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Pain and Symptom Management
Task Force
Report to
the
Seventieth
Oregon Legislative Assembly
and
Governor John Kitzhaber
January
1999
PAIN
AND SYMPTOM MANAGEMENT
TASK FORCE MEMBERSHIP
DANIEL
BEESON, D.C., is a chiropractic physician practicing in southeast
Portland. He serves on the
task force representing the Chiropractic
Association of Oregon.
KAREN
BELL is a registered nurse and Director of Hospice for Providence
Portland Medical Center’s Home Services.
She serves on the task force representing the Oregon Association of
Home Care.
ROBERT
BENNETT, M.D. is Professor of Medicine and Chairman the Division of
Arthritis and Rheumatic Diseases at the Oregon Health Sciences University.
In 1996, he co-founded the Oregon Fibromyalgia Foundation, a non-profit
organization dedicated to educating both patients and health care
professionals about fibromyalgia.
DIANE
COCKBURN is a registered nurse, oncology and pain & symptom
management clinical nurse specialist with Salem Hospital.
She serves on the task force representing the Oregon Nurses
Association and is active in many pain & symptom management
organizations.
WILLIAM
COMER is a pharmacist and pharmacy educator. Currently he serves as a
managed care consultant for Coram Healthcare, Inc. and is an advisory
board member for Hopewell House Hospice in Portland.
He serves on the task force representing the Oregon Society of
Health System Pharmacists.
LINDA DOWNEY
is a registered nurse and serves as Executive Director of Willamette
Valley Hospice. She has
served on the Board of Directors of Oregon Hospice Association. She serves
on the task force representing the Oregon Hospice Association.
KRIS
FASSENFELT is Vice-President of Medical Affairs for Liberty Northwest
Insurance. She serves on the
task force representing the Health Insurance Association of America.
JOHN
FLETCHER is Regional Director of the Health Services Integration
Division for Providence Health System.
In that capacity, he is responsible for quality & outcomes
management and clinical programs that include end-of-life and pain
services coordination for the Providence Health System.
SENATOR
BILL FISHER is a nursing home owner and operator.
He represents Senate District 23 including portions of Douglas,
Jackson, and Josephine counties. As
Co-Chair of the Joint Interim Committee on Human Resources, Senator Fisher
serves as an ex-officio member of the task force.
BARBARA
GILBERTSON, D.O., is Medical Director of the Klamath Falls Pain Clinic
and a board member of the Osteopathic Physicians and Surgeons of Oregon,
as well as a board member of the Office of Medical Research at Merle West
Medical Center. She has served on the task force representing Osteopathic
Physicians and Surgeons of Oregon.
KATHLEEN
HALEY is an attorney and Executive Director of the Board of Medical
Examiners. Since 1994 she has
served on the Task Force to Improve the Care of Terminally-Ill Oregonians
and edited The Oregon Death with
Dignity Act: A Guidebook for Health Care Providers.
KURT
HANSEN is an attorney and shareholder with Schwabe Williamson &
Wyatt, PC, in Portland and is Past-chair of the Oregon State Bar Health
Law Section. He serves on the
task force representing the Oregon State Bar.
GRANT
HIGGINSON, M.D., MPH, is the State Health Officer and Deputy
Administrator of the Oregon Health Division, Department of Human
Resources. He serves as Task
Force Chairman and represents the public health community.
REPRESENTATIVE
JEFF KRUSE owns and operates Kruse Farms in Roseburg. He represents House District 45 in Douglas County. As
Co-Chair of the Joint Interim Committee on Human Resources, Representative
Kruse serves as an ex-officio member of the task force.
BOB
MACLENNAN is a healthcare actuary with the Oregon Department of
Consumer and Business Services Insurance Division.
PAM
MILLER, M.S.W., Ph. D., is Associate Professor for Portland State
University’s Graduate School of Social Work.
She serves on the task force representing the National Association
of Social Workers, Oregon Chapter.
MARGARET
MURPHY CARLEY is a registered nurse and an attorney. She serves as
legal counsel for the Oregon HealthCare Association.
She serves on the task force representing the Oregon HealthCare
Association.
BETH
NEVUE is Social Services Supervisor at Salem Hospital.
She serves on the task force representing the Oregon Association of
Hospitals and Health Systems.
SIMON
PAQUETTE is a social worker active in mental health, hospice, and
aging issues currently serves as Director of Residential Operations for
Unity, Inc., in Portland.
JAMES
RADEMACHER, D.M.D., Ph.D., is a general dentist with a practice
emphasis including TMJ and orofacial pain problems.
In addition to dentistry, he has a degree in Psychology, and a
Ph.D. in Anatomy. Dr.
Rademacher was a visiting lecturer at OHSU School of Dentistry.
He serves on the task force representing the Oregon Dental
Association.
DOLORES
RAYMOND has a background in long-term care and is a member of the
American Association of Retired Persons Oregon State Legislative
Committee. She serves on the
task force as a consumer member for the American Association of Retired
Persons.
MARK
REID is Regional Minister for the Christian Church of Oregon and
Sociology of Religion Instructor for Marylhurst College.
He serves on the task force representing Ecumenical Ministries of
Oregon.
