Transcript Non-medical use - Michigan State University College of Nursing

Pain Treatment and
Prescription Drug Abuse
Cathy Carlson, PhD, APN, FNP-BC
Aaron Gilson, MS, MSSW, PhD
Conflict of Interest
Disclosure
• Authors Conflicts of Interest;
– C. Carlson, No Conflict of Interest
– A. Gilson, No Conflict of Interest
True Disclosure:
 WE ARE ONLY
RESPONSIBLE
FOR WHAT WE
SAY…….
 NOT WHAT THE
GOVERNMENT
DOES!!!
Opioid Rx per 100 People
per Year by State
MI = 107
CDC. (2012). Opioid painkiller prescribing infographic. Retrieved from
http://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html
The Problem….
 Deaths involving prescription opioid
analgesics now outnumber deaths
from heroin and cocaine combined
Overdose Deaths Involving Opioid Analgesics,
Cocaine, & Heroin: U. S. 1999-2013
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Opioid Analgesics**
Cocaine
Heroin
Center for Disease Control & Prevention. (2014). Release of 2013 multiple cause of death data file.
Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf
The Problem……
 Death involving prescription drug
abuse is one of the most prevalent
public health epidemics, outpacing
deaths from traffic fatalities
2013: Statistics on Death in the U.S.
Death Determinations
Drug Overdoses
Numbers of Deaths
43,982
Prescription Drug Overdoses
22,767
Overdoses involving Opioids
16,235 (71.3%)
Overdoses involving
Benzodiazapines
MVA
6,973 (30.6%)
33,804
Center for Disease Control & Prevention. (2014). Release of 2013 multiple cause of death data file. Retrieved from
http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf
Past Month Nonmedical Use of
Psychotherapeutic Drugs
Aged 12 or Older, 2002-2014
Percent Using in the Past Month
2.5
2
1.9
2.1
2
1.8
2.1
1.9
2.1
1.9
2
1.9
1.7
1.7
1.6
1.5
1
0.8
0.8
0.6
0.6
0.5
0.2
0.1
0.7
0.7
0.5
0.5
0.1
0.1
0.7
0.6
0.2
0.7
0.7
0.4
0.4
0.1
0.1
0.8
0.5
0.1
0.9
0.7
0.4
0.4
0.1
0.1
0.8
0.5
0.6
0.5
0.1
0.1
0.7
0.6
0.1
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Pain Relievers
Tranquilizers
Stimulants
Sedatives
U.S. Department of Health and Human Services. (2014). Behavioral health trends in the United States: Results
from the 2014 National Survey on Drug Use and Health. Retrieved from
http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm#idtextanchor001
Non-Medical Use of
Rx Opioids
What is “non-medical
use” of prescription
opioids?
Considering the Spectrum of
Non-Medical Use of Rx Opioids
Misuse
(intentional)
e.g.,
- recreational use for
psychic effects
- decide to increase dose
for pain control
- suicidal gesture
or attempt
Concurrent use
of illicit drugs
or
Undisclosed
Rx medication use
Misuse
Use involving
(unintentional)
aberrant behaviors
e.g.,
e.g.,
- sharing with others - forging/altering prescriptions
- unknowingly taking
- going to multiple doctors
larger amounts
- stealing drugs
than directed
- inadvertent poisoning
Opioid
Dependence
Abuse (“Addiction”)
“Substance Use
Disorder”
The Problem…
 Nonmedical users of pain relievers most
often get the drug from family and friends
How Different Nonmedical Users of Pain Relievers Get Their Drugs
Law Enforcement Definition
of Drug Diversion
“Diversion” is the transfer of a
drug from a licit to an illicit
channel of distribution or use.
