The Pain Relief Network

Reason Hit & Run
By: Jacob Sullum
Dec 9, 2009

This week the Institute for Justice and the Reason Foundation (which publishes Reason magazine and Reason Online) filed a friend-of-the-court brief on behalf of Siobhan Reynolds, the pain treatment activist who is fighting a federal prosecutor’s vindictive obstruction-of-justice investigation. As I explained in a September column, Reynolds, president of the Pain Relief Network (PRN), ran afoul of Assistant U.S. Attorney Tanya Treadway by publicly defending Haysville, Kansas, physician Stephen Schneider, whom Treadway is prosecuting on drug charges related to his painkiller prescriptions. After unsuccessfully seeking a gag order to prevent Reynolds from talking about the case, Treadway tried a different tack. She obtained grand jury subpoenas that demanded a wide range of material detailing PRN’s efforts on behalf of Schneider and other doctors Reynolds believes have been wrongly accused of running “pill mills.” Reynolds refused to comply with the subpoenas on First Amendment grounds and consequently is paying $400 a day in contempt fines. With help from the ACLU, she is asking the U.S. Court of Appeals for the 10th Circuit  to overturn the contempt finding and quash the subpoenas.

Because most of the record in the case (including Reynolds’ appeal brief) is sealed*, ostensibly to protect the secrecy of grand jury proceedings, it is hard to tell exactly how Treadway thinks Reynolds obstructed justice. But her theory seems to be that Reynolds did so by criticizing the government’s case against Schneider and thereby influencing the jury pool—i.e., by exercising her constitutional right to freedom of speech. The “evidence” sought by Treadway includes correspondence related to a billboard defending Schneider and a PRN video about the conflict between drug control and pain control. The I.J./Reason brief argues that forcing PRN to divulge information about its membership, finances, communications, and internal operations “chills speech and burdens the right to engage in anonymous speech and association.” It reinforces that point by citing I.J.’s research on the chilling effect of public disclosure requirements. It also argues that a fishing expedition like Treadway’s violates the First Amendment right to freedom of association by requiring disclosure of an activist group’s political strategies.

*Update: Before I wrote this post, I checked with Geoffrey Michael, the lead attorney on the I.J./Reason brief, to make sure it was OK to make the file available here. He thought that was fine, since the brief did not contain any secret grand jury information. But he has since informed me that the 10th Circuit’s clerk says the brief should not be published, which is why it is no longer here. This instruction illustrates the ridiculously broad notion of grand jury secrecy at play in this case, since the amicus brief is based entirely on publicly available information. Scott Michelman, the ACLU attorney who is representing Reynolds, told me he was not allowed to share his U.S. District Court brief opposing the subpoenas, although he was free to reiterate the arguments it contained.

http://reason.com/blog/2009/12/09/tanya-treadways-unconstitution

The New York Times
Nov 5, 2009
By John Tierney

Chronic pain affects more than 70 million Americans, which makes it more widespread than heart disease, cancer and diabetes combined. It costs the economy more than $100 billion per year. So why don’t more doctors and researchers take it seriously?

That is the challenge raised by a new report from the Mayday Fund, a nonprofit group that studies pain treatment. The report, which been endorsed by an array of medical groups, advocates a revolution in the training of doctors, the financing of research and the education of law-enforcement officials.

“The fact is that people aren’t getting competent and cost-effective treatment for chronic pain,” said Dr. Russell Portenoy, one of the co-chairmen of the panel that prepared the report.

Dr. Portenoy, the chairman of the department of pain medicine and palliative care at Beth Israel Medical Center, was one of the pain experts who supported William Hurwitz, the Virginia doctor who was imprisoned for prescribing opioid painkillers to patients who resold them. (Dr. Hurwitz’s sentence was reduced after a retrial in which Dr. Portenoy and other experts testified on his behalf.)

