Copyright 1999 Federal News Service, Inc.
Federal News Service
OCTOBER 13, 1999, WEDNESDAY
SECTION: IN THE NEWS
LENGTH:
1948 words
HEADLINE: PREPARED STATEMENT OF
THE PAIN
CARE COALITION - PCC
BEFORE THE SENATE COMMITTEE ON HEALTH,
EDUCATION, LABOR AND PENSIONS
SUBJECT - PAIN MANAGEMENT AND IMPROVING
END-OF-LIFE CARE
BODY:
The Pain Care
Coalition is pleased to present this statement on pain management and improving
end-of-life care. The Pain Care Coalition is a national coalition that advocates
for responsible pain care policies at the federal level. The Coalition was
formed in 1998 by concerned organizations representing the interests of pain
care professionals and their patients. Constituent members of the Coalition
represent a broad spectrum of physicians and other health care professionals
involved in the diagnosis and treatment of patients suffering from acute and
chronic pain. Members also include those professionals who conduct biomedical
and related research into the causes of pain and the effectiveness of diagnostic
and therapeutic approaches to freeing patients from pain or lessening the pain
of those who must live with it.
The Coalition appreciates the Committee's
interest in the issue of pain care. Pain is a major public health problem in
this country. It effects people of all ages and at every stage of life. It is
generally recognized that throughout the nation, and regardless of age, setting,
or health status, severe pain is often under-treated or mistreated, if not
overlooked entirely. Fifty million Americans are partially or totally disabled
by pain, and 45 percent of all Americans seek care for persistent pain at some
point in their lives. Pain imposes a tremendous burden on these individuals and
their families. It also imposes a tremendous burden on the economy, and upon the
health care system. For example, migraine alone affects over 24 million people,
the majority of them women in their 30's and 40's. This one painful disorder
alone leads to 157 million lost workdays each year at a cost to economic
productivity estimated at over $17 Billion. Costs attributable to low back pain
are even higher, and the total cost of pain to the economy is now estimated at
over $100 Billion.Pain accompanies a wide range of other clinical conditions
such as cancer, heart disease and arthritis. This form of pain is often referred
to as "secondary" pain, because it is' secondary to a primary physical illness.
For many patients, however, "primary" pain is the illness or disease. Primary
pain is pain without an identifiable cause or abnormality. Migraine is a good
example. Primary pain needs to be diagnosed and treated as aggressively as any
other major illness. However, evidence abounds that neither primary nor
secondary pain is adequately treated in this country. Recent studies of
end-of-life care in hospitals, of the elderly in nursing homes, and of the
general public in Michigan all reach the same conclusion: many, many people
endure unnecessary suffering due to inadequate pain care.
Several bills
addressing pain care issues in some manner have been introduced in this
Congress. The Pain Care Coalition welcomes these initiatives as an important
reflection of the growing awareness of and concern for pain as a public health
priority in this country, and among policy-makers at the federal level. While
the Coalition supports many of the provisions included in these bills, we are
concerned that all of the proposals put forward to date are too heavily focused
on end-of-life care at the expense of pain care more generally. Pain often
affects patients in the prime of life when effective treatment can restore
productivity and a normal life. To pain care professionals, symptom management
at the end of life, while critically important, represents only one portion of
the broad and complex spectrum of patients in pain which spans age groups,
disease states, and diagnostic and therapeutic modalities. In terms of the sheer
numbers of people who suffer from pain at various points in their lives,
end-of-life care is a relatively small portion of that broader spectrum. While
the needless suffering by those afflictedwith terminal illness cries out for
redress, is the needless suffering of a child whose pain is not
life-threatening, but keeps the child out of school, any less compelling?
Viewed in this broader context, recent proposals offered in the Congress
represent relatively timid first steps. If the Federal government is to address
pain as the serious public health problem which it represents, and to promote
pain relief by promoting good pain care, then bolder steps are required. The
Pain Care Coalition urges this Committee and other concerned Members of Congress
to consider at least the following steps as part of an initial federal pain care
agenda:
- Declare the first decade of the next century as the "Decade of
Pain Control." More than any other single step, this would dramatize the
prominence of pain as a public health problem and motivate both public and
private sectors to mount a concerted effort against needless suffering.
-
Authorize a focused pain care research agenda at the National Institutes of
Health with increased funding for both basic and clinical research. Because pain
cuts across so many diseases and disabilities, it has not been perceived as a
separate disease category and has not had its own focused constituency for
research funding. As a result, NIH spends pennies on pain care research in
relation to the impact of pain on the health care system, the economy, and the
lives of sufferers, and to the tremendous potential for continued progress in
effective diagnosis and treatment.
- Require the Medicare program to
recognize pain care as a medical specialty for claims processing purposes and
begin tracking the public expenditure of health care dollars for different modes
of treatment. Unlike the Veterans Health System, which has mounted a major pain
care initiative, the Health Care Financing Administration currently has no way
to measure what it is buying in terms of pain care or what its beneficiaries are
getting - nor does HCFA understand the amount of money that it is wasting in
misdirected or unnecessary care.
