Promoting a “Good Death”: Determinants of Pain-Management Policies in the United States

Abstract

Many Americans do not experience a good death. The inadequate treatment of pain at the end of life has been associated with a lack of supportive public policies more than a lack of evidence-based clinical practices or organizational efforts. Given a widespread lack of understanding about pain policies, we examine the critical role played by state medical boards in developing pain policies and then apply event history analysis to identify the variables most critical to the formation of these policies. We develop an integrated model and evaluate the adoption of eight different types of pain policies. The analytic models incorporate fifteen years of observational data and test the impact of contextual, political, extrinsic, and institutional variables. They reveal that the presence of legal counselors on state medical boards has consistently increased the likelihood that state boards adopt policies associated with progressive pain management. Further, policy has been negatively influenced by historical activity: boards that previously adopted one pain policy have been less likely to subsequently adopt additional pain policies. This work illuminates mechanisms behind state pain-policy adoption and provides valuable information for advocates who seek to improve pain-management policy and reduce the amount of pain at the end of life.

Pain and symptom management in palliative care and at end of life

“…Providers also lack knowledge about analgesics, symptom interventions, and side effects of therapies. Still other health care system-related barriers impede pain and symptom management, such as low priority given to pain and symptom management, reimbursement and access issues, and restrictive regulation for some therapies (Berry & Dahl, 2007; Imhof & Kaskie, 2008). Some progress has been made in research to reduce some of these barriers, which have been known for nearly three decades, but others remain, especially in palliative care and end-of-life settings.…”

How Can We Make the Pain Go Away? Public Policies to Manage Pain at the End of Life

“…Although Nice (1984) hypothesized that more liberal states would be more likely to develop pain management policies, Imhof and Kaskie (in press) found that two of the four policies examined were not related to political ideology and the other two were more likely to be advanced in more conservative states. Given that the purpose of these particular policies was to make it more difficult for government officials to have the authority to intervene in the provision of pain management (i.e., that prescription amount alone does not determine the legitimacy of a pain prescription and that practitioners’ fears of regulatory scrutiny are addressed), it may be the case that boards in more conservative states were interested in providing up-front policies that established the parameters for limited government intervention (Brown, 1995; Hedge & Scicchitano, 1994).…”

“…It is worth mentioning that Imhof and Kaskie (in press) found that the ideology of the state governments and citizen wealth had minimal effects on medical board policy-making activity, suggesting that pain management policy adoption by medical boards remains somewhat independent from political majorities, ideological posturing, and economic cycles. As such, the boards can focus on addressing the complex, technical aspects of pain management.…”

“…It can be informative for analysts and researchers who wish to ascertain why state governments create such variable outputs (Biggs & Helms, 2006; Brace & Jewett, 1995). In consideration of this, Imhof and Kaskie (in press) applied an event history analysis and tested how well a theoretical model of policy formation explained the passage of four different types of state board policies pertaining to pain management: (a) integrating pain management as a part of medical practice, (b) establishing that opioids are part of professional practice, (c) determining that pain management should not be defined by restrictive dosage levels, and (d) protecting practitioners’ fear surrounding professional scrutiny of the dispensation of medications to relieve pain. The theoretical model they tested assumed that these policies were shaped by economic, political, extrinsic, and institutional characteristics of the state medical boards (Kaskie et al, 2001; Ringquist, 1993a, 1993b).…”

“…Imhof and Kaskie (in press) provided some indication about how these efforts to advance policy may proceed. In particular, their research suggested that change initiatives might be navigated most effectively by state medical boards whose memberships include legal counsel who can inform policy discussions, consider how policies can be developed in compliance with existing state laws and regulations, and evaluate the potential liability associated with practicing pain management.…”