State Medical Boards
State medical boards may influence opioid prescribing practices through sanctions, regulations, and guidelines, as well as policy statements. The state medical boards promulgate regulations as official rules legislated and issued by the board. Regulations establish boundaries of acceptable physician conduct. Guidelines issued by medical boards are official statements only without the force of law. Medical board policy statements seek to clarify the board's expectations in matters of concern to the medical community.
Further needs in the war against pain include the greater role of state medical boards championing the cause of the pain patient and his or her healthcare provider, providing accountability for inadequate pain management and support for DAPD programming. In the late 1990s, after state medical boards liberalized standards for prescribing opioids, the use of prescription opioids increased.
Although most state's medical boards have opioid prescribing policies, some have negative language impeding the prescribing of opioid medications. State medical boards can also exert influence through sanctions on healthcare providers that under-treat pain. In 1999, Oregon was the first state medical board to issue sanctions for failure to provide adequate pain relief when the Oregon Board of Medical Examiners (OBME) disciplined Dr. Paul Bilder for failure to provide adequate pain relief to dying patients. The OBME required Bilder to complete a patient-physician communication course, enroll in peer evaluation and education, and continue psychiatric treatment.
While sanctions are necessary, state medical boards should be more proactive and reduce negative language impeding adequate pain management, such as implying that opioids are only to be used as a last resort, implying high dose opioids or opioids for chronic nonmalignant pain are outside legitimate medical practice, confusing physical dependence with addiction, restricting opioid prescription based upon patient characteristics, requiring consultations prior to initiating opioid therapy, and restricting quantities of opioid medication prescribed.
On the other hand, positive pain policy language should be encouraged. Positive policy language could include recognizing the importance of opioid medications for public health, recognizing pain management as a component of primary care practice, addressing practitioners' concerns regarding investigation and prosecution, recognizing that a large number of prescriptions or a large quantity per prescription is not in itself a determinate of inappropriate prescribing, recognizing the difference between physical dependence and addiction, and encouraging adequate pain management.
Successful implementation of medical board policy requires medical board investigator training, policy dissemination to physicians through workshops, websites, and newsletters, and mass media outreach to the general public. Uniformity among state medical board policies could be brought about by adopting favorable pain treatment policies from model guidelines adopted by the Federation of State Medical Boards (FSMB). Many states have adopted FSMB model guidelines for pain management.