Report 6 of the Council on Science and Public Health (A-07)

Standards, Laws, and Regulations Addressing Pain Medical and Medical Practice

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Summary

Objective:  To evaluate the various factors, as well as federal and state policies or standards, that influence pain management practices, particularly the prescribing of opioid analgesics.

Methods:  English-language reports on studies using human subjects were selected from a MEDLINE search of the literature from 1997 to March 2007 using the terms analgesics, opioid* or opioid-related disorders in combination with epidemiology, prevention & control*, prescriptions, drug/statistics & numerical data, government agencies, and substance abuse detections.  Additional articles were identified by manual review of the references cited in these publications. Web sites of the American Pain Society, American Academy of Pain Medicine, National Institutes of Health, Drug Enforcement Administration (DEA), Federation of State Medical Boards, and the Wisconsin Pain & Policies Study Group also were searched for relevant articles.
 
Results: Although prescriptions for opioid analgesics have increased substantially over the last 15 years, undertreatment of pain continues to be a problem. Unfortunately, there are clear indications that the unauthorized use of  prescription opioids has increased, although the sources of unauthorized supplies are varied.  In response to increasing prescription drug diversion and misuse, law enforcement has worked to limit access to these medications in the hope of reducing their use outside of regular medical practice.  Federal and state pain policies (or standards) affecting physicians have different features.  Generally, the language and provisions of state pain policies are more unbalanced than federal policies.  However, the actions and pronouncements of federal agencies carry substantial weight in influencing physicians’ prescribing behavior.  The advent of state-based electronic prescription drug monitoring programs also appears to significantly influence physicians’ prescribing behavior.

Conclusion:  Further research and policy evaluation and development, as well as better communication, cooperation, and education of all stakeholders, are needed to prevent or overcome barriers to patients receiving adequate pain management.  Further research is needed to determine the reasons why pain management is not adequate or sufficiently accessible. Youth and young adults remain populations at particular risk for unauthorized opioid use, as do pain patients with comorbid psychiatric disorders. These populations should be the target of more intensive prevention initiatives for drug misuse and addiction. Further research also is needed to identify the sources of diversion of opioid analgesics so that appropriate public health or law enforcement interventions can be devised. Several additional questions need to be addressed to better inform balanced pain management policies. Improvement in state-based pain policies should be a continuing priority.  A sustained cooperative effort is needed that is directed toward health professionals and law enforcement officials, and that involves the DEA and other relevant stakeholders.  The goal should be to improve the regulatory environment for pain management, clarifying regulatory policies and demonstrating a mutual commitment to a balanced approach between enforcement, regulation, and supply controls on the one hand, and assurance of access to proper medical care on the other. Efforts to address diversion should not interfere with medical practice or patient care.  Additionally, with the expansion of state-based prescription drug monitoring programs, the impact of such programs on medical care, including appropriate pain management, should be evaluated.

RECOMMENDATIONS

The following statements, recommended by the Council on Science and Public Health, were adopted  by the AMA House of Delegates as policy and directiveat the 2007 AMA Annual Meeting:

1. States should examine their pain policies and seek to improve them, based on the Federation of State Medical Boards Model Policy and/or criteria established by the Wisconsin Pain & Policies Study Group. (Policy)
2.  The impact of state-based prescription drug monitoring programs on medical care, including appropriate pain management, should be evaluated. (Policy)
3. The AMA urges the Drug Enforcement Administration to work with physician organizations and other relevant stakeholders to reconstruct a document similar to “Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel” to serve as a legitimate resource for physicians, regulators, and law enforcement personnel.  (Directive)

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