JOAN
ROBINSON is an attorney. She
has fibromyalgia and serves on the task force as a consumer member. She is
Senior Deputy Legislative Counsel for the Oregon Legislative Assembly.
GARY
SCHNABEL is a registered nurse and pharmacist.
He currently serves as Compliance Director for the Oregon Board of
Pharmacy. In 1997 he served
on the Task Force to Improve the Care of Terminally-Ill Oregonians.
He serves on the task force representing both the Oregon Board of
Pharmacy and the Oregon State Pharmacists Association.
ARLETTE
SIECKMAN, N.D., L.Ac., is a naturopathic physician and acupuncturist
practicing in Portland. Her
practice includes pain and symptom management for HIV/AIDS patients.
MARTIN
SKINNER, M.D., is internal medicine physician with HealthFirst Medical
Group in Portland and has been involved in palliative and hospice care for
over 15 years. In 1995 he
worked to get Oregon’s Intractable Pain Act passed and in 1997 he served
on the Task Force to Improve the Care of Terminally-Ill Oregonians.
He serves on the task force representing the Oregon Medical
Association.
PAUL
STULL, M.D., is board
certified in urology, hospice and palliative care. He is Past President of
the Oregon Hospice Association and author of SB 1071 (1997).
ALICIA
SUPER is a registered nurse consultant, clinician, researcher,
educator and author on issues of pain and symptom management, palliative
care, and end-of-life. She is President of Pain & Supportive Care
Services in the Portland Metropolitan area.
ROGER
WEEKS is a retired hospice chaplain and chronic pain sufferer. He serves on the task force as a pastoral counselor and
consumer.
TABLE
OF CONTENTS
Task Force
Membership
1
Introduction
2
Background
4
Current Law
6
Values and
Philosophies
9
Task Force Recommendations
12
Office of Chronic
Pain Management
12
Statutory Changes
13
Improved
Provider and Consumer Education
15
Improved
Access to Treatment
17
Regulatory
Changes
19
Appendix
21
INTRODUCTION
Created
by the 69th Legislative Assembly, the Task Force on Pain and
Symptom Management assessed current practices in pain and symptom
management as well as the problems faced by Oregonians with chronic
illnesses, terminal illness, and chronic pain conditions.
This document, the initial report of the task force, is submitted
in compliance with the legislative directive that the task force report to
the 70th Legislative Assembly and to the Governor.
Meetings of the Task Force
During 1998
the task force held more than 15 public meetings in Salem, Portland,
Eugene, Medford, and La Grande. The task force heard testimony from dozens of health care
providers, consumers and family members focused primarily on barriers to
providing and obtaining adequate pain relief.
Findings of the Task Force
and its Work Groups
Members of
the task force initially divided into two groups: one assessing current
practices in pain and symptom management and one to identify barriers to
obtaining adequate pain relief. While both work groups made significant findings and
recommendations to the full task force, the final recommendations reflect
only those proposals favored by a majority of the full task force.
In order to
maintain a complete record of the issues considered by the task force and
its work groups, the pages four through six of this document outline the
recommendations of each work group, without regard for the ‘success’
of a particular proposal before the full body.
Details of the recommendations adopted by the full task force begin
on page twelve.
Summary of Task Force
Recommendations
Based on a
review of current resources available and access to those resources, the
task force recommends the following:
Creation
of the Office of Chronic Pain Management within
the Oregon Health Division, Department of Human resources.
The Office, through a coordinator/ombudsman would develop a
broad-based approach for increased educational opportunities for
providers, persons with pain, and their families in order to improve
provider knowledge of, and patient access to, multidisciplinary care.
The task force envisions the coordinator facilitating advocacy for
persons with pain and acquiring grants to support regional conferences and
research. In addition, the coordinator would be responsible for
investigating the potential for developing a chronic pain management
registry and regional pain centers located in various parts of the state.
Statutory
Changes including the following:
·
The deletion of the requirement for provider consultation in the
Intractable Pain Act;
·
The extension of the task force sunset date to December 2002 and
modification of the membership and meeting requirements; and
·
Legislative consideration and adoption of a Resolution of Rights
for Persons with Pain
Improved
provider and consumer education at
the undergraduate and graduate levels, as well as in the area of
continuing education. The
task force recommends a review of educational curricula, as well as a
cooperative effort among professional organizations, health care
institutions, regulatory boards, and consumers to develop medical
education programs focusing on chronic pain assessment and treatment.
Improved
access to treatment for pain beginning
with the recognition and establishment of pain as a diagnosis.
The task force recognizes that one’s lack of financial resources
poses a significant barrier to obtaining adequate pain relief.
The task force recommends the legislature consider improving access
to palliative care, including access to hospice care for uninsured
patients and funding for a pilot program designed to evaluate the costs
and benefits of chronic pain treatment.
Regulatory
changes including the development
of a “Current Statement of Philosophy” by the Board of Medical
Examiners to make clear that the former board guidelines encouraging
physicians to limit prescriptions for controlled substances in the
treatment of chronic musculoskeletal pain have been withdrawn.
The statement is to make clear that the prescription of controlled
substances in such cases may be appropriate and that complaints of
under-treatment of chronic pain will be taken as seriously, and
investigated as thoroughly, as any other complaint.
