Pain Management and Disciplinary Action

How Medical Boards
Can Remove Barriers to Effective Treatment
By Chris Stern Hyman

The current debate about physician-assisted suicide and the question of whether patients would ask for such help if their pain were adequately controlled place in sharp focus the issue of undertreated pain. Studies have repeatedly documented the scope of the problem.

A 1993 study of 897 physicians caring for cancer patients found that 86 percent of the physicians reported that most patients with cancer are undermedicated for their pain.

A 1994 study found that noncancer patients receive even less adequate pain treatment than patients with cancer-related pain, and that minority patients, the elderly, and women were more likely than others to receive inadequate pain treatment.

Although the problem of undertreatment of pain is multifaceted, I only address how state medical boards contribute to the problem and suggest possible remedies.

The literature on palliative care describes the numerous barriers that impede effective pain management and that result in the inadequate prescribing of pain-relieving drugs for terminally and chronically ill patients.

One of the significant impediments is physicians' fear that prescribing an adequate quantity of opioids will result in an investigation by the state medical board, the Drug Enforcement Administration (DEA) , or the state agency responsible for regulating controlled substances.

Another is the woeful lack of knowledge of some physicians about how to treat intractable pain and their inaccurate perception about what is and is not legal. Even members of state medical boards do not have a clear understanding of what is legally and medically acceptable in using opioids to treat pain.

The most effective antidote to the physicians' fear is ensuring that state medical boards are not investigating and disciplining physicians who treat pain appropriately and that state medical boards and physicians are well informed about effective pain management. Is this best accomplished by statute, regulations, or guidelines, or by using experts and education? Statutes and regulations can give physicians some reassurance, but the key to appropriate enforcement is the level of knowledge about pain management of state medical boards' members and staffs. In attempting to remove barriers to effective pain management, state medical boards should take the following steps.

  1. Objectively assess the medical board's level of knowledge of effective pain management and the extent of the undertreatment of pain in their state.

  2. Enlist the assistance of physicians who are experts in pain management to review cases under investigation and to serve as expert witnesses in hearings.

  3. Consider how the regulatory process can be used to improve pain management.

  4. Evaluate how best to inform and educate licensees about pain management.

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