At a news conference Wednesday, Dr. Portenoy and the other co-chairman of the Mayday panel, Dr. Lonnie Zeltzer of the University of California, Los Angeles, said patients’ needs had to be better balanced against the concerns of law-enforcement officials, whose prosecutions of Dr. Hurtwitz and other doctors have made physicians reluctant to prescribe opioids. Dr. Zeltzer said doctors were especially reluctant to prescribe such painkillers to young people, and she cited the example of a teenager who had been incapacitated for six months until finding a doctor willing to prescribe opioids.

“Don’t assume that your doctor knows what to do to treat your pain,” Dr. Zeltzer advised patients. Read more…
She and the other members of the panel urged better pain-management training in medical schools and more money for pain research, which, according to the report, receives 1 percent of the budget of the National Institutes of Health.

The panel also urged the federal Department of Health and Human Services to reform the way doctors are reimbursed for treating pain. Dr. Portenoy said that the current system had “misaligned incentives” encouraging doctors to preform procedures like injections and surgery and that doctors who performed those procedures could make 10 times as much per hour as doctors who treated pain in other ways.

Distorted incentives and inadequate treatment are hurting patients at the same time they are driving up health costs, according to the report:

Instead of receiving effective relief, patients with persistent pain often find themselves in an endless cycle, seeing multiple health care providers, including many specialists in areas other than pain, who are not prepared to respond effectively. They often endure repeated tests and inadequate or unproven treatments. This may include unnecessary surgeries, injections or procedures that have no long-term impact on comfort and function. Patients with chronic pain have more hospital admissions, longer hospital stays and unnecessary trips to the emergency department. Such inefficient and even wasteful treatment for pain is contributing to the rapid rise in health care costs in the United States.

You can read the rest of the Mayday report and its recommendations here. Do you have any recommendations on what should be done, and any guess as to the likelihood of reforms in the treatment of chronic pain?

http://tierneylab.blogs.nytimes.com/2009/11/05/treating-the-pain-epidemic/#more-7005

Nov 4, 2009
Author Unknown
medicalnewstoday.com

Science now offers us ever more advanced ways to understand and control pain. But with those new treatments come new questions about the use (and misuse) of state-of-the-art technology and how far pain management can and should go. Is pain a symptom or a disease? How much pain should be relieved? Can reducing pain be inappropriate or detrimental? Can technologies capable of scanning the brain tell us whether a patient is really experiencing pain? And what questions arise in confronting (and treating) pain in animals and other non-human beings?

On November 13, the Center for Neurotechnology Studies at the Potomac Institute for Policy Studies will present the lecture “From a Neuroscience of Pain to a Neuroethics of Care” by Prof. James Giordano, internationally known for his work on the neuroscience and neuroethics of pain. The program will address the neuroscientific progress achieved during the Congressionally-designated Decade of Pain Control and Research, and discuss the ethical implications of this knowledge for medicine, and society at large. Researchers are now looking ahead to a Decade of the Mind, and this lecture raises questions about whether what we know about pain will both guide and be guided by what we seek to learn about the mind, and the nature of self and others.

What: CCNELSI Lecture: “From a Neuroscience of Pain to a Neuroethics of Care”

Who: James Giordano, Ph.D.

Where: Potomac Institute for Policy Studies, 901 North Stuart Street, Suite 200, Arlington, VA, 22203

When: November 13, 2009, 3:30 – 6:00 pm

More info: http://www.ccnelsi.com

http://www.medicalnewstoday.com/articles/169847.php

Oct 29, 2009
By Carrie Johnson
Washington Post Staff Writer

Heightened efforts by the Drug Enforcement Administration to crack down on narcotics abuse are producing a troubling side effect by denying some hospice and elderly patients needed pain medication, according to two Senate Democrats and a coalition of pharmacists and geriatric experts.

Tougher enforcement of the Controlled Substances Act, which tightly restricts the distribution of pain medicines such as morphine and Percocet, is causing pharmacies to balk and is leading to delays in pain relief for those patients and seniors in long-term-care facilities, wrote Sens. Herb Kohl (D-Wis.) and Sheldon Whitehouse (D-R.I.).
The lawmakers wrote to Attorney General Eric H. Holder Jr. this month, urging that the Obama administration issue new directives to the DEA and support a possible legislative fix for the problem, which has bothered nursing home administrators and geriatric experts for years.

