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| Neurologist and pain medicine specialist Gary Jay is a
busy man - perhaps too busy |
As medical director of the Headache and
Neuro-Pain Care Institute in Tamarack, FL, Jay averages five to seven new
consultation requests a day-many from the area's primary care doctors who,
he says, "are too afraid of giving any narcotic to any patient for any
reason."
The physicians who refer to Jay aren't unusually timid. Across the
country, many primary care physicians are fearful of prescribing narcotics
to treat pain, preferring to "refer away" their cases to specialists.
The problem with this approach, say experts, is that there aren't enough
pain specialists to go around, so patients often end up waiting a long
time before they're treated. Things are worse in rural and other
underserved areas, where treatment for pain is offered by primary care
doctors or not at all, according to Michael O. Fleming, president of the
American Academy of Family Physicians.
Even when generalists do provide pain management to their patients, they
often do so cautiously and, thus, ineffectively. "I've had patients walk
in to see me three weeks before their scheduled appointment," says Jay,
who's president-elect of the American Academy of Pain Management in
Sonora, CA. "I ask them why, and they tell me, 'I'm really in pain, and my
doctor only gave me a dozen Vicodin, and he refuses to give me any more.'
"
Why are primary care doctors stinting on their pain medications or
sentencing patients to long, sometimes painful waits for specialists?
Fear of prosecution is one reason, say observers. "There's no doubt
there's been a marked increase in the level of physician concern in recent
years," says David Joranson, director of the Pain & Policy Studies Group,
Comprehensive Cancer Center, at the University of Wisconsin. And
high-profile cases of physicians losing their licenses or worse, says
Joranson, "only reinforce doctors' fears."
Fear isn't the only factor for primary care doctors. Many also feel
ill-equipped to manage pain, especially in chronic cases. "Training for
pain management in most medical schools is pretty minimal, perhaps two to
three hours in four years, so many doctors are afraid they'll end up doing
something wrong," says Jay.
Despite these obstacles, experts argue, doctors on the front line of
medicine must include pain management as part of what they do if the
problem of undertreatment can ever be addressed.
We took a look at the issues to find out how you can enlist in the war on
pain-without ending up as one of its casualties.
DOCTOR BUSTS: MYTH VS REALITY
Doctors' fears of regulatory scrutiny are nothing new. Since the beginning
of US narcotic control efforts, physicians have often been viewed by
enforcement officials as easy, readily available targets, according to
psychiatrist and medical historian David F. Musto in The American Disease:
Origins of Narcotic Control (Oxford University Press, third ed., 1999).
Today, say experts, doctors are still sometimes seen as easy targets in
the war on drugs, despite the small number of bad apples within their
ranks.
"The criminals are hard to locate and the prescribers aren't, so some law
enforcement officials go after doctors-which is a little like searching
for your keys under the street lamp because that's where the light is,"
says Scott M. Fishman, chief of the division of pain medicine at the UC
Davis School of Medicine in California and board member of the American
Pain Society.
In recent years, specialists like New Mexico's Joan Lewis, Virginia's
William E. Hurwitz, and Arkansas' Robert L. Kale have found themselves
caught in the government's crosshairs. In the case of anesthesiologist
Joan Lewis, for instance, the New Mexico Board of Medical Examiners
accused her of "injudicious prescribing" and threatened to suspend or
revoke her license. As reported in Medical Economics last year, "The board
alleged that the Albuquerque physician had prescribed controlled
substances 'in quantities that exceeded what was medically indicated' for
six of her chronic-pain patients."*
The Lewis case-like the others-has sent chills through the physician
community, reinforcing doctors' longstanding paranoia that the government
is out to get them. One group, the Association of American Physicians and
Surgeons, has even launched a campaign to urge Washington lawmakers to get
drug enforcement officials off doctors' backs.
But whatever the merits of these high-profile cases-and each needs to be
looked at on its own terms-they have little to do with the average doctor
treating pain.
"Doctors who tend to get prosecuted are typically on the extremes, outside
that bell-shaped curve where the majority of doctors practice," says
Fishman. "If you're part of that majority-and if you practice according to
generally accepted standards of medical care-you have little to worry
about when it comes to pain management."
Fishman's claim is echoed by officials from the Federation of State
Medical Boards of the United States. "In and of itself, quantity doesn't
raise a red flag for us, unless it's an extreme case," says FSMB President
and CEO James N. Thompson, an otolaryngologist.
