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Physicians told not to fear discipline for pain treatment

Medical boards are better at evaluating pain-management cases, but pain specialists still warn doctors to be careful to provide appropriate care.

By Damon Adams, AMNews staff. June 16, 2003.

New studies have a message for doctors who prescribe pain medication: Don't fear discipline from medical boards or criminal prosecution if you follow pain guidelines and appropriately prescribe medications.

Three studies concerning medical boards, prosecution and pain-treatment guidelines are published in the Spring 2003 issue of the peer-reviewed Journal of Law, Medicine & Ethics.

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A survey of 38 medical boards found boards were abandoning drug quantity as a marker of questionable practice and assessing instead whether a doctor properly evaluated a patient and followed the board's pain-treatment guidelines. A second study of county prosecutors in Oregon, Maryland, Washington and Connecticut found the likelihood of investigation or prosecution "extremely low."

A third study said more boards had adopted pain-management guidelines but recommended that they take greater steps to train investigators about pain standards and circulate guidelines to physicians.

"Boards are becoming more sophisticated. They're trying to discern between drug diversion and appropriate prescribing for pain. Doctors should not be fearful if they're trying to legitimately treat pain and follow the guidelines established by the state board," said Diane E. Hoffmann, co-author of the study of 38 boards and director of the Law and Health Care Program at the University of Maryland School of Law, Baltimore.

Doctors who specialize in pain treatment said the studies would not reduce physician fears or purge images of armed drug enforcement agents sweeping into a doctor's office.

"They hear that stuff and they are terrified, particularly if they know the doctor," said Joel Hochman, MD, a Houston psychiatrist and executive director of the National Foundation for the Treatment of Pain. "They're coming in with SWAT teams and prosecuting these doctors with a whole litany of trumped-up criminal charges."

L. Jean Dunegan, MD, said boards are making progress in accurately addressing pain treatment but much work still needs to be done.

"There is no question that fear often keeps many of the average physicians afraid to prescribe," said Dr. Dunegan, director of the Hillsdale (Mich.) Pain Center. "All we need to see is one public [arrest], and there but for one prescription go I."

State board perceptions

Hoffmann's survey was based on the perceptions of board officials rather than actual numbers because most states don't track complaints based on opioid prescribing. Cases concerning opioid prescriptions typically are lumped by boards with other prescribing violations.

More than three in four boards said complaints, investigations and disciplinary actions stayed the same or increased from 1997 to 2001. Sixteen percent of the boards said disciplinary actions decreased during that time. Boards were more likely to look into overprescribing of drugs than undertreatment of pain.

Boards said greater public awareness of drug abuse was a key reason for the increase in complaints. But Hoffmann said boards had made strides in recognizing the need for adequate pain treatment, translating to improved attitudes and practices in recent years toward physicians' prescribing of opioids. "We found they are looking more closely at the facts and not relying on volume and duration [of drugs]. They're looking at the guidelines that many of them have established. Many are looking at documentation issues," she said.

In his survey of prosecutors, co-author Stephen J. Ziegler, PhD, found that 88% said no physicians had been prosecuted in the past year for prescribing violations.

"Doctors overestimate the risk of criminal investigation or prosecution stemming from the treatment of pain," said Dr. Ziegler, a political science professor at Washington State University in Pullman, Wash.

The Federation of State Medical Boards said disciplinary actions for prescribing violations, which include overprescribing for pain, have remained fairly stable over the past nine years. In 1994, boards took 403 actions against doctors for controlled substance violations, the federation said. In 2002, there were 362 actions for such violations.

Since the federation adopted model pain-treatment guidelines in 1998, more than 20 boards have formed policies based on the guidelines.

"When physicians follow those guidelines, it's extremely rare that they're going to get into trouble with the state medical board," said James Thompson, MD, chief executive officer of the Texas-based FSMB.

Medical board members agreed.

"If you practice good medicine, you're not going to lose your license," said Regina Benjamin, MD, a member of the Alabama State Board of Medical Examiners.

Dennis O'Neill, MD, chair of the Connecticut Medical Examining Board, added: "Nobody is pulling the trigger on these doctors precipitously. I don't think we're being overaggressive with physicians who are managing pain."

Still, Dr. Dunegan said doctors should proceed with caution, realizing that one board may approach the issue differently from another.

"That variability from state to state makes it very difficult," Dr. Dunegan said. "It's almost like a crapshoot that you're going to be in a state [where] you don't have to be afraid."

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Copyright 2003 American Medical Association. All rights reserved.
 

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