Discipline of Oregon Physician for Undertreating Pain
is an Appropriate Response to a Serious Problem

By S. Van McCrary, Health Law & Policy Institute

Recently, the Oregon medical board was the first in the nation to discipline a physician for failure to prescribe adequate pain relief medication. The physician, Dr. Paul Bilder, was ordered by the board to complete an educational program, a program on physician-patient communication, and undergo mental health treatment.

As noted in Physician Disciplined for Undertreating Pain, to some extent this case represents a cultural shift in medical regulation--from a single-minded pursuit of the "war on drugs" to an approach that recognizes that pain is too often undertreated as a result of doctors' justifiable fears of legal sanctions. Although limiting diversion of prescription pharmaceuticals into illegal markets is a legitimate goal, the history of medical boards generally is one of being too aggressive in disciplining doctors for prescribing opioids. If the Oregon board's actions are indicative of a real shift in policy, it is long overdue.

The physician in this case is, in one sense, the latest casualty of the war on drugs. For decades doctors have been severely disciplined for prescribing large doses of opioid analgesics because of aggressive federal and state law enforcement efforts. It was assumed by many medical boards that if very large doses were being prescribed it must indicate diversion. To avoid prescribing opioids was a rational response by physicians to such regulatory scrutiny. In fact, however, contemporary medical research has shown that there is no necessary upper limit on the amount of opioid medication that may be required adequately to control severe pain; thus, massive doses in themselves do not indicate diversion. Doctors, and regulatory boards, have too often been unaware of these research findings.

But if Dr. Bilder was the latest victim, then the patients who suffered unnecessarily as a result of his systematic undertreatment were the most significant and vulnerable victims of all.

This case is merely the tip of the iceberg--similar undertreatment of pain occurs with shocking frequency across the nation. Medical boards in other states should emulate the Oregon board's actions, first by taking steps to ensure that doctors have accurate information on pain control, and second by adopting explicit policies that physicians will not face disciplinary action for prescribing appropriate amounts of opioid analgesics for patients whose suffering has been well documented. Medical boards should become more cautious about disciplining doctors for prescribing large doses of opioids unless there is clear evidence of diversion of such drugs to the streets. Gradually, this may reduce the fear that has prevented administration of adequate pain relief medication.

The Oregon board's measured response in this case was the correct one. It should provide incentives for physicians to educate themselves about proper pain control and incentives to prescribe adequate medication for pain relief under clinically appropriate circumstances. The central goal in such cases should not be punishing physicians, but rather ensuring that appropriate levels of medication are made available to patients in pain. Countless patients have suffered unnecessarily for years as a casualties of the war on drugs. It is time that stopped.

09/21/99