anecdotes about threatening statements by medical disciplinary boards and about physicians who find the scrutiny and requirements sufficiently burdensome that they choose not to prescribe medications needed to manage pain effectively. In addition, the earlier discussion of regulations to limit drug diversion indicate that these policies may discourage the appropriate medical use of opioids and may discourage research to develop better medications.

More states could pass carefully drawn pain treatment laws. The American Medical Association (AMA) recently adopted a resolution to create a model state law, based on the Texas and California acts (AMA, 1996a). By protecting physicians from disciplinary actions, the AMA hopes to "provide patients with the security and knowledge that intractable pain resulting from terminal illness need not persist in a chronic, unrelieved manner" (AMA, 1996a, p. 4).

Although such laws constitute an important step to promote effective pain management for patients, they may not go far enough or may imply clinical clarity that does not exist. By making positive statements about the benefit of opioid use in the control of pain, legislators hope to reduce the fear of arbitrary medical board discipline. Yet they do not, in all cases, mark a clear area of medical practice in which physicians feel free to manage their patients' pain. The more specific laws, for example those that set out detailed prescription practices, may actually afford physicians less leeway in the practice of medicine. Additionally, by carving out an area of pain treatment that is immune from medical board discipline, there may be an implication that other forms of pain treatment should be subject to disciplinary review.

Even the strongest intractable pain law is still limited by the term intractable. Many cases are ambiguous, and physicians may believe that they must delay opioid treatment until pain is far enough along to be called intractable. An additional problem arises when state laws define addiction without regard to pain management. As noted earlier, California defines addicts as "habitual users," which might include patients taking opioids for chronic pain. Such confusing definitions once again expose physicians to the threat of medical board discipline.

Finally, the legal affirmations in these laws of the importance of pain control do not, in themselves, correct practice patterns or improve physician training. Laws could, however, encourage patients to expect diligence in pain relief, including use of generally effective medications. Medical boards could consider disciplining physicians who fail to apply proven methods of pain control.

Front Matter (R1-R18)

Summary (1-13)

1 Introduction (14-32)

2 A Profile of Death and Dying in America (33-49)

3 Caring at the End of Life (50-86)

4 The Health Care System and The Dying Patient (87-121)

5 Accountability and Quality in End-Of-Life-Care (122-153)

6 Financial and Economic Issues in End-Of-Life Care (154-187)

7 Legal Issues (188-206)

8 Educating Clinicians and Other Professionals (207-234)

9 Directions for Research to Improve Care at the End of Life (235-258)

10 Conclusions and Recommendations (259-271)

References (272-312)

Appendix A (313-320)

Appendix B (321-326)

Appendix C (327-357)

Appendix D (358-362)

Appendix E (363-382)

Appendix F (383-399)

Appendix G (400-404)

Appendix H (405-406)

Appendix I (407-412)

Appendix J (413-418)

Index (419-437)