More typically, says Thompson, doctors get in trouble when they ignore
repeated warnings from pharmacists that a patient is obtaining
prescriptions from multiple sources or doctor-shopping, when they
themselves are the source of drug-diversion, or when they're
self-prescribing or prescribing to family members. "Virtually all actions
against doctors for pain relief fall into one of these three categories,"
he says.
In fact, since 1996, the number of board disciplinary actions for
controlled substance violations, including excessive prescribing, has
remained fairly constant, averaging 374 actions each year, or 8 percent of
the total number of disciplinary actions. (For more data, see "State
Boards aren't 'cracking down'".)
Recently, in an effort to quell physicians' fears, the FSMB revised its
1998 "model guidelines" on the use of controlled substances in pain
management. This latest version-adopted in May-assures doctors that
treating pain with controlled substances is an integral part of the
practice of medicine and that good outcomes will weigh heavily in
evaluating physician conduct. The latest version also includes an updated
set of physician pain-management guidelines (which we discuss further on).
Overall, say pain-management experts, medical boards have made giant
strides in recent years, as have their individual board members. "We first
surveyed members' level of knowledge and attitudes in 1991," says Aaron M.
Gilson, assistant director of Wisconsin's Pain & Policy Studies Group.
"Our second survey, in 1997, showed a substantial improvement in
understanding, in terms of the legal and medical issues surrounding pain
management." The group's most recent survey, Gilson believes, will
continue this trend. Findings are scheduled to be released later this
summer.
STATE LAWS ARE BECOMING MORE BALANCED
Gun-shy physicians can also take comfort in another bit of news: States
have been passing regulatory guidelines-often based on the FSMB's model
guidelines-that make it easier for doctors to prescribe powerful narcotics
without fear of reprisal.
In a report released earlier this year, the Pain & Policies Studies Group
graded each state and the District of Columbia on whether its statutory
language "enhances or impedes pain management." Provisions deemed positive
increased an individual state's grade, while those viewed as negative
lowered it. Included on the plus side of the ledger were provisions that:
- Recognized pain management as part of general medical practice.
- Recognized the use of opioids as part of legitimate medical practice.
- Addressed practitioners' concerns about regulatory scrutiny.
- Recognized that quantity of medication was an insufficient yardstick for
determining treatment validity.
- Drew a distinction between physical dependence (or tolerance) and
"addiction."
On the flip side of the ledger, researchers also flagged "negative"
provisions that:
- Considered opioids a treatment of last resort.
- Perpetuated the belief that opioids hasten death.
- Restricted medical decision-making.
- Restricted length of prescription validity (to under 30 days).
- Included ambiguous language (like the "injudicious prescribing" standard
used in the Lewis case).
Based on these criteria, researchers assigned grades to each of the states
and the District of Columbia, and then compared these grades to those
assigned in 2000, when a similar survey was conducted.
In the 2003 report, 21 states (41 percent) scored above a C, compared to
15 states in 2000. The six states that didn't rise above the average in
2000 but did this time around were Iowa, Massachusetts, Michigan, Nevada,
South Carolina, and Wisconsin. Another six states-Hawaii, Idaho, Kentucky,
Missouri, Ohio, and Tennessee-also improved their grades, although not yet
above a C. No state in either survey received an A or an F. (For the full
chart, see "State grades: On the rise" .)
While most states boosted their score by adopting positive provisions,
some raised their grades by repealing or modifying negative ones. For
example, Idaho extended its prescription validity period from 7 days to
30. Similarly, Iowa, Massachusetts, and Michigan said it was no longer
necessary in every case for doctors to consult with specialists before
using controlled substances to treat pain.
"Overall, the momentum for positive change continues . . . ," concludes
the report card's authors. This seems to be the case, they say, because of
an "increasing national recognition of the need to improve pain management
and remove policies that . . . conflict with professional practice and
patient care."
BETTER TRAINING IS ALSO A MUST
Of course, good news on the regulatory front won't help much if doctors
still feel ill-equipped to manage pain, especially in chronic cases.
"Most primary care doctors know how to get someone through the first few
days after gall bladder surgery, but they don't have a conceptual model
for dealing with that pain if it persists," says B. Eliot Cole, pain
management consultant at Hawaii Permanente Medical Group, in Honolulu, and
director of education at the American Academy of Pain Management. "The way
they treat pain is to assume that it's always acute, even if it goes on
and on like the Energizer Bunny."
