Measure on pain control faces ax

Tuesday, May 2, 2000 | 11:15 a.m.

Something hurts. See the doctor. He makes it stop.

That's what most people expect.

However, relieving pain is turning into a complicated issue in Nevada, where the state Board of Medical Examiners is about to repeal pain management rules it adopted last fall.

For a few fleeting months, some say, those rules made Nevada physicians national leaders in relieving pain because they called for disciplinary action against doctors who failed to adequately treat it.

All that changes Thursday, critics say, when medical board members are scheduled to repeal the rules. They are doing so in the wake of complaints from doctors across the state who say the rules adopted in October imply that physicians must prescribe certain types of controlled substances for every patient.

The rules also have been criticized for outlining eight criteria patients must meet before being allowed to receive pain medicine. The criteria are cumbersome, in some cases calling for long-term plans and informed written consent before pain can be treated -- measures that could make terminally ill patients wait days for relief.

"They're absurd. They're a nightmare," said Weldon Havins, a Las Vegas physician who supports the repeal but opposes omission of disciplinary action for doctors who fail to treat pain.

In place of the old rules, medical board members are expected to adopt a measure that says physicians are safe from state disciplinary action for over-prescribing narcotics if they follow guidelines set by the Federation of State Medical Boards.

Larry Lessly, executive director of the state Board of Medical Examiners, said those guidelines provide a "safe harbor" for physicians and are designed to encourage them to prescribe whatever pain medicine is necessary. A physician can be disciplined for not properly following those guidelines, he added.

But they are guidelines, not mandates, Havins said. And the language isn't strong enough to place pain management responsibility where it belongs -- on doctors' shoulders.

"What they don't do is create a duty on the physician's part to treat pain," Havins said. "We were the only state in the union to say, 'You have a responsibility to control the patient's pain.' "

The change is distressing for terminally ill people who need adequate pain relief to make their last days tolerable, said Kathryn Tucker, legal affairs director for the Compassion in Dying Federation in Seattle.

About half of all dying patients do not receive the pain medication they need to be comfortable because physicians are reluctant to prescribe it, Tucker said.

Historically, physicians who write large numbers of narcotics prescriptions have fallen under state investigation. Such is not typically the case now, Tucker and other critics of the change have said. But the fear is still there.

"It's a huge, terrible and serious problem," Tucker said.

And it's one gaining national attention. In January an article in the Journal of the American Medical Association said pain control for cancer patients "is often inadequate."

In February the American Academy of Pediatrics released a statement that said medical workers should learn to recognize pain in newborns and outlined some basic signs of it.

And results of a Gallup survey released in April showed 89 percent of Americans experience pain at least once a month, and more than half believe it's just something people must tolerate. The survey, conducted for the Arthritis Foundation, also said 46 percent of women and 37 percent of men experience pain every day.

"One of the bright lights in the landscape was that Nevada took this progressive step. It's so long overdue," Tucker said. "There have never been any risks or scrutiny for under-prescribing."

Problems with the new rules arose earlier his year when a number of Nevada physicians claimed the wording made it sound as though controlled substances had to be prescribed in every case, Tucker said. No one is saying that's appropriate.

"But don't throw out the whole thing," she added.

Barry Cole, a Las Vegas physician and consultant for the American Academy of Pain Management, said although Nevada doctors may be protected from medical board disciplinary action, the absence of punishment may not put them in the clear.

He cited a case in which a California physician is being sued for malpractice for failing to adequately relieve the pain of a man who was dying of lung cancer. Part of the lawsuit calls for applying elder abuse standards because the man was older than 60.

Cole wonders whether the same standard could be applied to children younger than 18. Could a physician who failed to treat the child's pain -- such as an infant boy being circumcised -- be accused of child abuse?

"We don't know that yet," Cole said.

Tucker is the attorney representing the California family. She said family members first lodged a complaint with California's state medical board. That board agreed his pain had been under-treated, but members took no action against the doctor.

"They took no action at all -- no letter of reprimand, nothing," the attorney said.

And that made family members angry, pushing them into state court with a civil suit. The whole affair could have been avoided if the state had a clear policy for dealing with such an issue in the first place, Tucker said. Nevada has that opportunity.

Cole says physicians don't want to be told how to practice medicine, but people have a right to proper care when it comes to pain. Managing pain isn't even taught in most medical schools beyond the pharmacology classes, he said.

The medical care industry needs more emphasis on managing chronic pain, and that includes tough state standards. "Pain management is a critical issue. At least every other visit to a physician has to do with pain of one kind or another," Cole said. "It isn't like this is an academic exercise."

The medical board's hearing is at 4:30 p.m. Thursday in the Sawyer State Office Building, 555 E. Washington Ave.

Lessly said board members already have conducted workshops on the issue and have considered all written and oral comments submitted. But they may allow more comment from someone presenting new information before making their final decision.

Susan Snyder is a staff writer for the Sun. She can be reached at (702) 259-4082 or by e-mail at snyder@lasvegassun.com