States making progress in policies to help pain sufferers
Some states have adopted policies recognizing that controlled substances are necessary for public health, that pain management is part of quality medical practice, that medical education should include pain management and palliative care, and that patient care facilities have a responsibility to assess and treat pain.
That's the message from the University of Wisconsin's Pain & Policy Studies Group (PPSG) in its 2006 progress report card assessing state efforts in adopting effective policies to help people with pain alleviate their suffering.
The study was jointly funded by the American Cancer Society, the Lance Armstrong Foundation, and the Susan G. Komen Breast Cancer Foundation.
PPSG researchers evaluated whether state pain policies and regulations enhance or impede pain management. Each state was assigned a grade from A to F (www.painpolicy.wisc.edu/Achieving_Balance/PRC2006.pdf), reflecting the effectiveness of its pain policy. PPSG also evaluated policies in place for 2000 and 2003 to determine what changes have been made over time. It said results show continued momentum for positive policy change over the six-year evaluation period.
While progress has been made, the report says, in some states pain treatment using opioids is unduly restricted by policies reflecting medical opinion that was discarded decades ago.
"Practices that should be medical mistakes by today's standards include requiring opioids to be a treatment of last resort, equating the use of opioids to manage pain with drug addiction, requiring 'drug holidays,' and restricting the amount of medication that can be prescribed at one time, regardless of patient need," the researchers said. "Yet, such standards are common in today's state policies. Indeed, many states are now adopting model policies that avoid creating these potential barriers."
Pain, sometimes severe and debilitating, is associated with a variety of diseases, including cancer, sickle-cell anemia, HIV/AIDS, and other chronic conditions, according to the study. Adequate pain relief, it says, contributes to improved health and can restore quality of life. But unfortunately inadequate pain relief continues to occur too frequently.
The researchers estimated that 100 million Americans who are affected by chronic conditions and diseases suffer from pain, including pain associated with cancer. Pain, they say, is one of the most common physical complaints upon a person's admission into the health care system, and moderate to severe pain is frequently reported to be experienced throughout hospitalization, during treatment, and even after discharge.
Emotional and financial toll
Pain takes a significant toll, both emotionally and financially. The researchers said untreated or undertreated pain can devastate a person's quality of life by diminishing their function, productivity, or ability to interact socially, and can happen at any stage of life.
According to information published in the Journal of the American Medical Association, unrelieved pain annually exceeds $61 billion in lost productivity.
"Considering these tremendous adverse consequences, unremitting pain is recognized as a significant public health problem in the U.S.," the report said.
The report card says most, if not all, pain can be relieved, but only if knowledgeable health care professionals are able to properly use the many available safe and effective treatments. Opioid paid medications have a well-recognized role in managing pain, particularly when it is severe. But they also have the potential for abuse. The university researchers said the controlled substances and professional practice policies that have been enacted to govern these medications and prevent abuse always come into play when health professionals use opioids to relieve pain. Governments, according to the researchers, are obligated not only to establish a system of drug controls to prevent abuse and diversion, but also to ensure their medical availability. This is known in the field as the Central Principle of Balance. Balanced policies include those with a potential to enhance pain management while avoiding the potential to interfere with such treatment,
Using a research methodology that graded each state based on the quality of their pain policies, the report concluded that some pain policies are becoming more balanced,
Michigan and Virginia each received A grades and reportedly have the most balanced pain policies in the country. Some 82% of states received a grade above a C, and 19 states had a positive grade change since the last report in 2003. Rhode Island posted the greatest improvement, moving from a D+ to a B, while no state saw its grade go down over the last three years.
The researchers said the significant amount of policy improvements occurring between 2003 and 2006 was the result of 1) state health care regulatory boards adopting policies encouraging pain management, palliative care, or end-of-life care; and 2) state legislatures repealing restrictive or ambiguous policy language, including repealing multiple or single-copy prescription programs.
Barriers ahead
The momentum for change, which PPSG first reported in 2003, has continued, researchers said, supporting a conclusion that government agencies still see a need to remove regulatory barriers and encourage appropriate pain treatment.
"To achieve more balanced and consistent pain policy, most states face the challenge not only of adopting positive policies, but of removing restrictive language from legislation," they wrote. "Experience around the country is showing that a valuable state governmental mechanism to achieve balanced policy is the use of task forces, advisory councils, and summit meetings to examine state pain policy."
"We're seeing positive results because health care regulators have adopted policies encouraging pain management, palliative care, and end-of-life care," PPSG associate director of U.S. policy Aaron Gilson tells State Health Watch. "Additionally, many state legislatures have repealed restrictive or ambiguous policy language that has prevented health care professionals from aggressively treating pain. Despite this progress, most states still face the challenge of removing their remaining policy barriers, communicating the new or revised policies to health care practitioners, and ensuring that the spirit of these policies is put into practice."
Mr. Gilson says the University of Wisconsin researchers have been looking into pain policy since the mid-1980s. In the early- to mid-1990s, he says, national and global health care organizations said that restrictive policies were the cause for undertreated pain. The PPSG staff then developed the research methodology they use to assess state actions.
Michigan and Virginia achieved their top ranking by adopting the Federation of State Medical Boards' model guidelines and model policy and repealing all excessively restrictive and ambiguous policy. The PPSG researchers said that because there is no ceiling on policy quality, states with high grades still should continue to explore how additional policy can help to improve access to pain management while avoiding adoption of negative policies.
Since 2003, legislatures and health care regulatory agencies in 19 states have modified their policies sufficiently to improve their grades. Five states (Idaho, Kentucky, New Jersey, Vermont, and Wisconsin) improved their pain policies between 2000 and 2003 and again between 2003 and 2006.
Change need not be hard to do
The researchers said several states are in the unique position of being able to achieve significant policy change either by adopting positive policy or repealing restrictions. Alabama, Alaska, Maine, North Dakota, and Wisconsin currently have no restrictive or ambiguous language in state pain policies. Those states could achieve an A ranking, according to the report, simply by adopting additional positive policies. Five other states (Kansas, Nebraska, New Mexico, Oregon, and Vermont) would have received an A in 2006 had one or two restrictive or ambiguous provisions been repealed.
In 2006, more than 80% of states achieved a grade above C, a substantial improvement since 2003, when two-thirds of the states had a grade exceeding the average. While such progress is considered significant, the researchers said, for states to achieve more balanced and consistent pain policy, they must face the challenge of removing many long-outdated negative provisions from state statutes, some of which have been on the books for 30 years or more.
A particular challenge, the PPSG researchers said, may be in those states that have a considerable number of positive provisions but also have many negative provisions. In the last three years, they said, California, New York, and Texas repealed restrictive legislative language, but the changes have not improved their grades because of the large number of negative provisions remaining. For those states, they said, there must be a continued focus on reducing the number of restrictive or ambiguous provisions for any positive grade change to occur.
Mr. Gilson says the researchers have never heard of any opposition to the changes they recommend. In fact, he says, the PPSG proposals and the model guidelines have been adopted by some legislatures and others interested in patient care because they don't undermine legal drug control requirements but rather simply promote better use of medications for pain relief.
He notes that PPSG concentrates on state policies, while recognizing that improved policy doesn't necessarily mean there is improved patient care because other factors are involved in improving care including practitioner education, patient education, and public opinion.
Those working to improve pain policy, he says, recognize that legislation can result in improved policies but is not the primary driver. Rather, he says, they often find it is easier to work through state regulatory agencies than to seek legislative changes.
The report is available on-line at www.painpolicy.wisc.edu/Achieving_Balance/index.html. Contact Mr. Gilson at (608) 263-8448 or e-mail [email protected].
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