Steve in PA

[Guest guest]

I am appalled, and angered at the treatment, (or lack thereof) from the doctors

who took an oath and then forgot what it means. Have you contacted the American

Pain Society and/or other pain associations?

I would also call my senators and report what is happening as there are bills in

Congress about pain. Have you called methadone clinics to see if they can offer

help? Teaching hospitals?

In all probability you will have to go to the ER, if just to save your life. I

also know that why you don't feel like doing research, I am sure your wife can

help. Have her write your paper, letter to the editor. You must scream from

the mountain tops as you health and life are at risk. I would even call rehab

hospitals and talk to the doctors there, not to go to rehab, but maybe they

could offer help.

I will pray, cross my fingers and wish I could be of some help and hope that you

find someone soon. Call mental health? Pain psychiatrist? Thinking out

loud...

Peggy/MI

[Guest guest]

All,

The pain acts in states say you have to follow the contracts and that Doctors

can do this if you violate the contracts (missing appointments). It is a

courtesy to give the patient thirty days of medicine and referral to a Doctor

that does medication management.

The American Cancer Society is the contact and the American Pain Foundation does

tremendous lobbying and got the Mayday Act and I encourage each member to be

aware of the pain laws in your state. The Pain Society couldn't care less. There

is a petition you can sign on the American Pain Foundation site.

This is fueled by Washington State passing pain guidelines of limits of dosages

on opoids and who can be dispensed them. These guidelines have been passed

throughout the states, Doctors seminars, interns, Pain Society seminars and

doctors treating pain patients. They are GUIDELINES that do not consider the

manufacturer dosages. For example the maximum dosage per day of Morphine is

1600. The DMRG Director Medical Physician Group suggests maximum is 120mg which

if you divide that by 10 hours it is 12 mg per hours and 24 hour is 6mg or less

and with the considerations of peak and down levels , metabolism it could be 5

mg or less. So a patient is on a timed dose of over 120 mg, they are not

following the guidelines.

These guidelines were developed because the high incidence of people dying on

ovoid overdose . (It is not me) The report also states that non-cancer patients

and acute pain patients should not need high dosages. I love you steve but I

think I and others believe our pain matches cancer pain also, pain is pain and I

did not ask for 24/7 pain and people who have been damaged war and automobile

accidents and nueropathic pain, they are going to tell them, " Oh you don't need

that " .

Also. publicity with celebrates overdoses of prescription medications do not

help validated pain patients be able to get pain relief so they do not damage

vital organs that allow them to live.

I had to present all my medical records to the pain management psychiatrist that

was re known in the pain community and lead the cause for ovoid therapy for

relief and prevent oophobia

Washington Department of Healths stand on ovoid therapy and guidance to medical

community (they said they adopted into law because Washington State has higher

incidence of opined death than other states) ted rules.

http://www.doh.wa.gov/hsqa/professions/pain management/

The goal of the new pain management rules is to keep patients safe and give

practitioners who prescribe opioids the best practices in pain management. A key

component of the rules is to encourage practitioners to become better educated

in the safe and effective uses of these powerful drugs. The rules contain

specific mandatory elements required by the law, as well as guidance for

practitioners who care for patients with chronic non cancer pain.

Here is the link to the Report that was presented by the group who were Medical

Directors and presented the guidelines adopted by law:

Agency Medical Director’s Group (AMDG) recommendations. Their website is here:

http://www.agencymeddirectors.wa.gov

According to the AMDG, 120 mg of Morphine is equivalent to: (One Example)

800mg codeine

120 mg morphine (MS Contin, Morphine IR)

120mg hydromorphone (Vicodin, Endocet)

80 mg oxycodone (Oxycontin, Percocet)

40 mg methadone

40 mg oxymorphone(Opana)

30 mg hydromorphone (Dilaudid)

Some of the key points for the new rules include:

• A dosing threshold trigger for consultation with a pain specialist

• Criteria to be considered a pain specialist

• Elements for a patient evaluation

• Periodic review of a patient’s course of treatment

• Guidance for episodic care practitioners

• Consultation exemptions for special circumstances and for the practitioner

• Continuing education.

Now pain patients have to worry not only about their pain but the pain laws and

keep up with them. Be sure and check your state pain laws and the federal pain

law .

Here is an example of state laws and the link that lists them all :

Although most state laws and regulations still do not specifically recognize the

legality of opioids for intractable pain, this is changing. In the last several

years, some legislatures have begun to adopt laws to affirm the use of

controlled substances for intractable pain. Typically, legislators have been

responding to (a) the under treatment of patients with pain, ( inappropriate

medical board discipline of some physicians, and © proposed legalization of

physician-assisted suicide. Media coverage of physician-assisted suicide and

inadequate pain management as well as the efforts of patients and physicians who

are advocating for legislative action to improve pain management are fueling

state legislative interest in intractable pain treatment policy.

