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American Pain Society
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Glenview, IL 60025
David E. Joranson, MSSW, and Michael A. Ashburn, MD MPH, Department Editors
David E. Joranson, MSSW
Editor's note: The following article is a contributed commentary. I would like to thank Dr. Forest Tennant for his permission to refer to and quote from his work, The Dilemma of Severe Incurable, Narcotic-Dependent Pain Patients Referred to Narcotic Treatment Programs: Need for Administrative, Regulatory, and Legislative Relief (1996).
According to Dr. Forest Tennant, a California physician who operates a number of methadone maintenance treatment programs in California, chronic pain patients are gaining admittance to methadone maintenance programs not because they are addicts, but only for pain management. The apparent reason is that these patients lack either access to other programs or physicians who are willing to use opioid analgesics, especially in high doses.
Methadone programs (officially known as narcotic treatment programs [NTPs]) are specially registered with the federal and state governments as the only lawful means of using opioids for the maintenance treatment of opioid dependence, or addiction. However, opioid analgesics, including methadone, may be prescribed for patients with pain, including intractable pain, by any physician who can prescribe controlled substances.
Dr. Tennant says his programs are treating approximately 200 chronic pain patients, not for addiction, but for pain. Tennant explains that these admissions are necessary due to a "lack of understanding, disbelief, or bias" among California physicians about the high-dose opioid therapy that some patients with severe chronic pain need (Tennant, 1996). Writing to expose the situation and to stimulate discussion and response, Dr. Tennant says that despite the 1990 California Intractable Pain Treatment Act (IPTA) (California Business and Professions Code, 1980), there has been an increase in the number of patients with severe intractable pain who are referred to his NTPs. Although the California IPTA endorsed opioid treatment for intractable pain, Dr. Tennant asserts there remains a strong reluctance among physicians to prescribe the quantities of opioids needed by patients with severe chronic pain. Regulatory authorities in California have been among the most proactive in the country in reducing practitioners' fears about regulatory scrutiny and improving knowledge about pain management (Board of Registered Nursing, 1994; California Medical Board, 1995a, 1994b; California State Board of Pharmacy, 1996; Joranson, 1994).
Dr. Tennant contends that these patients are very ill, disabled, and have limited funds. Further, he states that he "has not been able to identify one solitary referral or placement site for the incurable, narcotic dependent pain patients referred to us. We are viewed as the 'last resort' treatment facility" (Tennant, 1996, p. 5).
Several questions are obvious. First, is it permissible under federal regulations for pain patients to be admitted to NTPs? It appears so. Federal regulations state that methadone may be used to treat a "narcotic dependent" person, defined as "an individual who physiologically needs heroin or a morphine-like drug to prevent the onset of withdrawal" (Narcotic Addict Treatment Act, 1974). Most pain patients who take opioids regularly for chronic pain would meet this outdated and incorrect definition of opioid dependence.
In 1995, an Institute of Medicine (IOM) Committee of the National Academy of Sciences issued a report on the federal regulation of methadone treatment, which recognized in part that physicians who are uneasy about chronic opioid therapy may make inappropriate referrals to methadone programs (Institute of Medicine, 1995). After studying the situation, the IOM committee said that treatment of pain and treatment of opioid addiction should, as a matter of policy, remain distinct, and made the following recommendation: "...the IOM committee proposes that the [federal] regulations establish a clear distinction between opiate addiction and dependence and that any guidelines developed for methadone treatment incorporate this distinction" (Institute of Medicine, 1995, p. 211). Unfortunately, the IOM committee's use of terms only adds to the confusion, since the term dependence is roughly synonymous with addiction (Joranson, 1995). It would have clarified matters if the committee had simply said that the federal regulations should establish a clear distinction between the treatment of opioid dependence and the treatment of pain. This may well have been the intent of the committee, which went on to recommend "...that the [federal] regulations prohibit the admission of a person being treated solely for chronic pain to an opiate addiction treatment program for treatment as an opiate addict" (Institute of Medicine, 1995, p. 211). The IOM proposal to prohibit, by federal regulation, the future admission of chronic pain patients to addiction treatment programs seems to be a reasonable policy approach to differentiate the treatment of addiction from the treatment of chronic pain. The policy would reserve needed treatment slots for addicts while endorsing the treatment of chronic pain patients in the general healthcare system.
