Pain
Wars:
New
Pain
Management
Standards
Go
Into
Effect,
But
Will
They
Protect
Doctors
from
the
Drug
Warriors?
1/12/01
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the organization that sets standards for hospitals, health maintenance organizations, and other health care providers, elaborated tough new standards for pain management last summer. Those new standards went into effect nationwide on January 1st. Advocates of pain treatment are cautiously optimistic, but continue to fear the drug war. Under the new standards, upon admission to hospital or other health care provider, patients must be screened for the presence of pain (http://www.jcaho.org/standard/stds2001_mpfrm.html). If pain is present, health care providers are required to assess its intensity, location, onset, alleviating and aggravating factors, present pain management regime, and pain management history -- all with an eye toward more effective pain control. According to broadcast news reports, hospitals are now typically using a "pain management scale" to meet JCAHO standards. The scale asks patients to rate their pain on a scale from one to ten, with ten representing intolerable pain and one representing no pain at all. A JCAHO press release estimated the number of Americans who suffer from pain at 120 million and said its new "evidence-based pain management standards require nearly 18,000 accredited health care facilities to make pain management an integral part of all treatment plans." A major, if not the only, impediment to effective pain treatment has been the status of opiates as controlled substances. Doctors both fear possible prosecution for "over-prescribing" opiates and carry with them attitudes about addiction and abuse that militate against effective pain management. The American Pain Society and the American Academy of Pain Management have called for dialogue with government and law enforcement officials to reach a new consensus of pain management since 1996 (http://www.ampainsoc.org/advocacy/opioids.htm). The two pain relief organizations wrote: "The purpose of laws that govern controlled substances and professional conduct is to protect the public. Our objective is for state policies to recognize but not interfere with the medical use of opioids for pain relief, while continuing to address the issue of prescribing that may contribute to drug abuse and diversion." Skip Baker, a pain patient and founder of the American Society for Action on Pain, or ASAP (http://www.actiononpain.org), told DRCNet the new standards will provide some breathing room for doctors hesitant to prescribe because of fears of persecution by government drug agents. "This will be a tremendous defense against the DEA when doctors are charged with over-prescribing," said Baker. "The DEA and state medical boards have for years been going after doctors for supposedly over-treating pain." For Baker, this is not just a public policy issue. A sufferer of ankylosing spondylitis, a painful arthritic condition, he takes ten four-milligram Dilaudid tablets every four hours. "It's the only way I can function," explained Baker, "and I can function -- I don't feel high or euphoric, but I can go about my daily life." "When the dosage is adjusted and titrated," Baker elaborated, "then the person can feel normal." This is something that law enforcement has trouble grasping. According to Baker, the "drug cops" at the Virginia state medical board are harassing his physician, Dr. Robert Solomon of Williamsburg, Virginia. "In my case, they're going after my doctor for prescribing too much," Baker told DRCNet, "but they don't understand the medicine. That's the problem with having police decide for doctors what a proper dosage is." But what about the potential for addiction or abuse? "Look," snorted Baker, "I'm Dilaudid dependent, just like someone with diabetes is insulin dependent. This isn't about abuse." "The people who keep talking about addiction don't know what they're talking about," said Baker. "True pain patients almost never become addicted," he asserted. The American Pain Society backs him up. "Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low. Furthermore, experience has shown that known addicts can benefit from the carefully supervised, judicious use of opioids for the treatment of pain," the professional society concluded. Baker is angry about the misapprehension. "It's amazing that the public has been so misled by an unending stream of propaganda that everything they believe about drugs is wrong," he growled. "The drug war is fueled by this kind of misinformation." "The public thinks it knows that pain patients risk becoming addicts, but what the public is not aware of is that, according to our research, the suicide rate is for pain patients is nine times the average," added Baker. "The problem is that doctors are afraid to prescribe adequate pain medication for fear of the DEA," said Baker. "It hasn't happened often, but when it does it scares all the others so badly they refuse to treat pain with opioids, period." Dr. Frank Fisher, a Shasta County, California, pain care specialist is one doctor who has had problems with law enforcement -- very serious problems. He and the married couple who ran the mom-and-pop pharmacy where Fisher's patients filled their pain prescriptions were arrested in February 1999 and charged with a variety of felonies, including several murder counts. (The murder counts included one patient who died as a passenger in a car accident, a person who stole prescribed drugs from a patient and overdosed on them, and, most egregiously, a patient who committed suicide weeks after Dr. Fisher was jailed and her access to pain medication cut off.) Prosecutors described Fisher as "a drug dealing mass murderer" in the press and in court. Fisher and the pharmacists spent five months in jail -- Fisher's bail was set at $15 million -- before the murder charges were dropped and they were released. But drug dealing charges remain, and Fisher and his pain clinic remain shut down. (Visit http://www.drfisher.org for more information and http://www.drcnet.org/wol/150.html#fishercase to read our August 2000 interview with Dr. Fisher and the pharmacists.) Dr. Fisher told DRCNet the new pain standards were necessary, but he doubted their impact would be immediate. "The fact that we needed new standards shows that the job of pain treatment isn't getting done," the Harvard-educated general practitioner said. "If there were adequate pain treatment, we wouldn't need these new regulations." "But I don't think the standards will have an immediate impact on pain management in this country," Fisher said. "Now, when a person goes in for care, the nurse who makes the initial contact will record pain levels, so we will see much new information gathered, but that won't cause doctors to immediately change their prescribing behavior." "What will happen," predicted Fisher, "is that all this information and documentation will form the basis for lawsuits when patients decide to take action for under-treatment. When doctors fear under-treatment as much as they fear regulators, then we will see a more balanced approach to pain treatment." "It's a shame that fear has to drive the whole process," he added. Fisher added that that fear manifests itself in different ways. "It's not always conscious," he told DRCNet, "it tends to get sublimated in the belief system that opioids are uniformly addictive. That's just not true." For Fisher, the problem is reckless and malicious law enforcement. "The DEA and state drug agents are mandated to check out allegations of over-prescribing, and if that's all they did, that would be fine," Fisher said. "But they go in with the attitude of 'we've got to make a big drug bust here.' By the time they send in an agent, they've already decided to bring charges." "That's what happened with me," Fisher pointed out. "They sent in agents posing as pain patients. None of them got anything because their concocted stories didn't ring true, but by then they were committed to charging me anyway." "This raises serious questions about how prosecutors decide who to charge." (Visit http://www.drcnet.org/guide10-96/pain.html to read about a previous chapter in the pain wars.)
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