Hostname: page-component-cd9895bd7-7cvxr Total loading time: 0 Render date: 2024-12-26T09:36:50.764Z Has data issue: false hasContentIssue false

Achieving the Right Balance in Oversight of Physician Opioid Prescribing for Pain: The Role of State Medical Boards

Published online by Cambridge University Press:  01 January 2021

Extract

Uncertainty regarding potential disciplinary action may give physicians pause when considering whether to accept a chronic pain patient or how to treat a patient who may require long-term or high doses of opioids. Surveys have shown that physicians fear potential disciplinary acrion for prescribing controlled substances and that physicians will, in some cases, inadequately prescribe opioids due to fear of regulatory scrutiny. Prescribing opioids for long-term pain management, particularly noncancer pain management, has been controversial; and boards have investigated and, in some cases, disciplined physicians for such prescribing. While in virtually all of these cases the disciplinary actions were successfully appealed, news of the success was not often as well-publicized as news of the disciplinary actions, leaving some physicians confused about their potential liability when prescribing opioids for pain. The confusion has perhaps increased as a result of two relatively recent cases, one where a physician was successfully disciplined by a state medical board for undertreatment of his patients’ pain, and another where the physician was successfully sued for inadequate pain treatment.

Type
Article
Copyright
Copyright © American Society of Law, Medicine and Ethics 2003

