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Pain management clinic (PMC) laws were enacted by 12 states to promote appropriate opioid prescribing, but their impact is inadequately understood. We analyzed county-level opioid overdose deaths (National Vital Statistics System) and patients filling long-duration (≥30 day) or high-dose (≥90 morphine milligram equivalents per day) opioid prescriptions (IQVIA, Inc.) in the United States in 2010-2018. We fitted Besag-York-Mollié spatiotemporal models to estimate annual relative rates (RRs) of overdose and prevalence ratios (PRs) of high-risk prescribing associated with any PMC law and 3 provisions: payment restrictions, site inspections, and criminal penalties. Laws with criminal penalties were significantly associated with reduced PRs of long-duration and high-dose opioid prescriptions (adjusted PR = 0.82, 95% credible interval (CrI): 0.82, 0.82, and adjusted PR = 0.73, 95% CI: 0.73, 0.74 respectively) and reduced RRs of total and natural/semisynthetic opioid overdoses (adjusted RR = 0.86, 95% CrI: 0.80, 0.92, and adjusted RR = 0.84, and 95% CrI: 0.77, 0.92, respectively). Conversely, PMC laws were associated with increased relative rates of synthetic opioid and heroin overdose deaths, especially criminal penalties (adjusted RR = 1.83, 95% CrI: 1.59, 2.11, and adjusted RR = 2.59, 95% CrI: 2.22, 3.02, respectively). Findings suggest that laws with criminal penalties were associated with intended reductions in high-risk opioid prescribing and some opioid overdoses but raise concerns regarding unintended consequences on heroin/synthetic overdoses., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: In response to the increase in opioid overdose deaths in the United States, many states recently have implemented supply-controlling and harm-reduction policy measures. To date, an updated policy evaluation that considers the full policy landscape has not been conducted., Objective: To evaluate 6 US state-level drug policies to ascertain whether they are associated with a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths., Design, Setting, and Participants: This cross-sectional study used drug overdose mortality data from 50 states obtained from the National Vital Statistics System and claims data from 23 million commercially insured patients in the US between 2007 and 2018. Difference-in-differences analysis using panel matching was conducted to evaluate the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, the prescription of MAT, and drug overdose deaths before and after implementation of 6 state-level policies targeting the opioid epidemic. A random-effects meta-analysis model was used to summarize associations over time for each policy and outcome pair. The data analysis was conducted July 12, 2020., Exposures: State-level drug policy changes to address the increase of opioid-related overdose deaths included prescription drug monitoring program (PDMP) access, mandatory PDMPs, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws., Main Outcomes and Measures: The outcomes of interests were quarterly state-level mortality from drug overdoses, known indicators for prescription opioid abuse and doctor shopping, MAT, and prevalence of drug overdose and opioid use disorder., Results: This cross-sectional study of drug overdose mortality data and insurance claims data from 23 million commercially insured patients (12 582 378 female patients [55.1%]; mean [SD] age, 45.9 [19.9] years) in the US between 2007 and 2018 found that mandatory PDMPs were associated with decreases in the proportion of patients taking opioids (-0.729%; 95% CI, -1.011% to -0.447%), with overlapping opioid claims (-0.027%; 95% CI, -0.038% to -0.017%), with daily morphine milligram equivalent greater than 90 (-0.095%; 95% CI, -0.150% to -0.041%), and who engaged in drug seeking (-0.002%; 95% CI, -0.003% to -0.001%). The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs (0.015%; 95% CI, 0.002% to 0.028%), pain clinic laws (0.013%, 95% CI, 0.005%-0.021%), and prescription limit laws (0.034%, 95% CI, 0.020% to 0.049%). Mandatory PDMPs were associated with a decrease in the number of overdose deaths due to natural opioids (-518.5 [95% CI, -728.5 to -308.5] per 300 million people) and methadone (-122.7 [95% CI, -207.5 to -37.8] per 300 million people). Prescription drug monitoring program access policies showed similar results, although these policies were also associated with increases in overdose deaths due to synthetic opioids (380.3 [95% CI, 149.6-610.8] per 300 million people) and cocaine (103.7 [95% CI, 28.0-179.5] per 300 million people). Except for the negative association between prescription limit laws and synthetic opioid deaths (-723.9 [95% CI, -1419.7 to -28.1] per 300 million people), other policies were associated with increasing overdose deaths, especially those attributed to non-prescription opioids such as synthetic opioids and heroin. This includes a positive association between naloxone access laws and the number of deaths attributed to synthetic opioids (1338.2 [95% CI, 662.5 to 2014.0] per 300 million people)., Conclusions and Relevance: Although this study found that existing state policies were associated with reduced misuse of prescription opioids, they may have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. This finding suggests that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the US.