1. DRUG CONTROL SYSTEM
(lawful distribution)
W
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2. PRIMARY DIVERSION
(unlawful; supplies some abusers
and re-distribution)
Manufacturers and
Distributors
Theft from manufacturers
and distributors*
(Common
Carriers)
Theft in transit *
•Pharmacies
•Hospitals/Clinics
•Internet w/Rx
•Practitioners
Prescribers
Dispensers
•Nursing homes
•Hospices
•Theft from hospitals*
Pharmacies/robbery*
Employee/customer
Pilferage *
Patients
(Lawful medical use)
Theft of Rx/forgery
•Script docs/pill mills
•Inappropriate prescribing
•Doctor shopping
•Patient sells or gives
•Theft from home
•Theft from patient
•Improper disposal
(“Prescribed”)
Medical
Use
PPSG, 2007
* = Amounts reported by law on DEA Form 106
International smuggling
Internet sales without Rx
Non-medical use
●Misuse
Unintentional
(sharing with others)
Intentional
(suicide attempt)
●Aberrant behaviors
(forging/altering Rx)
●“Substance Use
Disorders”
(abuse & addiction)
Substance Abuse and Mental
Health Services Administration,
Results from the 2012 National
Survey on Drug Use and Health:
Summary of National Findings,
NSDUH Series H-46, HHS
Publication No. (SMA) 13-4795.
Rockville, MD: Substance Abuse
and Mental Health Services
Administration, 2013.
“Prescription
medication”
≠
Prescribed
medication
Essential to determine whether
valid prescription was involved
Association Between
Overdose/ Deaths and
“Prescribing”
Factors to Consider










Hall et al.
(2008)
Dunn et al.
(2010)
Gomes et al.
(2011a)
Gomes et al.
(2011b)
Bonhert et al.
(2011)
Paulozzi et al.
(2012)
Diversion (i.e., no prescription found)
Doctor-shopping (i.e., diversion)
Motivations??
Non-medical routes of administration
Co-morbidities (e.g., substance use
history)
Poly-pharmacy
Previous overdose episodes
Legitimate
Little clinical information
Patients?
Not a linear effect
Not causal
Methadone
Controlled Substances Act
(CSA)
First enacted in 1970 to regulate
the manufacture, importation,
possession, use, and
distribution of certain
substances
DEA is responsible for
interpreting and enforcing the
CSA, although DHHS has a
number of supporting
responsibilities
Federal Drug Control Responsibility
(CSA)
“Many of the drugs included within this subchapter have
a useful and legitimate medical purpose and are
necessary to maintain the health and general welfare of
the American people…the illegal importation,
manufacture, distribution, and possession and improper
use of controlled substances have substantial and
detrimental effect on the health and general welfare of
the American people…the United States is a party to the
Single Convention on Narcotic Drugs, 1961, and other
international conventions designed to establish effective
control over international and domestic traffic in
controlled substances.”
21 USC § 801
Principle of Policy Change
Balance
 Opioids can be effective, are
indispensable
 Must be available to relieve pain and
suffering
 Opioids have a potential for abuse
 Must be controlled
 “Controlled substance” label does not
change medical value of medications
 Efforts to prevent abuse must not
interfere with medical practice and patient
care
PPSG. Achieving balance in federal and state pain
policy: A guide to evaluation (CY 2013). 2014.
Imperative to Achieve Balance
U.S. Sources
 Department of Health and Human Services (DHHS)
 Food and Drug Administration (FDA)
 National Institutes of Health (NIH)

National Institute on Drug Abuse (NIDA)
 Center for Disease Control & Prevention (CDC)
 National Cancer Institute (NCI)
 Substance Abuse and Mental Health Services
Administration (SAMHSA)
 Drug Enforcement Administration (DEA)
 Office of National Drug Control Policy (ONDCP)





Institute of Medicine (IOM)
American Medical Association (AMA)
American Cancer Society (ACS)
Federation of State Medical Boards (FSMB)
National Association of Attorneys General (NAAG)
Law Enforcement
on the Principle of Balance
“…the prevention of drug abuse is an
important societal goal that can and
should be pursued without hindering
proper patient care…”
U.S. Drug Enforcement Administration
2001 Joint Policy Statement
Still Awake???
Update: What is Happening at
the Federal Level….
1. Legislative and Regulatory
Mandates
2. Food and Drug Administration
(FDA) and Drug Enforcement
Agency (DEA) Requests/Rulings
3. Office of National Drug Control
Policy (ONDCP) - White House
Initiatives
Legislative and Regulatory
Mandates
Food and Drug Administration Safety
and Innovation Act (FDASIA)
 Signed into law on July 9, 2012, expanded the
FDA’s authorities and strengthens the agency's
ability to safeguard and advance public health.
