Relieving Pain in America

I was fortunate to serve on the Institute of Medicine (IOM) committee that published the report "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research," an effort that took rigorous data analysis seriously. The IOM report states that there is a "moral imperative" to treat pain. The report also points to legislative and regulatory barriers that may make it harder for people living with chronic pain to access care and treatments they need. Legislators, regulators, and other policy makers clearly have duties and responsibilities associated with the "moral imperative" principle as it relates to pain in our society. Two important public health policy matters that require the attention of policy makers seem to be constantly in tension with one another: the under-treatment of chronic pain and the abuse of prescription medications.

Unfortunately, the notion that there is a causal connection between prescribing medications for chronic pain and the abuse of these medications is held by many, including policy makers. This belief is based on a lack of understanding about the management of chronic pain, the paucity of data related to these matters, sloppy media reporting, and pressure from special interest groups. As a consequence, knee-jerk policy decisions have been made that make the lives of those with chronic pain even more miserable.

In forming policy, we must always acknowledge what we don't know. Despite numerous and easily-misinterpreted reports, we still lack meaningful data about abuse and addiction of prescription pain medications. Prescription drug diversion, abuse and misuse are terms that are related, but often incorrectly used as interchangeable and belie the importance of whether outcomes were caused by intentional acts, as in the case of abuse. Patient error is also behind some reports of misuse, as well as efforts to treat one's pain, only using someone else's medication. Clearly, different approaches would be taken to address prescription medication abuse and misuse.

In the absence of good evidence about the source and circumstances surrounding prescription drug abuse, there is a risk of shifting the brunt of the diversion problem onto pain patients -- either directly, through refusal to treat people with pain, or indirectly, through policies that not only enable, but encourage physicians to abandon their moral responsibility to ease pain and suffering.

Nearly a decade ago, David Joranson, founder of the Pain Policy Studies Group at the University of Wisconsin, and an expert consultant to the World Health Organization, recommended the creation of state pain commissions in response to this problem. Some states proactively acted on this recommendation. Other states created pain commissions in an effort to fix unintended consequences of previous policy decisions. However, the time is now for ALL states to establish a pain commission.

Policy makers bear significant obligations, and they deserve the benefit of unbiased, well-researched, objective information. They also deserve access to experts from a variety of disciplines and perspectives who can inform their process and, if not eliminate, dramatically reduce harms to innocent people as a result of ill-informed policy decisions. In our current environment of confusion and bias, the formation of state pain commissions offers an opportunity to truly transform the way that pain is treated across the country and in our own back yards.