Washington

In the state of Washington, the use of opioids for intractable pain became an

issue in 1987 when the Washington State Medical Disciplinary Board opposed

prescribing opioids for chronic pain:

Many cases reviewed by the Washington State Medical Disciplinary Board involve

inappropriate prescribing of controlled substances. A significant number of

these are related to the use of narcotics as a method to manage chronic pain.

During fiscal year 1987 the Board experienced nearly a 100% increase in

disciplinary actions related to prescribing of controlled drugs for chronic

pain. The Board does not recognize repeated prescribing of controlled drugs as

appropriate therapy for chronic pain [italics added]. (p. 1)

The subsequent outcry from physicians resulted in additional policy statements

in 1989 and 1992 explaining that the board had not wanted " to interfere with a

physician's exercise of appropriate clinical judgment " (State of Washington

Department of Health, 1989, p. 1), and that chronic pain is " best not treated

with opiates " (State of Washington Department of Health, 1992, p. 1). Concern

about the board's position continued, and in 1993, the state legislature enacted

a statute that borrowed a provision from a recently developed model for state

drug laws developed by medical and legal experts (National Conference of

Commissioners on Uniform State Laws, 1990):

A practitioner may dispense or deliver a controlled substance to or for an

individual or animal only for medical treatment or authorized research in the

ordinary course of that practitioner's profession. Medical treatment includes

dispensing or administering a narcotic drug for pain, including intractable

pain. (Washington Uniform Controlled Substances Act, 1993)

Colorado

In 1992, the Colorado legislature adopted an intractable pain treatment policy

as part of revisions to its controlled substances act. Colorado's approach is

similar to that used in Washington state.

Virginia

In 1988, Virginia enacted a law allowing physicians to prescribe heroin for

treatment of terminally ill cancer patients ( " Virginia Enacts Law, " 1988).

(Note: This occurred despite the fact that legislation at the federal level was

necessary to make heroin actually available and that Congress had already

soundly defeated such a bill.) The Virginia legislature adopted an additional

measure to allow prescription of pain medications " in excess of recommended

dosage " for patients with intractable pain ( " Relieving Intractable Pain, " 1988,

p. C5; Commonwealth of Virginia, 1988). Both laws exemplify how drug laws can

reflect common misconceptions, that is, that heroin has significant analgesic

advantages over currently available opioids, and that a physician's prescription

cannot legally exceed the dosage recommended in FDA-approved product labeling

(Angarola & Joranson, 1995).

Texas: The first intractable pain treatment act

The first intractable pain treatment act (IPTA) was approved by the Texas

legislature in 1989 and has received considerable publicity (Hill, 1992).

Physicians in Texas were concerned about board investigations of physicians and

ambiguous language regarding opioid prescribing in the state's Medical Practice

Act and went to the legislature for relief (Hill, 1992). The purposes of the new

act were to clarify legal ambiguities, bring Texas law into conformity with the

federal intractable pain regulation, and

assure that no Texan requiring narcotics for pain relief, for whatever reason,

was denied them because of a physician's real or perceived fear that the state

regulatory agency would take disciplinary measures against the physician for

prescribing narcotics to relieve pain. (Hill, 1992, p. 70)

The Texas IPTA (a) provides a definition of intractable pain that is similar to

that of the federal regulation, ( autliorizes physicians to use controlled

substances (not only opioids) for treatment of intractable pain, © prohibits

healthcare facilities from restricting the use of such drugs for intractable

pain, and (d) prohibits the Texas State Board of Medical Examiners from

disciplining a physician for using such drugs in the legitimate treatment of

intractable pain (Medical Practice Act of Texas, 1989).

The Texas IPTA also contains important exclusions. For example, the act does not

protect a physician if the pain patient is also being treated for chemical

dependency or when the physician should have known that the patient was using

drugs in a non-therapeutic manner.

Several years after adoption of the IPTA, the Texas State Board of Medical

Examiners issued a policy statement in its official newsletter that was drafted

by a board member, C. Stasney, MD, and by C. Stratton Hill, MD (1993).

The statement endorsed the federal intractable pain regulation and the IPTA and

stated that the board would use treatment outcome and not quantity or duration

of prescribing as a standard for evaluating cases against doctors. In 1995,

Hill, Rallston, and colleagues are seeking further clarification of Texas

policy and have submitted to the Board of Medical Examiners a proposed

regulation for the treatment of intractable pain in Texas (C.S. Hill, personal

communication).

