Pain management physicians, who often prescribe controlled substances like opioids, face intense scrutiny. Critics argue that investigations are overly aggressive, resembling fishing expeditions where investigators search broadly for any evidence of wrongdoing, often beyond the original complaint. A 2023 Los Angeles Times report noted that nearly 10,000 investigations were conducted in 2021–2022, with pain physicians disproportionately targeted due to outdated guidelines predating modern evidence-based practices. For example, the reliance on older standards, such as rigid opioid prescribing limits, fails to account for advancements in pain management, leading investigators to flag appropriate treatments as misconduct.

The use of paid experts, often lacking current expertise in pain management, compounds the issue. These experts, compensated to evaluate physicians, may rely on gut feelings to satisfy their hiring party rather than individualized, evidence-based approaches endorsed by opioid guidelines. This mismatch results in prolonged investigations—averaging 1,167 days—and damages physicians’ reputations and practices, even when allegations are unsubstantiated.

Lack of due process: a system stacked against physicians

Pain physicians also report inadequate due process in disciplinary proceedings. The process begins with the Central Complaint Unit (CCU) reviewing complaints, which may escalate to formal charges (an accusation) and a hearing before an administrative law judge. However, the reliance on experts with limited knowledge of modern pain management undermines fairness. These experts may misinterpret complex cases involving chronic pain, leading to biased recommendations. The high standard of proof, “clear and convincing evidence to a reasonable certainty,” prolongs investigations, leaving physicians in limbo without clear communication about allegations.

The lack of transparency is particularly acute for pain physicians, who may face vague accusations of “not following the standard of care” without specific evidence. The physician-majority board (eight physicians, seven public members) may also perpetuate biases, as members may not be versed in the nuances of pain management. There are instances where pain physicians faced prolonged investigations for prescribing practices aligned with current standards, underscoring the need for due process reforms to ensure impartial hearings and timely updates.

Unfair penalties: disproportionate consequences for pain physicians

Penalties are often criticized as disproportionate, particularly for pain physicians. Minor infractions, such as incomplete documentation of pain management plans—as simple as lacking mention of counseling or inconsistent urine toxicology results—can lead to probation, while serious allegations may result in lighter sanctions, creating inconsistency. A 2021 Los Angeles Times investigation found that only 439 of 90,000 complaints over a decade resulted in license revocation, but pain physicians faced harsher penalties due to the focus on controlled substances. For example, a pain physician might face license suspension for prescribing opioids within evidence-based guidelines, based on an expert’s outdated interpretation.

The reliance on paid experts exacerbates this issue, as their unfamiliarity with modern pain management approaches can lead to recommendations for severe sanctions. The California Medical Association (CMA) has argued that such penalties, combined with high licensing fees, deter pain physicians from practicing in California, worsening the state’s physician shortage. In September 2023, the CMA, along with the American Medical Association (AMA), filed a brief in federal court to shape the boundaries of California’s prohibition on the corporate practice of medicine, aiming to protect physicians’ professional judgment and the physician-patient relationship from external forces.

Bias against pain physicians: outdated rules and unqualified experts

Disciplinary processes are perceived as biased against pain physicians due to outdated regulations and the use of unqualified experts. A California Research Bureau study (2003–2013) found disparities in discipline, with pain physicians and minority groups facing higher scrutiny. In this study, an analysis of 125,792 physician records and 32,978 complaint records was carried out to identify any evidence of disparate treatment in disciplinary outcomes. The findings suggest that certain groups, including pain physicians and minority physicians, may have faced higher levels of scrutiny. This research highlights potential issues of systemic racism, discrimination, and structural inequities within the medical licensing and disciplinary system, which can lead to disparities in access to health care resources and unequal treatment of physicians.

Guidelines, rooted in pre-2016 opioid prescribing standards, fail to reflect advancements in evidence-based pain management, such as multimodal therapies or patient-centered care. Paid experts, often lacking board certification or adequate experience in pain medicine, may misjudge practices like interventional procedures or opioid tapering, leading to unfair accusations of misconduct.

Recent reforms: insufficient for pain physicians

Senate Bill 815 (2023) introduced reforms to address longstanding criticisms, including mandatory patient interviews, a complaint liaison unit, and victim impact statements. However, these changes do little to address the specific challenges faced by pain physicians. Proposals to lower the standard of proof for certain cases and increase licensing fees have raised concerns about further burdening physicians without addressing the reliance on unqualified experts. The CMA and pain management advocates argue that reforms must include updated guidelines reflecting evidence-based practices and the inclusion of board-certified pain specialists as expert reviewers.

A path to fair reform

To address the flawed disciplinary process, particularly for pain physicians, the following reforms are critical:

• Modernized guidelines: Update regulations to align with current evidence-based pain management standards, such as the CDC’s 2022 opioid guidelines, to prevent misinterpretation of appropriate care.
• Qualified experts: Mandate that paid experts be board-certified in pain medicine or have adequate clinical experience and knowledge of published research in the field to ensure fair evaluations.
• Streamlined investigations: Limit investigation scope to the original complaint and establish timelines to reduce the 1,167-day average, protecting physicians’ reputations by only publicizing the investigation after completion of litigation.
• Enhanced due process: Provide pain physicians with specific allegations early in the process and ensure regular updates during investigations to promote transparency.
• Proportional penalties: Implement clear guidelines for penalties, emphasizing education for minor infractions and reserving revocation for egregious misconduct.
• Addressing bias: Conduct audits to identify disparities in discipline and engage pain management societies to develop fair standards for diverse practices.

Conclusion

The disciplinary process, often described as a “fishing expedition,” disproportionately harms pain management physicians through aggressive investigations, inadequate due process, unfair penalties, and reliance on outdated rules and unqualified experts. While SB 815 offers some progress, it fails to address the unique challenges faced by pain physicians. By modernizing guidelines, ensuring qualified expert reviews, and enhancing fairness, the board can protect patients while supporting physicians who provide critical care in a complex field. Without these reforms, California risks further alienating pain physicians, exacerbating health care access issues in a state already facing a physician shortage.

Kayvan Haddadan is a physiatrist and pain management physician.