| ASAM Policy Statement |
Rights and Responsibilities of
Physicians in the Use of
Opioids for the Treatment of Pain |
| Background |
| Physicians' concerns regarding possible
legal, regulatory, licensing or other third party sanctions related to the prescription of
opioids contribute significantly to the under treatment of pain. |
| Physicians are obligated to relieve pain and
suffering in their patients. Though many types of pain are best addressed by non-opioid
interventions, opioids are often required as a component of effective pain treatment. In
patients complaining of pain, which is a subjective phenomenon, it is often a difficult
medical judgment as to whether opioid therapy is indicated. |
| This may be a particularly difficult judgment
in patients with concurrent addictive disorders for whom exposure to potentially
intoxicating substances may present special risks. It is, nonetheless, a medical judgment
which must be made by a physician in the context of the doctor-patient relationship based
on knowledge of the patient, awareness of the patient's medical and psychiatric conditions
and on observation of the patient's response to treatment. The selection of a particular
opioid medication(s), and the determination of opioid dose and therapeutic schedule,
similarly must be based on full clinical understanding of a particular situation and
cannot be judged appropriate or inappropriate independent of such knowledge. |
| Despite appropriate medical practice,
physicians who prescribe opioids for pain may occasionally be misled by skillful patients
who wish to obtain medications for purposes other than pain treatment, such as diversion
for profit, recreational abuse or maintenance of an addicted state. The physician who is
never duped by such patients may be denying appropriate relief to patients with
significant pain all too often. It must be recognized that physicians who are willing to
provide compassionate, ongoing medical care to challenging, psychosocially stressed
patients may more often be faced with deception than physicians who decline to treat this
difficult population. |
| Addiction to opioids may occur in the course
of opioid therapy of pain in susceptible individuals under some conditions. Persistent
failure to recognize and provide appropriate medical treatment for the disease of
addiction is poor medical practice and may become grounds for practice concern. Similarly,
persistent failure to use opioids effectively when they are indicated for the treatment of
pain is poor medical practice and may also become grounds for practice concern. It is
important to distinguish, however, between physicians who profit from diversion or other
illegal prescribing activities and physicians who may inappropriately prescribe opioids
due to misunderstandings regarding addiction or pain. |
| Physicians traditionally have received little
or no education on addiction or clinical pain treatment in the course of medical training.
This omission is likely a basis for inadequate detection and management of addiction and
inadequate assessment and treatment of pain. |
| Recommendations |
- Physicians who prescribe opioids for the treatment of pain
should use reasonable medical judgment to establish that a pain state exists and to
determine whether opioids are an indicated component of treatment. Opioids should be
prescribed in a legal and clinically sound manner, and patients should be followed at
reasonable intervals for ongoing medical management and to confirm as nearly as is
reasonable that the medications are used as prescribed. Such management should be
appropriately documented.
|
- Physicians who are practicing medicine in good faith and who
use reasonable medical judgment regarding the prescription of opioids for the treatment of
pain should not be held responsible for the willful and deceptive behavior of patients who
successfully obtain opioids for non-medical purposes. It is the appropriate role of the
DEA, pharmacy boards and other regulatory agencies to inform physicians of the behavior of
such patients when it is detected.
|
- Physicians who consistently fail to recognize addictive
disorders in their patients should be offered education, not sanction, as a first
intervention.
|
- Physicians who consistently fail to appropriately evaluate
and treat pain in their patients should be offered education as a first-line intervention.
|
- For the purpose of performing regulatory, legal, quality
assurance and other clinical case reviews, it should be recognized that judgment regarding
a) the medical appropriateness of the prescription of opioids for pain in a specific
context, b) the selection of a particular opioid drug or drugs, and c) the determination
of indicated opioid dosage and interval of medication administration, can only be made
properly with full and detailed understanding of a particular clinical case.
|
- Regulatory, legal, quality assurance and other reviews of
clinical cases involving the use of opioids for the treatment of pain should be performed,
when they are indicated, by reviewers with a requisite level of understanding of pain
medicine and addiction medicine.
|
- Appropriate education in addiction medicine and pain
medicine should be provided as part of the core curriculum at all medical schools.
|
- Legal and/or licensing actions against physicians who are
proven to profit from diversion of scheduled drugs or from other illegal prescribing
activities are appropriate.
|
| Adopted by the ASAM Board of Directors, April 1997 |
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