North Carolina, Pain Management and End-of-Life Care: Communicating the Policy

Since 1989, state medical boards have been adopting policies to encourage pain management and address physicians’ concerns about the use of controlled substances.¹ In 1998, to support this trend and encourage consistency, the Federation of State Medical Boards published Model Guidelines for the Use of Controlled Substances for the Treatment of Pain.^{2, 3} To date, 21 states have adopted these guidelines in whole or in part; a total of 43 states have at least one policy addressing the use of opioids for pain management. A number of states have gone further by collaborating with other health care boards to develop policy statements about chronic pain and end-of-life care, and communicating these new policies to licensees.^4,5

In this article, we describe the policy and communications efforts of the North Carolina Medical Board (NCMB) as an example of how a state medical board can be proactive in the development and communication of policies to improve pain management and end-of-life care. During the last six years, the NCMB has adopted several new policies to clarify its position on the use of controlled substances for palliative care, end-of-life care, and treatment of chronic non-malignant pain, and has taken steps to communicate these policies to licensees, health care professionals, and the public.

This series of efforts began in 1996 when the NCMB invited the University of Wisconsin Pain & Policy Studies Group (PPSG) to sponsor a workshop on pain treatment and public policy for its members and investigative and legal staff. Ten similar workshops were held in various regions across the United States. An evaluation of all of the workshops showed positive and lasting changes in the knowledge and attitudes of state medical board members about pain management.⁶ Following the workshop, faculty member June Dahl, MD, and Charles E. Trado, MD, President of the NCMB, discussed pain management on the local public radio station. Later that year, the NCMB adopted a new position statement, “Management of Chronic Non-Malignant Pain.”⁷ The statement was announced in Forum, the Board’s quarterly newsletter that informs all licensees and other readers of important policy changes and educational materials that are available. That issue of Forum included the full text of the new position statement and an essay on the importance of palliative care written by Dr. John C. Parker, MD, who had been diagnosed with terminal lung cancer.⁷

In 1997, the NCMB re-emphasized its position on the treatment of chronic non-malignant pain by reprinting the American Academy of Pain Medicine and American Pain Society consensus statement, “The Use of Opioids for the Treatment of Chronic Pain,”⁸ in the Forum. The consensus statement had been used in the creation of NCMB’s policy statement. Dr. Trado also participated in an original television production, “Health Connections: Pain Management,” a 60-minute video produced by the NCMB and the North Carolina Agency for Public Telecommunications. It was broadcast in 1997 on public access channels throughout North Carolina and advertised for sale in the Forum. The NCMB continues to show it to all prospective licensees.

In 1998, the NCMB continued to demonstrate its interest in pain management and end-of-life care by publicizing pain-related educational materials. A notice in Forum⁹ discussed new clinical practice guidelines for pain management that had been developed by the American Geriatric Society¹⁰ and provided access information. The NCMB and the North Carolina boards of nursing and pharmacy also began a dialogue on end-of-life care and began work on a position statement. Although the NCMB had made an ongoing effort through the Forum and other media to make North Carolina physicians aware of quality end-of-life care, the board had not issued a formal position statement on the subject. The 1996 policy had addressed the treatment of chronic nonmalignant pain with controlled substances, but it did not address public and professional uncertainty about treatment options and patient rights at the end of life.

The board convened an “End-of-Life Decisions Forum” on October 23, 1998. This was the first time a state medical board sponsored such a meeting with the boards of pharmacy and nursing, as well as other state agencies, health professionals, and interested citizens. After the meeting, the NCMB used the Forum to announce the availability of an audiotape of the Decisions Forum, along with a review of two resources on hospice care, written by Judi Lund Person, Executive Director of Hospice for the Carolinas. An article about the October 1998 meeting by Anne M. Dellinger, JD, a presenter at the Decisions Forum, was published in the Forum.¹¹ Dr. Dellinger discussed the many reasons for convening the meeting, including concerns about suicide, assisted suicide, euthanasia, pain relief, and life-sustaining treatment.

In 1999, the boards of medicine, pharmacy, and nursing adopted a position statement, “Joint Statement on Pain Management in End-of-Life Care.”¹² The NCMB also adopted its own statement, “End-of-Life Responsibilities and Palliative Care.”¹³ Later that year, the Forum included a brief introductory article mentioning the 1996 workshop conducted by the PPSG and the resulting chronic non-malignant pain policy,¹⁴ as well as an article containing the full text of the new medical board statement and the joint position statement.¹⁵

In 2000, the NCMB continued to highlight end-of-life care and to communicate its position on pain treatment. The NCMB again published all of its position statements in the Forum. In addition, the Forum contained the transcript of a speech by Walter J. Pories, MD, entitled “Living Will: We Forgot to Teach You about Death.”¹⁶ The speech had been given to medical students graduating from East Carolina University School of Medicine in April 2000, where every year faculty members are invited to the ceremony to offer their parting advice to graduating students. Dr. Pories focused on the fact that while death is not often discussed in medical school, physicians must address it. Dr. Pories spoke of how he would like to be treated at the end of his own life, including his expectation to be treated with dignity, to be able to show his emotions, and to have health care providers consider his family.

The NCMB has continued to communicate with North Carolina physicians regarding end-of-life and palliative care, not only through Forum, which has a circulation of 39,000 health care practitioners and the media, but also through its Web site at http://www.docboard.org/nc/. All of the NCMB’s position statements, regulations, and sections of the Medical Practice Act can be accessed and printed from the board’s Web site. Forum is also available on-line. Along with the newsletter, there is a listing of other NCMB publications, which include the audiotape transcription of the 1998 “End-of-Life Decisions Forum” and the videotape of the 1997 discussion and call-in Q&A session on the management of chronic pain and the NCMB’s position statement on that subject. The NCMB emphasizes that board members are available to respond to requests and questions and that contact information is easy to find on the Web site.

According to Dale Breaden, Editor of Forum, several North Carolina physicians have made it a point to tell him that the NCMB’s position statements and communication have been valuable tools. Breaden said that “by taking a progressive and intelligent approach to keeping physicians and other health care providers informed, they will feel more confident about providing pain relief at the end of life and recognize their efforts are not looked on negatively by regulatory authorities.

“The NCMB is pleased that North Carolina’s position statement is in the forefront and has been used as a model for other states,” he said.

The NCMB has provided sustained and exemplary leadership to improve state medical, nursing, and pharmacy policy about pain management and end-of-life care in North Carolina, and to communicate this progressive attitude to licensees and the public. The NCMB has been the catalyst for a thoughtful process that began in 1996 with a board workshop about pain management and state policy that was taken to heart. Board leadership in pain management and end-of-life care has continued to grow and mature, offering the citizens of North Carolina a better chance to receive the quality pain management and end-of-life care that is possible.