New tools help providers avoid undertreating pain

Under former guidelines developed by the Federation of State Medical Boards (FSMB), only overtreatment of pain through the misuse of controlled substances was considered a violation of the standard of care for physicians—not undertreatment. FSMB's house of delegates, which met last month, revised its guidelines to make undertreatment of pain equal grounds for state medical boards to discipline physicians. California and Oregon have already disciplined doctors for undertreatment of pain, and New Mexico revised its medical practice act to identify undertreatment of pain as grounds for "unprofessional conduct."

Lisa Robin, VP of leadership and legislative services at FSMB, believes the new guidelines "will alleviate physician fears of regulatory action by providing a clear picture of expectations." As one of the developers of the updated guidelines, she considers it a "good document that strengthens the board's stand that pain management is an integral part of treatment."

According to the revised FSMB guidelines, state medical boards shall judge the validity of treatment on an individual basis, utilizing documentation of the plan of care rather than simply evaluating the quantity or duration of medication use. To avoid scrutiny, the FSMB recommends that the physician, after completing a medical history and physical examination, document the nature and intensity of pain, current and past treatments, and comorbid conditions. The physician can then formulate a written treatment plan, stating the objectives that will be used to determine success and indications for further diagnostic evaluations.

Since the patient and physician must work as partners, the patient should be asked to consent, possibly in writing, to the plan. High-risk patients can also be asked to agree to random drug screening and to refrain from receiving Rxs from other prescribers. Accurate and complete records throughout treatment would ensure the prescriber is not in need of scrutiny.

"As our understanding about pain and the number of new treatment options grow, R.Ph.s need to keep abreast of current literature and complete continuing education pertaining to pain management," Robin said. FSMB is planning educational programs for state medical and pharmacy boards.

The American Pain Foundation (APF), recognizing that practitioners and patients describe pain differently and miscommunication can lead to inadequate treatment, is working to facilitate communication between healthcare providers and patients with pain. APF has created the TARGET Chronic Pain Notebook for patients and the TARGET Chronic Pain Card for clinicians as part of its TARGET Chronic Pain Initiative. In the notebook, patients, using the pain scales along with simple questions and checklists, can record their daily pain experience and its effect on their lives. The healthcare provider can then better assess if the current pain management regimen is adequate. The notebook also provides helpful tips for getting the most out of interactions with practitioners and treatment plans. The card, a quick reference for healthcare professionals, provides key questions for assessing a patient's pain, treatment strategies, visual aids, and a list of resources pertaining to controlled substances and pain management. Both tools explain common pain terms, e.g., intermittent, persistent, and breakthrough pain, in simple language to facilitate patient/practitioner communication. The tools are available on APF's Web site at www.painfoundation.org .

APF's Carol Harper said the card and notebook could provide pharmacists an opportunity to impact pain management. Many patients and physicians do not utilize the key questions necessary to assess pain levels and treatment. The pharmacist can assist the patient in formulating answers to the questions, as outlined on the card, to foster better communication with their physician.

Robin agrees that pharmacists can play an integral role in the treatment of pain. She said the key is maintaining a dialogue with physicians and sharing information pertaining to patients' medications.

ASHP's 2003 position statement also supports the participation of pharmacists in pain management as a multidisciplinary, collaborative process. It encourages pharmacists to aid in the selection of appropriate drug therapies, educate patients, monitor patients, and provide continual assessment of outcomes.