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State governments are giving unprecedented attention to pain management as a matter of public policy. Legislatures are adopting intractable pain treatment laws. Medical boards are revising guidelines for the use of controlled substances in the treatment of pain. Pain "summit" meetings have been held. All these activities demonstrate that the states have begun to address pain issues as a matter of public policy (Angarola & Joranson, 1994; Joranson, 1995a, 1995b). Recently, yet another type of governmental response to pain has appeared in the state pain commission. Pain commissions have been established in several states, including Florida, Michigan, Ohio, and Massachusetts, to study and address pain management issues in the healthcare system at the state level.
Pain commissions, like intractable pain treatment laws, are an indicator of increasing societal concern about pain, death, and dying. Pain commissions are ad hoc bodies established by the legislature or the state department of health to study one or more aspects of the pain problem and to develop recommendations. The commission membership is set by the appointing authority, and the commissions usually receive staff support from a state legislative or health agency.
The Florida legislature created the Florida State Pain Commission in 1994 to address acute postoperative pain, acute medical and traumatic pain, chronic pain, cancer pain, and acute and chronic pediatric pain. The goal of the commission, which is staffed by the Florida Agency for Health Care Administration (AHCA), is to identify deficiencies in the treatment of pain and to recommend practice guidelines on pain management to the AHCA. The membership of the commission is diverse; it includes members of APS and the Florida Cancer Pain Initiative.
The Florida commission has sponsored public hearings on pain that have made pain more visible in the state. Thanks to commission member (and APS member) Renee Steele Rosomoff, MBA RN, the testimony of patients and caregivers at a public hearing on pain has been recorded. See the box on page 8 for excerpts from an article by Rosomoff describing the public testimony.
The chair of the Health Policy Committee of the Michigan House of Representatives, John Jamian, has established the Michigan Council on Pain to undertake a broad review of the impact of managed care on the treatment of patients with pain. Joel R. Saper, MD FACP, APS member and cochair of the APS Public Affairs Committee, is chair. The group plans to develop legislation to protect the rights of patients with pain in a managed care and regulatory environment and to make certain that the quality of pain management in Michigan is maintained and enhanced. Saper urges all APS members to develop relationships with their state legislators and to work to establish pain commissions. He can be reached at 313/973-1155.
Under the direction of Peter Somani, MD PhD, the Ohio Department of Health is also taking a state leadership role in policy development for patient-centered chronic pain management. Somani has appointed a committee of experts to study the status of resources and education in pain management. For example, one subcommittee is considering surveys of advertised pain management clinics to ascertain the distribution and staffing of these clinics. Another subcommittee is considering educational needs of the public and of healthcare providers. In addition, the department has held discussions with the state medical board and plans to meet with insurance company representatives and other third-party payers. A number of legislators are also interested in pain and public policy, including the speaker of the Ohio House of Representatives. The department would like to hear from interested parties. The contact person is Tom Halpin, MD MPH, Chief, Division of Prevention, Ohio Department of Health, 246 N. High Street, PO Box 118, Columbus, OH 43266-0118.
A special task force on pain management was appointed by Gov. William Weld in 1992 to improve the management of pain of all types in the Commonwealth of Massachusetts. Chaired by Sen. Marc Pacheco and Rep. Harriet Chandler, the task force aims are to identify problems regarding the management of pain and to recommend strategies for the education of professionals, regulators, and the public. According to task force (and APS) member Daniel B. Carr, MD, the task force has a broad range of participation, including pain management physicians and nurses from both hospice and acute pain management settings; members of the state cancer pain initiative; medical educators; and representatives of the state medical board, the peer review organization, and the private sector. A number of meetings have been held, and public hearings throughout the state are planned. The task force will prepare recommendations for action by the legislature and is considering a continuing medical education requirement in pain management for physician licensing.
The scope of pain commissions as study groups can be broad. They can study the adequacy of pain management throughout the state, in certain facilities, or specifically in managed care. They can study the changes needed in controlled substance laws and medical board guidelines. A government commission can also help put pain in the public spotlight, where it belongs. The personal stories told by patients and caregivers to the Florida pain commission are commentaries on how our system is failing to deal with people's pain. Those who are responsible for the administration of health care must hear these true life stories. Making pain visible is as essential in the public policy arena as it is in the clinical setting. The visibility of unrelieved pain must be sustained over time to ensure a continuing response. This is no easy task for a pain commission with a short life span. What can pain commissions or other government agencies do to increase the visibility of unrelieved pain and to institutionalize better pain management within a state? I offer several suggestions:
- Your state health agency could fund studies to assess the baseline prevalence and severity of unrelieved pain in different practice settings and also determine the state of knowledge and attitudes of health professionals, patients, and the public; the results can then be publicized and used to plan interventions.
- The health committees of your legislature could ask the state health or budget agency for a study of the costs of unrelieved pain in the state. These committees could also evaluate whether there are impediments to pain management in state Medicaid or workers' compensation policies.
- Your state insurance agency could determine whether managed care plans in your state offer reasonable coverage for pain management and provide adequate information to the consumer.
- The state agency that regulates health facilities in your state could review pain management policies and training plans for hospitals, nursing homes, hospices, and other regulated patient care organizations.
- The state health agency (perhaps the cancer control program) could support development of a pain education program for the public as many states have done for drug abuse education.
Every opportunity to advance public policy may also present some risks. Government might expand regulatory control over the developing field of pain medicine, for example, by interfering with clinical decisions or by favoring treatments not supported by the scientific evidence. Will commissions recommend effective methods for changing practice? Are guidelines or mandatory continuing education effective? Groups with an economic interest in pain management might narrow the scope of study and, therefore, the outcomes. Risks diminish when the membership and leadership of state pain commissions are well informed and have adequate support and a balanced agenda.
What will be the result of this important period of state government interest in pain? Will it have a positive, a negative, or no impact on the quality of pain care received by patients? Will state pain commissions serve effectively as opportunities to make pain visible and to institute better pain management? Was the commission's potential to enlist the assistance of a variety of state agencies fully realized?
A number of APS members and state cancer pain initiatives are involved in state pain commissions. Sometimes these pain advocates and specialists are new to the public policy arena and have limited time to contribute. Fortunately, these professionals are reaching out to others to communicate about objectives and to assemble resource materials. These volunteers should have support for their activities as well as an opportunity to formulate common goals for improving pain relief in the states. One forum for discussing these issues is the APS Public Affairs Committee. In addition, APS could consider sponsoring a special meeting to discuss ways to maximize the contribution of state pain commissions. Readers' comments and suggestions are welcome.
David Joranson is associate director for policy studies with the Pain Research Group at the University of Wisconsin Medical School, Madison, WI. He cochairs the APS Public Affairs Committee and is a member of the Board of Directors.References
Angarola, R.T., & Joranson, D.E. (1994). California sponsors pain summit; Maryland fends off new regulations. APS Bulletin, 4(3), 11-12.
Joranson, D.E. (1995a). Intractable pain treatment laws and regulations. APS Bulletin, 5(2), 1-3, 15-17.
Joranson, D.E. (1995b). State medical board guidelines for treatment of intractable pain. APS Bulletin, 5(3), 1-5.
Rosomoff, R.S. (1995, July). The faces of pain. The SPS News, 3-4.