In 2011, Florida established a prescription drug monitoring program and adopted new regulations for independent pain-management clinics. We examined the association of those reforms with drug overdose deaths and other injury fatalities. Florida's postreform monthly mortality rates-for drug-involved deaths, motor vehicle crashes, and suicide by means other than poisoning-were compared with a counterfactual estimate of what those rates would have been absent reform. The counterfactual was estimated using a Bayesian structural time-series model based on mortality trends in similar states. By December 2013, drug overdose deaths were down 17% (95% credible interval: -21, -12), motor vehicle crash deaths were down 9% (95% credible interval: -14, -4), and suicide deaths were unchanged compared with what would be expected in the absence of reform. Florida's opioid prescribing reform substantially reduced drug overdose deaths. Reforms may also have reduced motor vehicle crash deaths but were not associated with a change in suicides. More research is needed to understand these patterns. Bayesian structural time-series modeling is a promising new approach to interrupted time-series studies., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: With a rapid increase in prescription opioid overdose deaths and a proliferation of pain clinics in the mid-2000s, Florida emerged as an epicenter of the opioid overdose epidemic. In response, Florida implemented pain clinic laws and operationalized its Prescription Drug Monitoring Program. This study examines the effect of these policies on rates of inpatient stays and emergency department visits for opioid-related overdoses., Methods: Using data from the 2008-2015 State Emergency Department Databases and State Inpatient Databases, quarterly rates of inpatient stays and emergency department visits for prescription opioid-related overdoses and heroin-related overdoses were computed. A comparative interrupted time series analysis examined the effect of these policies on opioid overdose rates. North Carolina served as a control state because it did not implement similar policies during the study period. The data were analyzed in 2019., Results: Compared with North Carolina, Florida's polices were associated with reductions in the rates of prescription opioid-related overdose inpatient stays and emergency department visits, a level reduction of 2.31 per 100,000 and a reduction in the trend of 0.16 per 100,000 population each quarter. The policies were associated with a reduction of 13,532 inpatient stays and emergency department visits for prescription opioid-related overdoses during the study period. No statistically significant association was found between the policies and heroin-related overdose inpatient stays and emergency department visits., Conclusions: To address the opioid overdose epidemic, states have implemented policies such as Prescription Drug Monitoring Programs and pain clinic laws designed to reduce inappropriate opioid prescribing. Such laws may be effective in reducing prescription opioid-related overdoses., (Published by Elsevier Inc.)

