Patients, providers, communities, and healthcare systems have struggled to achieve balance in their pain policies. This is particularly evident when weighing the benefits and harms associated with opioid treatment for chronic pain and potential harmful consequences of long-term opioid therapy—especially misuse, addiction, and overdose. The Pain and Policies Study Group, the Joint Commission, and government guidelines all provide guidance to healthcare providers and organizations involved in the treatment and management of pain.

The Central Principle of Balance

For several years, the University of Wisconsin Pain and Policies Study Group has been grading state pain policies. A state’s grade represents the quality of its policies affecting pain treatment, based on the Central Principle of Balance; higher grades mean more balanced state pain management policies, including the medical use of opioids. Oregon received an “A” in 2013, and joins 15 other states as having the most balanced pain policies in the country (PPSG, 2014a).

The Central Principle of Balance represents a state’s obligation to establish a system of drug controls that prevent abuse, trafficking, and diversion of narcotic drugs while ensuring the adequate medical availability of needed medications. It encourages governments to ensure the adequate availability of opioids for medical and scientific purposes. This includes empowering medical professionals to provide opioids in the course of professional practice; allowing them to prescribe, dispense, and administer according to the individual medical needs of the patient; and ensuring that a sufficient supply of opioids is available to meet medical demand (PPSG, 2014b).

The Joint Commission

The Joint Commission, in collaboration with the University of Wisconsin, has developed pain management standards for accredited ambulatory care facilities, behavioral healthcare organizations, critical access hospitals, home care providers, hospitals, office-based surgery practices, and long-term care providers. The standards require organizations to:

1. Recognize the right of patients to appropriate assessment and management of pain
2. Screen patients for pain during their initial assessment and, when clinically required, during ongoing periodic re-assessments
3. Educate patients suffering from pain and their families about pain management as a part of care (Joint Commission, 2013)

The Joint Commission’s pain guidelines further state that:

1. Clinicians must be competent in the assessment and management of pain.
2. Pain should not interfere with optimal level of function or rehabilitation.
3. Pain and symptom management must be included in discharge planning. (Joint Commission, 2013)

The Joint Commission does not require healthcare organizations to assess pain as a fifth vital sign (Joint Commission, 2016), although the Commission does require that patients be screened for pain during the initial assessment. Some large organizations, including the Veteran’s Administration (VA), decided to describe pain as the fifth vital sign, to be assessed along with temperature, pulse, respiration, and blood pressure. Acknowledging that assessing pain as a fifth vital sign may have contributed to the overprescribing of opioids, in June 2016 the American Medical Association recommended that pain be removed as one of the vital signs for which patients are assessed.

Intractable Pain Treatment Acts

Intractable pain is commonly defined as “a pain state . . . which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible. . . .” (PPSG, 2014b).

Intractable pain treatment acts (IPTA) are statutes originally intended to improve access to pain management by providing physicians immunity from regulatory sanctions for prescribing opioids to patients with intractable pain. The first IPTA was adopted by Texas in 1989 (PPSG, 2014b).

In 1995 the Oregon Legislative Assembly passed its own Intractable Pain Act. This act allowed a physician to prescribe or administer controlled substances to a patient diagnosed with a condition causing intractable pain without fear of sanction from the Oregon Board of Medical Examiners, so long as that physician complied with the provisions of the statute.

IPTAs were probably not intended to formalize the use of opioids for pain as being within medical practice only when meeting the IPTA standards. The IPTA language was often ambiguous and was not consistent with the recognition that pain management, including the use of opioid medications, is part of general medicine and is a legitimate professional practice (PPSG, 2014b).

In 2008 Oregon repealed the definition of intractable pain from its IPTA. The resulting laws now govern the treatment of all types of pain. Instead of statutes, many states, including Oregon, have chosen to develop guidelines or regulations containing language aimed at enhancing pain management (PPSG, 2014b).