understanding and expertise. The absence of a prescribed medication might signify lack of use and diversion, but it may also indicate reduction of dosing because of inability to afford medicine or from unwanted side effects. On the other hand, the concentration threshold of the drug test in question needs to be known so that a drug test is not inadvertently considered negative because of a high threshold. Quantitative screens may also be useful for monitoring.

The use of drug screening should be considered a best practice, and the lack of use does not necessarily constitute a deviation from the standard of care.

Background checks:
Some pain specialists actually evaluate the criminal backgrounds of clients before prescribing narcotic pain medications. This practice walks a fine line between the practitioner exercising due diligence on one hand and serving as a policeman on the other. If a provider chooses to undertake evaluation of criminal backgrounds, that certainly constitutes a best practice and is not a requirement for standard of care. It is reasonable and appropriate for practitioners to positively identify patients before providing strong and potentially toxic medications.

Some states have established prescription monitoring programs (16). A wide variety of options for such programs exist, and it appears that the computerized models with inputting of information by pharmacists may be the least intrusive to practice. However, there does exist a chilling effect if profiles are readily used by regulatory agencies.

Congress is working on legislation to try to mandate states to make web-based resources available to physicians so that drug-abusing patients can be identified. Unfortunately, a significant number of issues need to be ironed out before such legislation is widely accepted. One issue certainly is the sharing of patient information in a way that does not violate confidentiality laws. Concern exists that law enforcement might use such resources to try to profile physicians and thus target them for arrest. However, law enforcement and criminal justice data sharing would be extremely useful for providers to have access to. A web-based system that gives providers an edge in identifying criminal or abusive patients would be a welcome resource.

Use of Medications:
The arena of pain medicine is fortunate to have a wide array of medicines available. The spectrum of choices has vastly increased over the last 10 years. Unfortunately, every opiate-based narcotic pain medicine has a potential to cause physical dependence, abuse, or overdose. Numerous discussions exist in the literature regarding the choices of narcotics for chronic pain (17,18).

As a general rule, if an opiate pain medicine is required for chronic pain, medicines with long half-lives are preferable for maintenance while the short-acting medicines are reserved for episodes of breakthrough pain. Long half-life preparations will provide sustained coverage over the course of a day rather than the roller coaster that is caused by the short half-life medicines. Sustained release oxycodone (eg. Oxycontin ), morphine (eg. MS Contin or Avinza), methadone, oxymorphone (Opana) and fentanyl patches (eg. Duragesic)  are all excellent choices. All of these medicines unfortunately have a street value, may be abused, and all except methadone are relatively expensive.

It is beyond the scope of this article to discuss specifics of dosage and the wide variety of medicine available. Table 1 provides some suggested ranges of narcotic medication dosing. Generally, narcotic analgesics as well as adjunctive medications should be started at low doses and titrated with attention to patient acceptance, side effects, and efficacy in mind. Toxicity is generally avoidable if patients are instructed to slowly titrate medicines. It may also beneficial to use creative dosing schedules to minimize sedation or toxicity or to maximize pain relief during sleep. An example would be dividing the doses of Oxycontin into 4-6 doses per day with varying strengths such as 10mg in the AM, 10 mg mid day, 10 mg afternoon, 20 mg dinner, 40 mg hs. Despite the fact that this drug is most often administered  twice daily (BID), such a regimen makes use of the peak doses targeting pain at times, while reducing sedation during the day. Similarly, methadone can be split into several doses if sedation or nausea occur with larger BID dosing.

There exists a wide range of attitudes regarding how to dose opiate pain medications. One school of thought is that there is virtually no upper limit on dosing. If there is even temporary benefit from a dose, then pushing to gain pain control is acceptable to practitioners in this camp. Such a view has some merit, but it also risks overdosing from massive doses, high cost, and potential toxicity.  The effective use of intrathecal narcotics is a good example of delivering equivalents of several thousand milligrams of an oral dose. Because of the intrathecal route, a greater analgesic benefit can be obtained with less systemic toxicity. Such therapy is extremely expensive and requires specialty training for implantation and maintenance.

The identification of narcotic-induced hyperalgia (19) has given pause to the unlimited dose approach. If a patient seems to actually experience heightened pain with increasing doses, this must be considered. It is also important to periodically consider tapering doses to identify the pain threshold. The pain threshold may vary widely over the course of years.

