Annual study shows states moving to more balanced pain policies

Many states have made great progress in adopting policies that balance medically appropriate access to opioid analgesic therapy with state efforts to limit diversion of such drugs, according to a recent analysis.

The University of Wisconsin-Madison's Pain & Policy Studies Group evaluated states' pain policies based on how well they strike this equilibrium. In 2000, 49% of states received grades better than a "C" in the group's now-annual progress report card. This year, 86% of states hit that mark. Indeed, since 2000, no state has adopted a policy that worsened its grade. Two more states, Kansas and Wisconsin, now have "A" grades, joining Michigan and Virginia. Six other states improved their marks in the last year: Arizona, California, Colorado, Connecticut, Massachusetts and New Hampshire.

Aaron M. Gilson, PhD, the report card's principal investigator, said states have used the document as a guide to craft policies that would make physicians feel safer about prescribing the most effective pain treatments. For example, Connecticut's grade improved this year from a "C-plus" to a "B," because it adopted a prescription monitoring program to prevent doctor-shopping and other abuses, while not heavily impeding legitimate pain treatment.

"We are aiming to have policy that promotes effective use of controlled substances for pain management and avoid practices that will make abuse and diversion more likely," Gilson said. "We don't want to undermine abuse policies in the states, but focus on policies that promote legitimate practice and effective pain control. It's that approach that's really resonating across the states."

Gilson also credits progress to the Federation of State Medical Boards' model policy on using controlled substances to treat pain, first adopted in 1998 and updated in 2004. The Drug Enforcement Administration, the American Academy of Pain Medicine, the American Pain Society and the National Assn. of State Controlled Substances Authorities all signed on to the statement.

But translating paper into practice is a major challenge, experts say.

"One thing is to change the grade, but it's another to improve the quality of patient care," said June L. Dahl, PhD, a University of Wisconsin School of Medicine and Public Health pharmacology professor and co-founder of the Alliance of State Pain Initiatives, a network of health professionals and patients pushing for more balanced pain policies. "Now it's time to work to take those good words written and published by the medical boards and have an impact on the people taking care of patients in pain. That's the step that has to happen next."

Along those lines, FSMB is publishing Responsible Opioid Prescribing: A Handbook for Physicians, which it plans to distribute to all practicing physicians in the U.S. through their state medical boards, at a cost of $2.2 million. The organization is raising the money through its research and education foundation. New Mexico physicians will be the first to get the book, sometime this fall. Other states will follow as soon as their medical boards endorse the idea and funding becomes available.

"When a package comes from the state medical board, doctors tend to open it," said author Scott M. Fishman, MD, chief of the pain medicine division in the University of California, Davis, Health System.

The book is meant as a primer to help physicians who are not pain specialists -- but treat the millions of Americans in pain -- navigate the still-emerging specialty of pain medicine, Dr. Fishman said.

"The handbook is exposing the fact that doing the right thing with opioids isn't a science and no one expects doctors to be foolproof," he said. One misconception Dr. Fishman hopes the book can dispel is that patients will eventually become addicted to opioids during therapy, as opposed to being physically dependent on the pain relief they provide.

Still, the specter of addiction and misuse haunts pain medicine. A July 2007 study in the Journal of Pain found that 801 adult patients receiving opioid therapy from 235 family physicians were nearly four times more likely than the general public to misuse the drugs. Those receiving therapy had a 3.8% abuse rate, compared with 0.9% in the general population.

Patient misuse included deliberate oversedation, raising the dose without the physician's permission and attaining an intoxicated feeling using the medication. Study authors said the patients may have been self-medicating to compensate for undertreated pain.

Dr. Dahl said the study is encouraging because it shows primary care physicians are willing to prescribe opioids for patients with neuropathy, fybromyalgia, degenerative arthritis and chronic low back pain.

"Yes, there was a small incidence of opioid addiction," she said. "But the rate is relatively low, and given the benefit, that small risk is worth it because the quality of life of these patients has no doubt improved."

Meanwhile, an August Associated Press investigation of DEA retail prescription data found that sales of five leading painkillers -- codeine, morphine, oxycodone, hydrocodone and meperidine -- doubled between 1997 and 2005.

But pain experts said that could be due to increasing recognition of the importance of treating pain, and that such data say little about whether the prescribing that led to those sales was appropriate.