Doctor's
Undertreatment
of
Pain
Draws
Penalty
4/16/99
One of the worst consequences of the "war on drugs" is a national epidemic of untreated and undertreated severe chronic pain. Many patients in severe pain require opioids (narcotics) to obtain adequate relief and be able to function. The same substances are also used and abused non-medically, and powerful regulatory and enforcement agencies, who tend to favor limited opioid prescription, monitor physician prescribing practices very closely. Many physicians, including the nation's leading pain control experts, consider the boards' and enforcers' prescription quantity standards to be unrealistically low. Compounding the problem is that most doctors do not receive training in pain management during medical school. (See our discussion of this issue at http://www.stopthedrugwar.org/pain.html.) In an unusual, perhaps unprecedented move, the Oregon Board of Medical Examiners has taken disciplinary action against a physician for undertreating pain, according to the Oregonian last month (3/27). Dr. Paul A. Bilder, a 54-year old pulmonary disease specialist, has been accused by the Board of failing to give seriously ill or dying patients adequate pain medication. Some of the same physicians who have challenged the system's obstacles to adequate treatment of pain, are encouraged by the increasing awareness and understanding of pain treatment issues, but have expressed concern that a disciplinary approach to undertreatment may backfire. Dr. William Hurwitz, whose battle with the Virginia Board of Medicine over pain treatment was featured on Sixty Minutes in 1996 (http://www.drcnet.org/guide10-96/pain.html), told the Week Online, "Although it sounds like the doctor was indifferent to his patients' pain, anxiety, and misery, I don't think that the best way to deal with this is through disciplinary action by Boards of Medicine. There are probably rational and defensible grounds that might plausibly justify the doctor's treatment. Disciplinary actions are always undertaken with the benefit of hindsight, and here, in the context of shifting standards of care." "It is fundamentally unfair to hold the doctor to a standard that was certainly not the community standard from 1993-1998," Hurwitz continued. "By increasing the risk to doctors of treating pain patients, whether it be for charges of overprescribing or undertreatment, it will simply make it harder to find doctors willing to treat these patients at all." Dr. Harvey Rose, a California physician who successfully defended his pain treatment approach against the California Board, spearheaded legislation in that state to protect patients' rights to pain treatment, and was also involved in passing similar legislation in Oregon. Dr. Rose commented, "To see the Oregon board go after somebody for underprescribing now is a mind-blower." An Oregon state task force, created by the legislature in 1997, found that the Oregon Board of Medical Examiners' had a history of aggressively pursuing physicians for prescribing narcotics, constituting a significant regulatory barrier to good chronic pain care, according to the American Medical Newspaper last January. "I think [Dr. Bilder] refused [to provide narcotics], not because he's a mean guy, I'm sure he's not," Dr. Rose said. But he's afraid to give narcotics. If he gave narcotics to these people, and if he pushed them over and they died or something, he'd get blamed for it. See, there is no law against underprescribing, but there are laws against excessive prescribing. I think what should be done with him would be an educational type discipline, where you make him take some continuing medical educational courses in pain management." The Week Online asked Dr. Rose about the impact of the DEA on pain treatment: "The DEA claims that whenever they go after a doctor, it's been reviewed by a doctor. But who does the DEA choose to review the cases? Ultra-conservative, anti-narcotic type doctors. You choose who you want, you get the opinion that you want. They could choose a doctor who was a little more compassionate, a little more liberal in prescribing, but then they wouldn't get the result that they want. They couldn't go after the doctor. The war on drugs has created a climate now where it's become a war on patients and doctors. The war on drugs is the root of all evil. That's what's created this whole business of undertreatment of pain, and it's crazy." A New Jersey report by the Commission for the Study of Pain Management Policy, chaired by state Assemblywoman Charlotte Vandervalk (R-Westwood), found that patients often could not get appropriate pain relief, even though it was medically possible to provide it, and made recommendations for making pain medication more available. Vandervalk wrote in an editorial in the April 2 issue of the Bergen Record, "We heard a lot about fear. Physicians feared trouble with law enforcement for prescribing large doses of controlled substances, especially if they have a practice with a heavy caseload of patients with intractable pain. Pharmacists were also afraid of losing their licenses for filling prescriptions for high doses of painkillers. Patients feared that their supply of medicine would run out, so they cut back and did not take the optimal dosage. Some patients feared that they would be considered weak or troublesome if they complained about their pain." Vandervalk concluded, "Government must do all that it can to eliminate obstacles, so that the best medical care becomes easier to give and receive. Science has shown us how to eliminate pain. The need for action is clear. We would be barbaric if we did not go forward with these recommendations."
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