The DEA has sought to prevent drug theft and abuse by staff members in nursing homes, requiring signatures from doctors and an extra layer of approvals when certain pain drugs are ordered for sick patients.
The law, however, “fails to recognize how prescribing practitioners and the nurses who work for long-term care facilities and hospice programs actually order prescription medications,” Kohl and Whitehouse write. They conclude that delays can lead to “adverse health outcomes and unnecessary rehospitalizations, not to mention needless suffering.”

Most nursing homes do not have pharmacies or doctors on site, adding to delays for patients who fall ill late at night or in transition from a hospital.

Justice Department and DEA officials had no immediate comment. The DEA sent out guidance last summer in response to some of the pleas, but it did not resolve the central issue of whether a nurse could serve as an agent of a doctor and administer pain medication with a verbal directive rather than a written prescription from a doctor.
The problem took on new urgency this year after the drug agents heightened their enforcement of the rules at pharmacies in Ohio, Michigan, Wisconsin and Virginia. The pharmacies face tens of thousands of dollars in fines if they deviate from strict controls that require doctors to sign paper prescriptions and fax them to a pharmacy before a nurse can administer them in the nursing home setting.

“The system is broken. It isn’t working, and patients are suffering,” said Claudia Schlosberg, director of policy and advocacy for the American Society of Consultant Pharmacists. “While we need to ensure there are proper controls on the medications, the overall law enforcement concern has to be compatible with meeting patients’ needs, and right now it’s not.”

Doctors in nursing homes say the restrictions do not take into account that many more patients, with higher levels of illness and pain, are moving into long-term-care sites and out of hospitals.
William Smucker, medical director of the Altenheim Nursing Home in Ohio, said that the “delay is not what I would want for myself or my family, and it’s not the way I practice in other settings.”
Terence McCormally, a doctor who cares for patients in nursing homes in Northern Virginia, said the tug of war reflects “the tension between the war on drugs and the war on pain.”
“For the doctor and the nurse, it’s a nuisance,” he said, “but for the patient it is needless suffering.”

http://www.washingtonpost.com/wp-dyn/content/article/2009/10/28/AR2009102803146.html?utm_source=The+Freeman&utm_campaign=26e0b19fdd-In_brief_10-20-2009&utm_medium=email

Medical News Today
Oct 27, 2009

A new Pain Medicine Position Paper published by leaders of the American Academy of Pain Medicine (AAPM), reveals businesses lose $61 billion annually due to ineffective pain care and the lack of optimal pain care delivery. Leaders from the organization are now implementing and teaching a new, “population-based” approach to delivering care with the goal of alleviating pain so patients can get on with their lives.

AAPMedicine’s President Rollin M. Gallagher, MD MPH comments, “Pain affects everyone, and for many millions, pain becomes chronic, a scourge that affects every part of their lives–their work, their hobbies, their friendships, their families, their sex, their fun, their finances, their mood, and even their fundamental sense of identity, who they are. According to the National Institutes of Health, pain is one of our most important national health problems, costing the American public more than $100 billion each year in health care, compensation and litigation. The AAPMedicine’s Position Paper offers solutions that will fundamentally change the way pain is approached in the health care system. The Paper proposes a population-based approach to pain management that will both improve the competency of the health care system to manage pain for the millions of patients suffering needlessly in hospitals with acute pain and on into their lives with chronic pain, and will also reduce the cost of pain to our society. People will be able to work who couldn’t work before. People who work will work longer, better and more productively. People with terminal cancer will die in comfort, preserving their personal dignity and mitigating the emotional suffering of their families. The Proposal is consistent with the medical home approach being fostered as a solution to the problems besetting our health care system, an approach that emphasizes patient responsibility, early effective treatment, and when pain becomes chronic, competent longitudinal treatment, what we call ‘chronic illness management’.”

