National and state initiatives target pain
Shining a spotlight on inadequacies, barriers
The growing momentum to address documented deficiencies in how the American health care system treats pain is finding new outlets at the legislative, philanthropic, and managed care levels. The July issue of Hospice Management Advisor (p. 78) highlighted a comprehensive report by the Washington, DC-based Institute of Medicine’s Committee on Care at the End of Life, which made regulatory barriers to pain management a centerpiece of its critique of conventional medical care of the dying. A story in the August issue (p. 94) highlighted a new grant by the Robert Wood Johnson Foundation in Princeton, NJ, to the Pain and Policy Studies Group at the University of Wisconsin, Madison, to study and target regulatory barriers at their source: America’s state medical boards.
California patients’ bill of rights
Other efforts are now under way in California, Illinois, and New Jersey, as well as an HMO in Massachusetts (see related story, p. 103), to tackle stumbling blocks to effective pain management.
In California SB 402, The Pain Patient’s Bill of Rights, designed to guarantee access to adequate opioid treatments for patients with severe, chronic, and intractable pain, passed the state Senate in July and moved on to the Assembly. Sponsored by state legislator Forest Tennant, MD, MPH, executive director of Community Health Projects of West Covina, CA which runs 38 dependency and pain clinics across the state this bill is targeted at loopholes in California’s 1990 Intractable Pain Law. In a July press conference in Sacramento, Tenant said the bill, by specifying that there is no upper limit for opioid dosages, would save patients from the dilemma of having to "grovel for sympathetic attention of the medical community or resort to the Kevorkian alternative.’"
The California State Hospice Association is "following" SB 402, neither endorsing nor opposing it. Other pain management advocates privately question whether a legislative fix is the right approach, and whether fear of regulatory second-guessing of physicians’ pain drug prescribing is still the real culprit. In recent years, California has seen a series of initiatives by the state’s regulators, including a 1994 Summit on Effective Pain Management, and increasingly liberal policy statements issued by the medical, pharmacy, and nursing regulatory bodies. California is also testing a new program that potentially could replace its cumbersome "triplicate" multiple-copy opioid prescription forms with a computerized electronic monitoring system.
In Illinois, hospice physicians are spearheading an effort targeting triplicate requirements in that state as well, although repeated efforts by HMA to reach doctors involved in the effort were not successful.
In New Jersey, the state’s medical society targeted regulatory barriers in a recent issue of its magazine, New Jersey Medicine. New Jersey is one of only nine states with laws specifying unit dosing restrictions. (Doctors can only prescribe a 30-day supply or 120 units of certain pain drugs, whichever is less.) The regulations have had a chilling effect on doctors, says Leah Ziskin, MD, a member of the state’s Board of Medical Examiners.
However, recent national attention to regulatory barriers has not kept pace with changes going on in state medical boards, explains David Joranson, MSSW, director of the Wisconsin Pain and Policy Studies Group and principal investigator in the Robert Wood Johnson Foundation project. "State medical boards are in a unique and unprecedented phase of reevaluation, and the upward trend line is steep," he observes.
A federation of the state boards has endorsed Joranson’s project, and a series of six workshops will be offered to board members. In addition, the project will evaluate the connections between pain medicine prescribing and drug abuse, "and will prepare us to work with prescription monitoring programs, to ensure that programs like triplicates or electronic monitoring do not interfere with drug prescribing for pain management."
Joranson does not believe in legislative solutions to the pain problem. "If I had my choice of action, I’d start with a state study commission or task force authorized to hold hearings and do more public education. Out of the study process, representing different constituencies, can come a much richer array of recommendations for improving pain management in the long term," he says.
"I don’t think one piece of legislation after another is the answer." He offers a caution to hospices, reflecting the current legislation in California. "A lot of new policies that will affect them may be driven by chronic pain interests rather than cancer pain interests. So they ought to be observant and involved in these efforts."
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