1. Pain Management: a Regulatory Perspective William J. Schmidt, J.D. Senior Counsel, Investigations, Compliance & Enforcement Randy Beck Investigative Supervisor State Medical Board of Ohio

2. OVERVIEW Organization of Medical Board Key provisions of pain management statutes & rules

3. State Medical Board of Ohio The Medical Board is a state regulatory agency founded in 1896

4. Board Organization To protect and enhance the health and safety of the public through effective medical regulation Mission

5. Structure 12 members appointed by Governor to staggered five-year terms; may be reappointed 7 MD’s, 1 DO, 1 DPM, and 3 consumer representatives Monthly meetings in Columbus Board Organization

6. Operations 87 full time employees $ 8 million plus annual operating budget funded solely by licensing & renewal fees No money from general revenue fund Board Organization

7. Approximately 60,000 professionals*, including Medical Doctors MD35,872 Doctors of Osteopathic Medicine DO 4,788 Doctors of Podiatric Medicine DPM 956 Licensed Massage Therapists LMT 10,699 Physician Assistants PA 1,886 Anesthesiologist Assistants AA 129 Acupuncturists A or RAC 147 Cosmetic Therapists CT 209 Doctors in training 5,214 MEDICAL BOARD LICENSEES * and c*and coming soon… Radiologist Assistants Data as of 12-31-08

8. Regulatory Authority STATUTES - Chapters 4730, 4731, 4760, 4762 & 4774, Ohio Revised Code RULES - Chapters 4730, 4731 & 4774 Ohio Administrative Code Medical Board interprets & enforces statutes and rules

9. The Medical Board’s Pain Management Guidelines

10. The Medical Board has never taken an action against a physician for the appropriate use of medication

11. The Medical Board has never taken an action against a physician for the treatment of cancer pain

12. Ohio Intractable Pain Statute – October 1997 Section 4731.052, Ohio Revised Code Required Medical Board to write rules defining standards & procedures for diagnosing & treating intractable pain

13. Ohio Intractable Pain Statute Physician who manages intractable pain with dangerous drugs in accordance with law not subject to Medical Board disciplinary action

14. The Medical Board’s Pain Management Rules Chapter 4731-21, O.A.C.

15. Medical Board Rules Intractable pain is not –Pain associated with a terminal condition, or –Pain associated with a disease that may be expected to result in a terminal condition

16. Rules do not apply to... Treatment using only non-CNS drugs or antidepressants

17. Rules apply only to... Treatment on a protracted basis Use of amounts & combinations of drugs that may not be appropriate in other conditions For example: Using doses far exceeding PDR’s usual recommended dosage Adding opioids for breakthrough pain

18. Requirements for Treating Intractable Pain

19. Initial Evaluation 4731-21-02, O.A.C Initial Evaluation 4731-21-02, O.A.C. Patient history, including alcohol & substance abuse Assessment of pain impact on function Review of previous studies & therapies Assessment of coexisting illnesses Physical exam

20. Medical Diagnosis Document presence of intractable pain Identify signs, symptoms & causes Nature of underlying disease Pain mechanism

21. Individualized Treatment Plan Specify medical justification for drugs and role of drug therapy Document drugs that did not succeed, adjust drug therapy Document response Modify treatment plan as necessary

22. Evaluation by Specialist Evaluation by Specialist Must specialize in treatment of anatomic area, system or organ perceived as pain source Evaluator must review prior treatment records & prepare written report Referring physician must keep copy of specialist’s report May assume patient’s care, but usually acts as a consultant

23. Evaluation not required … if patient had prior satisfactory evaluation within reasonable time if treating physician has records of prior evaluation

24. Informed Consent Obtain from patient or person having authority to consent Inform of benefits & risks of treatment Inform of treatment alternatives Document in patient record

25. need for using more than one controlled substance in pain treatment patient’s name & address, dates, amounts, dosage forms & refills of all prescription drugs Consider use of duplicate prescription forms Be Sure to Document

26. Other Considerations Consider Pain Contract with patient –Consequences of non-compliance –Expectation of refills & follow-up visits Consider urine sample for drug screening to confirm patient’s use Ohio Automated Prescription Reporting System (OARRS) report

27. OARRS Ohio Automated Prescription Reporting System, a prescription monitoring program overseen by Ohio Board of Pharmacy OARRS contains dispensing information for all controlled substances, carisoprodol products and tramadol products within the past 2 years Physicians may register for OARRS access to review patient prescription history reports

28. OARRS Registration www.ohiopmp.govwww.ohiopmp.gov for registration information to obtain a user name and password Patient prescribing report requested on-line; data from January 1, 2006 provided; turn around time is about 15 minutes for report Approximate 25 day lag time in data entry, as pharmacies send dispensing reports to OARRS twice a month

29. Patient Follow-Up Periodically assess treatment efficacy Assure drug therapy still indicated Evaluate progress toward treatment objectives Note functional ability & quality of life Consider drug screens Consider OARRS report review

30. Obtain Objective Measures Ability to engage in work Pain intensity & interference with life Family & social activities Physical activity

31. Suspected drug abuse? Physician may obtain a drug screen if there are indications of drug abuse Consult with substance abuse specialist

32. If drug abuse suspected If drug abuse suspected Continue therapy consistent with specialist’s recommendations Refer patient to substance abuse specialist if recommended Continue to monitor for signs of abuse Keep copy of any report from consultant If termination of patient is considered, refer to Rule 4731-27, OAC

33. Tolerance and physical dependence do not always equal addiction or require cessation of opioid therapy

34. med.ohio.gov Medical Board website has links to: Pain Rules (Chapter 4731-21, OAC) Policy – Office-based Treatment of Opioid Addiction

35. State Medical Board of Ohio 30 E. Broad St. 3 rd Floor Columbus, OH 43215-6127 Phone: 614-466-3934 FAX: 614-728-5946 MED.OHIO.GOV