HOW H.R. 2260 PROMOTES PAIN RELIEF

By Burke J. Balch, J.D., Director
NRLC Department of Medical Ethics

Physicians at the frontiers of American medicine currently have the capacity to manage virtually all physical pain. The American Medical Association (AMA) told the U.S. Supreme Court in its brief in the 1997 Washington v. Glucksberg case, "The pain of most terminally ill patients can be controlled throughout the dying process without heavy sedation or anesthesia." In the case of "a very few" patients, sedation is necessary--but, the AMA emphasized, there should be no need for a patient to die in pain.

Despite this capacity, however, there is widespread evidence that pain is frequently undertreated. A representative study by the American Society for Clinical Oncology, released in May 1998, found that a quarter of all cancer patients do not receive optimal pain management. More than half of oncologists report that more than one out of five of their patients die in pain.

This gap between knowledge and performance in pain control is generally agreed to be the result of two factors, both addressed by the Pain Relief Promotion Act.

First, many health care providers at the clinical level are inadequately trained and experienced in the techniques of pain control well known to top specialists. In response, the bill authorizes $5 million annually for new programs to collect protocols and evidence-based practices concerning palliative care and disseminate them to public and private health care programs and pro-viders, health professions schools, hospices, and the general public, as well as to provide grants for the training of health care professionals in palliative care in schools and hospices.

Second, some physicians are reluctant to prescribe adequate doses of pain-relieving medication because they fear investigation or discipline by authorities on the lookout for drug abuse. In response, the bill adds to the Controlled Substances Act this provision: "[A]lleviating pain or discomfort in the usual course of professional practice is a legitimate medical purpose for the dispensing, distributing, or administering of a controlled substance that is consistent with public health and safety, even if the use of such a substance may increase the risk of death."

For these reasons, the American Medical Association and key specialist organizations dealing with the treatment of pain have endorsed the bill. These include the American Society of Anesthesiologists and the American Academy of Pain Management, as well as the National Hospice Organi-zation and the Hospice Association of America.

Contrary to some press reports, the bill does not increase in any way the Drug Enforcement Administration's authority to revoke DEA registrations of doctors who use federally controlled substances to assist suicide in any of the 49 states (and D.C.) where assisting suicide is not expressly authorized as a matter of state law. Attorney General Janet Reno has made clear that authority exists under current law.

Even in Oregon, the bill will not increase DEA investigations of doctors because, as the House Judiciary Committee report makes clear, "reports and records required by the assisted suicide law will demonstrate whether federally controlled substances have been intentionally dispensed to assist suicide. ... [I]n order to escape criminal liability that would otherwise exist under Oregon law for assisting a suicide, a physic