Publications
APS Bulletin • Volume 8, Number 4, 1998
Pain and Public Policy
Robert J. Gatchel, PhD, Department Editor
Pain—the Public, the Politics, the Perception:
The Virginia Experience, Part 2
Stephen P. Long, MD
EDITOR'S NOTE: This is the second installment of a two-part article on the specialty of pain medicine and the various barriers to the administration of opioid analgesics in the treatment of acute and cancer pain. We appreciate Dr. Long's description of the Virginia experience, and encourage similar descriptions and comments from others who are working at the state level to improve pain management. The Virginia medical guidelines and pain-related laws and regulations, along with those of 24 other states, are currently available on the World Wide Web at http://www.medsch.wisc.edu/painpolicy.
Pain management education
The legislative pain subcommittee, realizing that the problem of pain treatment originates at the fundamental level of education of health professionals, particularly physicians, encouraged the Medical Society of Virginia to develop these guidelines. Because education, particularly that of physicians, about pain is lacking, the subcommittee asked the state's medical schools to study and report about the educational process and opportunities at the undergraduate, graduate, and postgraduate levels. In addition, because of the many unanswered questions and problems associated with the treatment of pain, the subcommittee felt that its work was far from complete and decided to continue into 1998 and 1999 in order to reach a final resolution of the legislation that had been enacted during the previous 4 years.
The joint subcommittee's work was intensive. Its accomplishments include
- reinforcing the excess dosage law
- requiring the Board of Medicine to inform its regulated professions about provisions in the law
- successfully implementing a national symposium
- successfully passing a general off-label drug reimbursement bill
- examining controversial and difficult issues, such as regulatory and law enforcement actions related to pain management and medical marijuana usage
- evaluating pain management curricula offered through the commonwealth's three medical schools
- developing guidelines for the use of opioids to treat chronic pain and the historic approval of these guidelines by the Legislature of Virginia, the Medical Society of Virginia, and the Virginia Board of Medicine (perhaps the first set of guidelines endorsed on such a widespread basis in the history of the country) (Figure 1).
FIGURE 1. Legislative Actions in Virginia Resulting from the Joint Subcommittee's Study of the Commonwealth's Current Laws and Policies Regarding Chronic, Acute, and Cancer Pain Management
HJR 583-1994: Authorizes a pain management summit SJR 368-1994: Requests commonwealth's medical schools, healthcare professionals, professional associations, health-related agencies, and health regulatory boards to assist in educating the public and practitioners on acute and cancer pain management SB 1085-1995: Confirms and clarifies physicians' authority to prescribe extraordinary doses of pain-relieving agents HJR-256-1995: Revises the mission of the joint subcommittee to focus on chronic, acute, and cancer pain management SJR-366-1996: Authorizes a joint study among three medical schools (the Medical College at Hampton Roads, the School of Medicine of Virginia Commonwealth University, and the University of Virginia Medical Center) to examine the inclusion and existence of pain management in the medical school curricula SJR 368-1996: Authorizes a study by the Department of Medical Assistance Services to determine how pain resulting from illness or injury affects Medicaid costs and services HJR 565-1996: Encourages the Medical Society of Virginia to develop chronic pain guidelines for Virginia SB 1164-1997: Requires insurers to reimburse for certain off-label drug use for any drug prescribed to treat a covered indication so long as the drug has been approved by the U.S. FDA for at least one indication and the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature SJR 165-1998: Places into public record the Medical Society of Virginia's report of the pain management subcommittee and its guidelines for the use of opioids in the management of chronic noncancer pain HJR 172-1998: Continues the Joint Subcommittee to Study the Commonwealth Current Laws and Policies Related to Chronic, Acute, and Cancer Pain Management as the Joint Subcommittee to Monitor the Implementation of Certain Guidelines for Use of Opioids in Chronic Pain SB 549-1998: Amends the Code of Virginia to allow the Board of Medicine to endorse the chronic pain and opioid practice guidelines of the Medical Society of Virginia |
The Virginia effort culminated in the adoption and approval of the Medical Society of Virginia's "Guidelines for the Use of Opioids in the Management of Chronic, Noncancer Pain" by the Medical Society of Virginia, the Senate and House of the Virginia Legislature, and the Virginia Board of Medicine. The document is historic because physicians from diverse geographic locations and specialty interests joined lay, public, and elected representatives of the Virginia House of Delegates and Senate, as well as representatives from the attorney general's office and the Virginia Board of Medicine, to draft the document. The document is reported to be the first of its kind in the United States (Long, 1997). It clarifies a mechanism by which physicians can more comfortably, safely, and intelligently prescribe proper analgesics to the unfortunate and underserved population of chronic pain patients with less fear of regulatory repercussion.
The document is intended to reflect the view of Virginians—patients, physicians, legislators, administrators—that physicians have an obligation to treat patients with intractable pain and to lessen suffering, and reaffirms the fact that physicians may appropriately and safely prescribe opioids for many pain conditions, provided they follow acceptable protocols and standards. Although the guidelines are fairly specific in content, the committee's intent was to produce a fluid document that serves not as a definitive practice standard but as a flexible dynamic statement that offers practitioners a template for logical and safe medical practice when prescribing opioids for pain patients. As attitudes and experience change and expand, the document and guidelines will undergo updates.
The guidelines are the first of their kind in the nation to be simultaneously endorsed by a state medical society, legislature, and board of medicine (Koontz, 1998). To date, many states have also published opioid policy statements reflecting their particular groups' opinions. But Virginia's efforts reflect an emerging trend to integrate the opinions and support of many special interest groups at a statewide level of acceptance.
Through the joint subcommittee, the Medical Society of Virginia Pain Committee (which is now a standing committee chaired by Stephen P. Long, MD), and the Board of Medicine, Virginia continues to support and recommend educational and legislative activities that raise the provider community's level of awareness about pain and its management. The legislature recognizes that it cannot legislate away pain and disease but that it can make pain management more accessible to the citizens of the commonwealth, can take steps to ensure that they are cared for by practitioners who endorse contemporary methods of pain therapy, and that third-party payers should be required to include payment for pain specialty treatment and interventions. It is the hope of the Joint Legislative Committee and the Medical Society of Virginia Pain Committee that Virginia will continue to ensure that the very real problem of pain is addressed at all levels, and will share its experience with those willing to look at the problem—the one based on perception and politics.
References
Koontz, W. (1998). Guidelines for the use of opioids in the management of chronic, noncancer pain. Virginia Medical Quarterly, 125, 11.Long, S.P. (1997). Preliminary report of ad hoc committee: Pain management. Virginia Medical Quarterly, 124, 222-223.
Stephen Long is medical director of the Center for Pain Relief, Inc., in Richmond, VA.