Pitfalls in Pain Treatment

Growing attention to the inadequacies of and barriers to pain management—and the role of controlled substances regulation in those barriers—led to the 1998 promulgation of “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain” by the Federation of State Medical Boards.11 These guidelines, promoting the legitimate role of opioids in relieving pain and acknowledging providers’ concerns about being disciplined, were revised in 2004 and have been adopted by 21 states.12

The effect remains, however. “For decades, physicians have reported being reluctant to prescribe opioids because of the fear of the stress, expense, and consequences of being investigated by licensing agencies or law enforcement,” states a 2006 state report card issued by the Pain & Policy Studies Group at the University of Wisconsin in Madison.13 “Some states—but far from all—have adopted policies which recognize that controlled substances are necessary for public health. … But in some states, pain treatment using opioids is unduly restricted by policies reflecting medical opinions that were discarded decades ago.”

The Pain & Policy Studies Group’s report card, which advocates for a balanced approach to the regulation and prescribing of controlled substances, has given every state a grade for how well it meets this goal. According to the 2006 report card, Michigan and Virginia get top grades for achieving balance in pain policy, while Georgia gets the lowest grade.

“Regulation is a real concern,” says Daniel Burkhardt, MD, associate professor and director of the Acute Pain Service at the University of California-San Francisco. “Every time a prosecutor arrests someone for prescribing too much pain medication, these things travel, adding to the extra regulatory burden on physicians.”

Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., says the burden has lessened somewhat in California because that state eliminated its requirements for triplicate paper prescribing forms for controlled substances.

A related concern involves the potential diversion of controlled substances by impaired healthcare professionals for personal use and abuse. This is another of the fears that have driven archaic pain regulation in many states. In fact, current estimates suggest that a substance abuse-related impairment will affect between 8% and 18% percent of physicians sometime in their lives, and that 2% of physicians are dealing with an active substance abuse problem.14

A recent medical journal letter to the editor from the Wisconsin Pain & Policy Studies Group suggests public policies on opioid diversion should focus more on sources of diversion such as “thefts, including armed robberies, night break-ins, and employee and customer pilferage,” rather than just the doctor-patient prescribing relationship.15

Physician diversion data don’t break out hospital medicine as a category, but some hospitalists say they have not heard of diversion problems involving hospitalist colleagues. That may reflect the fact that hospitalists, unlike some other health professionals, generally don’t administer controlled substances directly to the patient or have ready access to hospital drug storage facilities. TH

Larry Beresford is a regular contributor to The Hospitalist.

References

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2. American Pain Society. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Available at www.ampainsoc.org/advocacy/opioids2.htm. Last accessed April 13, 2007.
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11. Federation of the State Medical Boards of the United States. Dallas, Texas. Available at www.fsmb.org. Accessed April 13, 2007.
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13. Pain & Policy Studies Group. University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Available at: www.painpolicy.wisc.edu. Accessed April 13, 2007.
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