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Friday, March 13, 2009

Session 6: Public Comments

Larry Driver


CHAIRMAN PELLEGRINO: I think we'll go ahead, if you don't mind. We have one commentator who is Dr. Larry Driver, whom I know from previous associations, the University of Texas, M.D. Anderson Cancer Center. Larry?

DR. DRIVER: Thank you very much. Dr. Pellegrino, members of the Council, I appreciate the opportunity to enter these remarks into the record today and address this Council and/or future councils.

Pain is a leading reason for people to seek access to our healthcare system. Fortunately, most painful conditions can be relieved with appropriate treatment. Unrelieved pain increases suffering, impedes recovery from surgery or injury, is associated with adverse physical affects and events, compromises physical and psychosocial functioning, aggravates anxiety and depression, decreases productivity because of absence from work or lowered function at work, negatively affects relationships with family, friends, and co-workers, consumes healthcare resources, and generally decreases quality of life for the individual suffering, those around them, and society at large.

Up to 40 percent of patients report inadequate pain relief following surgery. About 25 percent of adults suffer from chronic pain at any given time. And about 50 percent of adults over age 65 have problematic pain. About 76 million Americans suffer from chronic pain. Up to 70 percent of people with cancer suffer from pain from their disease or its treatment. And people with advanced cancer report moderate to severe pain up to 50 percent of the time and very severe pain up to 30 percent of the time.

The financial impact is estimated by some to be over 100 billion dollars in terms of healthcare expenditures and lost work productivity. Pain clearly is an issue for all of us. Most agree that there are various reasons to treat pain.

Improving patient outcomes in terms of pain relief and decreased suffering, improved functionality, and improved quality of life for the person with pain are obvious. Legal and regulatory requirements must be met for risk management and accreditation purposes.

Physicians and other clinicians, by their professional commitments, recognize the moral and ethical reasons underlying pain management. The core ethical principles of bioethics of nonmaleficence, beneficence, respect for individual autonomy, humanity, and dignity and the ideals of social justice lie at the heart of pain treatment for individuals and society.

Yet many people in pain and their healthcare providers often face a variety of barriers that impede effective pain management. These barriers include issues of knowledge, attitudes, and perceptions that exist in patients and their clinicians and real or perceived legal and regulatory impediments to good pain care.

Persistent disparities in pain care because of race or ethnicity, gender, age, socioeconomic status, or culture must be addressed at multiple levels. If healthcare is a human right and good pain management is considered to be integral to healthcare, then pain care must be considered a basic human right, and adequate resources must be allocated for that care.

There are a variety of published clinical guidelines regarding assessment of pain, including guidelines from the World Health Organization, Agency for Healthcare Policy Research, the American Pain Society, and American Academy of Pain Medicine, among others.

The United States Congress declared 2001 through 2010 as the decade of pain control and research. Last year Congress passed and the President signed into law the Military and Veterans Pain Care Acts of 2008. These acts hopefully will positively impact the lives of America 's wounded warriors and help them assume the greatest functionality possible as they return home.

Congress is now considering the National Pain Care Policy Act of 2009, H.R. 756, which authorizes a pain consortium at the National Institutes of Health to expand research on causes and treatments for pain, provides for comprehensive pain care education and training for healthcare professionals, creates a national public awareness campaign on pain management, and authorizes an institute of medicine conference on pain management.

This will make pain care and pain management a public health priority and improve the understanding, assessment, and treatment of pain. I encourage a future council to weigh in on this issue of adequate pain treatment. Join the discussion to elucidate and clarify for policy makers, the public, and the scientific and clinical communities the ethical underpinnings and mandates for pain care in the United States.

Your input can illuminate for insurance companies and the pharmaceutical and medical device industries the clinical implications of financial hurdles that impede patient access to expensive medications or complex treatment device modalities.

As we appear to be embarking on paradigmatic change in our healthcare system, policy makers and others should--must--be aware of the multi-faceted ethical support for treating pain and relieving suffering.

Recall the adverse consequences of inadequate pain relief mentioned above. Imagine the mirror image of outcomes from effective pain treatment, decreased personal and family suffering, improved socialization, improved functioning, increased productivity, decreased healthcare costs, all benefitting the individual and society. The bottom line is better quality of life for individuals, those around them, and society at large.

And finally, as a physician who spends my days trying to relieve the pain and suffering of people with cancer, whether they have active disease receiving treatment, have responded to that treatment and are now survivors, or have advanced disease because they didn't respond to curative efforts and are now facing the end of life.

I consider that there are no cares that are futile. There may be some futile treatments, but care is never futile. And I frequently tell colleagues, reminding myself and them, as well as residents and fellows, that we should never say, "I have nothing left to offer." As physicians and other healthcare professionals, we always have something left to offer, even if it's just sitting quietly at the bedside holding the patient's hand.

Thank you.

CHAIRMAN PELLEGRINO: Thank you very much, Dr. Driver. Any comments? I certainly agree with you. Every word I've ever written on this says care is never futile, and I think that's important, that message you've given us. Thank you.

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