The minimalist approach assumes that there are just too many problems associated with opiate pain medicine and works only with interventional treatment, non-opiate analgesics, and alternate modalities. It is this author’s opinion that the most effective approach combines reasonable dosing, careful assessment of efficacy, working to adjust doses of pain medicine to stay just above the pain threshold, and to employ alternative modalities.

Two medications warrant some additional discussion because of problems that are unique. The first medication, methadone, is a very effective pain medicine and is very inexpensive. Unfortunately, the increased focus on pain management coupled with the increased use of methadone has had the unintended consequence of resulting in increased drug overdose deaths. This is likely due to the fact that methadone use is associated with early toxicity if doses are increased rapidly, but relatively late onset of analgesia. Thus, it is easy for a patient or provider to increase dose too quickly because of a lack of analgesia. Toxicity builds, analgesia is not yet obtained, and then overdose may occur (20). Individual toxicity causes great variability with the overdose phenomenon and becomes very difficult to predict.

Because of this phenomenon, it is generally recommended that methadone should have a starting dose of 10-20 mg daily and only be increased by around 10 mg per week. Dosing increases much faster than this should be closely monitored and preferably avoided. Other short-acting narcotics can be used to fill in for breakthrough pain as the methadone reaches a therapeutic dose. It is essential that patients understand this toxicity phenomenon and the fact that methadone must never be taken in an as-needed manner. Best practices would suggest that the patient sign documentation acknowledging such warnings; however, that is difficult to accomplish consistently.

An additional confusion surrounds the use of methadone and the stigma of the methadone maintenance programs that are used for substitution treatment maintaining chronic narcotic addicts. Such programs require specific licensing by the Drug Enforcement Administration, while use of methadone for pain does not. It is important to document in the medical record that the use of methadone is for chronic pain and not to maintain a chronic addict. However, the lack of such documentation is not a deviation from the standard of care. 

The second unique narcotic pain medication, transdermal fentanyl patches, delivers the drug in two manners. One form is a reservoir behind a permeable membrane. The greatest advantage of this form is its relatively stable and uniform absorption. However, some addicts have learned to obtain the fentanyl for injection by simply using a hypodermic needle to puncture the membrane and then to administer the drug. Others peel back the membrane and scrape out or lick the fentanyl.

A newer form of fentanyl patch uses an imbedded matrix design. This design also allows for effective transdermal absorption, but it also makes abuse via buccal administration quite easy.

Both forms have a significant risk of overdose if the patch is occluded with tape or significantly heated such as with a heating pad. Other problems have occurred when the patches are placed on body parts that are occluded by sleeping positions, pillows, or heavy clothing. Furthermore, even though the best dosing is obtained in the typical 72 hour administration timeframe, the patches continue to deliver the drug if left on the skin.
Thus, overdose may occur unless the patches are removed at the end of the prescribed administration interval. It is useful to suggest that the removal date be written on the patch and that the patches be rotated in a predictable pattern.

Adjunct medications:
While opiate related pain medications are the most effective substances used for pain, numerous other medications may augment pain control. With the use of such medicines, narcotic doses can often be substantially reduced or not increased.

Neuroleptic medicines are interesting and useful substances. Even the ancient drug Dilantin has some adjunctive qualities. Carbamazepine, and valproic acid have also been found to have some degree of pain attenuation. The GABA specific substances gabapentin (Neurontin) and pregabalin (Lyrica) have found particular use in neuropathic type pain such as post-herpetic neuralgia, diabetic neuropathy, complex regional pain syndromes, and fibromyalgia. Oddly, it has been our personal experience that the GABA agents have at least some benefit with non-neuropathic pain syndromes as an adjunct.

Tricyclic antidepressants and related substances such as amitriptyline, nortriptyline, tramadol, as well as the SNRI’s venlafaxine (Effexor) and duloxetine (Cymbalta) all have potential uses in chronic pain. They tend to be particularly helpful in fibromyalgia and myofascial disorders especially when an element of depression exists. This list is intended to neither be all-inclusive nor exhaustive. 

Non-steroidal anti-inflammatories (NSAIDs) are excellent adjuncts, particularly in the treatment of musculoskeletal or myofascial disorders. Caution must certainly be exercised to watch for blood pressure elevations, renal dysfunction, and GI irritation or ulceration. Muscle relaxants likewise are potentially beneficial.

The question then is where does the standard of care apply? Certainly, the early use of adjunct medications is a best practice. Standard of care would generally suggest that these agents should be considered when narcotic doses alone appear to not be working. This might be when doses of narcotics continue to increase with no clear benefit in reducing pain. On the other hand, tolerance to narcotics can result in dose increases, so this determination is very subjective and difficult to assess. A deviation from the standard of care might exist in the lack of use of adjunct medicines despite extreme doses of a narcotic and poor continued pain control.

