Report:
In
Search
of
a
New
Ethic
for
Treating
Patients
with
Chronic
Pain
4/24/99
An article in last week's issue, "Doctor's Undertreatment of Pain Draws Penalty," discussed the issue of pain treatment and the war on drugs, surrounding the Oregon Board of Medical Examiner's decision to take disciplinary action against a physician for the undertreatment of pain, possibly the first medical board in U.S. history to take such a step. (See http://www.stopthedrugwar.org/pain.html for a general discussion of the impact of the drug war on pain treatment, and visit http://www.drcnet.org/wol/087.html#undertreatment for last week's article.) A report published in the Winter 1998 issue of the Journal of Law, Medicine & Ethics examines the "ethic of underprescribing" and steps that states and boards have taken to begin to reverse it. Author Ann Martino concludes that underprescribing for pain is the norm or prevailing standard, and describes three principles that contribute to the underprescribing ethic: 1. Just Say No -- a generalized fear of narcotics and addiction, known as opiophobia, on the part of both physicians and patients. Martino writes, "Opiophobia has been heightened in recent years by the rhetoric accompanying the government's War on Drugs. One of the central tactics in the War on Drugs has been to focus broadly on the horrors of addiction in media campaigns and anti-drug and prevention programs, without drawing distinctions between drug dependency and abuse or types of addictive drugs. It is thus not surprising that many patients fear that taking any drug in large doses for relatively long periods of time will cause addiction." Additionally, doctors who do treat pain aggressively often face the threat of investigation by medical boards or the DEA, a circumstance that can ruin the careers of doctors, even when cleared. Hence, internal values and external consequences contribute to the Just Say No ethic in pain treatment. 2. Grin and Bear It -- the conception of pain as a moral good that builds character or an inevitability that should simply be endured. Martino writes, "[A]lthough it is hard to imagine that anyone who regularly engages in the practice of chronic pain management would purposefully deny relief to a patient experiencing unrelenting pain, the available empirical evidence clearly shows that it happens all the time." 3. Avoid Risks –- the decision or tendency to not prescribe pain medication in adequate quantities, knowing that doing so can result in trouble with medical boards, insurers or enforcers. "The be investigated or sanctioned by a board could result in a loss of stature, reputation, institutional privileges, or access to insurance panels, even if no restrictions or limitations are imposed on the license to practice." Martino discusses why efforts states have made at regulatory relief, including Intractable Pain Treatment Acts by legislatures and pain treatment guidelines by boards, have not yet succeeded changing the opiophobic climate in pain treatment. The report, titled "In Search of a New Ethic for Treating Patients with Chronic Pain: What Can Medical Boards Do?," includes illustrative quotes from doctors, pharmacists, patients and family members, as well as a chart listing the many causes of underprescribing. It can be ordered purchased for $10, including postage, from the American Society for Law, Medicine & Ethics, 765 Commonwealth Ave., 16th Floor, Boston, MA 02215, (617) 262-4990, [email protected], http://www.aslme.org. To learn more about the pain issue and find out how to get help or get involved, visit the American Society for Action on Pain at http://www.actiononpain.org. (Use http://www.druglibrary.org/schaffer/asap/index.htm temporarily if you get an error message.)
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