New Jersey

The only state of which we are aware that currently has a regulation on

intractable pain treatment is New Jersey. The regulation mirrors the federal

intractable pain regulation in part. The New Jersey regulation, however, has

several conditions that delimit the boundaries of intractable pain treatment:

When protracted prescribing [of narcotic drugs] is utilized for the alleviation

of intractable pain, practitioners shall remain alert to the availability of new

or alternative types of treatment. The practitioner should attempt periodically

to either cease the medication or taper down the dosage, or try other medication

or treatment modalities in a regular and vigilant effort to reduce the addiction

propensity for the patient. (New Jersey Board of Medical Examiners, 1993, p. 64)

Regulations have the force of law, and compliance with specified conditions

becomes the responsibility of the practicing physician. Indeed, failure to

comply with such conditions might constitute a violation. Thus, a New Jersey

physician who prescribes opioids for intractable pain should document compliance

with the additional conditions in the patient's chart.

California

In 1990, California became the second state to adopt an IPTA due to the efforts

of State Sen. Leroy Greene and Harvey Rose, MD. This legislation was the

consequence of professional and public concerns about inadequate pain

management, the harsh effects on patients, and physicians' concern about

investigations by the state medical board. California's law is essentially

identical to the Texas IPTA, although it requires evaluation of the patient by a

specialist in addition to the attending physician (California Business and

Professions Code, 1990).

The adoption of the California IPTA has also served as a catalyst for a number

of governmental and professional actions to identify and remove barriers to pain

management. For example, other new legislation required examination of

alternatives to the triplicate prescription program, distribution of information

on pain management and the California intractable pain treatment policy to all

physicians by the medical board, and a medical board survey of state medical

schools' curricula on pain management. In March 1994, the governor sponsored the

Summit on Effective Pain Management: Removing Impediments to Appropriate

Prescribing to prepare a strategy for a statewide effort to improve pain

management (Angarola & Joranson, 1994; State of California Department of

Consumer Affairs, 1994). The licensing and disciplinary boards for medicine,

pharmacy, and nursing developed positive guidelines for the appropriate use of

opioids in intractable pain. The American Pain Society Board of Directors

endorsed the medical board's guidelines (correspondence of APS President J.

to D. Arnett, Executive Director, California Medical Board, January 11,

1995; see page 20 of this newsletter for details). The State of California's

actions to make pain management a priority are exemplary.

Florida

In 1994, following an intense debate on euthanasia and physician-assisted

suicide, the Florida legislature instead approved an intractable pain treatment

provision. Intractable pain is defined as " pain for which, in the generally

accepted course of medical practice, the cause cannot be removed and otherwise

treated " (Florida Statutes, 1994, p. 2). A licensed and qualified physician must

diagnose intractable pain. The new provision permits use of any controlled

substance in Schedules II-V, not only opioids, to treat a person with

intractable pain, provided the physician conforms to a standard of care that

would be recognized by reasonably prudent physicians under similar circumstances

[italics added] (Florida Statutes). (One might ask what this means, given the

prevalence of inadequate pain management and the history of discouragement of

extended use of strong opioids for chronic noncancer pain.) Florida's

intractable pain provision also recognizes that the state does not condone

euthanasia and bans the use of intractable pain treatment for such a purpose.

Discussion

The development of intractable pain treatment laws gives much-needed recognition

to the necessity for better treatment of intractable pain and can help to

correct past policy, which discouraged any use of opioids. However, the

opportunity to develop new legislation merits our careful consideration of both

benefits and risks.

For example, could there be unintended consequences from making opioid therapy

for intractable pain a " treatment of last resort " ? Is it medically appropriate

to require physicians to demonstrate that every chronic pain problem - whether

due to terminal illness or any other chronic condition-is refractory to other

therapies before prescribing opioid analgesics? How much time must elapse? How

many therapies must be tried, and at what expense to the patient and the

healthcare system? Although these questions should be answered by the physician

and patient, they may also become legal questions once intractable pain

treatment laws and regulations are enacted.

Are state intractable pain treatment laws really needed? Although the states

have the power to regulate medical practice, the results can be unpredictable

when state legislators and other interest groups start writing new laws,

especially when the subject is drugs and medical practice - witness, for

example, Virginia's approval of heroin in an effort to treat cancer pain.

Moreover, after a new law is passed, a state agency may adopt regulations to

codify, and perhaps restrict, the treatment of intractable pain, potentially

leading to new issues. For example, if intractable pain regulations include

conditions and restrictions, as in New Jersey, these may expand recordkeeping

requirements and, thus, increase instead of decrease the potential for

violations when controlled substances are prescribed for pain.

States do not now directly prohibit by law or regulation the use of opioids for

intractable pain. If a state medical, pharmacy, or nursing board discourages the

use of opioids for intractable pain, this is informal policy and it should be

changed. Such a change can occur without legislation-for example, through a

cooperative effort of regulatory boards and pain experts to develop and

communicate new guidelines (Commonwealth of Massachusetts Board of Registration

in Medicine, 1989; Medical Board of California, 1994).