Background: Pain clinic laws are designed to cease or modify high-risk prescribing behavior. However, prior evaluations have not differentiated between these types of prescriber responses in their analysis, even though they may have different implications for patients. The purpose of this analysis is to investigate the effect of a 2016 Tennessee pain clinic law on the two types of prescriber responses., Methods: We used data on opioid prescriptions from the Tennessee Controlled Substances Monitoring Database (CSMD) between July 1 st , 2015 and July 1 st , 2017. Prescribers were assigned to the cessation or modification group based on the date of their last opioid prescription during the time period July 1 st , 2015 to July 1 st , 2018 and its relationship to the change in law. A risk score was developed based on five indicators to capture two categories of risky prescriber behavior: increased risk for diversion or increased patient's risk of overdose. Within-prescriber differences were used to assess the effect of the law on several outcomes that capture the quantity and content of opioid prescriptions., Results: There was a significant decline in the number of prescriptions (cessation mean = -45.18 pval<0.001; continuation mean = -24.41 pval<0.001) and patients (cessation mean = -16.68pval<0.001; continuation mean = -10.92 pval<0.001) in both prescriber response groups, but the magnitude of decline was much larger in the cessation group. High-risk prescribers were more likely to cease prescribing than modify., Conclusions: Prescribers who ceased prescribing in response to the pain clinic law disproportionately contributed to overall declines in opioid prescriptions., (Copyright © 2019. Published by Elsevier B.V.)

Objectives: States in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures., Methods: State-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends., Results: Requiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p < 0.01). Further analysis revealed that the reduction associated with pain clinic laws was pronounced in exposures reported by healthcare facilities., Conclusions: This multi-state study provided new evidence that the implementation of pain clinic laws was associated with a significant reduction in prescription opioid exposures. Pain clinic laws may deserve further evaluation and consideration., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Physicians can encounter a web of confusion and unfairness when it comes to navigating the Texas Medical Board (TMB). A Travis County district court has given Texas physicians clarity and hope when it comes to certain medical board investigations. The court's decision, if it holds up, establishes an important precedent for when physicians are required to register their facility as a pain management clinic.

Background: In response to widespread opioid misuse, ten U.S. states have implemented regulations for facilities that primarily manage and treat chronic pain, called "pain clinics." Whether a clinic falls into a state's pain clinic definition determines the extent to which it is subject to oversight. It is unclear whether state pain clinic definitions model those found in the medical literature, and potential differences lead to discrepancies between scientific and professionally guided advice found in the medical literature and actual pain clinic practice. Identifying discrepancies could assist states to design laws that are more compatible with best practices suggested in the medical literature., Methods: We conducted an integrative systematic review to create a taxonomy of pain clinic definitions using academic medical literature. We then identified existing U.S. state pain clinic statutes and regulations and compared the developed taxonomy using a content analysis approach to understand the extent to which medical literature definitions are reflected in state policy., Results: In the medical literature, we identified eight categories of pain clinic definitions: 1) patient case mix; 2) single-modality treatment; 3) multidisciplinary treatment; 4) interdisciplinary treatment; 5) provider supervision; 6) provider composition; 7) marketing; and 8) outcome. We identified ten states with pain clinic laws. State laws primarily include the following definitional categories: patient case mix; single-modality treatment, and marketing. Some definitional categories commonly found in the medical literature, such as multidisciplinary treatment and interdisciplinary treatment, rarely appear in state law definitions., Conclusions: This is the first study to our knowledge to develop a taxonomy of pain clinic definitions and to identify differences between pain clinic definitions in U.S. state law and medical literature. Future work should explore the impact of different legal pain clinic definitions on provider decision-making and state-level health outcomes.

Nonmedical use of prescription opioids has reached epidemic levels in the United States and globally. In response, federal, state, and local governments are taking actions to address substantial increases in prescription opioid addiction and its associated harms. This study examines the effect of two state laws specifically designed to curtail access to prescription opioids to nonmedical users: pain management clinic and doctor shopping laws. We use administrative data on overdose deaths and admissions to specialty substance use disorder treatment coupled with a differences-in-differences design. Our findings suggest that both pain management clinic and doctor shopping laws have the potential to reduce prescription opioid overdose deaths. Moreover, doctor shopping laws appear to reduce prescription opioid treatment admissions. As many states have adopted these laws in recent years, the full effects of the laws may not yet be realized. Future research using more postlaw passage data should reevaluate the effectiveness of these laws., (Copyright © 2017 John Wiley & Sons, Ltd.)

The Texas Medical Board's new rules on inspecting clinics for failure to register as pain management clinics have provisions of potential concern for doctors.

