Signed into law on August 9, 2010, Chapter 283 of the Acts of 2010 provides additional safeguards to the Massachusetts Prescription Monitoring Program (PMP). Among the new safeguards, Chapter 283 amended M.G.L. Chapter 94C, section 18 (e) to require practitioners who prescribe controlled substances to complete education relative to:
  • effective pain management,
  • identification of patients at high risk for substance abuse, and
  • counseling of patients about the side effects, addictive nature and proper storage and disposal of prescription medications.

Effective January 1, 2011, this new education mandate is a prerequisite to obtaining or renewing professional licensure for dentists and all other prescribers. In light of the foregoing, the Board of Registration in Dentistry has amended its Advisory on the Management of Pain. The full text of the Advisory follows.

Title: Advisory on the Management of Pain

Date Adopted: March 11, 2009; Amended: July 20, 2011

Scope of Practice: Dentistry

Purpose: To provide a framework for ensuring patient access to clinically necessary and effective pain management.

The Board of Registration in Dentistry (the Board) encourages the development and implementation of practices to ensure the appropriate application of up-to-date knowledge and treatment modalities that serve to improve the quality of life for those patients who suffer from pain and reduce the morbidity and costs associated with untreated or inappropriately treated pain.

For purposes of this Advisory, the inappropriate management of pain includes non-treatment, under-treatment, over-treatment and the continued use of ineffective treatment. The Board encourages dentists to view pain management as a part of quality dentistry practice for all patients experiencing pain within the maxillofacial area. All dentists should become knowledgeable about assessing and diagnosing patients' pain and effective methods of pain management. (1)

Advisory: A dentist licensed by the Board is responsible and accountable for engaging in the practice of dentistry in accordance with accepted standards of care.

It is the Board's current position that these standards, in the context of appropriate, legitimate and effective pain assessment, diagnosis and management of pain, include:

  • development and implementation of a patient's pain management plan that is evidence-based and includes a comprehensive and on-going pain assessment, appropriate pharmacological and non-pharmacological modalities, and the substantiation of adequate symptom control;
  • complete, accurate and legible entries in all appropriate patient or resident records required by federal and state laws and regulations, and accepted standards of care;
  • use, when appropriate, of controlled substances including opioid analgesics in the management of all pain types. All medications provided to a patient by the dentist should be an appropriate therapeutic pharmaceutical commensurate with the patient's diagnosis;
  • inter-disciplinary consultation and collaboration with the patient's medical care provider(s).
  • recognition that tolerance and physical dependence are normal consequences of sustained use of opioids and are not synonymous with addiction: tolerance is a physiologic state resulting from regular use of a drug in which (a) an increased dosage is needed to produce a specific effect, or (b) a reduced effect is observed with a constant dose over time (2); and physical dependence is a state of adaptation that is manifested by drug class specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist (3);
  • exercising sound professional judgment to recognize that pseudo-addiction may develop as a direct consequence of inadequate pain management and that pseudo-addiction can be distinguished from true addiction in that inappropriate drug seeking behaviors resolve when pain is effectively treated;
  • recognition that patients with chemical dependency may require specialized pain management involving controlled substances including opioids (4);
  • recognition that a patient who suffers from extreme pain or disease progression may require increased doses of pain medication and that the appropriate dose is the dose required to effectively manage the patient's pain in that particular circumstance;
  • adherence to system safe-guards that are designed to minimize the potential for abuse and diversion when controlled substances are used;
  • acceptance of patient self-determination and autonomy; and
  • culturally sensitive patient, family/significant other and/or caregiver education.

The dentist is also responsible and accountable for acquiring and maintaining the knowledge, skills and abilities necessary to practice in accordance with accepted standards of care for pain management. Such competencies may be obtained through basic, graduate or continuing education programs, as appropriate to the dentist's scope of practice. These competencies include, but are not limited to, knowledge of the current federal and state laws and regulations for the prescription, dispensing, administration and destruction of controlled substances, and current evidence-based guidelines developed by nationally recognized professional organizations in the assessment and management of pain. Pursuant to M.G.L. Chapter 94C, Section 18(e), a Dentist licensed by the Board must complete the following education mandates as a prerequisite to obtaining or renewing professional licensure:

  • effective pain management,
  • identification of patients at high risk for substance abuse, and
  • counseling of patients about the side effects, addictive nature and proper storage and disposal of prescription medications.

(1) Adapted from the Preamble, Model Policy for the Use of Controlled Substances for the Treatment of Pain (2004), Federation of State Medical Boards of the United States, Inc. Available at http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf.

(2) Adopted by the Federation of State Medical Boards of the United States from the Definitions Related to the Use of Opioids for the Treatment of Pain: A Consensus Document of the American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine (2001). Available at http://www.painmed.org/pdf/definition.pdf.

(3) Adopted by the Federation of State Medical Boards of the United States from the Definitions Related to the Use of Opioids for the Treatment of Pain: A Consensus Document of the American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine (2001). Available at http://www.painmed.org/pdf/definition.pdf.

(4) In the event the patient with chemical dependency is a licensee of the Board who is enrolled in the Board's substance abuse rehabilitation program, the specialized pain management plan may be developed in collaboration with the Board's substance abuse rehabilitation program.




T his information is provided by the Division of Health Professions Licensure within the Department of Public Health.