Physician Disciplined for Undertreating Pain

By Ronald L. Scott

On September 1, 1999, the Oregon medical board disciplined a physician accused of undertreating the pain of six of his patients in a case of first impression.  The action taken may reflect a policy shift in the way physicians and society view treatment for pain. In one instance, the physician prescribed Tylenol to treat pain suffered by a terminally ill elderly cancer patient. The physician was also cited for refusing morphine for an 82-year-old man with congestive heart failure, and for declining to resume pain medication for a woman on a mechanical ventilator.

Although a few state medical boards have investigated complaints of physicians undertreating pain, a spokesperson for the Federation of State Medical Boards believes this is the first time a state board in the United States has taken action for giving too little pain medication. In years past, physicians have been disciplined for over-prescribing pain medication, particularly opioid analgesics, due to a largely groundless fear about patients becoming addicts. Newer studies find that most patients in severe pain do not become addicted to pain medication, and that many patients needlessly suffer pain.

A study in 1998 that found one in four elderly cancer patients in nursing homes received nothing for their daily pain. See New Research Indicates that Untreated Pain is a Major Problem Among Older Nursing Home Residents With Cancer (posted 07/01/98).

A July 1999 article in the Journal of the American Medical Association (JAMA) notes that during the past few years the pendulum has swung from concern about the risks of overprescribing to the consequences of underprescribing pain medication, especially for the elderly. The authors note that: (1) opioid analgesics reduce pain and improve cancer patientsí quality of life; (2) underprescribing of analygesia means that cancer patients suffer needlessly; and (3) pain guidelines are available to help physicians manage cancer pain. Nonetheless, the study found a general reluctance among physicians to prescribe necessary opioid analgesics to older people. One study examined the experiences of 1308 patients with metastatic cancer treated on an outpatient basis. A majority of the patients (769) reported experiencing pain, and 475 described the pain as substantial. Also, older patients were more likely to report inadequate treatment for pain compared with younger patients. The authors suggest that physicians may be reluctant to adequately treat older patients out of fear that such patients will experience adverse side effects such as delirium or constipation. Also, financial barriers may limit access to drug therapy by the elderly, since many Medicare enrollees have no coverage for outpatient drugs.

A number of states have passed legislation shielding physicians from disciplinary action if they prescribe drugs necessary to treat patients with intractable pain. Oregon is the first and only state to approve an assisted suicide law. See Oregon Reports on the First Year of Legal Physician-Assisted Suicide (posted 02/26/99).