A population-based approach to pain includes stepped care that is designed to deliver timely access to levels of care that are needed to prevent chronic pain from beginning, or when pain persists, minimizing morbidity through effective care:

Step One: Prevention of disease or injury with the use of evidence-based self-care, such as diet, exercise, ergonomics (alteration of work activities) or cessation of smoking and other drug abuse to reduce the risk of injury or disease.

Step Two: If self-care is not working, patient will then visit their primary care physicians for evaluation and management using evidence-based algorithms.

Step Three: If disabling pain persists, the patient will be referred to a pain medicine specialist who will collaborate with a team of providers, including, nurse case managers, psychologists and physical therapists.

Step Four: If the patient remains in disabling pain, he or she will be referred to a pain medicine specialist within a subspecialty of care.

Currently there is no unified organizational model of pain medicine, which has led to ineffective and fragmented pain care with poor outcomes and higher costs than necessary. This fragmentation threatens patient safety and causes the passing of a patient from doctor to doctor for a diagnosis and pain treatment, even though that doctor may have had minimal or even no specific training in chronic pain management. The Academy believes one of the solutions to this complex problem is the establishment of Pain Medicine as a recognized primary medical specialty. This recognition would allow Pain Medicine’s specialized knowledge, education, training, and multidisciplinary approach to provide standardized training for all physicians and integrated and comprehensive pain care to millions of Americans suffering with acute, cancer and chronic pain.

One segment of society that has carried the burden of an ineffective pain care delivery system is the business community. It is estimated to cost $61.2 billion annually in lost productive time. The majority of this cost (76.6%) is attributed to reduced performance while at work, not work absence. During the course of two weeks, 13 percent of the total workforce experienced a loss in productive time due to a common pain condition. An estimated 3.8 billion hours of work are also lost annually due to pain.

As the largest purchasers of healthcare, businesses have much to lose from ineffective pain treatment of their employees. Finding a unified approach to pain medicine is critical. Back pain alone cost businesses $19.8 billion in lost productive time, with almost three-quarters of the cost attributed to complications of back pain from the lack of proper care.

“The ineffective treatment of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the brain and spinal cord. This is referred to as neuropathic pain, a neurobiological disorder that is difficult to diagnose and manage. Persistent pain of this nature often results in further bio-psycho-social changes, which in turn result in further pain and increasing disability. This vicious cycle transforms a human being into a patient who unwittingly becomes a burden to himself, his family and society at large. The emotional, societal and financial costs are immeasurable,” according to AAPMedicine’s Executive Medical Director, Philipp M. Lippe.

Currently there are not enough pain medicine specialists to treat back pain and other pain conditions, and the system for training physicians in the discipline of pain medicine remains insufficient. The Academy’s solution calls for better residency training programs in pain medicine, which will lead to better and more cost-effective pain care.

Recognizing pain medicine as a primary medical specialty would also increase federal funding into pain research. As the population ages, there will be an increased need for physicians who have both specific expertise in pain medicine and broader training in the needs of an aging population. An increase in federal funding for pain research is critical to keep pace with the growing problem of pain in America.

Taking these steps will also improve health care coverage for pain care. Insurance companies often refuse to cover pain-relieving treatments, and access to pain rehabilitation is non-existent in many parts of the country. The Veteran’s Affairs’ medical system has recognized the need for change in pain care and now requires VA health care institutions to provide organized pain assessment and management. Developing an optimal system of pain care delivery would not only address better healthcare for the millions of Americans in daily pain, but its benefits would filter down to both businesses and society. Safe, effective and affordable pain treatment is possible, and the benefits are immeasurable. Click here to view the Pain Medicine Position Paper.

About the AAPMedicine

For more than 25 years, the American Academy of Pain Medicine (AAPM) is the premiere medical specialty society representing more than 2,200 physicians practicing in the field of comprehensive pain medicine.

Source: American Academy of Pain Medicine

http://www.medicalnewstoday.com/articles/168771.php