In addition, the task force recommends the Board of Medical
Examiners continue to develop and disseminate information on the
intractable pain law and that all health professional regulatory boards
disseminate to their licensees and applicants board expectations and
information regarding appropriate pain and symptom management.
BACKGROUND
According to
the federal Agency for Health Care Policy and Research, the ethical
obligation to manage pain and relieve a patient’s suffering is at the
core of a healthcare professional’s commitment.
Although the ethical duty to relieve pain is well established, the
question of managing pain effectively remains unanswered.
There is concern among patients and providers throughout Oregon
over access to appropriate medical treatment, including opioid therapy,
for both chronic intractable pain and end-of-life pain.
In an effort
to assess access to adequate pain management, the 1997 Legislative
Assembly created the Pain and Symptom Management Task Force.
The subject of Senate Bill 1071 (1997),
the task force was charged to study and make recommendations on the
following:
·
The problems in obtaining relief from pain faced by Oregonians with
chronic illness, terminal illness, or conditions causing chronic pain;
·
The nature of current pain and symptom management practices;
·
The resources and remedies available for pain and symptom
management;
·
Any policy changes that should be made by state agencies and groups
that deal with pain and symptom management to encourage more effective
management and access to services; and
·
Any statutory changes necessary to encourage more effective pain
and symptom management and to improve access to services.
The task
force consists of thirty members appointed by the State Health Officer.
Membership consists of consumers, physicians, a dentist, complementary
healthcare providers, nurses, home healthcare workers, social workers,
pharmacists, public health workers, healthcare actuaries, health insurers,
and other professionals working in education, law, and medicine.
The task force held meetings throughout the state and heard
testimony from dozens of providers, insurers, persons with pain, family
members, and other advocates. In all, 15 public meetings of the task force
and its work groups were held between December 1997 and December 1998.
The task
force formed two work groups to address specific charges set forth in
Senate Bill 1071: the Current Practices Work Group and the Barriers Work
Group.
Barriers
Workgroup
The Barriers
Work Group discussed the barriers consumers face in obtaining adequate
pain and symptom management. The work group identified barriers in
education, access, regulation and cooperation for task force
consideration:
Education
Barriers
·
Inadequate knowledge of pain physiology and available treatments by
professional providers;
·
Poor pain assessment techniques;
·
Lack of consumer education;
·
Fear of opioids, addiction, tolerance, and adverse effects of
analgesics;
·
Attitudinal and cultural differences;
·
Inadequate knowledge of non-pharmaceutical and complementary
therapies such as psychosocial, spiritual, homeopathic, chiropractic,
musical, imaging, etc.;
·
Challenge of bringing pain management research to the practicing
physician; and
·
Lack of understanding of relationship of the interrelation of
physical, spiritual, psychosocial, and economic needs.
Access
Barriers
·
Reimbursement issues and lack of financial incentives to study and
provide adequate pain management services;
·
Availability of care in rural areas;
·
Challenges in pain assessment in children, the elderly, and
minorities with language difficulties;
·
Managed care and insurance plan limitations affecting access to
specialty care and specific prescription drugs;
·
Inadequate state and federal financial aid for pain management
programs; and
·
The cost of under-utilization or misuse of resources.
Regulation
Barriers
·
Board of Medical Examiners (BME) and federal Drug Enforcement
Agency (DEA) past legacy of aggressively pursuing physician prescribing of
narcotics;
·
Lack of standardized compliance documents adequate to satisfy BME
regulations; and
·
Different and confusing chronic pain management guidelines,
critical paths, and standards.
Cooperation
Barriers
·
Lack of safety net to ensure all patients have necessary resources
to adequately manage pain;
·
Lack of cooperation and sharing of resources among community
providers (hospitals, care facilities, providers, managed care practices,
and third-party payers); and
·
Lack of a clearinghouse for information relating to pain
management.
The
task force made a determination to deal with both chronic and terminal
pain and, consequently, all identified barriers pertain to both types of
pain. However, there are differences such as easier access and readiness
to treat terminal patients compared to those with chronic non-terminal
pain. Reimbursement, insurance coverage, general physician
acceptance, and BME regulations are perceived to make it more difficult
for those with chronic non-malignant pain to obtain adequate treatment.
They are often seen as drug seekers, or malingerers, and are a low
priority for society’s rehabilitative efforts.
There are prejudices based on ignorance and lack of education,
especially related to the elderly and children, in how they express their
pain and pain treatment needs. It
is only in understanding how barriers inhibit proper assessment and
treatment that unnecessary suffering may be reduced.
Current
Practices Workgroup
The
Current Practices Work Group was charged with assessing current resources
and remedies for the treatment of chronic pain.
The group heard testimony from consumers, physicians, nurses,
complementary medicine providers, health educators, the Board of Pharmacy,
and the Board of Medical Examiners. The
work group identified the following areas for investigation: physician
fear of the Board of Medical Examiners associated with controlled
substance prescribing practices, lack of understanding among primary care
physicians and consumers regarding pain management, the lack of
incorporating complementary medicine, and provider misunderstandings about
addiction.
