Experts call for balance in addressing under treated pain and drug abuse

Healthcare decisions must remain in the hands of healthcare professionals for the sake of patients

A balance must be struck between physicians’ responsibility to treat chronic pain and the Drug Enforcement Administration’s (DEA) duty to combat drug abuse, according to a series of seven commentaries by national thoughtleaders published today in the February issue of Pain Medicine.

The commentaries explore the current state of the use of pain medicine from a variety of perspectives, with an emphasis on the tension between physicians treating legitimate pain and the DEA. Pain Medicine is the journal of the American Academy of Pain Medicine (AAPM).

According to the American Pain Foundation, chronic pain affects more than 50 million Americans. People suffering from chronic pain may need pain medicine to lead normal lives, such as being able to work and to participate in family life. Many patients with chronic pain have lost access to appropriate medical care due to tension between regulatory/legislative bodies and the medical community.

The lead commentary describing current DEA policy on pain care with controlled substances was written by Howard A. Heit, MD, a pain and addiction medicine specialist who has collaborated with the DEA. AAPM President Scott M. Fishman, MD, presents the collision of the war on drugs with efforts to improve pain care. Jennifer Bolen, JD, Former Assistant US Attorney with the United States Department of Justice, makes a compelling case that current DEA policies are founded on erroneous and inappropriate positions. Edward Covington, MD, Steven Passik, PhD, and Ben A. Rich, JD, PhD, add additional dimensions to the current perceived state of imbalance, while Will Rowe, Executive Director of the American Pain Foundation, a patient advocacy organization, provides perspective on patient’s rights.

Victories and Defeats in Pain Care

Dr. Heit and others worked with the DEA to develop the August 2004 Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel, which the DEA subsequently disavowed causing “confusion and consternation” among physicians who treat pain.

“It is now apparent to me that the spirit of cooperation that existed between the DEA and the pain community to achieve the goal of balance has broken down. The DEA seems to have ignored the input and needs of the healthcare professionals and pain patients who actually prescribe, dispense and use controlled substances,” Dr. Heit states in his commentary.

“It is essential that we resume dialogue between the DEA and healthcare professions for the benefit of our patients and society,” continues Dr. Heit. “The DEA and the healthcare professionals treating pain both have an important job to do in ensuring those who need [controlled substances] for pain receive them while preventing misuse and diversion. Only through dialogue based on and mutual trust and respect can this balance be restored.”

Other government initiatives have challenged the line between health policy and law enforcement. This includes Congress’s empowerment of the DEA allowing the agency authority in reviewing new drugs, a role previously held only by the Food and Drug Administration, according to Dr. Fishman. On Nov. 4, 2005, Congress reversed itself and rescinded the DEA’s new authority.

As healthcare’s regulatory authority shifts from health agencies to law enforcement agencies, the DEA and Federal prosecutors have used the courts to bypass state medical boards when scrutinizing physician practices. Dr. Fishman says that the recently passed national law, National All Schedules Prescription Electronic Reporting Act (NASPER), which institutes a national prescription monitoring program, may offer some steps forward, but it also carries the potential to impede optimal prescribing and could even perpetuate aberrant prescribing that may facilitate abuse. While this new law is presented to the public as a clinical tool to improve patient care and safety, “…profound inadequacies suggest that this law may be intended less as a clinical tool than as a physician mouse trap,” Dr. Fishman states.

“Healthcare decisions, including those involving legitimate use of analgesics, must remain in the hands of healthcare professionals,” comments Dr. Fishman. “The DEA should be required to work with health agencies and healthcare professionals in finding common ground and reaching the rational position of balance that is in the public’s best interest…Healthcare oversight must remain within agencies whose primary responsibility is to improve public health. Contrary to recent events in Washington, we must continue to insist that drug abuse can be curbed without undermining patients in pain and striving for such policies is in the best interest of society. The least we can do is to make sure that the casualties of the war on drugs are not suffering patients who legitimately deserve relief.”

Freedom to Care for Pain Patients Critical

Reluctance to prescribe powerful pain medicine among the medical community for fear of retribution has led to the needless suffering of countless people in pain.

The Department of Justice must “stop the abuse and diversion of prescription medicines without harming access to these medicines for people affected by pain,” states Will Rowe, Executive Director, American Pain Foundation, in his commentary. The commentary points to a failure on the part of the DEA in not abiding by its commitment to the pain community to pursue a balance between the war on drugs and the rights of pain patients, and also cites “the failure of those in authority over the DEA to assert the more comprehensive command.”