Five states have the most balanced pain policies in the country, according to a report card released last year. They are Kansas, Michigan, Virginia, Wisconsin and Oregon. All received a grade of A in “Achieving Balance in State Pain Policy: A Progress Report Card,” the July 2008 report found.

“States that have an ‘A’ have been able to adopt a number of state laws, regulations, guidelines and policies that promote the safe and effective use of opioid medications without establishing barriers to their use,” said Aaron M. Gilson, director of the U.S. Program at the University of Wisconsin Pain & Policy Studies Group (PPSG).

The study, which was published by PPSG, evaluated states based on their ability to support public health with proper pain management protocols and, at the same time, protect public safety with legislation to protect against drug abuses. The report termed this dual function the Central Principle of Balance.

“Balanced policies have the potential to enhance pain management while avoiding the potential to interfere with such treatment,” according to the report.
Still, many states have policies that impede medical practitioners’ medical use of pain medications. Also, certain state drug abuse laws interfere with the legitimate use of pain medications.

“Many states have policies that create barriers to patients getting their pain treated adequately, or are silent about recognizing pain relief as part of quality healthcare practice; it is these types of policies we are trying to improve,” background information on the report said.

Criteria for determining grades
To judge state policies, the PPSG developed 16 criteria based on the Central Principle of Balance. Essentially, it analyzed states’ policy language to determine whether it promoted pain management or hurt pain management.
The PPSG considered positive those provisions that encouraged pain management and recognized it as a part of general practice. Also recognized as good pain policies were those that treated the medical use of opioids as legitimate professional practice and did not confuse physical dependence or analgesic tolerance with “addiction.”

By contrast, it considered negative those provisions that included language that stigmatized pain management. It also disapproved of those provisions that considered opioids a treatment of last resort, those that implied the medical use of opioids to be outside legitimate professional practice, and provisions that confused physical dependence or analgesic tolerance with “addiction.”

The punitive nature of many pain policies hinders many practitioners from using medications to alleviate pain, according to the report. Health professionals may be reluctant to prescribe such medications because of the risk of violating laws that aim to prevent trafficking and abuse of controlled substances. Such regulations not only restrict healthcare decision making, but they also communicate negative messages about pain management and using pain medications, according to the report.

Progress over the years
Over the last eight years, state pain policies have become more balanced, the report found. Seven states showed positive grade changes since 2007. No states received a D, D+ or F, and no state’s grade decreased since last year or since 2000. Also, in 2008, for the first time in recent years, no state added restrictive or ambiguous policy language.

“The momentum of positive policy change, first reported in 2003, seems to be thriving,” the report noted.

Based on findings from five separate PPSG evaluations of state pain policies, each state was assigned a grade for 2000, 2003, 2006, 2007 and 2008. Most states lie somewhere in the middle of the grade scale last year, according to the report.
While five states received the highest grade, a total of 11 states, including Alabama, Massachusetts, Rhode Island and Utah, received a B+. The largest number of states—17—received a B. These states ranged from Arkansas to Florida, to Hawaii to South Dakota. Meanwhile, 12 states received a C+ and six states received a C. (The District of Columbia, considered a state for the report, received a C+.)

Overall, states are becoming more progressive in terms of their pain policies, the report suggested. The difference between achieving a low grade and a high grade often was simply a matter of adopting new statutory language and discarding outdated provisions. Georgia, as an example, rose from a D+ to a B from 2007 to 2008 with its adoption of a provision recognizing the medical use of opioids as a part of legitimate professional practice. It also replaced a restrictive medical board guideline adopted in 1991 with a policy based on the Federation of State Medical Board’s “Model Policy for the Use of Controlled Substances for the Treatment of Pain.” This state showed the biggest improvement in its pain policies from 2007 to 2008.

Still other states also took positive steps to recognize the importance of pain medications. Oregon jumped to an A in 2008 from a B+ in 2007 by repealing the term “intractable pain” from statute. Maine, meanwhile, moved from a B to a B+ over those same two years by adopting a provision recognizing that the use medical use of opioids is part of legitimate professional practice.

Room for improvement
Unfortunately, too many onerous policies still exist throughout the country, according to the report. Drug-abuse laws that interfere with legitimate medical practice and patient care pose a problem.

“Many states now face the challenge not only of adopting positive policies, but of removing restrictive language from legislation or regulations,” according to the report. “Even for states that have achieved an A, there remains the potential for additional policy activity (however well-intentioned) that might introduce potentially restrictive requirements or limitations.”

Gilson feels dismayed about the extent to which archaic definitions of addiction in state laws have largely remained unchanged in the last eight years. Many of those definitions are based on a definition from federal law from the 1970s, he noted.
“One thing that hasn’t been addressed is definitions for patients who are taking opioids but have developed dependence,” he said. “They could be classified as an addict in 16 states.”

Some states face the challenge of getting rid of negative statutory language. While New York and Texas have repealed restrictive legislative or regulatory language, they still have a large number of negative provisions, the report said.
“There’s been a lot of effort to remove legal barriers that have persisted for many years, if not decades,” Gilson said. “But more still needs to be done.”
 
Encourage states to change
To improve their attitudes toward pain management, many states have developed task forces, commissions, advisory councils, and convened summit meetings. Such bodies should work to evaluate a state’s pain policies. Membership should include governmental and non-governmental stakeholders, and dedicated staffing should be available, the report recommends.

As states continue to adopt balanced policies toward pain management, they need to communicate that to professional caregivers, according to John R. Seffrin, CEO of the American Cancer Society.

“States must effectively inform the medical community about improved pain policies so people with pain can benefit from them,” he said in a public statement. “Patients, health organizations, health care professionals, regulatory officials, licensing boards, and policymakers all have a role to play to promote a balanced approach to pain control policy and practice.”

PPSG expects to release another report about pain as it relates to nursing practice policy in 2011.
To learn about states’ individual pain initiatives and to find state contacts, visit the American State Pain Initiative’s Web site at www.aspi.wisc.edu. Click on “State Pain Initiatives” on the left navigation column.
Also, for more information about pain for patients, caregivers and healthcare professionals, go to the American Pain Foundation’s Web site at www.painfoundation.org.

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