Controversy over the Drug
Enforcement Administration's (DEA) mysterious vanishing guidance to physicians
and law enforcers about what constituted permissible opioid prescribing
practices for the treatment of pain -- the pain FAQ -- continues, this
time with criticism of the agency coming from a most unexpected quarter:
the nation's state attorneys general.
After years of consultations
with academic pain specialists over the increasingly contentious issue
of proper pain management with opioids versus the DEA's concerns about
prescription drug abuse and diversion, the agency last summer posted the
pain FAQ. While criticized by some pain patients' advocates and physicians
with experience with unfounded prosecutions, the
pain FAQ at a minimum represented an acknowledgment by the drug-fighting
agency that prescribing even large amounts of opioids for pain management
falls within the scope of legitimate medical practice.
But weeks later, the
pain FAQ vanished, pulled from the DEA's web site without explanation.
The agency also requested, without forewarning or explanation, that academic
medical organizations that had participated in creation of the pain FAQ
also pull down their copies of the Guidelines. Only after a rising
storm of criticism from pain treatment advocates and the offended academics
alike did the agency deign to explain that it felt the
pain FAQ positions were too constraining on the government's power
to investigate and prosecute physicians.
Now, the embattled agency
has formally requested comments on the question of the proper prescribing
of opioid pain medications. Leading pain physicians were quick to
respond to news of the request, as would be expected, but so was the National
Association of Attorneys General, representing the top law enforcement
officers in each state. They were not pleased with the agency.
In a January 19 letter signed
by 30 attorneys general -- more than half -- the organization pronounced
itself "concerned" about the DEA's recent actions regarding pain medication
policy and "surprised" that the agency had suddenly shifted its views,
especially without consulting them. That concern included fears that
"state and federal policies are diverging with respect to the relative
emphasis on ensuring the availability of prescription pain medications
to those who need them."
Noting its own adoption of
a 2003 resolution seeking balance in promoting pain relief and preventing
prescription drug abuse, the NAAG called the pain FAQ reflective of "a
consensus among law enforcement agencies, health care practitioners, and
patient advocates that the prevention of drug abuse is an important societal
goal that can and should be pursued without hindering proper patient care."
Its replacement with a tougher DEA interim policy statement in November
"emphasizes enforcement, and seems likely to have a chilling effect on
physicians engaged in the legitimate practice of medicine," they group
wrote.
The unexpected display of
thoughtfulness from the attorneys general is worth quoting at length:
"As Attorneys General have worked to remove barriers to quality care for
citizens of our states at the end of life, we have learned that adequate
pain management is often difficult to obtain because many physicians fear
investigations and enforcement actions if they prescribe adequate levels
of opioids or have many patients with prescriptions for pain medications.
We are working to address these concerns while ensuring that individuals
who do divert or abuse drugs are prosecuted. There are many nuances
of the interactions of medical practice, end of life concerns, definitions
of abuse and addiction, and enforcement considerations that make balance
difficult in practice. But we believe this balance is very important
to our citizens, who deserve the best pain relief available to alleviate
suffering, particularly at the end of life."
The attorneys general concluded
by noting the DEA's solicitation for comments and pointedly asking DEA
administrator Karen Tandy for an early March meeting -- the AGs will be
in Washington for their annual conference -- to discuss their concerns.
If the DEA is catching flak
from its friends, it is also hearing from some former friends. Dr.
Russell Portenoy, chair of the Department of Pain Medicine and Palliative
Care at New York's Beth Israel Medical Center and the lead expert in the
joint collaboration between academic pain specialists and the DEA that
led to the pain FAQ, told the American Medical News this week that he had
"little enthusiasm" for any further involvement with the agency.
Dr. David Joranson of the
University of Wisconsin's Pain and Policy Studies Group was a little bit
more forgiving. He told the American Medical News that it appeared
the DEA had new people working on prescription drug diversion and they
needed to be educated. "I think everyone in the pain field -- clinicians,
administrators and patients -- should take the DEA request very seriously,"
he said.
And maybe the DEA should
take seriously the rising chorus of objections to its hard-line stance
on the issues of pain management and prescription drug diversion.