Background: Opioids are frequently used in chronic pain management but are associated with significant morbidity and mortality in some patient populations. An important avenue for identifying complications-including serious or rare complications-is the study of closed malpractice claims. The present study is intended to complement the existing closed claims literature by drawing on claims from a more recent timeframe through a partnership with a large malpractice carrier, the Controlled Risk Insurance Company (CRICO). The goal of this study was to identify patient medical comorbidities and aberrant drug behaviors, as well as prescriber practices associated with patient injury and malpractice claims. Another objective was to identify claims most likely to result in payments and use this information to propose a strategy for reducing medicolegal risk., Methods: The CRICO Strategies Comparative Benchmarking System is a database of claims drawing from >350,000 malpractice claims from Harvard-affiliated institutions and >400 other academic and community institutions across the United States. This database was queried for closed claims from January 1, 2009, to December 31, 2013, and identified 37 cases concerning noninterventional, outpatient chronic pain management. Each file consisted of a narrative summary, including expert witness testimony, as well as coded fields for patient demographics, medical comorbidities, the alleged damaging event, the alleged injurious outcome, the total financial amount incurred, and more. We performed an analysis using these claim files., Results: The mean patient age was 43.5 years, with men representing 59.5% of cases. Payments were made in 27% of cases, with a median payment of $72,500 and a range of $7500-$687,500. The majority of cases related to degenerative joint disease of the spine and failed back surgery syndrome; no patients in this series received treatment of malignant pain. Approximately half (49%) of cases involved a patient death. The use of long-acting opioids and medical conditions affecting the cardiac and pulmonary systems were more closely associated with death than with other outcomes. The nonpain medical conditions present in this analysis included obesity, obstructive sleep apnea, chronic obstructive pulmonary disease, hypertension, and coronary artery disease. Other claims ranged from alleged addiction to opioids from improper prescribing to alleged abandonment with withdrawal of care. The CRICO analysis suggested that patient behavior contributed to over half of these claims, whereas deficits in clinical judgment contributed to approximately 40% of the claims filed., Conclusions: Claims related to outpatient medication management in pain medicine are multifactorial, stemming from deficits in clinical judgment by physicians, noncooperation in care by patients, and poor clinical documentation. Minimization of both legal risk and patient harm can be achieved by carefully selecting patients for chronic opioid therapy and documenting compliance and improvement with the treatment plan. Medical comorbidities such as obstructive sleep apnea and the use of long-acting opioids may be particularly dangerous. Continuing physician education on the safest and most effective approaches to manage these medications in everyday practice will lead to both improved legal security and patient safety.

Background: Chronic pain is considered to be among the most disabling and costly diseases in North America, Europe and Australia. A large survey was conducted on chronic pain in Europe, called Pain in Europe. Italy ranks third in Europe in terms of prevalence, with 26% of the population suffering from chronic pain at some point. In 2010 Italy passed Law 38/2010, to ensure treatment for pain control in patients with oncological diseases as well as in patients with chronic non-cancer pain through a network of care services. This study aims to provide preliminary information regarding the application of L.38/2010 in the Abruzzo region of Italy., Methods: A descriptive study was conducted on a non-probabilistic sample of people who attended pain therapy centres of the local health service in 2014. The patients (129) were interviewed by centre staff using a validated questionnaire. Recruitment was carried out by enrolling consecutive cases over a three-month period (February to April)., Results: Almost two-thirds of the patients had visited several physicians before requesting help. The initial visit to the pain therapy centre was made after some months in 37.2% of cases, and in 38% of patients it was made years after the onset of pain. The reasons given for this long wait before seeking specialist medical treatment for chronic pain reveal a wait-and-see attitude on the part of patients, who controlled their pain by taking painkillers. Responsibility for this delay in requesting assistance can however also be attributed 'externally' to the fact that patients were not aware that this kind of centre was available., Conclusion: The results of the study describe, in a regional context, a situation in which L.38/2010 is hard to apply. The study showed how the care pathway for these patients is still characterised by difficulty in accessing the network of local services. Clearly, more effort needs to be directed towards an effective application of L.38/2010, with increased availability of resources to develop and strengthen the network of services at regional level.

