Dear PCC member,
There has been considerable confusion regarding the Pain Relief Promotion
Act as to what it will do and what it won't do. We hope that the
following update serves to clarify why this important legislation,
already approved by the U.S. House of Representatives, should also
be passed in the U. S. Senate and signed into law by the President. >>>>>
PCC physician update: Pain Relief Promotion Act
The Pain Relief Promotion Act was passed by the U.S. House of Representatives
with solid bipartisan support (271-156) and will soon come to the
Senate for vote (S. 1272).
WHAT IS THE PAIN RELIEF PROMOTION ACT?
- It helps doctors and patients by funding education concerning
state-of-the-art practices on relieving pain and other palliative
- It provides research grants to improve treatment of pain, depression,
and other causes of suffering in the seriously ill.
- It specifically reads into the Controlled Substances Act for the
first time the physician's right to aggressively manage pain in the
seriously ill, even if that treatment, in rare circumstances, might
increase the likelihood of death, and clarifies that controlled substances
may not be used to cut short pain and palliative care through assisted
suicide or euthanasia.
WHAT ARE SOME MEDICAL ASSOCIATIONS THAT SUPPORT THE PAIN RELIEF
American Medical Association National Hospice Organization Hospice
Association of America American Academy of Pain Management American
Society of Anesthesiologists And many others ...
WHY DOES THE AMERICAN MEDICAL ASSOCIATION SUPPORT THE PAIN RELIEF
The American Medical Association (AMA) reminded the authors of the
Pain Relief Act that it is squarely opposed to physician-assisted
suicide and believes it is antithetical to the role of physician
as healer. The authors of the Pain Relief Act responded to previous
concerns the American Medical Association (AMA) expressed by strengthening
the bill and protecting doctors. In a statement issued June 28, 1999,
the AMA said:
"Physicians have been deeply concerned that such legislation must
recognize that aggressive treatment of pain carries with it the potential
for increased risk of death, the so-called 'double effect.'"
"Thus, we are very pleased to note that your bill would recognize
the 'double effect' as a potential consequence of the legitimate
and necessary use of controlled substances in pain management, and
explicitly includes this as a provision of the Controlled Substance
Act. This is a vital element in creating a legal environment in which
physicians may administer appropriate pain care for patients and
we appreciate its inclusion."
DOES THE PAIN RELIEF ACT CREATE NEW AUTHORITY FOR THE DEA?
No. The Pain Relief Act creates no new authority for the DEA. It
introduces new protections for doctors. For twenty-nine years, the
DEA has had the right in all 50 states to regulate the use of controlled
substances. The Pain Relief Act, however, does not allow one state,
Oregon, to exempt itself from federal regulation which disallows
the use of controlled substances for assisted suicides instead of
pain and palliative care. It creates new protections for doctors
by recognizing that appropriate pain management can sometimes increase
the risk of death.
WHAT IS AN EXAMPLE OF HOW THE PAIN RELIEF ACT CAN PROTECT DOCTORS?
Under current law, in all 50 states, if a doctor were to give a
medically ill patient a large prescription of pain medication and
the patient were to die of an overdose of that medicine, the doctor
could potentially (although, admittedly, rarely) lose his or her
DEA registration only with evidence of negligence, no need to prove
intent. With the Pain Relief Promotion Act's new clarification, the
bar is raised for the DEA. The doctor will have increased protection
because of the new, specific recognition that aggressive pain management
may carry an increased risk of death and is legitimate. Intent, not
just negligence, would have to be demonstrated and the benefit of
the doubt would go to the doctor. This is new protection for all
doctors in all states.
WHAT ABOUT PENALTIES?
Some assisted suicide advocates are now claiming up to a "20 year" jail
sentence for doctors under the Pain Relief Promotion Act. This is
false claim and an obvious scare tactic. Nowhere does the Pain Relief
Act mention a jail sentence or any other penalty! Certainly, in all
50 states, doctors can have their prescribing licenses revoked (and,
theoretically, receive criminal penalties under different laws),
for misusing those licenses. Oregon wants the federal government
to exempt from these penalties the Oregon doctors who use federally
regulated drugs to assist in suicides. It seems better, however,
to protect the vast majority of doctors in all states by making it
perfectly clear for the first time that aggressive pain management
is legitimate medical care even if in rare instances it may increase
the likelihood of death.