- Guarantee access to appropriate specialty
care for pain, including access to centers of credentialed treatment expertise,
as part of a comprehensive patient bill of rights. Adequate
pain relief should be a central benefit of any health insurance plan, yet
overzealous gatekeepers and restrictive provider networks prevent many patients
in severe pain from reaching the practitioners and programs that could relieve
their suffering. These patients are not just "locked in" to their managed care
plan's network, they are virtually locked into their own pain and they often
seek desperate solutions as a result. These solutions are both costly and
dangerous. Relief for these individuals may be only achieved if they can obtain
the services of a certified pain care specialist.
- Ensure access to
emergency care for severe pain as part of any comprehensive patient bill
of rights. Congress has already mandated access to emergency care for
Medicare patients under the prudent layperson standard, and it should do the
same for patients in other managed care plans. Seeking relief of severe and
relentless pain is in and ofitself a justification for emergency care, yet
managed care has a poor record of addressing the needs of patients in pain and
providing prompt patient access to appropriate diagnosis and treatment by
Physicians credentialed in pain medicine. If managed care plans are serious
about "putting patients first," covering emergency visits for patients in severe
pain is a good place to start.
In addition to these broad
recommendations, the Pain Care Coalition urges the Committee to consider the
following more limited suggestions in connection with certain aspects of the
several bills that have already been introduced:
The Pain Relief Promotion
Act of 1999 (S. 1272)
This year's version of the legislation introduced by
Senators Don Nickles (R-OK) and Joseph Lieberman (D-CT) is clear in its
recognition that the use of controlled substances to relieve pain - even when
such use may have secondary effects that raise the risk of death - is a
legitimate medical practice. However, the bill calls upon the Drug Enforcement
Administration to make difficult distinctions between this legitimate medical
use of controlled substances on the one hand, and physician-assisted suicide on
the other, based upon the motives and intent of the treating practitioner. It is
this aspect of the bill that still threatens to have a "chilling" effect on the
appropriate use of controlled substances to ease pain. To address that threat,
the Coalition urges the Committee to raise the standard of proof in civil
proceedings brought by the DEA in cases of suspected assisted suicide. An
amendment for this purpose is attached. The amendment would require the DEA to
prove its case by clear and convincing evidence in any proceeding brought to
suspend or revoke a DEA registration based on alleged physician assisted
suicide. Theamendment would not affect registration proceedings based on other
grounds. Essentially the same provision was included in the bill reported by the
Senate Judiciary Committee last year.
The Pain Care Coalition also
recommends that the pain care promotion initiatives in .Title II of S. 1272 be
expanded to address pain care more broadly. The initiatives, while promising,
are limited in scope and heavily focused on end-of-life care. A proposed
substitute to achieve this purpose is also attached.
The Conquering Pain Act
of 1999 (S. 941)
The Conquering Pain Act introduced by Senators Ron Wyden
(D-OR) and Connie Mack (R-FL) represents a milestone in federal legislation in
so far as it recognizes pain as a major public health problem in this country.
However, the legislation is also heavily focused on palliative measures with a
bias towards end-of-life care. The bill seems to ignore a fundamental aspect of
modem pain care - that for many patients, pain is the disease, not a symptom of
another illness. In these cases, the pain needs to be diagnosed and treated
aggressively, and rehabilitating patients and controlling their pain is
increasingly possible. The Coalition urges a broader focus on diagnosis and
treatment in the bill, rather than an exclusive focus on "pain management."
The Advance Planning and Compassionate Care Act of 1999 (S. 628)
This
legislation, introduced by Senators Jay Rockefeller (D-WV) and Susan Collins
(RME), aims to improve end-of-life care by expanding and clarifying requirements
for advancedirectives to ensure that an individual's health care decisions are
complied with. The Pain Care Coalition is particularly interested in Section 8
of the bill, which would add a limited outpatient prescription drag benefit to
the Medicare program targeted to patients suffering chronic pain from
life-threatening disease. The Coalition urges consideration of the attached
amendment, that would add intractable pain generally and acute pain at the end
of life to the conditions eligible for coverage. Beneficiaries who suffer from
intractable pain and pain associated with a number of end-of-life conditions now
have Medicare coverage for appropriate pain medications only if they are
institutionalized or if they are within the six month hospice "window." The
Coalition urges Committee members to support this modest improvement to what is
already a good bill.
The Pain Care Coalition applauds the Committee for
holding this hearing, and for focusing badly needed attention on issues
affecting pain care policy at the Federal level. The Coalition welcomes the
opportunity to work with interested members of Congress to advance legislative
proposals that promote appropriate pain care--care that is increasingly
available to reduce needless suffering throughout the population.
END
LOAD-DATE: October 14, 1999