But that's a faulty assumption, Cole argues. "If an internist or FP were
treating a patient for hypertension and the patient's blood pressure
remained elevated, he'd know the treatment was wrong. But in managing
pain, he's likely to renew the same Vicodin prescription, month in and
month out. In fact, years might go by before someone says, 'Wait a minute.
This patient's taken a lot of Vicodin, and he doesn't look a bit
different.' At some point, doctors need to switch conceptual gears, and
say to themselves, 'What I'm treating is no longer acute pain, like when
my patient broke his wrist or when he came out of surgery. The strategies
I employed before are no longer valid.' "
The average doctor doesn't shift gears in this way, says Cole, because he
hasn't been trained to. "Few medical schools offer pain management as part
of their standard curriculum-not as an elective, but as mandatory for
graduation. In California, the legislature has made it mandatory for
licensure for all 2004 graduates. And the University of Oklahoma College
of Medicine requires students to learn about end-of-life care and
palliative care, which includes some pain management. But beyond these two
states, there isn't much else. I went to medical school, and learned
nothing about pain management."
To fill this gap, Cole thinks our "national goal" should be "mandatory
pain-management education in every medical school and every residency
program." For doctors already in practice, he'd like to see retroactive
training, as California now mandates. If a practicing doctor fails to
fulfill the requirement, says Cole, the state can refuse to renew his
license.
In addition, doctors interested in learning more about the clinical side
of pain management can attend CME seminars presented by the American
Academy of Pain Management (http://www.aapainmanage.org), the American
Academy of Pain Medicine (http://www.painmed.org), and the American Pain
Society (http://www.ampainsoc.org).
TIPS FOR AVOIDING TROUBLE
For doctors who already incorporate pain management into their practice-or
who are contemplating it-staying on the right side of the law isn't hard.
The FSMB's new guidelines are a good place to start. Like the earlier
guidelines, they list seven steps every physician treating pain should
follow:
1. Conduct a thorough patient evaluation, including documenting history of
substance abuse, if any.
2. Outline a treatment plan.
3. Obtain informed consent and a treatment agreement.
4. Conduct periodic reviews.
5. Refer the patient for additional evaluation, if necessary, especially
when the person is "at risk for medication misuse or diversion."
6. Maintain complete, accurate, and up-to-date medical records.
7. Comply with controlled substance laws and regulations.
To fulfill the informed consent provision, many doctors draft contracts or
agreements that spell out precisely the terms of their doctor-patient
relationship. For instance, Rhode Island FP John J. Machata requires his
patients to sign a detailed contract, identifying 18 conditions they must
agree to before treatment. Among other things, patients must disclose a
history of substance abuse, agree to additional tests should addiction
concerns arise, have opioid prescriptions filled at a single pharmacy,
provide blood or urine specimens "at the provider's discretion," keep
their medications secure to guard against theft, and refrain from any
illegal activities (selling or distributing drugs, altering prescriptions,
or forging prescriptions).
FP Andrew S. Alpart, of Slingerlands, NY, follows a similar procedure,
ending with a clear message to violators that their "controlled medicines
will be discontinued as quickly as is safely possible to prevent
withdrawal" and that they risk being "permanently discharged" from the
practice.
For FP Randall L. Oliver of Evansville, IN, the key to staying out of
trouble is step 6, maintaining good medical records. "Typically, the
doctors who run the 'pill mills' don't have time to write long notes. The
average doctor can prescribe whatever his patient needs, as long as he
documents his reason for doing so," says Oliver, whose secondary specialty
is pain management.
Can such precautions be taken to the extreme, in the belief that doctors
can thwart unscrupulous patients completely? Some like FP Frederic Porcase,
Jr., of Jacksonville, FL, think they can be: "Realize that occasionally a
patient is going to burn you. Accept it, deal with it, learn from it, but
don't let it prevent you from providing adequate patient care."
Doctors must also realize, say experts, that they can't fight the war on
drugs alone. It's unfair to ask doctors and their patients to shoulder
most of the burden for preventing drug diversion, says David Joranson of
the Pain & Policy Studies Group. "At least part of the problem has to be
corrected by adjusting the law enforcement side of the equation."
Eliot Cole of the American Academy of Pain Management agrees, which is why
he ends his own tip list with the admonition to doctors to stay engaged:
"The practitioners and regulators have to work together, or we
practitioners will be saddled with severe draconian measures."
The above message comes from "Medical Economics", who is solely
responsible for its content.
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