The
following are recommendations of the work group for task force
consideration:
·
Development of a broad, cooperative provider education effort among
the Board of Medical Examiners, the Oregon Medical Association, the State
Board of Nursing, the Oregon Nurses’ Association, the Board of Dental
Examiners, the Oregon Dental Association, the Oregon State Pharmacists
Association, Oregon Health Sciences University and other related
interests;
·
Review of the Intractable Pain Act passed in 1995
and elimination of the statutory consultation requirement;
·
Development of standardized forms for informed consent;
·
Dissemination of information
regarding federal DEA regulation and procedures relating to the
prescription of opiates;
·
Improved physician and dental education about addiction;
·
Education of pharmacists, physicians, dentists, medical and dental
students, nurses and nursing students, etc.;
·
Encouragement of health provider teaching institutions to establish
an internal committee to
review pain management curriculum;
·
Development of an information source for patients and providers
(pain clinics, website, or telephone line);
·
Adoption of a pain patients’ bill of rights ;
·
Evaluation of the role of early intervention with complementary
medicine in the treatment of chronic pain; and
·
Consideration of nurse practitioner and clinical nurse specialist
Schedule II prescription authority.
CURRENT
LAW
Oregon is
one of at least 13 states with laws regarding the treatment of intractable
pain with controlled substances. The common theme among these statutes is
the protection of physicians from criminal and medical board disciplinary
proceedings based on controlled substance prescribing practices.
Oregon’s Intractable Pain
Act
The
Intractable Pain Act defines intractable pain as “a pain state in which
the cause of the pain cannot be removed or otherwise treated and for
which, in the generally accepted course of medical practice, no relief or
cure of the cause of the pain has been found after reasonable efforts,
including, but not limited to, evaluation by the attending physician and
one or more physicians specializing in the treatment of the body area,
system or organ perceived as the source of the intractable pain.”
In the
course of treatment, the Act allows a physician to prescribe or administer
controlled substances to a person diagnosed with a condition causing
intractable pain. Before a physician can commence treatment of intractable
pain under the Act, the physician must provide the patient with a written
notice, which the patient must sign, disclosing the material risks
associated with the prescribed or administered controlled substances.
According to
the Act, the Board of Medical Examiners (BME) is prohibited from
disciplining a physician for the prescribing or administering controlled
substances in the course of treatment of a person for intractable pain.
However, the Act does not prohibit the BME from disciplining physicians
for one of the following activities:
1.
prescription or administration of controlled substances for
non-therapeutic purposes;
2.
failure to keep accurate records;
3.
treatment of patients without a legitimate medical purpose;
4.
prescribing, administering, or dispensing controlled substances in
a manner detrimental to the public or in violation of the federal and
state controlled substances acts; or
5.
Falsifying prescription information, including, but not limited to,
the identity of the recipient.
In addition
to legislative action addressing intractable pain,
Oregon is among 18 states with medical board guidelines addressing the
treatment of intractable pain. A physician may prescribe controlled
substances to a person for a diagnosed condition causing intractable pain
without concern of disciplinary action from the BME unless the controlled
substances are prescribed or administered:
1.
to a person for chemical dependency resulting from the use of
controlled substances;
2.
to a person known to a physician to use controlled substances for
non-therapeutic purposes;
3.
to terminate life in intractable pain, except as allowed under
Oregon’s Death with Dignity Act;
or
4.
For a controlled substance that is not approved by the Food and
Drug Administration (FDA) for pain relief.
In 1995, the
Oregon Medical Association released a policy statement regarding the
treatment of chronic, nonmalignant pain.
The policy statement includes guidelines regarding diagnosis and treatment
options. According to the guidelines, an initial work-up should include
the patient’s complete history containing a description of the
patient’s physical condition, psychosocial profile with a listing of his
or her daily activities, level of suffering, and any history of substance
abuse. The guidelines include the documentation of reasons for previous
unsuccessful treatment.
In
developing a treatment plan, the policy statement suggests physicians
perform periodic reassessments of the patient’s status, giving special
attention to the patient’s responsiveness to the treatment. Treatment
options include, but are not limited to psychiatric evaluation and
treatment, counseling, non-steroidal anti-inflammatory drugs (NSAID),
tricyclics, physical therapy, patient education, exercise, ultrasound,
transcutaneous nerve stimulation (TNS), acupuncture, nerve blocks,
vocational rehabilitation, and narcotic analgesics.
Pain
should be defined as a condition in its own right and not only as a
symptom of other conditions.
Pain is
defined as “an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such
damage.”
It may be classified as ‘acute’ (short lived, sudden) or ‘chronic’
(lingering, on going). Chronic (or intractable) non-malignant pain is
defined as ‘pain that persists or recurs over a prolonged period of
time, severely restricting normal lifestyles.
Malignant pain is associated with pain caused by terminal illnesses
such as cancer.
Currently,
pain is classified as a symptom of specific conditions. This has a
significant impact on chronic pain patients enrolled in the Oregon Health
Plan. If a condition causing pain appears in the funded portion of the
list, all medical and/or surgical procedures are covered. For conditions
that are below the funding level, treatment after the diagnostic work up
is not covered, and the patient is instructed on how to manage symptoms
with over-the-counter medications and self-care at home.