WHAT EFFECT WILL THERE BE ON PAIN AND PALLIATIVE CARE?
The Pain Relief Act will improve pain and palliative care by funding
new educational programs for doctors, nurses and hospice works. It
will also fund research in pain and palliative care. It will create
an encouraging legal environment by providing new protections for
Some assisted suicide and euthanasia proponents have falsely claimed
that the new law could have a so-called "chilling effect" on pain
and palliative care. The facts show their claims are without scientific
Rhode Island provides an interesting example. After that state passed
legislation very similar to the Pain Relief Act, that state nearly
doubled its per capita morphine use the following year. Clearly encouraging
aggressive pain management while disallowing the use of controlled
substances for assisted suicides had no "chilling effect" on that
state's prescription of morphine.
An analysis of per capita morphine use follows:
The most recent DEA figures on per capita morphine use show Oregon
with the highest per capita consumption of morphine, at 2332 grams
per 100,000 population. Kansas is a very close second, with 2287.
Regarding Oregon itself, two comments are in order. First, these
figures do not indicate what the morphine is used for. The Oregon
Health Division says it does not know how many unreported assisted
suicides or cases of active euthanasia may be occurring in the state
due to the greater freedom physicians feel they have under the new
assisted suicide law; some of these cases may use large doses of
morphine, as did one of the 15 reported cases in 1998. Second, the
per capita consumption now (2332) is slightly less than it was during
the first half of 1998 (2385), when Oregon physicians were allegedly
operating under the "chilling effect" of threatened DEA action; from
June to December 1998, after attorney general Janet Reno rescinded
the DEA's interpretation of federal law and told Oregon it had a
right to use controlled substances for assisted suicide, the per
capita rate fell from 2385 to 2160.
Regarding other states:
- Of the top ten states, seven have specific statutes against assisted
suicide (Kansas, Florida, Arizona, New Hampshire, Tennessee, Louisiana
and Missouri). One state bans the practice by common law (Vermont),
and one has no law (Nevada).
- A legal vacuum on assisted suicide is certainly no guarantee of
free- wheeling pain control practices. The ranking in morphine use
for the other three states with no clear law on assisted suicide
are 35th (Wyoming), 46th (Utah) and 48th (Hawaii).
- The second-ranking state, Kansas, is an interesting case. Kansas
strengthened its ban on assisted suicide in 1998, adding civil penalties
to the existing criminal penalties so family members and others can
sue a doctor who assists a suicide. Kansas was 35th in morphine use
in 1997, the year before the civil ban; 11th in the first half of
1998, before the civil ban passed; 7th for the entire year of 1998;
and is now second highest.
- Louisiana passed its ban in 1995. It was 41st in morphine use
in 1994, the year before the ban; it is now 9th among states.
- Tennessee passed its ban in 1993. It was 16th in morphine use
in 1992, the year before the ban; it is now 8th.
Clearly, banning use of controlled substances has no adverse effect
on the prescription of morphine.
WHAT ABOUT STATES' RIGHTS?
The federal government has had explicit jurisdiction over the interstate
commerce of controlled substances for twenty-nine years. Perhaps
it was partially out of respect for the rights of states that the
authors of this bill confined the Pain Relief Act's statement on
assisted suicide to an area where there is clearly no state's rights
issue. Oregon is not free, anymore than any other state, to exempt
itself from federal regulations about the interstate commerce of
dangerous controlled substances.
DOES THE PAIN RELIEF ACT HELP THE CHRONICALLY ILL?
Yes. The Pain Relief Act was amended in the House Commerce Committee
to include the chronically ill, not just those who may soon die from
their illness. Education, research and new legal protections for
physicians also apply to the chronically ill.
CAN I GET A COPY OF THE PAIN RELIEF PROMOTION ACT ON THE INTERNET?
Yes. For a list of sponsors and the text of the Pain Relief Promotion
Act you can contact http:www.senate.gov/~nickles/releases/pain.cfm.
N. Gregory Hamilton,
M.D. William L. Toffler, M.D.
November 20, 1999