AMERICAN PAIN INSTITUTE,
ARKANSAS CHAPTER
INTRACTABLE PAIN TREATMENT LAWS
While the use of opioid
analgesics to manage chronic non-cancer pain is being reassessed clinically and
scientifically, it is clear that medical boards are issuing guidelines to
recognize this use.
State legislatures
are also deciding the legal parameters for prescribing opioids. Legislative consideration of IPTAs is
usually stimulated by chronic pain patients who are concerned about access to
opioids or by physicians who are concerned about the attitude of their state
medical board. However, some of these
laws may further restrict rather than expand access to opioids for chronic pain
management.
Most IPTAs are
based on the Texas law adopted in 1989 (Medical Practice Act of Texas,
1989). The Texas IPTA defines
intractable pain and grants immunity from disciplinary action by the medical
board to physicians when they prescribe opioids for intractable pain. After adoption of the IPTA, the Texas Board
of Medical Examiners issued a positive statement that recognized the value of
controlled substances in the treatment of pain and specified that the
appropriateness of treatment will not be defined solely on the basis of
quantity or duration of prescribing, but rather on the basis of diagnosis and
treatment objectives (Stasney & Hill, 1993). More recently, the board issued another positive policy on
intractable pain, in this case a regulation (not a guideline) (Texas State
Board of Medical Examiners, 1995).
In 1990, California
adopted an IPTA that followed closely the Texas provisions but in addition
required that all patients have a consultation so that the physician can
qualify for immunity (California Business and Professions Code, 1990).
BENEFITS OF
IPTAs:
One possible
benefit of an IPTA is to recognize in the law that there is a legitimate place for
opioids in the treatment of chronic pain.
Another perceived benefit is that an immunity provision may protect
physicians from discipline, although perhaps not from investigation and its
attendant legal costs. Another benefit
of legislative consideration of IPTAs may be the enhancement of public
attention to the inadequate treatment of pain.
Such consideration could lead to creation of a state pain commission,
which would have access to all of state government and which could conduct a
careful study of the problem and guide the development of a variety of needed
responses.
RISKS OF IPTAs:
IPTAs are state
pain policies created by elected officials, not by organizations representing
medicine and science. Opening the door
to legislative action on medical issues requires careful consideration. This process is political and complex, and
its outcomes are difficult to foresee.
Although IPTAs are
not always alike, the following is a list of potentially restrictive aspects
that are now official policy in some states:
**IPTAs generally define medical use
of opioids for intractable pain as a therapy of last resort.
**IPTAs apply to all intractable
pain patients, even if they have cancer.
**IPTAs imply that opioids may be
used for pain only in cases where the cause of pain
cannot be removed.
**IPTAs exclude pain patients who
use drugs “for non-therapeutic purposes”.
**IPTAs require an evaluation of
every pain patient by a specialist in the organ system
believed to be the cause of pain.
**Some IPTAs require a signed
informed consent form in every case.
It is not difficult
to imagine how each of these limitations, if actually enforced, could interfere
with medical practice and patient care.
It is also difficult to see how IPTAs would actually increase patient
access to pain management.
CONCLUSION:
We should recall
that state medical boards have a duty to protect the public from improper
prescribing, but that they are also responsible for promoting public
health. A number of boards have
recognized the need to clarify their policy regarding prescribing for
pain. Increased collaboration between
the pain community and state professional licensing boards should be encouraged
and should aim to harmonize clinical practice and regulatory policy.
In all of these
deliberations, we should strive to achieve a balance so that the management of
pain, including the use of opioids when needed, is not impeded by state laws,
regulations, or other policies that are based on outdated information.
The bottom line is
that after weighing all the risks and benefits, the state of Arkansas needs to
adopt into law an Intractable Pain Treatment Act. All citizens deserve the same rights, responsibilities, and treatment. Quality of life, pain free and able to
function, should not be afforded only to those that are either healthy or
dying. It is time for those patients
that fall in the middle to no longer be pushed aside and ignored. Everyone one deserves the right to experience and live their lives in
quality and not quantity.