 An amendment to the Act:
Section 1139 “Scheduling of Hydrocodone”
• Required FDA to hold a public meeting
• Solicit advice and recommendations to assist
in conducting a scientific and medical
evaluation and scheduling recommendation to
DEA regarding drug products containing
hydrocodone, combined with other analgesics,
or as an antitussive
FDA. (2014). Food and Drug Administration Safety and Innovation Act (FDASIA). Retrieved from
http://www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/SignificantAmendmen
tstotheFDCAct/FDASIA/
Hydrocodone Rescheduling:
Yesterday’s Solutions for
Today’s Problem
(Barber, L. (2013, Nov 19). DEA Chronicles
• Hydrocodone combination
products were officially
rescheduled, 8.22.2014
• Effective 10.6.2014
New Rule Effect
• Need a new written prescription for
each 30 day supply
• May write up to 90 day supply
(multiple prescriptions – with
instructions indicating earliest date
when pharmacy may fill each)
• May fax prescription, but patient
must have written prescription to
obtain Rx from pharmacy
• May call in for an emergency
– Only for amount needed to cover
emergency
– Need written prescription within 7
days
Wide Availability Leads to
Leftovers
• Utah post-op patients
reported:
– Most received
hydrocodone (63%)
– 67% had leftover
medication
– 92% received no
disposal instructions
– 91% kept the extra
medication at home
• Will rescheduling
change this data?
(Bates et al, 2011; Webster, 2013)
Beware of Unintended
Consequences
“supply reduction … in the
absence of demand reduction and
harm reduction could
paradoxically increase
overdoses.”
Albert et al., 2011, Project Lazarus: Community-based overdose
prevention in rural North Carolina, Pain Medicine, 12, p. S83
Unintended Consequences
• There was a large increase in the number of the
opioid prescriptions from 2002-2010
• Followed by a slight decrease in the number of
opioid prescriptions during 2011-2013
• The rates of opioid diversion and abuse and
opioid related deaths followed a similar pattern of
a large increase during the years of 2002-2010
followed by a slight decrease during 2011-2013
• Findings suggest that the U.S. may be making
progress in controlling the diversion and abuse of
prescription opioids and decreasing opioid
related deaths
• Abuse of heroin and the number of deaths from
heroin has tripled during the years of 2011-2013
Dart, R. C., Surratt, H. L., Cicero, T. J., Parrino, M. W., Severtson, S. G., Bucher-Bartelson, B.,
& Green, J. L. (2015). Trends in opioid analgesic abuse and mortality in the United States.
New England Journal of Medicine, 372(3), 241-248
FDA Requests/Rulings
 Oxycodone extended-release capsules with
abuse deterrent properties (Xtampza ER) close to
being approved by FDA (approved by advisory
committees 9.11.2015)
 Hydrocodone bitartrate extended-release
capsules (Zohydro ER) approved 10.25.2013
 Guidance for Industry: Abuse-Deterrent Opioids –
Evaluation and Labeling” issued 4.1.2015
 Hydrocodone bitartrate with abuse deterrent
properties (Hysingla ER) approved 11.20.2014
 Combination products with greater than 325 mg
of acetaminophen per unit were voluntarily
withdrawn by the manufacturers at FDA’s request
• Effective 01.01.2014
 Naloxone hydrochloride auto-injection (Evzio)
approved 04.03.2014
 Oxycodone hydrochloride and naloxone
hydrochloride extended-release tablets (Targiniq
ER) approved 07.23.2013
Office of National Drug
Control Policy (ONDCP)
National Drug Control Strategy 2014
1. Emphasizing prevention over
incarceration
2. Training health care professionals to
intervene early before addiction
develops
3. Expanding access to treatment
4. Taking a "smart on crime" approach
to drug enforcement
5. Giving a voice to Americans in
recovery
Office of National Drug
Control Policy (ONDCP)
Epidemic: Responding to
America’s Prescription Drug
Abuse Crisis 2011
1. Education – parents, youth,
patients, & HCP
2. Tracking & Monitoring
3. Proper medication disposal
4. Enforcement
Prescription Drug Monitoring
Programs (PDMPs)
 Where
 When
 Why
 What
All states but 4 (3 of the 4 have
legislation)
Most states established PDMPs to
address the prescription drug abuse
problem beginning in 2005
To reduce prescription drug abuse and
diversion
Statewide electronic databases
• Collect, monitor, and reports
electronically transmitted dispensing
data on controlled substances
 Who
Authorized healthcare professionals
• Physicians (known as prescribers)
• Pharmacists (known as dispensers)
• Other authorized HCPs
PDMP Value
 PDMPs contain useful information
• Identify patients who are potentially
abusing or diverting prescription
drugs
• Inform clinical decisions regarding
controlled substances
 The issue is how to make this
information more available to three
key groups of clinical decisionmakers:
• HCP practices
• Emergency departments
• Pharmacies
PDMP Usage
 PDMPs are not used as much as desired
because of issues with awareness and
system registration
 Members of the care team supporting
prescribers and dispensers often are not
permitted access to PDMP systems
 The use of standalone Web portals and
unsolicited reports do not adequately
support clinical practices and workflows
 There is a lack of system-level access and
standards among PDMPs, EHRs, and
pharmacy systems.
