Responsible Opioid Prescribing: A Physician's Guide


  • Bill McCarberg MD

    1. Founder, Chronic Pain Program
      Kaiser Permanente San Diego
      Adjunct Assistant Clinical Professor
      University of California San Diego, USA
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Responsible Opioid Prescribing: A Physician's Guide
Waterford Life Sciences , Washington, DC, USA , 2007
ScottFishman ( ed. )
Pages: 137
Price: $12.95

Commissioned by the Federation and State Medical Boards, this book is written by Scott Fishman with an expert advisory board including Aaron Gisbon, co-director for U.S. Policy Research, Pain & Policy Studies Group/WHO Collaborating Center at the University of Wisconsin-Madison; James Thompson, president/CEO, Federation of State Medical Boards; and David Thornton, immediate past executive director of the Medical Board of California and many other excellent contributors.

In 1997, the Federation of State Medical Boards introduced the first Model Guidelines for the Use of Controlled Substances for the Treatment of Pain. These guidelines were subsequently updated to a Model Policy in 2004, and have been adopted verbatim by 28 states with 10 states using similar language. The purpose of Responsible Opioid Prescribing is to extract the information presented in the Model Policy such that busy practitioners can understand the information and apply it to clinical situations seen in a daily practice. Scott Fishman has admirably accomplished this task. The book is well written, concise, and short enough to read in one sitting.

After an introduction, the Model Policy is distilled into seven concise principles:

  • 1Evaluation of the patient
  • 2Treatment plan
  • 3Informed consent and agreement for treatment
  • 4Periodic review
  • 5Consultation
  • 6Medical records
  • 7Compliance with controlled substances law and regulations

Each chapter examines these seven principles starting with a quote from the Model Policy describing the underlying idea behind the code. Even a well-written and concise manuscript would be of little value if it were not practical. When sitting with a patient in a defined appointment slot, the seven principles need to be applied. This is where Dr. Fishman has excelled. Simple, effective, and time-efficient advice is given on each principle.

An example comes in the first chapter under evaluation of the patient. We are familiar with the concept of location, character, exacerbating factors, etc., in the evaluation of patients. But what about managing the time pressures when patients present with complex problems? Rarely is enough time allotted to fully evaluate a patient, especially when the problem includes psychosocial issues or substance abuse. Dr. Fishman recommends not rushing through the evaluation, but “taking control of time.” In patients with persistent pain, our best judgment starts by listening, hearing clues hidden behind the language, and pursuing these clues. Taking control of time using reflective listening is demonstrated using multiple practical examples throughout the book.

The treatment plan chapter not only discusses pain reduction, but also focuses appropriately on function. Methods for determining functional outcome and discussing treatment goals with patients are laid out. Pain leads to loss of function and deterioration in quality of life, as does addiction to medication. The difficulty of determining the underlying cause of dysfunctional behavior, and distinguishing between poor pain control and addiction is discussed.

A patient in pain can exhibit disruptive behavior in the office, splitting staff and producing a difficult workplace. Patients can be confrontational and abusive to staff when pain medication is not given. Dr. Fishman defines this behavior in the context of the treatment agreement established with the patient during the initial evaluation. Discharging a disruptive patient is always possible and sometimes prudent. Another approach is to look at why a patient offends staff accustomed to difficult behaviors. Is this just a coping style or a reaction to unrelieved pain? Is this an opportunity for a different treatment strategy instead of a letter of discharge? How patients react to stress, how to respond, and how medical boards view abandonment are fully reviewed.

The most common fault seen by medical boards reviewing providers’ interactions with pain patients is lack of adequate documentation. There are many reasons for this documentation problem. What constitutes sufficient documentation and how to document efficiently is a major issue to the provider. The record-keeping chapter addresses these concerns with practical, proficient solutions. Following the simple suggestions protects every practice, and represents reasonable and competent medical care.

Many of us have developed methods to comply with the Model Policy's seven principles. Patients and medical staff fill out forms; electronic medical records have required fields to be completed at each visit for example. Yet, we all can benefit from the precise message contained in Responsible Opioid Prescribing. This book is particularly useful to primary care providers who do not deal frequently with chronic opioid prescribing. Efforts are underway to distribute this book to all Drug Enforcement Administration registrants through medical boards as they have done in California.

Opioid management of persistent pain provides meaningful improvements in pain and quality of life for many patients. Responsible Opioid Prescribing is an excellent handbook for practitioners treating pain and seeking expert and practical guidance on doing this effectively and safely within the time constraints of everyday practice. Our job is to relieve suffering, and this book is invaluable in this endeavor.