If the voluntary development of positive guidelines by a board proves

unsuccessful, political action, including lobbying for intractable pain

treatment legislation, merits consideration. In Idaho, an intractable pain

treatment act was introduced to protect physicians who prescribed opioids for

intractable pain from the medical board. Although the bill was not adopted, the

medical board has undertaken a review of its policy on prescribing for

intractable pain (Idaho State Board of Medicine, 1994).

Which language should be used? The Texas and California IPTAs might be useful if

the primary goal is to protect physicians from a medical board when, in fact,

that threat exists or when the board is reluctant to clarify and communicate its

policy. The Texas and California IPTAS, however, also appear to restrict

prescribing of opioids to substance abusers, even if they have pain. The laws in

Washington and Colorado do not exclude substance abusers and are consistent with

the nationally approved model for drug control laws in the United States. On the

other hand, they do not establish a legal protection for physicians from their

medical boards.

Can legislation be an opportunity to initiate action? A new intractable pain

law, by itself, probably will do little directly to change practice patterns or

improve the management of patients' pain. In California, however, the

legislative sponsor and key supporters of the new IPTA have served as powerful

catalysts for other positive actions to improve pain management in the state.

In addition, either a legislature or a governor can establish a pain commission

to study the problem and make recommendations for action. Study commissions can,

however, also waste time and energy and actually delay real progress unless

there is (a) strong support for implementation of the recommendations; ( a

clear mission focused on better and more cost-effective pain management; ©

willingness to identify and address common myths and barriers; (d) competent and

adequate staff resources; and (e) a membership that is balanced, knowledgeable,

and committed to the mission.

Conclusions

Long-held medical beliefs and regulatory traditions have rejected the use of

opioids for chronic noncancer pain but are now undergoing reassessment in light

of new knowledge, recent clinical experience, and the public attention being

given to better pain management. The ultimate goal of a balanced public policy

should be to harmonize medical and drug regulation with clinical practice so

that physicians are free to use this treatment according to good medical

judgment. This harmony can sometimes be promoted through laws and certainly

through the development of medical, pharmacy, and nursing guidelines. Such

guidelines should encourage pain management and help clinicians select and

manage patients and avoid investigation. Guidelines should also continue

sanctions against sloppy and unprofessional practices that can contribute to

drug abuse. Such guidelines as those issued in Texas and California give medical

boards unique opportunity to encourage quality care while at the same time

allowing them to focus limited resources on cases in which there is harm to

public health. (Note: The second article in this series will discuss state

medical boards' development of intractable pain guidelines.)

As the development of intractable pain policy proceeds in the United States, we

should take care not to oversimplify the complexity of chronic pain and its

treatment. We should avoid creating the impression that all prescribing of

opioids is appropriate or that any person with chronic pain has a right to

opioids. We should also avoid creating the impression that new policies will

correct deficits in practitioners' knowledge and attitudes.

The appropriate use of a range of therapeutic options, including

nonpharmacologic treatments, opioids, and other drugs, depends on careful

evaluation and monitoring of results by knowledgeable professionals supported by

regulatory policy and practice. Opioids and other individual therapeutic

modalities should neither be prescribed nor proscribed by laws, regulations, or

policies.

Do the differences in today's state intractable pain laws and regulations

suggest we are moving toward a balkanized approach to the use of opioids for

chronic pain? How can we uniformly raise the quality of pain care if policies

differ from state to state? The quality of intractable pain treatment policy at

the state level would benefit from a dialogue aimed at acheiving consensus among

healthcare professional, regulatory, and patient interests in the United States.

One aim of such a dialogue should be to achieve reasonable uniformity of policy

among the states; another would be to address the needs of individual patients

who have fallen through the cracks. The author would appreciate having readers'

perspectives and any additional information about state policies.

Acknowledgments

The author gratefully acknowledges comments on the manuscript from Albert M.

Brady, June L. Dahl, Kathleen M. Foley, M. Gilson, D. Loeser,

L. Marcus, K. Portenoy, Harvey L. Rose, and R. Saper.

Joranson is associate director for policy studies with the Pain Research

Group at the University of Wisconsin Medical School in Madison, WI.

This article from a link of research studies:

http://www.painpolicy.wisc.edu/index.htm.

Steve here is a point of contact for you and information. I am sorry this is

long but I wanted to share what I already researched and became so appalled !

Keep up with your law and make sure if your Doctor is treating you for pain that

is 24/7 that is annotated in your records you have intractable pain, and not

miswritten type of pain, it is important what category you are labeled as you

see.

Steve here is a contact for you to check out. Bennie

Pennsylvania Cancer Pain Initiative

c/o Georgia Brown, RN, MS, Director

Penn State College of Medicine, MC A210

PO Box 855

Hershey, PA 17033-0855

Phone:

E-mail: pcpi@...