Financial Disclosure/Conflicts of Interest

1. Financial Disclosure/Conflicts of Interest The Pain & Policy Studies Group domestic program currently receives unrestricted educational grant support from Purdue Pharma.

2. Barriers to Patient Pain Relief Social, cultural values Drug regulation Health care system Caregivers Patient, family

3. The Principle of Balance A principle central to medicine, controlled drugs, and the protection of public health and safety • Opioids are necessary medicines for pain relief • Opioids pose risks, need to be controlled • “Controlled substances” does not diminish medical utility • Healthcare professionals: Relieve pain/avoid contributing to diversion • Law enforcement/regulation: Address diversion/avoid interfering with medical practice and patient care

4. www.painpolicy.wisc.edu

5. (+) Criteria: Policy Language That CanEnhance Pain Management • 1. Controlled substances necessary for the public health • 2. Pain management is general medical practice • 3. Medical use of opioids is legitimate professional practice • 4. Pain management is encouraged • 5. Practitioners’ concerns about regulatory scrutiny are addressed • 6. Prescription amount is insufficient to determine legitimacy • Addiction is not confused with physical dependence or analgesic tolerance • Other positive language

6. (-) Criteria: Policy Language That CanImpede Pain Management • 9. Opioids are a last resort • 10. Opioids are outside legitimate professional practice • 11. Addiction is confused with physical dependence or analgesic tolerance • Medical decisions are restricted • Prescription validity is restricted • Additional prescription requirements (e.g., restrictive PMPs) • Other restrictive language • Ambiguous language

7. Do State Policies Address Practitioners’ Concerns About Regulatory Scrutiny? * Also establishes immunity from criminal prosecution Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation(5th edition). 2008.

8. Clarifies the Difference Between Addiction and Physical Dependence Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation(5th edition). 2008.

9. Confuses Addiction and Physical Dependence Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation(5th edition). 2008.

10. Further Confuses Concept of Addiction Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation(5th edition). 2008.

11. www.painpolicy.wisc.edu

12. State Pain Policy Grades for 2008 • Kentucky (B) • Louisiana (C) • Maine (B+) • Maryland (B) • Massachusetts (B+) • Michigan (A) • Minnesota (B+) • Mississippi (C+) • Missouri (C+) • Montana (C+) • Nebraska (B+) • Nevada (C) • New Hampshire (B) • New Jersey (C+) • New Mexico (B+) • New York (C) • North Carolina (B) • North Dakota (B) • Ohio (B) • Oklahoma (C+) • Oregon (A) • Pennsylvania (C+) • Rhode Island (B+) • South Carolina (C+) • South Dakota (B) • Tennessee (C) • Texas (C) • Utah (B+) • Vermont (B+) • Virginia (A) • Washington (B+) • West Virginia (B) • Wisconsin (A) • Wyoming (C+) • Alabama (B+) • Alaska (C+) • Arizona (B+) • Arkansas (B) • California (B) • Colorado (B) • Connecticut (B) • Delaware (C+) • Dist. of Columbia (C+) • Florida (B) • Georgia (B) • Hawaii (B) • Idaho (B) • Illinois (C) • Indiana (+) • Iowa (B) • Kansas (A)

13. Are State Policies BecomingMore or Less Balanced? Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card (4th edition). 2008.

14. Are State Policies Becoming Balanced?Distribution of Grades: 2000 Average2000 Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card (4th edition). 2008.

15. Are State Policies Becoming Balanced?Distribution of Grades: 2008 Average2008 Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card (4th edition). 2008.

16. State Pain Policies1989-2008 Number of Policies Pain & Policy Studies Group. Database of state laws, regulations, and other official governmental policies governing pain management. 2008.

17. Future Need for Change:Repealing Restrictive Law • Most prevalent negative provision – definition that confuses physical dependence with addiction (or drug dependence) • 14 state statutes (Controlled Substances Act) • 2 state healthcare regulations • Can legally classify a patient being treated with chronic opioid therapy as an “addict” • Based on 40-year old definition from federal law • Does not conform to current medical and scientific understanding Pain & Policy Studies Group. Achieving Balance in State Pain Policy: A Progress Report Card (4th edition). 2008.

18. Suggestions for Change • Repeal restrictive statutory and regulatory language • Medical Practice Acts could conform more completely to Federation’s model Medical Practice Act • Medical Board could update Guidelines/Policy statements to conform to Federation’s model policies • Other healthcare regulatory boards could adopt Guidelines/Policy statements (e.g., Pharmacy, Nursing) • Joint Policy Statement (Medical, Pharmacy, Nursing) • State Prescription Monitoring Programs should be Balanced • Legislative Task Force (i.e., Pain Commission, Advisory Council, etc.)