To address the opioid overdose epidemic in the United States, states have implemented policies to reduce inappropriate opioid prescribing. These policies could affect the coincident heroin overdose epidemic by either driving the substitution of heroin for opioids or reducing simultaneous use of both substances. We used IMS Health's National Prescription Audit and government mortality data to examine the effect of these policies on opioid prescribing and on prescription opioid and heroin overdose death rates in the United States during 2006-13. The analysis revealed that combined implementation of mandated provider review of state-run prescription drug monitoring program data and pain clinic laws reduced opioid amounts prescribed by 8 percent and prescription opioid overdose death rates by 12 percent. We also observed relatively large but statistically insignificant reductions in heroin overdose death rates after implementation of these policies. This combination of policies was effective, but broader approaches to address these coincident epidemics are needed., (Project HOPE—The People-to-People Health Foundation, Inc.)

Today, opiate-based prescription painkillers account for significant morbidity and mortality in the U.S. According to the Centers for Disease Control and Prevention, prescription painkiller overdose has reached epidemic proportions over the past decade. This article explores the focus on inadequate treatment of pain in the U.S. and the subsequent rise of prescription painkiller abuse, misuse, and overdoses. Since 2007, states have increasingly used their authority to address inappropriate prescribing. State strategies to address this complex problem have included: establishing and strengthening prescription drug monitoring programs, regulating pain management facilities, and establishing dosage thresholds above which a consult with a pain specialist is required. With chronic pain affecting at least 116 million adults in the United States, it will also be important to evaluate the impact these policies are having on legitimate access to pain care., (© 2013 American Society of Law, Medicine & Ethics, Inc.)

The health care landscape has changed with new legislation addressing the unsustainable rise in costs in the US system. Low-value service lines caring for expensive chronic conditions have been targeted for reform; for better or worse, the treatment of spine pain has been recognized as a representative example. Examining the Patient Protection and Affordable Care Act and existing pilot studies can offer a preview of how chronic care of spine pain will be sustained. Accountable care in an organization capable of collecting, analyzing, and reporting clinical data and operational compliance is forthcoming. Interdisciplinary spine pain centers integrating surgical and medical management, behavioral medicine, physical reconditioning, and societal reintegration represent the model of high-value care for patients with chronic spine pain., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Texas has fewer pill mills churning out massive volumes of prescriptions for powerful narcotics thanks to the Texas Medical Board (TMB). Since Sept. 1, 2010, pain management clinics must be TMB-certified to continue operating. The board has been busy enforcing the law. At press time, TMB had suspended 11 pain management clinic certificates and five physicians' medical licenses because of rule violations.

