Study Shows That New State Regulations Encourage Appropriate Pain Management

NEW YORK—State regulators and medical boards are adopting new pain management policies favorable to physicians and patients even at a time when drug abuse issues are at the forefront of national attention, according to policy researcher Aaron M. Gilson, PhD.

"Government and regulatory policy to encourage pain management in the United States has increased at a phenomenal rate," said Dr. Gilson, assistant director of the University of Wisconsin Comprehensive Cancer Center Pain & Policy Studies Group (PPSG), Madison.

The PPSG report Annual Review of State Pain Policies: 2001, released at a media briefing held by the American Medical Association, shows that state pain policies easing constraints on use of opioid analgesics are being adopted at a steady rate. In 1989, the PPSG identified only six state policies addressing appropriate use of controlled substances for pain; in 2001, there were more than 80 in 44 states.

"It appears that state health care regulatory boards continue to recognize that pain management needs to be encouraged, that physician concerns about investigation and discipline do need to be addressed, and that effective patient care needs to be maximized," said Dr. Gilson, describing the findings of the report.

Notably, the 2001 review showed that, for the first time, policies are being drafted that contain explicit statements that efforts to control drug abuse and diversion must not interfere with patient care. "We are especially pleased to see that West Virginia had such a policy in 2001, despite this state being involved in recent drug abuse issues," Dr. Gilson said.

In addition, the PPSG did not identify any "panic policies" developed in 2001—in other words, policies designed to address the drug abuse issue but instead result in restrictions in the use of these substances for the treatment of pain.

However, according to Dr. Gilson, many policies contain language that can impede pain management. "They contain language that can restrict medical decisions, increase physician concerns about regulatory scrutiny, and, ultimately, impede patient access to effective pain relief," he noted. Only two states—Alabama and Maine—do not have any regulatory policies with restrictive language.

Model Guidelines

Of the policies that contained less restrictive language, most were based, to a large extent, on model guidelines from the Federation of State Medical Boards (FSMB), which were developed largely to deal with physician concerns regarding regulatory scrutiny. The model guidelines outline the basic standards of medical practice that physicians should use when treating pain.

Those model guidelines represent an "unprecedented" policy development in the United States, Dr. Gilson said, because it represents the first time that a national regulatory agency has developed a policy about pain management, drawing from a multidisciplinary team of experts in pain management, health care policy, and medical regulation.

To date, 22 state regulatory agencies have adopted 24 policies based, at least in part, on the FSMB guidelines, Dr. Gilson said.

It is not clear if adoption of new state pain policies has translated directly into a greater willingness by physicians to prescribe appropriate pain medication, Dr. Gilson said. However, the increase in the number of state pain policies has occurred at the same time that there has been a substantial increase in the medical use of morphine in the United States. Between 1989 and 2000, morphine use increased by more than 750%, according to data from the Drug Enforcement Administration.

Those findings together do suggest some progress since 1990, when a Wisconsin survey found that a significant portion of physicians reported they would change their controlled substance prescribing practices based solely on fear of being disciplined by their state medical board.

A subsequent survey of state medical board members suggested those fears may have been warranted. The 1991 national survey found that only 75% of regulators agreed that prolonged prescription of pain medication to patients with cancer pain is lawful and acceptable medical practice. Only 46% said that prolonged pain medication prescribing is lawful and acceptable in patients with cancer pain and a history of substance abuse.

The PPSG’s 2001 report also finds that professional licensing boards for medicine, nursing, and pharmacy are collaborating more frequently to create pain policies. "Pain management is being seen less and less as the sole purview of physicians," Dr. Gilson said. "Nurses and pharmacists are being encouraged to do what they can to provide pain relief to the patients."

The 2001 annual review, full text of state pain policies, the model guidelines, and other resources can be found at the Pain & Policy Studies Group website: www.medsch.wisc.edu/painpolicy.