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Hoffmann, D.E., “Undertreating Pain in Women: A Risky Practice,” Journal of Gender-Specific Medicine, 5 (2002): 1015, at 12.Google Scholar
Id. at 12.Google Scholar
Id., citing Martino, A.M., “In Search of a New Ethic for Treating Patients with Chronic Pain: What Can Medical Boards Do?,” Journal of Law, Medicine & Ethics, 26, no. 4 (1998): 332–49, at 332.CrossRefGoogle Scholar
Marcus, D.A., “Treatment of Nonmalignant Chronic Pain,” American Family Physician, 61 (2000): 1331–38, 1345–46; Portenoy, R.K., “Opioid Therapy for Chronic Nonmalignant Pain: Clinician's Perspective,” Journal of Law, Medicine & Ethics, 24, no. 4 (1996): 296–309.Google Scholar
Lipman, A.G., “Treatment of Chronic Pain in Osteoarthritis: Do Opioids Have a Clinical Role?,” Current Rheumatology Reports, 3 (2001): 513–19.; McCarberg, B.H. and Barkin, R.L., “Long-Acting Opioids for Chronic Pain: Pharmacotherapeutic Opportunities to Enhance Compliance, Quality of Life, and Analgesia,” American Journal of Therapy, 8 (2001): 181–86.CrossRefGoogle Scholar
Aronoff, G.M., “Opioids in Chronic Pain Management: Is There a Significant Risk of Addiction?,” Current Review of Pain, 4 (2000): 112–21; Sees, K.L. and Clark, H.W., “Opioid Use in the Treatment of Chronic Pain: Assessment of Addiction,” Journal of Pain & Symptom Management, 8 (1993): 257–64.CrossRefGoogle Scholar
Massing, M., The Fix (New York: Simon & Schuster, 1998).Google Scholar
Johnson, S.H., “Disciplinary Actions and Pain Relief: Analysis of the Pain Relief Act,” Journal of Law, Medicine & Ethics, 24, no. 4 (1996): 319–27.CrossRefGoogle Scholar
Hill, C.S., “The Barriers to Adequate Pain Management with Opioid Analgesics,” Seminars in Oncology, 20 (1993): 15; Levin, M.L. et al., “Management of Pain in Terminally III Patients: Physician Reports of Knowledge, Attitudes, and Behavior,” Journal of Pain & Symptom Management, 15 (1998): 27–40.Google Scholar
Brockopp, D.Y. et al., “Barriers to Change: A Pain Management Project,” International Journal of Nursing Studies, 35 (1998): 226–32. Research has shown the fears of addiction and overdose or hastened death with opioid use to be highly exaggerated. See Bercovitch, M. et al. “High Dose Morphine Use in the Hospice Setting. A Database Survey of Patient Characteristics and Effect on Life Expectancy,” Cancer, 86 (1999): 871–77; Boyd, K.J. and Kelly, M., “Oral Morphine as Symptomatic Treatment of Dyspnoea in Patients with Advanced Cancer,” Palliative Medicine, 11 (1997): 277–81.CrossRefGoogle Scholar
See Johnson, , supra note 8.Google Scholar
Alpers, A., “Criminal Act or Palliative Care? Prosecutions Involving the Care of the Dying,” Journal of Law, Medicine & Ethics, 16, no. 4 (1998): 308–31.CrossRefGoogle Scholar
Von Roenn, J.H. et al., “Physician Attitudes and Practice in Cancer Pain Management. A Survey from the Eastern Cooperative Oncology Group,” Annals of Internal Medicine, 119 (1993): 121–26.Google Scholar
Turk, D.C. et al., “Physicians’ Attitudes and Practices Regarding the Long-Term Prescribing of Opioids for Non-Cancer Pain,” Pain, 59 (1994): 201–08.CrossRefGoogle Scholar
Weissman, D.E. et al., “Wisconsin Physicians' Knowledge and Attitudes About Opioid Analgesic Regulations,” Wisconsin Medical Journal, 90 (1991): 671–75.Google Scholar
See Turk, et al., supra note 15.Google Scholar
Joranson, D.E. et al., “Pain Management, Controlled Substances, and State Medical Board Policy: A Decade of Change,” Journal of Pain & Symptom Management, 23 (2002): 138–47, at 140.CrossRefGoogle Scholar
The Mayday Fund was established in 1992 with funds from the estate of the late Shirley Steinman Katzenbach. It is dedicated to the reduction of the physical and psychological effects of pain. See <http://www.painandhealth.org/mayday/mayday-home.html>..>Google Scholar
FSMB's Model Guidelines were adopted on May 2, 1998. They recommend evaluation of the pain patient by the physician, formulation of a treatment plan, securing informed consent for treatment, performing periodic review of therapy and outcomes, obtaining appropriate consultations or referrals for patients when necessary (e.g., patients with substance abuse history), keeping accurate and complete medical records, and maintaining compliance with controlled substance laws and regulations. See Johnson, S.H., “Introduction: Legal and Regulatory Issues in Pain Management.” Journal of Law, Medicine & Ethics, 26, no. 4 (1998): 265–66.CrossRefGoogle Scholar
Joranson, D.E. et al., 2001 Annual Review of State Pain Policies: A Question of Balance (Madison: Pain & Policy Studies Group, University of Wisconsin Comprehensive Cancer Center, 2002), available at <www.medsch.wisc.edu/painpolicy/publicnt/01annrev/conrents.htm>.Google Scholar
Goodman, E., “From Oregon, A Call for Compassionate Care,” Boston Globe, September 9, 1999.Google Scholar
“Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing Act,” a Joint Statement from 21 Health Organizations and the Drug Enforcement Administration (October 21, 2001), available at <http://www.medsch.wisc.edu/painpolicy/dea01.htm>..>Google Scholar
See U.S. Drug Enforcement Administration, OxyContin: Pharmaceutical Diversion, Drug Intelligence Brief (March 2002), available at <http://www.usdoj.gov/dea/pubs/intel/02017/02017.html>..>Google Scholar
Meier, B., “OxyContin Preseribers Face Charges in Fatal Overdoses,” New York Times, January 19 2002; Meier, B., “A Small Town Clinic Looms Large as a Top Source of Disputed Painkillers,” New York Times, February 10, 2001.Google Scholar
Individuals who reviewed the draft survey include: Aaron Gilson from the Pain & Policy Studies Group at the University of Wisconsin, Sandra Johnson from Saint Louis University School of Law, Jack Schwartz and Tom Keech from the Maryland State Attorney General's Office, Kathryn Tucker from Compassion in Dying, and Irwin Weiner, a retired physician board member of the Maryland Board of Physician Quality Assurance.Google Scholar