Fear
of controlled substances, addiction, and diversion should not be barriers
to effective treatment.
The task
force received considerable testimony from Oregonians presenting their
personal experiences with inadequate pain treatment. One of the major
themes is that pain patients are labeled as addicts and/or drug seekers
when they request adequate or increased amounts of prescribed medication.
The use of controlled substances to treat non-malignant chronic pain is
controversial and complex. Lack of education and fear of discipline
continue to create conflicts for providers and pain patients regarding the
use of controlled substances.
A part of
the controversy lies in the terms ‘physiologic dependence’ and
‘addiction’. The terms are not synonymous.
Dr. Marvin Seppala, M.D., Addictionologist, Oregon Health Sciences
University, defines physiologic dependence in the following manner: “a
patient has been on an opiate for a long enough period and high enough
doses to develop a dependence but no addictive behavior; it’s not an
addiction and is not a problem for that patient or for the prescriber, but
can be viewed as a problem by other people who don’t have the proper
understanding of addiction or pain treatment.” Addiction is
characterized by psychological dependence, compulsive drug use and/or
associated behavior.
Individuals who are truly addicted may or may not be physically dependent.
Fear of addiction by pain patients, their families, and attending
physicians results in the hesitation to use or prescribe controlled
substances. Pain specialty clinics have developed successful treatment
plans and guidelines for controlled substance therapy, but there is a lack
of available research data addressing these concerns. As noted above, many
physicians are concerned about potential disciplinary actions by the BME
associated with prescribing practices.
Although
the task force received testimony regarding the potential for diversion of
prescribed opiates, no specific data was presented regarding the frequency
with which such diversion occurs. While
the task force acknowledged the possibility of diversion, the task force
heard from numerous consumers who were amused by the thought of allowing
their perhaps “nearly-impossible-to-come-by” pain medications to be
used for anything other than the treatment of their pain.
A coordinated,
multi-disciplinary approach to the treatment of pain is vital.
The task
force received considerable testimony regarding the importance of a
multi-disciplinary approach to the treatment of pain.
The task force recognizes the value such an effort.
Multidisciplinary teams typically consist of physicians and
psychologists trained and often board certified in pain management,
physical and occupational therapists, pharmacists, nurses, spiritual
ministers, and vocational specialists.
Other team members may include biofeedback specialists, ergonomic
specialists and social workers. Multi-disciplinary
treatment is designed to teach self-control pain management techniques, to
improve function at home and at work, and to assist in finding and
obtaining appropriate resources to maximize independence and independent
functioning.
Improved
access to, and recognition of, complementary modalities is a necessity.
For as much
as treatment with controlled substances ignites debate and controversy,
inadequate access to complementary treatment modalities is also a concern.
Many pain patients realize little significant relief from the conventional
medical model of treatment.
According to
a study designed to document trends in alternative medicine use in the
United States between 1990 and 1997, alternative or complementary
therapies were used most frequently for chronic conditions including back
problems, anxiety, depression, and headaches.
The study concluded that complementary medicine use and
expenditures increased substantially between 1990 and 1997, attributable
primarily to an increase in the proportion of the population seeking
complementary therapies, rather than increased visits per patient.
Extrapolations to US population suggest a 47.3% increase in total
visits to complementary medicine practitioners, thereby exceeding total
visits to all US primary care physicians.
In addition, the study found that in 1990, 64% of users paid
entirely out of pocket for complementary services.
By 1997, that figure had been reduced only slightly.
The task
force was presented with information from pain patients and complementary
care providers about the success and the need for complementary treatment
options. These discussions acknowledged that limited resources, geographic
location, and clinician availability are all factors that have an impact
on treatment options for chronic pain patients.
Insufficient income should not be a barrier
to adequate treatment for pain.
The American
Medical Association (AMA) reports that one in three Americans suffers from
chronic pain – the kind of pain that persists for weeks, months, or even
years. This pain, if untreated, can lead to decreased productivity and
unemployment, even death. According to one study, pain costs Americans
$120 billion annually.
The cost of
pain management varies, depending on the treatment method. The uninsured
patient may incur the cost of many office visits, At the other end of the
spectrum, an inpatient pain management program that may include a 3 to 4
week stay, may cost $8,000-25,000.
The task
force received emotional testimony from many persons in pain who are among
the working poor – that is, their resources prevent them from qualifying
for state assistance, but they are unable to afford health insurance.
Many testified to the fact that they seem to have “fallen through
the cracks.” They recognize
that they will be eligible for Medicaid if they quit or lose their job,
but maintain a strong desire to remain productive.
With the onset of Oregon’s Family Health Insurance Assistance
Program, the task force recognizes that, to a very limited extent, this
problem is being addressed. However,
the task force is acutely aware of the need for the commitment of
additional resources in this area.
TASK
FORCE RECOMMENDATIONS
1.
Creation of the Office of
Chronic Pain Management
As
indicated above, the Barriers Work Group and the Current Practices Work
Group addressed similar issues: education of providers and consumers,
dissemination of information to providers and consumers and improved
access to care and care options. To incorporate and develop a broad based
approach for increased educational opportunities for providers, patients
and families, to provide a resource(s) for providers, and to improve
patient access to multidisciplinary teams and complementary care, the task
force recommends the 70th Legislative Assembly establish the
Office of Chronic Pain Management within the Health Division, Department
of Human Resources. This recommendation has several components:
A.
