Date Adopted: March 31, 2009; Revised August 16, 2011
Scope of Practice: Registered Pharmacists
Purpose: To Insure Patient Access to Appropriate and Effective Pain Management
The Board of Registration in Pharmacy (Board) recognizes that principles of quality pharmacy practice must ensure that patients have access to appropriate and effective pain relief.
This Policy expresses the Board's support for pain management practices that assure appropriate application of up-to-date knowledge and treatment modalities in the practice of pharmacy that may improve the quality of life for patients suffering from pain, as well as reduce the morbidity and costs associated with untreated or inappropriately managed pain.
For purposes of this Policy, the inappropriate management of pain includes non-treatment, under-treatment, over-treatment and the continued use of ineffective treatment.
The Board encourages pharmacists to view pain management as a part of pharmacy practice for all patients in pain, whether acute or chronic. All pharmacists are encouraged to become knowledgeable about effective methods of pain management. (1)
A pharmacist registered by the Board should provide access to pain medication to patients with legitimate needs in accordance with accepted standards of pharmacy practice.
It is the Board's position that these standards, in the context of appropriate and effective pain management, include:
- complete, accurate and legible entries in all appropriate patient or prescription records required by federal and state laws and regulations, and recognized standards of care;
- conducting a prospective drug utilization review (DUR) before each prescription is dispensed or delivered for the purpose of promoting therapeutic appropriateness;
- reconciliation of a patient's individual history, including drug allergies, drug interactions, and other considerations relevant to the patient's drug therapy;
- the use, when appropriate, of controlled substances including opioid analgesics in the management of all pain types;
- interdisciplinary consultation and collaboration as appropriate;
- understanding that tolerance and physical dependence are normal consequences of sustained use of opioids not synonymous with addiction; that 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 that 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);
- recognition that pseudoaddiction may develop as a direct consequence of inadequate pain management and that pseudoaddiction can be distinguished from true addiction in that inappropriate drug seeking behaviors resolve when pain is effectively treated (4);
- recognition that patients with chemical dependency may also require specialized pain management involving controlled substances (including opioids) for other conditions;
- 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; and
- adherence to system safeguards that are designed to minimize the potential for abuse and diversion when controlled substances are used, including a corresponding responsibility to assure that controlled substance prescriptions are issued by a practitioner for a legitimate medical purpose in the usual course of the practitioner's professional practice.
Pharmacists are encouraged to acquire and maintain current knowledge, skills and abilities necessary to practice in accordance with accepted standards of care for pain management. Such competencies may be acquired through continuing education programs, as appropriate to the pharmacist's scope of practice (5), in the areas of current federal and state laws and regulations for the prescribing, dispensing, administration and destruction of controlled substances, as well as review of the current edition of the United States Pharmacopeia Drug Information, pharmacy best practice recommendations, peer reviewed medical literature, 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 Pharmacist licensed by the Board who is authorized to prescribe controlled substances (e.g. participate in collaborative drug therapy management with a supervising physician pursuant to a written collaborative practice agreement) 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) Adapted from the Definitions, 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.
(5) Continuing education programs developed in accordance with 247 CMR 4.05.
This information is provided by the Division of Health Professions Licensure within the Department of Public Health.