On March 15th 2010, Italy adopted the Law no. 38 "Disposizioni per garantire l'accesso alle cure palliative e alla terapia del dolore" (Provisions aimed at ensuring access to palliative care and pain therapy). The aim of pain therapy is to enable patients with chronic diseases to achieve pain control. Palliative care, as defined by the World Health Organization, aims at "improving the quality of life of patients and families, who face the problems associated with incurable diseases, through prevention and relief from suffering, achieved through an early identification and treatment of pain by pharmacological medication and other physical, psychosocial and spiritual techniques". The main issues addressed by the law concern the monitoring of pain (the doctors will have to record on the clinical report form every level of pain intensity suffered by the patient, the appropriate therapy administered, and the pain relief achieved. This report must be kept accurately in all settings: hospital, day hospital and in outpatients). The law also suggests the establishment of two kinds of regional networks. One network (including Hospices) ensures the administration of palliative care to terminally ill patients; the other, including clinics and centers of pain therapy, provides assistance to patients with chronic pain. These networks involve general practitioners, hospital specialists and pain therapy specialists in order to ensure the best patient care. Simplification of the prescription of opiate drugs is also included in the law. In the prescription of opiates, the National Health Service medical staff can use the normal prescription form, and opiates will reimbursed by the NHS, like all other drugs. In addition, the technical papers provide precise indications of the appropriate modality of administration. The law allocates (art. 12, paragraph 2) 100 million euros per year and € 2,450,000 in the biennium 2010-2011 to implement experimental regional projects: "hospital-territory without pain". The Ministry of Health has established a deadline within which this law must be implemented at the regional level, and further establishes a specific National Observatory, an annual report on the use of drugs in the treatment of pain, and other provisions. The levels of spending by region will also be monitored in compliance with this law; university courses and masters are required to update professionals involved in pain treatment. In July 2010, in Florence, during the interdisciplinary IMPACT 2010 summit, Institutions and Scientific Societies met to define the concrete implementation of Law No. 38, in terms of the arrangements to ensure access to palliative care and pain management. Subsequently, last November, a new meeting was held bringing together medical directors from public hospitals; further meetings are planned with Regional Health Authorities to reaffirm the importance of this law and to implement it. The most important molecules in the opioids are traditionally divided into two groups: weak and strong. Among the strong analgesics are morphine, methadone, buprenorphine, fentanyl, oxycodone, hydromorphone. Among the weak are codeine and tramadol, or opiates administered at low doses, such as oxycodone combined with acetaminophen. IMPACT's aim is also to stimulate scientific association to consider with attention and continuous medical education on the appropriates of diagnosis and administration of these medications according to data flow sheets approved in Italy. Regarding the headaches, it should be noted that the law 38 cited above includes all forms of pain, and headaches should be integrated into the care networks. In this context, several multi-disciplinary professionals within the centers (hub and spoke) or territory (GPs, specialists from neurologists and other professionals involved) should be integrated to offer the best response to the needs of the citizen. The diagnosis and treatment of various forms of headache have to be integrated into the path of pain, both National and Regional, in line with the rest of the organization.

Cancer is an increasing problem in the Middle Eastern (ME) countries. It is the fourth leading cause of death in this region. At present, resources for cancer control in the ME countries as a whole are not only inadequate but directed almost exclusively to treatment. In the majority of countries of this region, cancer is generally diagnosed when it is at a relatively advanced stage. Pain is prevalent among people who have cancer, and is one of the most feared and burdensome symptoms. Pain negatively affects the quality of life of patients with cancer. Inadequate and inappropriate pain management of patients who experienced cancer pain has been documented in several studies and this is possibly due to insufficient understanding of pain assessment and management. Middle Eastern countries include a wide range of economically diverse countries, from technically advanced countries with high level cancer care to countries with little or no cancer treatment capabilities. There are large differences in population size, wealth and health expenditure. Palliative care (PC) is an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases; relieving pain and suffering is an essential part of PC. The need for improved palliative care in ME countries is great. Of 58 million people who die every year, 45 million die in developing countries. An estimated 60% (27 million) of these people in developing countries would benefit from palliative care, and this number is growing as chronic diseases such as cancer rise rapidly. From the situation analysis of palliative care in the ME countries, suggesting that pain relief is insufficient, improvements in palliative care delivery are a high priority.We reviewed the situation of pain management and pain control in Lebanon and the ME countries, the barriers that are present, and we propose the priorities and a reform for an integrated approach to address the problem of under-treated pain at all levels:

Chronic non-cancer pain management is an urgent global problem. To set up pain clinics is a promising and economically sound approach. There are pain clinics operating in Russia; however, there are no unified approaches to solving their organizational, therapeutic, and educational-and-methodological problems. An antipain care model is proposed for patients with chronic non-cancer pain, which makes it possible to optimize the treatment of the patients, to train pain specialists, and to enhance the economic efficiency of management.

