Legal Landscape of Pain Treatment
Pain is the reason most people seek health care. The cost in lost productivity is in the billions of dollars annually. Over the years there have been major changes in the way pain is analyzed and treated. Thanks to the efforts of dedicated health care professionals, researchers, and legislators, there now exists a more compassionate and scientifically-based approach to pain management. Cooperative progress between law and medicine has opened up more freedom for legitimate prescribing. Organizations such as the Joint Commission of Accreditation of Hospitals Organization, the International Association for the Study of Pain and the Drug Enforcement Agency have incited changes in both federal and state laws.
In prior years, physicians were restricted in their prescribing practices of controlled substances — there was always the implied threat of disciplinary action if they prescribed “too much." As a result, many people had to learn to live — or die — with their pain.
Many barriers still exist to adequate pain management. Prominent among the barriers is the continued lack of knowledge on the part of many health care providers, as well as the lay public. Consequently, pain continues to be inadequately treated. As options to treat pain expand, there must be continuing education of health care professionals; ethical practice demands it and the legal environment may dictate it.
The International Association for the Study of Pain defines pain and some of its varying forms as follows:1
- Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
- Central Pain is pain initiated or caused by a primary lesion or dysfunc- tion in the central nervous system.
- Neuralgia is pain in the distribution of a nerve or nerves.
- Neuritis is inflammation of a nerve or nerves.
- Neurogenic pain is pain initiated or caused by a primary lesion, dysfunc- tion or transitory perturbation in the peripheral or central nervous system.
- Neuropathic pain is pain initiated or caused by a primary lesion or dys- function in the nervous system.
- Nociceptive pain results when a nox- ious stimulus (one which is damaging to normal tissue) stimulates a prefer- entially sensitive receptor.
Pain can be acute or chronic. Chronic pain is pain that generally lasts more than six months and, if untreated, it can of itself become a disease state. The Agency for Health Care Policy and Research (AHCPR) and the American Pain Society (APS) have developed recommendations for acute pain management. Acute pain management typically occurs in health care institutions or offices, although not restricted to these settings. Table 1 presents the AHCPR recommendations for treating acute pain:2
The AHCPR, in addressing cancer pain, published the ABC’s of pain management.3 It simplifies a philosophy of treatment as indicated in Table 2.
Several years ago, the late John Bonica, MD, dedicated himself to the relief of pain. Dr. Bonica, an Italian immigrant to the U.S., suffered debilitating pain resulting from sports injuries and subsequently wrote volumes about various pain treatments. Dr. Bonica left a legacy in the form of the ever-expanding International Association for the Study of Pain (IASP). The International Association is now in 60+ countries and holds a World Congress, convening to exchange research results and reports of specialty groups. The 2001 Congress passed the Patient’s Bill of Rights.
The American Pain Society (APS) is the U.S. arm of the IASP. Many regional and local societies have formed throughout the U.S. and the world. The focus is to relieve the many types of pain common to mankind. In 2002, the APS produced a guideline for the management of the pain of osteo-arthritis, rheumatoid arthritis and juvenile chronic arthritis.
|p Implement a valid and reliable pain assessment tool in clinical practice. |
p Inform patients that treatment of their pain is important.
p Tell patients to notify someone if they are in pain.
p Set a goal with the patient for an acceptable level of pain intensity.
p Systematically document the pain experience. This should include factors influencing perception, evaluation of pain and pain responses, as appropriate.
p Assess pain at regular intervals — after initiation of treatment, at each new report of pain, and at suitable intervals after treatment.
p Treat the pain within 15 minutes.
p Use both drug and non-drug therapies to treat pain as appropriate.
p Determine if pain relief is acceptable to the patient.
p Institute a formal and collaborative institutional approach to pain management with clear lines of responsibility.
There is currently a patchwork of state laws governing the prescribing of controlled substances for pain. It is crucial that physicians be familiar with both applicable state and federal regulations to avoid legal complications. Following are samples of state laws that impact on prescribing for pain.
In Texas, the Intractable Pain Treatment Act was approved in 1989. The purpose of the Act was to develop some degree of immunity from state medical boards for physicians who prescribe controlled substances for pain. The Intractable Pain Treatment Act Texas has helped physicians to treat unrelenting pain in a more benign environment.
Maine enacted a comprehensive law effective March 22, 1999 entitled “Chapter 11, The Use of Controlled Substances for Treatment of Pain."12 The law emanates from The Department of Professional and Financial Regulation. It is comprehensive and inclusive and encourages physicians to practice effective pain management as part of quality medical practice.
The Massachusetts Board of Registration in Medicine published Prescribing Practices, Policy and Guidelines effective May 3, 1989 and amended December 12, 2001. The Board specifically endorsed the Federation of State Medical Board’s Model Guidelines for the Use of Controlled Substances in the treatment of pain (see the section following titled ‘Model Guidelines’).