The survey was designed to be administered during a phone interview, but a minority of respondents opted to complete the survey in written form.Google Scholar
See Pain & Policy Studies Group, University of Wisconsin Comprehensive Cancer Center, Data-base of State Laws, Regulations, and Other Official Government Policies, at <http://www.medsch.wisc.edu/painpolicy/matrix.htm> (last updated November 5, 2002).+(last+updated+November+5,+2002).>Google Scholar
See Pain & Policy Studies Group, University of Wisconsin Comprehensive Cancer Center, Prescription Monitoring Programs, at <http://www.medsch.wisc.edu/painpolicy/domestic/diversion.htm> (last visited February 12, 2003).+(last+visited+February+12,+2003).>Google Scholar
In addition to formal written complaints, twenty-two of the thirty-eight respondents also accepted complaints by phone, e-mail, or anonymously, although anonymous complaints were investigated only in rare circumstances (i.e., regarding serious complaints when sufficient information was provided to investigate further). Some states first considered allegations that were transformed into complaints after a formal process in which preliminary evidence was collected.Google Scholar
This could include complaints against physicians for prescribing opioids for pain patients they were treating, prescribing for themselves, or trading opioids for money or sex.Google Scholar
This is consistent with the findings of Weiner and Pound in their “Project on Legal Constraints on Access to Effective Pain Relief,” in which they interviewed medical board members (cited in Johnson, supra note 8, at 321), and found that the boards were “not able to separate actions against physicians treating patients for pain from the more general disciplinary category of abuse of prescription drugs.”Google Scholar
The actual range of values was 0 to 250. To correct for the outlier values of 100 and 250, these values were “windsorized” to the next highest values of 57 and 58, respectively. Those numbers were then divided by the number of physicians per state (see data at <http://www.education-world.com/a_lesson/TM/WS_census_states.shtml>) and multiplied by 1,000.)+and+multiplied+by+1,000.>Google Scholar
The task of investigating and disciplining physicians was implemented by different individuals, departments, or agencies, depending on the structure of the board and whether it was part of an “umbrella” agency. When referring to boards' investigating or disciplining physicians, we are referring to whatever mechanism the individual board implements to investigate or discipline physicians in that particular state.Google Scholar
See Pain & Policy Studies Group, supra note 29.Google Scholar
The lowest dose of OxyContin is 10 mg. An opioid-naïve patient with chronic pain is typically started on 10 mg of OxyContin twice a day, and the dose is increased until the patient's pain is controlled (unless the pain is refractory to opioid therapy or other circumstances exist). Suggested dosing for OxyContin is twice a day or every 12 hours, not four times a day. Patients with cancer pain are more likely than patients with chronic nonmalignant pain to take larger daily doses, but there is usually no way of knowing by daily mg dosing alone whether a physician has over-prescribed OxyContin for an individual patient.Google Scholar
The respondent conveyed that referral to a pain management specialist would be expected for primary care physicians treating patients with complex chronic pain.Google Scholar
Eighteen respondents thought their boards had not received any such complaints — their pain undertreatment complaint estimate was entered as zero. Of the nineteen who thought their boards had received such complaints, fifteen were able to give a 2001 estimate. If a range was given, the median of the range was entered. The actual range of values was 0 to 25. To correct for the outlier value of 25, that value was “windsorized” to the next highest value of 13. Raw values were then divided by the number of physicians per state (see data at <http://www.education-world.com/a_lesson/TM/WS_census_states.shtml>) and multiplied by 1,000.)+and+multiplied+by+1,000.>Google Scholar
We specifically asked about prisoners as a source of complaints, as they tend to file complaints with state medical boards regarding poor medical care in general. One respondent said he “tended to investigate most prisoner complaints because they're in a duress situation; they might not get the best care,” while another commented, “Some department of corrections issues, like prisoners’ being undertreated, we don't investigate. Even if it's true, are we going to do anything about it?”Google Scholar
Estimates for four of the five respondents whose boards had not used a pain management expert were entered as zero (one reported no cases of pain undertreatment complaints and did not know the number of opioid overprescribing complaints. We did not assume that this board had complaints about opioid prescribing to investigate, so we considered data for that board as missing). Of the twenty-three respondents whose boards had used a pain management expert and who gave an estimate of the percentage of investigations in which such an expert was used, if a range was given, the median of the range was entered.Google Scholar
Joranson, et al., supra note 22.Google Scholar
The following scenarios may also indicate inappropriate quantities of opioids being prescribed: (1) the doctor is prescribing relatively low dose tablets but in great volume and does not know to shift the patient to a higher dose, a longer acting version, or a different drug, when the current drug is no longer effective; (2) the doctor may be prescribing in the hundreds of tabs a day. However, focusing on quantity alone is generally insufficient to determine that a physician is overprescribing.Google Scholar
See Martino, , supra note 3.Google Scholar