COLUMBUS, Ohio -- Doctors may sometimes be reluctant to adequately treat the pain of seriously ill patients because they fear legal problems for prescribing powerful narcotics, according to one expert who has studied the issue.
Although some physicians may be overly skittish about their legal vulnerability, this concern may mean some patients don't get the pain treatment they need, said Timothy Jost, professor of law and health services management at Ohio State University.
"The prospect of drug use reviews and even fraud and abuse enforcement can inhibit physicians from prescribing adequate narcotics," Jost said.
Jost examined how narcotics fraud and abuse laws affect doctors who treat pain as part of a larger study on public financing of pain management. His findings appeared in a recent issue of the Journal of Law, Medicine & Ethics.
For the study, Jost surveyed state Medicaid Drug Use Review (DUR) programs to see how their practices and policies affected doctors. He received responses from 27 states.
One of the roles of DUR programs is to monitor physician prescribing to guard against medication abuse. DUR programs can also refer doctors to state Medicaid fraud agencies. "Fraud and abuse laws affect every federal and state health program benefit, including pain management," Jost said. "Some of have perceived them as having a particularly negative effect on pain management."
DUR programs will often send letters or make other contacts with doctors who are seen as prescribing large quantities of narcotics for patients with severe pain. The study found that 10 of the DUR programs had sent out more than 100 notices to physicians regarding pain management prescribing in 1996, and two state programs sent out more than 1,000 such notices. Twelve DUR programs sent more than 100 notices to pharmacists regarding pain management in 1996, while six programs sent more than 1,000 notices.
"Most of these letters do not seem particularly threatening and show a legitimate interest in making sure there is no fraud or abuse," Jost said. "However, some letters were less tactful and some seemed to demand rather than request a response. This may discourage aggressive pain management. DUR programs need to be responsive and sensitive to pain management issues and doctors shouldn't be intimidated out of appropriate use of narcotics to deal with pain."
Physicians can be prosecuted for fraud and abuse of narcotics control laws, and even some doctors who use narcotics legitimately may be concerned about that possibility, Jost said. He interviewed prosecutors, defense attorneys and physicians who have been involved in narcotics fraud and abuses cases.
Jost said prosecutors uniformly told him they were not interested in using their limited resources to pursue doctors who legitimately use narcotics to control pain. "Doctors, on the other hand, become nervous when they receive a routine DUR inquiry about their prescribing," he said.
Law enforcement agents need to take a realistic view of the difficulties doctors face when treating serious pain, he said. But doctors also need to understand that inquires from the DUR are not the equivalent of the filing of criminal charges, and they need to candidly discuss their prescribing habits.
"Pain management providers and fraud and abuse enforcers are likely to continue having an uncomfortable relationship for the foreseeable future," he said.
Fraud and abuse enforcement is only one problem in the public financing of pain management, according to Jost. The major public health care providers -- Medicare and Medicaid -- often stand in the way of, or at least fail to facilitate, adequate pain management.
One of the biggest problems is the large gaps in coverage. Medicare, for example, does not cover oral prescription pain medication for most outpatients. Another problem is that many of the regulatory requirements mandated by Medicaid and Medicare ignore pain management issues. For example, nursing homes must follow hundreds of pages of rules and regulations in order to be certified for Medicaid or Medicare. But none of these regulations cover pain management for their patients.
The problem of public financing of pain management touches on some deep concerns of Americans, Jost said. First, Americans are ambivalent about public assistance. We want to help the needy, but only if we can be sure they truly need our help.
Also, the subjective nature of pain makes it difficult for many people to decide who truly needs the most powerful narcotics. "We have this idea that people should keep a stiff upper lip and endure pain if they can," he said.
And finally, Americans are ambivalent about controlled substances. "We're fighting a war on drugs in this country and some of the drugs we're fighting against -- like morphine -- are the drugs that people in serious pain really need."
"With all these concerns, it's easy to see why we have a problem with public financing of pain management," he said. "But I think if most people really understood what is going on, they would be more supportive of pain management. Our health care financing system is failing those people who truly need pain relief."