Turning point for patients: state laws and guidelines that encourage adequate pain relief

Some states have become more aware of the necessity of opioid treatment for intractable pain and have either passed legislation known as Intractable Pain Acts (IPAs) or have prepared guidelines on how board members should review physician prescribing patterns. These laws and/or guidelines generally:²¹

• advocate for patients’ rights to receive adequate pain treatment
• provide medical boards with specific definitions of addiction
• provide medical boards with guidelines that allow them to identify more easily who is a legitimate physician and who is a physician selling drugs on the black market
• allow physicians to provide adequate amounts of pain relief to their patients
• sometimes provide physicians protection from state medical board discipline

Tables 5 and 6 identify those states who have created IPAs or guidelines that outline treatment for intractable pain.

Table 5. States that have IPAs and when they were initiated.²¹

Table 6. States that have guidelines on intractable pain treatment and when they were initiated.²¹

Benefits and risks of Intractable Pain Acts (IPAs)

As explained earlier, IPAs provide many benefits to all parties involved in opioid treatment for intractable pain, including:²¹

• recognizing that there is a legitimate place for opioids in the treatment of chronic pain
• providing immunity provisions that may protect physicians from discipline (although not from investigation and its attendant legal costs)
• enhancing public awareness of the inadequacies present in today’s treatment of pain

Although quite minor, risks exist with the development of legislation governing medical practice with IPAs that could further restrict rather than expand access to opioids for intractable pain, including:²¹

• defining the medical use of opioids for intractable pain as a therapy of last resort
• applying laws to all intractable pain patients, even if they have cancer
• implying that opioids may be used for pain only in cases where the cause of pain cannot be removed
• excluding pain patients who use drugs "for nontherapeutic purposes"
• requiring an evaluation of every pain patient by a specialist in the organ system believed to be the cause of the pain
• requiring a signed informed consent from in every case (some IPAs)

All-in-all, IPAs are beneficial to state medical boards, physicians, and patients because they create an atmosphere of acceptance for adequate intractable pain treatment.

California guidelines as model guidelines for other states

The Medical Board of California (MBC) guidelines on prescribing controlled substances for intractable pain continue to serve as a model for state medical boards across the country who seek adequate pain treatment for their citizens. Built on principles of good medical practice, the MBC created a prescription framework for physicians, allowing them to prescribe controlled substances without concern of regulatory scrutiny or dosage unit limitations. These guidelines were reviewed and adopted unanimously by pain and legal experts. After adoption and distribution of the MBC guidelines, the American Pain Society endorsed them.²¹

The MBC guidelines state:²²

While some progress is being made to improve pain and symptom management, the Board is concerned that a number of factors continue to interfere with effective pain management. These include the low priority of pain management in our health care system, incomplete integration of current knowledge into medical education and clinical practice, lack of knowledge among consumers about pain management, exaggerated fears of opioid side effects and addiction, and fear of legal consequences when controlled substances are used.

Opioid analgesics and other controlled substances are useful for the treatment of pain, and are considered the cornerstone of treatment of acute pain due to trauma, surgery and chronic pain due to progressive diseases such as cancer. Large doses may be necessary to control pain if it is severe. Extended therapy may be necessary if the pain is chronic. The Board recognizes that opioid analgesics can also be useful in the treatment of patients with intractable non-malignant pain especially where efforts to remove the cause of pain or to treat it with other modalities have failed.

The Board believes that addiction should be placed into proper perspective. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy and are not the same as addiction. Addiction is a behavioral syndrome characterized by psychological dependence and aberrant drug related behaviors. Addicts compulsively use drugs for nonmedical purposes despite harmful effects; a person who is addicted may also be physically dependent or tolerant. Patients with chronic pain should not be considered addicts or habitués merely because they are being treated with opioids.

Concerns about regulatory scrutiny should not make physicians who follow appropriate guidelines reluctant to prescribe or administer controlled substances, including Schedule II drugs, for patients with a legitimate medical need for them.

To better treat intractable pain patients, all parties involved in providing adequate amounts of opioids for intractable pain, whether physician, pharmacist, nurse, patient, state medical board member, or DEA agent, should aim to work together to appropriately manage drug diversion while stipulating a medical need for adequate pain relief.²¹