Chronic Pain Ombudsman/Office Coordinator
The
task force recommends the legislature support the establishment of one
full-time position within the Office of Chronic Pain Management to serve
as an ombudsman for patient and provider concerns.
The individual holding this position will also be responsible for
the coordination of efforts to implement task force recommendations.
Specific
duties of this position would include, but are not limited to:
·
Coordination, facilitation, and advocacy for chronic pain patients
and providers;
·
Monitor and facilitate implementation of task force
recommendations;
·
Establishment of office procedures for the Office of Chronic Pain
Management;
·
Documentation and reporting of statistics that would be used to
generate reports submitted by the Office of Chronic Pain Management;
·
Development, maintenance and dissemination of current resources
that would address pain patients and providers;
·
Investigation of the
development of regional pain centers (see below), including the assessment
of the funding requirements for operation;
·
Investigation of the
establishment of a Chronic Pain Registry (see below); and
·
Acquisition of funding to support regional conferences and research
management.
In
the event that resources are not available to support the establishment of
the Office of Chronic Pain Management in its entirety, the task force
strongly recommends establishment of the ombudsman position. While the Office for Oregon Health Plan Policy and Research
and the Board of Medical Examiners were considered, the task force felt
the Health Division is the most appropriate agency to take on this role.
B.
Regional Conferences
The
Office of Chronic Pain Management would recruit and develop organizations
or individuals to organize regional conferences on pain assessment and
management, which would offer workshops focused on provider concerns,
patient and family needs, as well as integrated sessions. These
conferences would be a result of collaborative efforts among many
interests, including the Oregon Health Division, the Board of Medical
Examiners, the Oregon Medical Association, the Board of Dental Examiners,
the Oregon Dental Association, Oregon Health Sciences University, health
care organizations, and the Foundation for Medical Excellence. Conferences
would be designed to increase provider and patient education and to
increase provider/patient interaction.
C.
Research Management
The
task force recommends the Office of Chronic Pain Management be responsible
for facilitating and monitoring pain and symptom management research. The office would work cooperatively with the Office of
Oregon Health Plan Policy and Research (OOHPPR) to explore and evaluate
pain management as a performance measurement.
The office would also encourage state agencies, universities,
health care providers, institutions, and health plans to conduct research
in pain assessment techniques, complementary disciplines, and service
delivery.
D.
Chronic Pain Management Registry
The
task force recommends serious consideration be given to the establishment
of a Chronic Pain Management Registry.
The purpose of the registry would be to improve patient care,
facilitate referrals to multidisciplinary pain teams when appropriate,
evaluate measurable improvements in functional outcome, reduce the
potential for drug seeking behavior by patients, and decrease health care
provider apprehension regarding possible sanctions by regulatory bodies.
To function effectively, incentives for both persons with pain and
providers would need to be great enough to ensure adequate participation.
The
task force recommends the Office of Chronic Pain Management work with
health professional licensing boards, persons with pain, advocacy groups,
and other appropriate entities to explore the possibility of developing
such a registry. The task
force recommends the Office report on the status of the project by
December 2000. Should
agreement be reached regarding the value of the registry and how it should
operate, the task force recommends the Office seek grant funds to design,
develop, and implement a Chronic Pain Management Registry.
E.
Regional Pain Centers (located in various parts of the state)
The
task force sees potential value in the development of Regional Pain
Centers located in various sites around the state and recommends the
Office of Chronic Pain Management investigate the feasibility of setting
up such centers.
Regional
Pain Centers would be centralized clinics, coordinated with existing
programs such as the Area Health Education Centers, offering access and
referral to, and continuing education of, multidisciplinary clinicians,
including complementary medicine providers. Regional pain centers could
also work to increase awareness of attitudinal and cultural differences
and to dispel myths relating to pain and pain treatment.
2. Statutory Changes
(Legislative Concepts)
Although
Oregon began to address intractable pain with the passage of SB 671 in
1995, barriers for prescribing controlled substances still remain.
Adequate pain treatment is an evolving priority, and physician fear of BME
discipline relating to prescribing practices remains prevalent within the
medical community. The task
force recommends the following changes to statutory law:
A.
Amend the Intractable Pain Act (ORS 677.470 – 485)
The task
force recommends the deletion of the requirement for provider consultation
in the Intractable Pain Act. Several
members of the task force voiced strong objections to the statutory
requirement that a physician treating a person with intractable pain
consult another physician prior to prescribing controlled substances under
the Act.
The concerns centered on the fact that the requirement may act as a
barrier to effective treatment for persons with pain.
Further, if a physician is maintaining the current standard of
care, consultations should be conducted routinely without the law
requiring them. The
establishment of a statutory requirement for only one condition – pain
– has led to provider and patient misunderstanding and confusion.
The dissenting opinions expressed center around the concern that
elimination of the requirement would lead to further confusion.