Second, how many chronic pain patients are in methadone programs, and what are the reasons? Have these patients received all that the pain management system has to offer them? Based on my personal communications with state agencies, methadone programs, and law enforcement personnel, it appears that the admission of chronic pain patients to methadone programs is real and is probably not limited to California. A survey of methadone maintenance programs in the United States could be accomplished quickly with the help of the National Institute on Drug Abuse. If it demonstrates a national pattern, there are ethical and policy issues as well as practical questions about patients' access to pain management services that must be addressed.
Third, is legislation the answer to improving patients' access to pain management? There is already a marked trend in the United States to address underprescribing of opioids for pain through state legislation, including IPTAs. However, some of the IPTAs pose new requirements and restrictions on the treatment of chronic pain (Joranson & Gilson, 1997), and potentially conflict with the consensus statement that the American Academy of Pain Medicine (AAPM) and APS recently adopted entitled The Use of Opioids for the Treatment of Chronic Pain (1996). In part, this trend in new state laws on pain is the result of the advocacy activities of well-intended chronic pain patients who have met with frustration in their attempts to obtain access to adequate pain relief, including opioids. Proposals for more pain legislation are being discussed in many states, including California. We should ask how adopting more laws will improve patients' access to appropriate pain management. Isn't the immediate need to directly assist chronic pain patients in locating professionals and programs that will provide high-quality treatment, including opioids? Aren't many patients receiving chronic opioid therapy from physicians and pain management programs all over the country?
One way to address this need for better patient access would be for professional organizations such as APS to experiment with sponsoring informal meetings between pain programs and patient groups, not at the national level, but at the community and state levels. Pain program directors could explore ways to make pain management more accessible to people in their own vicinities. Patients who have "failed" to obtain relief from what the system has provided so far merit particular attention. We should accept that some of these patients and families may feel frustration and anger.
The pain field is evolving under all sorts of influences. Professionals in an evolving field should pay close attention to policy developments, including what happens on the periphery of the field, because this is where policy issues sometimes germinate. In that sense, we should take note of two ironies on the periphery of the pain field that are full of policy ramifications: that methadone maintenance programs for drug addicts may, in some locations, offer a last resort for chronic pain patients and that chronic pain patients are helping to get laws passed that may result in more, not less, regulation of pain management. The policy issues here are not simple; however, there is one clear line of direct action that addresses the underlying issue in both: We need to become much more active in improving patients' access to effective pain management.
American Academy of Pain Medicine and American Pain Society. (1996). The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Glenview, IL: Author.
California Board of Registered Nursing. (1994). Pain management policy. Summit on effective pain management: Removing impediments to appropriate prescribing, 42.
Cal. Bus. & Prof. Code Chapter 1588 §2241.5(b) (1990).
California Medical Board. (1994a, October). Text of "Guideline for prescribing controlled substances for intractable pain." Medical Board of California Action Report, 1, 8.
California Medical Board. (1994b). A statement by the medical board: Prescribing controlled substances for pain. Federation Bulletin: The Journal of Medical Licensure and Discipline, 81(3), 203-205.
California State Board of Pharmacy. (1996). Dispensing controlled substances for pain: A statement of the California State Board of Pharmacy. Health Notes, 4-5.
Institute of Medicine. (1995). Federal regulation of methadone treatment. Washington, DC: National Academy Press.
Joranson, D.E. (1994). California sponsors pain summit; Maryland fends off new regulations. APS Bulletin, 4(3), 11-12.
Joranson, D.E. (1995). Current thoughts on opioid analgesics and addiction. Symptom Control in Cancer Patients, 6(1), 105-110.
Joranson, D.E., & Gilson, A.M. (1997). State intractable pain policy: Current status. APS Bulletin, 7(2), 7-9.
Narcotic Addict Treatment Act. Code of Federal Regulations, 21 §291.505 (a)(5) (1974).
Tennant, F. (1996). The dilemma of severe incurable, narcotic-dependent pain patients referred to narcotic treatment programs: Need for administrative, regulatory, and legislative relief. West Covina, CA: Research Center for Dependency Disorders and Chronic Pain Community Health Projects Medical Group.
We should ask how adopting more laws will improve patients' access to appropriate pain management. Isn't the immediate need to directly assist chronic pain patients in locating professionals and programs that will provide high-quality treatment, including opioids?
David E. Joranson is director of the Pain and Policy Studies Group, University of Wisconsin Comprehensive Cancer Center and the World Health Organization Collaborating Center for Policy and Communications in Cancer Care.