 The business and health IT landscape
increasingly contains third‐party
intermediaries which currently lack
optimized business agreements to
adequately protect information
Prescription Drug Overdose:
Prevention for States
CDC plans to give 16 states annual awards
between $750,000 and $1 million to advance
prevention in four key areas:
• Enhancing and Maximizing State Prescription
Drug Monitoring Programs (PDMPs)
• Implementing Community or Insurer/Health
Systems Interventions
• Conducting Policy Evaluations
• Developing and Implementing Rapid Response
Projects
Arizona, California, Illinois, Kentucky, Nebraska,
New Mexico, North Carolina, Ohio, Oklahoma,
Oregon, Pennsylvania, Rhode Island, Tennessee,
Utah, Vermont, and Wisconsin
State Successes
CDC. (2014). Opioid painkiller prescribing infographic. Retrieved from
http://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html
National All Schedules
Prescription Electronic Reporting
Reauthorization Act of 2015
• S. 480 – 2014
– Assigned to a congressional
committee on 2.12.2015
• 1% chance of being enacted.
• H.R. 1725
– Passed the House
– To the Senate
– 44% chance of being enacted
We Cannot Bury Our Heads in
the Sand and Not Act
Promote Government and
Society Actions
– Require comprehensive prescriber education
on opioid pharmacology and management-including risks, benefits, and alternatives
– Advocate for increased access and funding for
mental health treatment services, including
substance use disorder treatment
– Advocate for increased research funding for
pain management and substance use disorder
treatment
– Develop safe, convenient and environmentally
friendly medication disposal programs
– Expand Prescription Drug Monitoring Program
features
• Support expanded access for all health
professionals to PDMP websites
• Support interstate/national sharing of information
• Simplify and standardize state requirements for
account registration
Institutes of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention,
care, education, and research. Retrieved from http://www.nap.edu/catalog.php?record_id=13172
HCP Actions to Decrease Risks
Associated with Opioid RX
• Conduct a thorough history and physical exam
including the patient’s medical, psychiatric, and social
history that also ascertains any substance use
disorder
• Obtain records from other providers treating the
patient with pain
• Facilitate interdisciplinary management (including
specialist referrals) of comorbid conditions, including
psychiatric and substance use disorders/conditions
that may affect risk with opioid use (i.e., OSA, obesity,
depression, PTSD, anxiety)
• Utilize multimodal pharmacologic treatment, combining
non-opioids with opioids
• Initiate opioid therapy as a trial with the understanding
if it decreases pain and increases function it may be
maintained
CDC.(2013). Common Elements in Guidelines for prescribing opioids for chronic pain. Retrieved from
http://www.cdc.gov/homeandrecreationalsafety/pdf/Common_Elements_in_Guidelines_for_Prescribing_Opioidsa.pdf
HCP Actions Cont…
•
•
Start opioid therapy on lowest effective dose. Recommend
pain specialist referral with higher doses of opioids (Some
guidelines cite 90-100 mg morphine sulfate equivalents
[Nuckols, Anderson, Popescu, Diamant, Doyle, Di Capua, &
Chou, 2014])
Use Pain Management Universal Precautions regularly to
monitor and manage potential risks with chronic opioid
use (Gourlay, Heit, & Almahrezi, 2005):
– Employ regular risk evaluations for all patients on opioids
– Implement written Pain/Opioid treatment agreements
– Determine opioid adjustments on outcomes of the 5 ‘A’s:
Analgesia, activity, adverse effects, aberrant behavior, and
affect
– Employ intermittent adherence monitoring measures as
indicated, including:
• Urine drug testing
• Pill counts
• State prescription monitoring program (PMP) websites
– Plan for safe opioid tapering when discontinuing therapy
Nuckols, T. K., Anderson, L. Popescu, I. Diamant, A. L., Doyle, B., Di Capua, P., & Chou, R. (2014).
Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain. Annals
of Internal Medicine, 160(1), 38-47.
Gourlay, D. L., Heit, H. A., & Almahrezi, A. (2005). Universal Precautions in Pain Medicine: A
Rational Approach to the Treatment of Chronic Pain. Pain Medicine, 6(2), 107-112.
Let’s Change from
Federal to State
Why State Policies are
Important
 Authorize healthcare practice, medical
use of drugs
 Define unprofessional conduct, and
prohibit unauthorized distribution of
controlled substances
 Restrict prescriptive practices
Policies can also…
 Recognize value of controlled substances
and pain management
 Encourage pain management
 Address barriers (e.g., concern about
regulatory scrutiny)
Recognizing Types of State Policy
Legislation
Regulatory Policy
(Statutes)
(Regulations or Guidelines/Policy Statements)
Practice Acts
Controlled
Substances
Act
Legislature
(members of
legislative committees)
Past sponsors of
related bills
Healthcare Regulations
Boards
Executive Director
(with Nursing, focus
on license-specific
division)
Entity
Governing
Controlled
Substances
Policy Change/Adoption
 Add language that promotes safe and
effective pain relief and palliative care
 Repeal or avoid potential barriers
 Severe restrictions
 Archaic terminology
 Ambiguous requirements
 Content and clarity of policy is
essential
 Unintended consequences
 Example – Prescription Monitoring
Programs
PPSG. Achieving balance in state pain policy: A progress report card (CY 2013). 2014.
(+) Criteria: Policy Language
Enhance Pain Management
1. Controlled substances necessary for public health
2. Pain management is general healthcare practice
3. Medical use of opioids is legitimate professional
practice
4. Pain management is encouraged
5. Addresses practitioners’ concerns about
regulatory scrutiny
6. Prescription amount is insufficient to determine
legitimacy
7. Addiction not confused with physical
dependence/tolerance
8. Other positive language
Category A: Issues related to healthcare professionals
Category B: Issues related to patients
Category C: Regulatory or policy issues
(-) Criteria: Policy Language
Impede Pain Management
9. Opioids are relegated as last resort
10. Opioids are outside legitimate practice
11. Addiction is confused with physical
dependence/tolerance
12. Medical decisions are unduly restricted
13. Prescription validity is restricted
14. Additional undue prescription requirements
15. Other restrictive language
16. Ambiguous language
Category A: Arbitrary standards for legitimate prescribing
Category B: Unclear intent contributing to misinterpretation
Category C: Conflicting or inconsistent policies or provisions
Why a Progress Report Card?
 Simplifies complex evaluation
 Single index of quality to compare
states
 Positive context for critical
evaluation
 Simplifies measurement of
progress
 Supports goal-setting
 Increases visibility of the need to
improve pain policy
Distribution of Grades
2006, 2012, & 2013
Number of States
25
2006
2012
2013
20
15
10
5
0
F
D
D+
C
C+
B
B+
A
PPSG. Achieving balance in state pain policy: A progress report card (CY 2013). 2014.