Adjunct therapies such as interventional pain management (discussed further in this publication), physical therapy, acupuncture, psychotherapy, and manipulation therapies all have potential benefits to patients. Along with this, specific consultations such as pain management, orthopedics, neurology, physiatry, or psychology/psychiatry, are examples of some of the specialties that may be useful to employ in the management of pain.

The use of adjunct therapies and consultation certainly constitutes best practices, but the lack of use does not necessarily suggest a deviation from the standard of care. Typically, a determination for deviation from the standard of care would suggest that significant pain continued along with extreme doses of narcotic pain medications and that alternative modalities were neither discussed nor considered.

Prescribing for the known addict:
Unfortunately, patients with previous addiction histories often suffer legitimate pain disorders. While some in the recovering community may disagree, the judicious use of narcotic pain medication for known addicts with legitimate pain disorders is well-defined in the pain literature and is not a deviation from the standard of care (21,22,23).
Nonetheless, managing such situations can be daunting and challenging. Best practices would suggest that most, if not all, of the interventions for confirming legitimacy of medication administration should be followed.

If possible, it is preferable to minimize the use of opiate pain medications, particularly short-acting pain medications with addicts. The use of long half-life narcotics helps to minimize the potential euphoric effects. Nonetheless, prescription drug addicts are quite resourceful and are able to capitalize off of any opiate pain medicine.

Several aberrant behaviors are potentially indicative of abuse, addiction, or diversion. Early refills are the most frequently seen problem. If one considers even small repeated incursions with early refills, it is possible to have significant supplies of narcotics to abuse or sell. Legitimate excuses certainly exist such as episodes of worsening pain, vacations or travel out of town, odd refill dates that occur on a weekend, and even miscounting. Excuses such as losing medicine, having a spouse throw it away, or having it stolen should be viewed with suspicion. It is critical to emphasize the importance of positive control of narcotics, especially if children or potential abusers are part of the household. A best practice in this regard is to require the patient to purchase either a lockbox or safe to secure the medications.  Some lenience is reasonable in the early phases of establishing the relationship with a pain patient, but this should not be a repetitive problem. Conversely, long-term and well-known patients might warrant some lenience if their behavior has been reliable and trustworthy.

If patients do repeatedly request early refills, it is a deviation from the standard of care to blindly refill medications without at least some questioning of the patient and documentation of a justification.

The number of scams that are used to divert or obtain narcotics for abuse are myriad. Some patients will forge or change medical records to appear to have legitimate justification for narcotics. One scam employed an individual who would drive several patients around who had quasi-legitimate diagnoses, take them to provider offices, and then split the value of the prescriptions.

Some patients falsify symptoms such as placing gravel in urinalysis cups to mimic passing kidney stones. Cough, back pain, myofascial pain, and neuropathic pain are all subjective enough that creative abusers can take advantage of them. Other patients have been creative enough to falsify CT scans and medical records in an attempt to legitimize their medication.

Unfortunately, there is no foolproof process to demonstrate the legitimacy of a pain patient. It requires substantial experience as well as the use of some of the confirmatory modalities to identify abuse or confirm legitimacy. As stated above, it is not appropriate to expect providers to serve as police or sleuths. Rather, providers should be trusting but vigilant.

Pain management with the use of opiate-based analgesics is an essential part of medical practice. The judicious choice and administration of medications augmented by careful document of rationale and patient status is essential in order to avoid litigation or regulatory risks.

Biography
Dr. Voth is a specialist in Internal Medicine, pain management, and Addiction Medicine as well as a medical director at Stormont-Vail HealthCare in Topeka, Kansas. He is the chairman of the Institute on Global Drug Policy, is recognized as an international authority on drug use, and lectures on drug policy-related issues, pain management, and appropriate prescribing practices. Dr. Voth previously served as the former medical director of the St. Francis Chemical Dependence Services. He also serves as an advisor on alcohol and drug abuse issues to the Kansas State Board of Healing Arts, is a member of the National Advisory Committee for the Center for Substance Abuse Treatment of HHS, and is a Clinical Associate Professor of Internal Medicine at the University of Kansas School of Medicine.

Dr. Voth has advised Reagan, Clinton, both Bush administrations, and has advised or testified for numerous Congressional offices on drug related issues. He has appeared on or consulted to, numerous other radio media, and has been quoted by numerous international print media.

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