Since the Board of Medical Examiners has instructed physicians on
interpreting the Intractable Pain Act, including the requirement to obtain
a consulting opinion, a few task force members objected to the elimination
of the statutory requirement.
B. Extension of Task Force Sunset Date
In order to
insure continuity of efforts and to refine task force recommendations, the
task force recommends the extension of the December 31, 1999, sunset date
to December 2002. It is further recommended that the required number of
task force members be eliminated, and that the task force be directed to
meet ‘periodically’ rather than once every two months as the original
language requires. In addition, the task force should be authorized to
accept reports from those entities responsible for implementing the
recommendations of the task force, and be directed to report to the 71st
and 72nd Legislative
Assemblies and the Governor.
C. Legislative Consideration and Adoption of a Resolution of
Rights for Persons with Pain
The
task force recommends the 70th Legislative Assembly consider
and adopt a Resolution of Rights for Persons with Pain. The resolution should recognize the following:
Inadequate
treatment of acute and chronic pain, whether due to malignancy or
non-malignant disorders, is increasingly being recognized as a significant
health problem. Health care providers need to recognize that effective
pain management is the single most important treatment that a provider can
provide for some patients. The State of Oregon encourages health care
providers to view effective pain management as a part of quality medical
practice of all patients with pain, whether it is acute or chronic. All
providers are encouraged to become knowledgeable about effective methods
of pain treatment as well as the statutory requirements for prescribing
controlled substances. The medical management of pain should be based upon
current knowledge and research and include the use of both pharmacologic
and non-pharmacolgic modalities. Pain should be assessed and treated
promptly and the quantity and frequency of medications and other
treatments should be adjusted according to the intensity and duration of
the pain. Providers should recognize that tolerance and physical
dependence are normal consequences of sustained use of opioid analgesics
and are not synonymous with addiction.
Physicians
and other health care professionals should not have to fear disciplinary
action from the Oregon Board of Medical Examiners or other regulatory
agencies for prescribing, dispensing, or administering controlled
substances, including opioid analgesics, for a legitimate medical purpose
in the usual course of professional practice.
Persons with pain have the right to have their pain report be believed and
to not be discriminated against because of age, gender, mental abilities
and prior or current substance abuse history.
Persons
with pain have the right to considerate and respectful care from all
health care professionals involved in the management of their pain.
Persons
with pain have the right to spiritual, psychological and other appropriate
support in dealing with their pain disorder.
Persons
with pain have the right to have the diagnosis, prognosis, and treatment
plan explained and discussed in an atmosphere of mutual cooperation.
Persons
with pain have the right to be informed of all complementary treatment
modalities that are available for management of their pain disorder.
Persons
with pain have the right to refuse any and all treatments and to be
informed of any of the medical consequences of such refusal.
Persons
with pain have the right to request a second opinion regarding their
diagnosis and treatment plan.
Persons
with pain have the right to be advised of their own responsibilities in
following through with a mutually agreed upon plan of treatment.
Therefore,
the 70th Legislative Assembly directs the directors of Department of Human
Resources, health-related boards commissions and health care professional
organizations to make every effort to support the rights of persons with
pain as outlined above and to widely distribute this information to
applicants, licensees and the general public.
3.
Improved Provider and Consumer Education
A.
Undergraduate Education
The task
force encourages all health professional training programs to incorporate
both classroom and clinical or practical experience in pain management.
These programs should incorporate and promote multi-disciplinary
approaches.
B.
Graduate Education
The
task force encourages all health professional training programs to
incorporate student training with at least one chronic pain patient.
These programs should incorporate and promote multi-disciplinary
approaches.
The
task force encourages schools of medicine, dentistry, pharmacy, nursing,
chiropractic and complementary medicine to appoint a curriculum
subcommittee, consisting of specialists in the areas of pain management
and end-of-life care. The subcommittee will conduct a review of current
curriculum and make recommendations regarding improved education on pain
and symptom management. The
task force recommends the schools report their efforts in this regard to
the task force in December 1999 and December 2000.
In
addition, the task force supports a proposal set forth by OHSU
calling for the inclusion of chronic pain patient cases into the
performance-based assessment for third year medical students as well as in
the dental school curriculum. This
approach will enable OHSU to determine whether the students are developing
adequate skills in chronic pain management and treatment. Should adequate
resources be found to support this activity, the program could be added to
the curriculum by 2000.
C.
Continuing Education
To
improve provider knowledge and, thus, patient care, the task force
recommends a collaborative effort in provider education.
Specifically, the task force recommends that health care
professional organizations, regulatory boards, educational institutions,
and consumers cooperate in providing continuing medical education programs
focusing on chronic pain assessment and treatment.
The task force recommends consultation with specialty societies,
the Foundation for Medical Excellence, and the International Association
for the Study of Pain (IASP).
The
task force further recommends the Board of Medical Examiners, the Board of
Pharmacy, the Board of Nursing, the Board of Dental Examiners and the
related professional associations regularly provide information to their
members regarding the latest developments in the treatment of chronic
pain. The Office of Chronic
Pain Management, if established, would facilitate these efforts by
soliciting grant funds for continuing medical education programs. The task
force recommends these entities report their efforts in this regard to the
task force in December 1999 and December 2000.