National Council of
State Boards of Nursing
2008 Policy:
Report of
Disciplinary
Resources
Committee
(September, 2008,
pp. 114-324)
Pain Management Policies
(n=49)
WA
VT
ME
ND
MT
MN
OR
NH
ID
SD
MI
WY
AK
IL
WV
KS
VA
MO
KY
NC
TN
OK
AR
NM
SC
MS
TX
HI
DE
MD
IN
CO
AZ
NJ
OH
UT
CA
RI
CT
PA
IA
NE
NV
MA
NY
WI
AL
GA
LA
FL
DC
Nursing Regulatory Pain Policy
(n=27)
WA
VT
ME
ND
MT
MN
OR
NH
ID
SD
MI
WY
VA
MO
KY
NC
TN
OK
AR
NM
SC
MS
TX
HI
DE
MD
IN
WV
KS
AZ
NJ
OH
IL
CO
CA
CT
PA
UT
AK
RI
IA
NE
NV
MA
NY
WI
AL
GA
LA
FL
DC
APN Prescribing Authority
2010, 2012, & 2013
25
20
Number of States
2010
2012
2013
15
10
5
0
No Rx
authority
MD
involvement
+ limits
MD
Independent
involvement Rx authority
PPSG. Achieving balance in state pain policy: A progress report card (CY 2013). 2014.
Independent Prescribing
Authority
(23 states)
 Alaska
 Arizona
 Colorado
 Connecticut
 DC
 Hawaii
 Idaho
 Iowa
 Maine
 Maryland
 Minnesota
 Mississippi
 Montana
 Nevada
 New Hampshire
 New Mexico
 North Dakota
 Oregon
 Rhode Island
 Vermont
 Virginia
 Washington
 Wyoming
Prescribing Requires Formal
Physician Involvement
(12 states)
 California
 Delaware
 Indiana
 Kansas
 Massachusetts
 Nebraska
 New Jersey
 New York
 Tennessee
 Texas
 Utah
 Wisconsin
Prescribing Requires Formal
Physician Involvement/Other
Limits (8 states)
 Illinois
 Kentucky
 Louisiana
 Michigan
 North Carolina
 Ohio
 Pennsylvania
 South Dakota
PPSG. Achieving balance in federal and state pain policy: A guide to evaluation (CY 2013). 2014.
No Prescribing Authority
(8 states)
 Alabama
 Arkansas*
 Florida
 Georgia*
 Missouri*
 Oklahoma*
 South Carolina*
 West Virginia*
* No prescribing authority for Schedule II medications only
PPSG. Achieving balance in federal and state pain policy: A guide to evaluation (CY 2013). 2014.
Potential Policy Barriers to
Nursing Pain Practice
 Prescribing authority is prohibited
 Formal physician involvement (??)
 Additional requirements/limitations
 Supply limits (e.g., 24 hours, 72 hours,
7 days, 30 days)
 Not for chronic pain (including cancer
pain)
 Ambiguous language
 Recent, not widespread, regulatory
guidance
PPSG. Achieving balance in federal and state pain policy: A guide to evaluation (CY 2013). 2014.
Ways to Improve Practice
Related to Pain Management
“Multidisciplinary” (team approach)
Reimbursement
Research to inform practice
Integrating PDMP with EMR
Harmonizing both professional and
regulatory guidance
Increasing use of risk identification
and mitigation strategies
States with “Pill Mill” Activity
(n=46)
WA
VT
ME
ND
MT
MN
OR
NH
ID
SD
PA
IA
NE
IL
WV
KS
AZ
VA
MO
KY
NC
TN
OK
AR
NM
SC
MS
TX
HI
AL
GA
LA
FL
Assessed via Internet search, September 14, 2015
DE
MD
IN
CO
CA
RI
CT
NJ
OH
UT
AK
2
MI
WY
NV
MA
NY
WI
DC
What We Can Do to Engage at
the State Level
Engage with existing initiative
Established network with policy-makers
• Supportive of pain management issues
• Sponsors
• “Cue-givers” (Matthews & Stimson, 1975)
Multidisciplinary
Anticipate other policy implications
Relevant initiatives becoming more
prevalent
Gilson, Joranson, & Maurer. Improving state pain policies: Recent progress and
continuing opportunities. CA: A Cancer Journal for Clinicians. 2007;57:341-353.
What We Can Do to Engage at
the State Level
 State Pain Policy Advocacy Network
(SPPAN)
• State Legislation and Regulations
Tracking
• http://sppan.aapainmanage.org
 ACS Cancer Action Network
• Quality of Life/Access to Care
Initiatives
• http://www.acscan.org
 U.S. Pain Foundation
• Pain Advocacy Efforts (e.g., PDMPs,
Federal)
• http://uspainfoundation.org/uspain-advocacyefforts.html
Questions???