Intractable Pain Treatment Acts

Like tort liability, legislation can also turn greater attention to pain management. Many state legislatures have passed what are generically called Intractable Pain Treatment Acts (IPTAs) to deal with the under-treatment of pain with opioid medications. This wave of IPTAs began in 1989 and hoped to give physicians regulatory relief for prescribing opioid medications for pain. However, there are serious shortcomings in current IPTAs. Current IPTAs are too narrow, contain provisions containing counter-effects, are not nationwide, and lack accountability. Counter-effective provisions include clauses that opioids are to be used as a last resort, required evaluations by at least two physicians prior to prescribing opiates in some states, preclusion of treatment of intractable pain in chemically dependent patients, lack of recommendations for practitioner education, lack of accountability, reasonably prudent physician standards based on custom of under-treatment, lack of applicability to nonphysician opioid prescribers and dispensers, and lack of nationwide coverage.

The provisions that opioids are only to be used as a last resort lack inclusion of guidelines as to what comprises a reasonable effort prior to last resort status being achieved. The required evaluations by two physicians prior to prescribing opioids limit patient accessibility because of increased cost and inconvenience. The preclusion of opioid treatment of chemically dependent patients deprives these patients of pain treatment while undergoing rehabilitation for abuse of other drugs. The lack of recommendations for prescriber education may increase patient accessibility because the barriers for physician opioid prescribing are lower; however, the need for prescriber education is great due to confusion about opioid tolerance, addiction, and optimal dosing. The state IPTAs provide safe harbor for physicians who prescribe opioid medications according to guidelines, but do not require disciplinary actions for those physicians who do not prescribe adequate opioids for pain relief. The lack of accountability for not prescribing adequate opioids contributes to oligoanalgesia.

Reasonably prudent physician standards based on custom of under-treatment contribute to oligoanalgesia and make appropriately-treating physicians appear to be overtreating by comparison. Lack of applicability to nonphysician opioid prescribers and dispensers limits the benefits of IPTAs to physicians, excluding physician assistants, clinical nurse practitioners, and pharmacists, who still have no safe harbor. Lack of nationwide coverage also limits the effectiveness of IPTAs to the states where they are enacted. The number and breadth of IPTA counter provisions squelch an otherwise well-intentioned law to address under-treatment of pain.