Follow Us On
Contact Us
info@ampainsoc.org847.375.4715
American Pain Society
4700 W Lake Ave
Glenview, IL 60025
Ronald Kulich, PhD, Department Editor
Scott Strassels, PharmD BCPS
It is probably a safe bet that any topic being discussed both in the nation's newspaper comic strips and in the editorial section of one of the country's leading newspapers is one that is on many people's minds. In the past several months, the Wall Street Journal has published two editorials addressing the topic of pain ("Treat the Pain," July 27, 1998; "Progress Against Pain," August 11, 1988). The undertreatment of pain was also addressed this past summer in the nationally syndicated comic strip, "Doonesbury," and at least two states recently took steps at the regulatory level to address problems associated with the prescription of analgesics (Massachusetts Department of Public Health and Board of Registration in Pharmacy, 1998).
What has brought us to this point? Published reports of suboptimal treatment of pain and pain-related disability have been available for at least 25 years, and anecdotal evidence of the problem has existed for much longer (Marks & Sachar, 1973; Task Force on Pain in the Workplace, 1995). Recently published studies also indicate the extent of the problem at the end of life (The SUPPORT Principal Investigators, 1995; Lynn et al., 1997). Knowing what the problem is, however, has proved to be much different from understanding how to solve the problem.
Recently, several states, including New York, Ohio, Florida, Virginia, and Massachusetts, have begun to take steps to improve pain care by addressing the problems at the structural level of health care. The New York legislature has taken steps to streamline the process for prescribing pain-relieving medications, including discontinuing the use of triplicate prescription forms and making changes in the terminology used to describe persons who use narcotics ("Progress Against Pain," 1998). The Ohio legislature recently passed two laws, one of which concerned the use of opioids for treating cancer pain, and the other, more recent, law concerned the prescription of opioids for nonterminal chronic pain patients. Consequently, the State of Ohio Medical Board has developed educational pamphlets for distribution to all licensed physicians in Ohio. The Florida legislature and the Medical Society of Virginia have issued medical practice guidelines for pain treatment and guidelines for the use of opioids to manage chronic noncancer pain, respectively.
In contrast, regulatory agencies that deal with work-injured patients also have proposed practice guidelines in many states, and some restrict opioid use. Regulations often conflict within a state, depending on the regulatory agency. In Massachusetts, changes to the state's Controlled Substances Act, sponsored by state representative Harriette Chandler and Sen. Mark Montigny, became effective this summer (Massachusetts Department of Public Health and Board of Registration in Pharmacy, 1998). Unlike the initiatives developed by other states, which generally focus on addressing the obstacles related to prescribers, the Massachusetts law contains some provisions that directly affect pharmacy practice. Controversies related to prescribing guidelines are avoided with this approach.
These changes in pharmacy practice are expected to significantly affect obstacles to appropriate pain care relative to the structures, processes, and outcomes of health care (Donabedian, 1966).
First, the new law allows prescriptions to be transmitted electronically. This could help reduce waiting time for patients who are on their way home after outpatient surgery, a discharge from a hospital, or an office visit. The new law also permits pharmacists to fill Schedule II prescriptions originating from any state, whereas the previous law allowed them to fill such prescriptions only from one of the six states bordering Massachusetts. This is a substantial benefit for patients who receive care at referral facilities far from home or for patients who come to Massachusetts for care while still being treated for pain by a physician in their home state. Patients have been facing the difficulty of finding a pharmacy that either has enough of a prescribed drug in stock or is able to obtain the needed quantity before prescriptions expire. Until now, this was frequently a challenge for patients, prescribers, and pharmacies. Prior to the new law, Schedule II prescriptions expired within 5 days after being written, even if the prescription had not yet been filled for the quantity for which it was originally written. Under the new law, Schedule II prescriptions are now valid for 30 days, permitting much more flexibility on the part of everyone involved. Another useful change in the law allows Massachusetts pharmacists to fill prescriptions for a 90-day supply of Schedule II and III implantable infusion pumps. Last, physicians are no longer required to report the names of patients being treated for substance abuse to the Massachusetts Department of Public Health.
These changes can be interpreted in at least three ways. In the short term, because the legislation addresses obstacles to appropriate pain treatment at the structural level of health care, it will be easier for patients to receive needed care. These legal steps will also serve as a model for other regulatory bodies in Massachusetts and in other states. We can hope that these efforts to improve health care are an indication that American society is finally ready to start and sustain serious discussions about improving pain relief for patients after surgery or an injury, people with cancer, and people who are suffering from pain at the end of life.
Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44(Suppl.), 166-206.
Lynn, J., Teno, J.M., Phillips, R.S., Wu, A.W., Desbiens, N., Harrold, J., Claessens, M.T., Wegner, N., Kreling, B., & Connors, A.F. Jr. (1997). Perceptions by family members of the dying experience of older and seriously ill patients: SUPPORT Investigators Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Annals of Internal Medicine, 126, 97-106.
Marks, R.M., & Sachar, E.J. (1973). Undertreatment of medical inpatients with narcotic analgesics. Annals of Internal Medicine, 78, 173-181.
Massachusetts Department of Public Health and Board of Registration in Pharmacy (1998). Pharmacy update. Boston: Author.
Progress against pain. (1998, August 11). Wall Street Journal, p. A18.
The SUPPORT Principal Investigators. (1995). A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). Journal of the American Medical Association (JAMA), 274, 1591-1598. [A correction erratum appears in the April 24, 1996, issue of JAMA on p. 1232.]
Task Force on Pain in the Workplace. (1995). Back pain in the workplace: Management of disability in nonspecific conditions (Wilbert E. Fordyce, Ed.).
Seattle: IASP Press.
Treat the pain. (1998, July 27). Wall Street Journal, p. A14.
Trudeau, G.B. (1998, July 26). Doonesbury. Doonesbury [comic strip]. Boston Globe, Comics/Fun section, p. 1.
Scott Strassels is an outcomes research pharmacist at New England Medical Center in Boston.