The
task force supports the two continuing education models submitted by OHSU.
The task force encourages further development and detailed
proposals be submitted to the Office of Chronic Pain Management.
D.
Consumer Education
The
task force recommends all health care providers and institutions provide
accurate, thorough, and timely information on pain treatment options and
resources to pain patients and the general public.
4.
Improved Access to Treatment for Pain
A.
Establishment of Pain as a Diagnosis on the Oregon Health Plan List
of Prioritized Services
Pain
is a symptom rather than a diagnosis and, for this reason, does not appear
on the Oregon Health Plan List of Prioritized Services. All necessary diagnostic services are covered until a
diagnosis is made. Once a
diagnosis is established, further treatment coverage, including the
management of pain and other symptoms, is determined by the ranking of the
condition as described by the Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) in the prioritized list.
Currently, there are 743 condition/treatment pairs.
Lines 1 to 574 are currently funded (covered).
If
the condition causing pain appears in the funded portion of the list, all
medical and/or surgical procedures as identified by CPT codes on each
line, are covered. Any
ancillary services such as prescription drugs, physical therapy, and
durable medical equipment are covered.
Conditions in the funded portion of the list that frequently
involve pain include cancer, trauma, cardiac conditions, and chronic
debilitating conditions such as arthritis and late effects of
neuromuscular conditions. The
latter are covered on four funded dysfunctional lines that group multiple
conditions resulting in dysfunction in eating, swallowing, bowel/bladder
control (Line 215), dysfunction in posture and movement (Line 334),
dysfunction resulting in loss of ability to maximize self-directed care
(Line 457) and dysfunction in communication (Line 458).
Comfort care measures for the terminally ill rank high on the list
(Line 263). This line
includes pain management, palliative care, and hospice services.
For
conditions appearing below the line (not covered), treatment following the
diagnostic work up is not covered. The
patient is instructed on how to manage symptoms with over-the-counter
medications and self-care at home. Conditions
involving pain that currently appear below the line include fibromyalgia
(Line 606) chronic low back pain without neurological involvement (Line
609), and bursitis (Line 663). Chronic
Fatigue Syndrome (CFS) does not appear on the list as it is listed in the
symptoms, signs, and ill-defined section of ICD-9-CM.
As a rule, ICD-9-CM codes in this section do not appear on the list
because they are not definitive diagnoses.
Many syndromes that do not have proven effective treatments do not
appear on the list. Treatment can be provided for components of CFS – such as
depression- that are diagnoses listed in the funded portion of the list.
The
task force recommends the Health Services Commission seriously consider
pain as a diagnosis as well as a symptom. The task force further
recommends that chronic pain and corresponding treatment be placed on the
prioritized list of conditions covered by the Oregon Health Plan.
In addition, the task force requests the commission include pain
centers as ancillary services.
In
the meantime, within existing commission procedures, the task force
recommends the commission’s Health Outcomes subcommittee consider moving
pain conditions to a “covered line” on the prioritized list.
Those conditions include, but are not limited to fibromyalgia
(currently on line 606), acute and chronic disorders of the spine without
neurological impairment (currently on line 609) and bursitis (currently on
line 663).
B.
Palliative Care
“Palliative
care is the active total care of patients whose disease is not responsive
to curative treatment. Control
of pain, other symptoms, and of psychological, social and spiritual
problems is paramount. The
goal of palliative care is achievement of the best possible quality of
life for patients and their families.
“Palliative
care affirms life and regards dying as a normal process, neither hastens
nor postpones death, provides relief from pain and other distressing
symptoms, integrates the psychological and spiritual aspects of patient
care, offers a support system to help patients live as actively as
possible until death, and offers a support system to help the family cope
during the patient’s illness.”
The
task force recommends universal access to palliative care for all persons
in pain. Palliative care
applies to individuals with chronic, acute, and end-of-life conditions.
Financial barriers are a significant problem to obtaining adequate
pain and symptom management. Therefore, the legislature should seriously consider
legislation to improve access to palliative care, including access to
hospice care for uninsured patients and fund a pilot project that
evaluates the costs and benefits of chronic pain treatment.
Demonstration
Project for Accesss to Chronic Pain Care
The
task force recognizes that chronic pain care is in need of a new economic
model and recommends the Office for Oregon Health Plan Policy and Research
and the Office of Medical Assistance Programs participate in a
demonstration project with the goal of improving the management of
chronic, non-malignant pain. An
outline of one such model may be found at Appendix B.
Improved
Access to Hospice Care
Although
many assert Oregon leads the nation in end of life care, there is still
room for improvement. Most
uninsured hospice patients are referred at a very late stage in their
disease and are usually referred following costly emergency or inpatient
hospital care. Access to hospice for the uninsured would mean more timely
admission to hospice, better comfort care and pain management, as well as
reduced hospital costs.
Generally,
terminal patients without coverage for hospice care are under 65 years of
age and are not eligible for Medicare or the Oregon Health Plan. Often,
they are the working poor with income slightly above the poverty level.
These clients are provided uncompensated hospice care, creating a
financial burden for hospice programs.
In the alternative, these patients receive more costly treatment as
inpatients in a hospital setting, or receive no treatment at all.
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