Preventing undertreatment of pain: Model policy on controlled substances

Some physicians who specialize in treating pain fear that law enforcement officers will bust through their doors for prescribing opioids. OxyContin abuse and diversion have grabbed headlines and turned the spotlight on problems of overtreating pain.

Undertreatment of pain has received less attention. But that's changing, pain experts say, as federal and other agencies look more closely at how physicians treat pain.

This month, the Federation of State Medical Boards passed a model policy on the use of controlled substances for the treatment of pain. The policy revised guidelines adopted in 1998 to give state medical boards and physicians direction on proper pain treatment.

The strengthened pain policy encourages boards to view undertreatment of pain as serious a violation as overtreatment. If boards embrace the policy as their own, doctors would face greater scrutiny for undertreatment of pain, board officials and pain experts said.

"This outlines guidelines that can assure a doctor that if he or she is following these guidelines that they will have the umbrella of safety of their state," said James Thompson, MD, CEO of the Texas-based federation, which represents 70 medical boards.

The new policy said physicians should not fear disciplinary action from boards if they treat pain for a legitimate medical purpose. Boards would judge the validity of a doctor's treatment based on available documentation.

The policy is not radically different from the 1998 guidelines. But medical board leaders saw a need to create a stronger policy to address emerging issues such as undertreatment.

Board leaders said the policy is not intended to increase physicians' fears or to send boards after pain specialists. Rather, the policy is meant to provide guidance to boards so doctors treat pain adequately.

"You certainly don't want patients suffering because doctors are afraid to treat, and that's why it's important to give some guidelines to the boards," said Regina Benjamin, MD, a member of the federation's board of directors and a family physician in Alabama. "You don't have to fear being disciplined for doing the right thing."

New policy raises concerns

Some pain experts say the policy might have the opposite effect: Doctors could become more fearful of being disciplined for pain treatment.

"I wouldn't be surprised if a number of doctors who are faced with over- or undertreating would opt out of treating patients where they have to address that issue on a daily basis. It'll be a hot potato situation where you pass the pain patient on to somebody else," said Mark Lema, MD, PhD, chair of the anesthesiology department at the University of Buffalo and anesthesiology, critical care and pain medicine chair at Roswell Park Cancer Institute in Buffalo, N.Y.

The 1998 federation guidelines had been adopted in all or in part by 22 state boards as of January 2004. Boards in Oregon and California disciplined doctors for undertreatment, and New Mexico revised its medical practice act to include pain undertreatment as grounds for unprofessional conduct, the federation said.

The federation a few months ago gathered board leaders and pain experts to work on a new pain treatment policy. The AMA gave its input.

"The AMA is looking for a balance in the treatment of pain patients so it's not undertreatment or overtreatment of patients," said AMA Trustee Rebecca J. Patchin, MD, a pain management specialist in Riverside, Calif.

The new policy said doctors should keep a medical record that documents the nature and intensity of the patient's pain, current and past treatments for pain and the effect of pain on physical and psychological function. A written treatment plan should state objectives to be used to determine treatment success. Physicians should periodically review the course of pain treatment.

Dr. Thompson, of the federation, expects many medical boards to adopt the new policy or develop similar policies. Pain experts who worked on the policy said more attention should be focused on undertreating pain.

"This [policy] makes it clear that it's not just excessive use of medication" that is inappropriate care, said Scott Fishman, MD, of California, president-elect of the American Academy of Pain Medicine. "It's also a problem to ignore pain."