Can Reform Spell Relief?

Hundreds of pages into the Affordable Care Act lies Section 4305, "Advancing research and treatment for pain care management." Amid the partisan waves lashing at "Obama-care," this provision for pain care stands out as a tiny bipartisan island. But those unfamiliar with the troubled history of pain relief may not realize that a bipartisan consensus even on this provision was an accomplishment. And they may wonder why the legislation deals with pain care at all.

For decades, pain relief has been a vexing problem for patients, practitioners, and policy-makers. More than 50 million adults suffer frequent, and often disabling, chronic pain, and millions of others experience severe pain from migraines, fibromyalgia, cancer, and other conditions. Overcoming the difficulties those patients encounter in the health-care system as well as misconceptions and fears among the public at large has become an important policy challenge.

In the United States, pain medicine has also been politically contentious. At the heart of the conflict has been an epic tension between Americans' desire for compassionate care and relief and their fears of drugs and dependency. Progressives have tended to be sympathetic to claims for pain relief and compensation, while conservatives have been skeptical of liberal relief. Those divisions showed up in the 1980s, for example, in disputes about whether people in chronic pain should qualify for disability benefits. In the late 1990s, in the intentionally misnamed Pain Relief Promotion Act, the conservative Republican chair of the House Judiciary Committee, Henry Hyde, took aim at Oregon's physician-assisted suicide law and threatened practitioners with prosecution if they used pain medicine on terminally ill patients in the name of relief but in the service of euthanasia. That bill did not pass.

The past decade, however, has seen a shift toward a new spirit of compromise about pain care. In 2003, Rep. Mike Rogers, a Michigan Republican, introduced a bill for a "national pain-care policy," which California Democrat Lois Capps co-sponsored in 2007. The bill called for spending $26 million to educate practitioners about pain care, reduce barriers to treatment for underserved groups, support a national conference to re-evaluate pain management, and pay for a public-awareness campaign.

The Capps-Rogers bill passed the House in March 2009, weeks after Obama's inauguration, and in early 2009 Sen. Orrin Hatch, a Utah Republican, and Christopher Dodd, a Connecticut Democrat, sponsored it in the Senate. At that time, Hatch said he hoped the funding would address inadequate professional training, support the "public-awareness campaign highlighting pain as a serious public-health issue," and "create a comprehensive framework for addressing coordinated research" and greater training capacity. Cancer patients, Hatch said, "should not have to spend their final days in pain."

During the negotiations over health reform in 2009, however, the pain agenda narrowed -- and when the pain initiative was folded into the larger measure, the dollars authorized in the Capps-Rogers House bill were stripped. What survives in the Affordable Care Act is a requirement that the Institute of Medicine (IOM) convene a conference aimed at increasing recognition of the problem, evaluating current pain practices, identifying barriers, and establishing an agenda for action. (The National Institutes of Health has stepped in to fund this conference.) Other provisions call for coordination across federal agencies on pain research and instruct the NIH and other divisions of the Department of Health and Human Services to give priority to grants addressing "barriers to patient access" to pain care. As welcome as these steps are, they are unlikely to do much to address the complex regulatory, physician-education, and patient-awareness issues that once defined the call for comprehensive pain reform.

Relief, in other words, is not yet in sight. Rep. Capp's press secretary, Ashley Schapitl, observes that "the purpose of the IOM report is to give a clearer picture of the state of pain care and what barriers remain that we can then translate, if necessary, into further policy recommendations." Yet research findings alone will not be enough to drive reform. A comprehensive approach will require more of the ambitious bipartisan spirit that produced the Rogers -- Capps-Hatch-Dodd pain initiative. It will demand political courage from scientists in federal agencies to tackle difficult topics such as addiction and end-of-life care. Lest pain reform become a mirage, it needs higher priority as a public-health issue. But at least this legislation lets millions of chronic-pain sufferers envision, even if in the distance, the tantalizing hope of relief.