To determine whether a physician is prescribing appropriately, the most important question to ask is whether his patients are actually improving with the medical intervention. Fortunately, the Federation of State Medical Boards recently adopted guidelines that clearly provide a framework for pain management. For the first time, physicians have an excellent, defensible set of guidelines within which to operate. In Kansas, the State Board of Healing Arts has determined that if these standards are followed, the board will support those physicians if questioned by other regulatory or enforcement agencies. 4 Physicians have a responsibility to relieve the suffering of their patients, but this must be done within certain boundaries.
Evidence suggests that adequate pain management reduces morbidity and the likelihood of abuse.
The ladder is not meant to be an exclusive approach, and physicians may find that using some of the medications concurrently is beneficial. If the patient's pain is severe enough to justify the use of narcotic medication, I prefer starting with small amounts and then carefully increasing the dosage as necessary. I never provide the patient with more than a single month of narcotic medication, and I require that the prescription always be filled only by me at the same pharmacy. If it is clear that the occasional narcotic medication is not adequately relieving the pain, I will ultimately choose a long-acting agent. Sustained-release morphine derivatives lend themselves nicely to the treatment of chronic pain.