Question 2: Why do we want to have mandated pain management?

Raymond Sinatra, MD: Jean, you talked about mandated pain management in particular, could you give me some reasons why we want to have mandated pain management and assessment, treatment of pain? It seems like we're going to be tied on one end that we can't prescribe drugs for fear that the government's looking over our shoulder, and on the other hand the courts are telling us that we have to provide mandated pain management ... I wonder if you can comment on that.

L. Jean Dunegan, MD, JD, FCLM: Absolutely, this is one of the greatest examples of the interface of law and medicine. I mean there is no question that we now have products in order to treat pain. I mean we have products that can treat pain which we know darn well is ATC or around the clock. We also have products that can treat pain only with certain activities. We have knowledge about how to assess pain and how to properly treat it. But I really believe that until physicians have some motivation to obtain and apply the knowledge ... in other words, unless there are consequences for not adequately assessing and treating pain, it just won't be done.

Let's look at an example. We know that even for the past decade there have been states that have tried very hard to create safe harbors for physicians who prescribe pain medication. For example in California their state legislature passed an Intractable Pain Treatment Act in 1990, long before the joint commission decided to mandate pain management. Four years later, in 1994 the Medical Board of California adopted a policy statement encouraging aggressive pain treatment throughout the state. Even though we have had these attempts to create safe harbors for physicians, it has not been done. Now if you look at the fact that in the ethics of our profession itself, the very first precept is that of beneficence.

Beneficence essentially means whatever it is we do for a patient in our profession we should do it with the objective of improving the quality of that person's life as they live it in society. Now there's no way you can better help a patient have a quality of life than by controlling their pain and suffering. If you look at the cost of unrelieved chronic pain in our nation, it's more than $50 billion a year. If you combine that with lost work it's $85 billion. In an age of steady cost cutting and a managed care environment we will no longer be able to afford this kind of a cost. Then you look finally at the quality of people's lives who suffer chronic pain, not only do they suffer lost sleep and jobs, they suffer the joy of living itself and they often lose their relationships with loved ones, contemplate suicide or even take their own lives. We have the products to improve the quality of these people's lives and those products are now threatened to be taken away from hundreds of thousands of people.