Revised Pain Management Guidelines Target Inadequate Pain Control: A Newsmaker Interview With N. , MD

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Revised Pain Management Guidelines Target Inadequate Pain Control: A

Newsmaker Interview With N. , MD

Laurie Barclay, MD

April 5, 2004 ‹ Editor's Note: Recognizing that undertreatment of pain is a

public health priority, the Federation of State Medical Boards (FSMB) of the

United States, Inc., is recommending a revision of guidelines stating that

undertreatment of pain, like overtreatment, is a practice violation.

A panel of medical board representatives, experts in pain management and

addiction medicine, and state and federal government representatives

convened by the FSMB recently reviewed suggested revisions to the Model

Guidelines for the Use of Controlled Substances for the Treatment of Pain.

Inspired by new insights in pain management, especially regarding the

undertreatment of pain, the revised guidelines will be submitted to the

FSMB's House of Delegates in May for consideration as policy. Since the

original guidelines were released in 1998, more than 300,000 copies have

been distributed nationally and adopted in whole or in part by 22 state

medical boards.

How should the revised guidelines shape current practice in pain management?

To find out, Medscape's Laurie Barclay interviewed N. , MD,

president and chief executive officer of the Federation of State Medical

Boards in Dallas, Texas.

Medscape: What was the rationale for the FSMB recommending a revision of

guidelines regarding pain treatment?

Dr. : Over the last decade, there has been a great deal of progress

made in our understanding of pain and how to better manage it, especially

regarding the undertreatment of pain. There is a significant body of

evidence suggesting that both acute and chronic pain continue to be

undertreated. Many terminally ill patients suffer needlessly in their last

weeks of life. The revised guidelines encourage state medical boards to

recognize that the treatment of pain is a fundamental part of good

healthcare.

Medscape: What do the revised guidelines recommend?

Dr. : The guidelines address the inadequate management of pain and

barriers that stand in the way of patients getting appropriate treatment.

These barriers include a lack of knowledge among some physicians on what

appropriate pain management entails. Another obstacle is a fear some

physicians have that they'll be investigated by regulators if they prescribe

controlled substances for pain.

The guidelines also encourage state medical boards to consider the

undertreatment of pain as much of a violation of the standard of care as

other kinds of prescribing violations.

They also stress the need for government to develop a system that prevents

abuse and diversion of controlled substances while simultaneously ensuring

they are available for legitimate medical purposes. And the guidelines also

update definitions of addiction, chronic pain, and physical dependence to

reflect current consensus and expertise in the medical community.

Medscape: Are these guidelines likely to vary from state to state?

Dr. : More than likely, yes. While the guidelines do provide the

states a blueprint to follow so that there is some consistency from one

jurisdiction to the next, each state adopts policies in accordance with the

needs of its residents. Twenty-two states have adopted all or part of the

current version of the Federation's model guidelines on pain, and nearly all

states have some sort of policy, position statement, or statute about

appropriate pain management. I think the states will move to address both

the issues of abuse and undertreatment. The wording of how they do this

will, of course, vary from state to state, but in general we believe they

will come close to reflecting the intent of the guidelines.

Medscape: Which states have begun disciplining physicians for undertreatment

of pain, and how is this likely to affect regulatory conduct in other

states?

Dr. : To date, California and Oregon have disciplined doctors for

the undertreatment of pain. I anticipate that we will see this number grow

in the future as more and more states specifically address undertreatment in

their statutes.

Medscape: How can physicians and regulatory agencies best balance the need

to treat pain associated with terminal illness or other intractable

conditions with the need to prevent addiction, abuse, and diversion of

controlled substances?

Dr. : Our hope is that these guidelines will help state medical

boards and physicians treating pain to achieve that kind of balance. The

physician who follows these guidelines should not have any problems with

their state medical board. The guidelines don't interfere with the practice

of medicine, but assure physicians they aren't at risk of being scrutinized

by state medical boards if they follow good medical practice. The guidelines

set forth good practices to follow when treating pain, such as documentation

of records and communication of risks and benefits of medication to the

patient. But they don't tell a doctor or patient how their pain is to be

treated. If a physician follows these guidelines they should be free from

regulatory scrutiny.

Reviewed by D. Vogin, MD