In Volume 87, Number 4, of the Journal, Kathryn L. Tucker, JD, and Ronald Joseph give their views on the proper way for medical boards to establish a regulatory environment in which physicians will prescribe adequately to relieve pain. They agree that boards should act to ensure physicians treat pain appropriately. Unfortunately, both are wrong in their approach.
Ms. Tucker argues that board investigation and discipline for “perceived excessive prescribing” has led to a climate of fear in which “physicians are reluctant to prescribe controlled substances for treatment of pain.” She asks for boards to investigate and discipline inadequate pain care.
On its face, this is a reasonable suggestion. In particular cases, it may be called for. However, it would only compound the problem. If concern about investigation and discipline has made physicians reluctant to treat pain with controlled substances, making them similarly fearful of under-prescribing cannot help. Their perception will be that straying from some vaguely defined middle is treacherous. Physicians will prefer not to traverse between this Scylla and Charybdis; many likely will see to it they are not placed in the position of treating severe pain.
Mr. Joseph argues that boards should attempt education as well as discipline. He points out that the board in his state, California, has told physicians that they need not fear the board if they prescribe in accordance with the board’s Pain Relief Guidelines. The board also sponsors CME on the subject. Most states have well-publicized laws, rules, or guidelines similar to those in California. All are commendable efforts. These states seem to have meant what they have said and generally do not discipline physicians who follow these laws, rules, or guidelines.
The fear of discipline, therefore, should be waning. Unfortunately, it is not. In many of these states, boards still initiate investigations on bare allegations of prescribing controlled substances in large numbers. Because boards behave this way, physicians who treat severe pain can expect to be investigated and can expect to be required to prove that they conform to their state’s standard. This generally is an expensive and unsettling undertaking. Fear of this process is a strong deterrent to treating pain, even though, as the guidelines promise, the outcome is no discipline.
Boards have done well in promulgating reasonable guidelines regarding prescribing. Now they must take the next step. They must stop investigating physicians simply because they prescribe controlled substances in large numbers. Large numbers do not constitute a violation of the board guidelines, and small numbers will not either. Boards should initiate investigations only when they have reason to believe a physician is prescribing other than in accordance with their guidelines, whether the impropriety has led to over-prescribing or under-prescribing. Where a violation of the guidelines is shown, a prosecution may be undertaken. This, together with continued educational efforts, will remove the perception of fear surrounding prescribing controlled substances and help physicians treat their patients well while keeping controlled substances out of the hands of those who would abuse them.