Interventional pain management now stands at the crossroads at what is described as "the perfect storm." The confluence of several factors has led to devastating results for interventional pain management. This article seeks to provide a perspective to various issues producing conditions conducive to creating a "perfect storm" such as use and abuse of interventional pain management techniques, and in the same context, use and abuse of various non-interventional techniques. The rapid increase in opioid drug prescribing, costs to health care, large increases in death rates, and random and rampant drug testing, can also lead to increases in health care utilization. Other important aspects that are seldom discussed include medico-legal and ethical perspectives of individual and professional societal opinions and the interpretation of diagnostic accuracy of controlled diagnostic blocks. The aim of this article is to discuss the impact of several factors on interventional pain management and overuse, abuse, waste, and fraud; inappropriate application without evidence-based literature support (sometimes leading to selective use or non-use of randomized or observational studies for proving biased viewpoints - post priori rather than a priori), and issues related to multiple professional societies having their own agendas to push rather than promulgating the science of interventional pain management. This perspective is based on a review of articles published in this issue of Pain Physician, information in the public domain, and other relevant articles. Based on the results of this review, various issues of relevance to modern interventional pain management are discussed and the viewpoints of several experts debated. In conclusion, supporters of interventional pain management disagree on multiple aspects for various reasons while detractors claim that interventional pain management should not exist as a speciality. Issues to be addressed include appropriate use of evidence-based medicine (EBM), overuse, overutilization, and abuse.

Through the perspectives of the children, this essay examines the communication between pediatric pain patients and their doctors. Based upon the oral history responses of thirty-two patients with chronic pain present for evaluation at the Pediatric Pain Clinic at UCLA, oral testimony was employed to uncover a wide range of topics related to a child's experience with pain such as family dynamics, how and when pain became a life-changing factor, coping strategies, and external sources that contribute to the child's understanding of pain. Most important, children were encouraged to explain what it was like to be in pain, not only to describe symptoms but also to share their dreams and hopes, their fears and uncertainties -- as well as the place of pain in their world.

Unlabelled: Three national surveys were conducted in 1991, 1997, and 2004 to evaluate state medical board members' knowledge and attitudes about prescribing opioid analgesics for pain management. Topics addressed include perceived legality of prolonged opioid prescribing, characteristics of addiction, prevalence of medication abuse and diversion, and perceived importance and influence of medical board policy. Questions were added in 2004 to determine board members' views about law enforcement involvement in physician investigations and prosecutions. This study assesses medical regulators' current beliefs and compares the 2004 responses with previous responses to determine how knowledge and attitudes about prescribing opioids have changed in recent years. Survey results show that board members have a greater understanding of pain management issues, particularly regarding characteristics of addiction and the legality of prolonged opioid prescribing for chronic noncancer pain. During the last 15 years, there has been substantial regulatory policy development, with medical boards adopting regulations, guidelines, or policy statements to provide guidance to licensees about using opioids to treat pain. However, many board members believe that federal and state law enforcement agencies have increased criminal investigations and prosecutions of physicians. We discuss appropriate regulatory and law enforcement responses to opioid prescribing violations, and suggest crucial next steps., Perspective: The authors examine the evolution of state medical board members' knowledge and attitudes about prescribing opioid analgesics to treat chronic pain, demonstrate that medical regulators believe that there have been increased criminal investigations and prosecutions of physicians for their prescribing practices, and suggest ways to avoid unwarranted criminal prosecutions.

This study involved an audit and a survey of the Acute Pain Service at Princess Alexandra Hospital. It was found in the audit that the relative choice of epidural analgesia had declined by 50% over the five-year time period of 1998-2003. The survey of consultants showed that 82% of them had changed their practice and that they were performing fewer epidural anaesthetics. Two of the most common reasons given for this change in practice related to fear of litigation (34%) and lack of evidence (21%). These results show that within this department approaches to postoperative pain control had changed and that this appears to have resulted from factors such as the medicolegal environment and the possible influence of evidence based medicine.