Chronic Pain Patients - Pain Action Alliance to Implement a National ...

October 13, 2017

Chronic Pain Patients: Collateral Damage in the War on Opioids

painsproject.org

Chronic Pain Patients: Collateral Damage in the War on Opioids The War on Opioids has captured the attention of the public, the media, and state and federal governments. Lost in the furor and volume of the efforts to combat the rising incidence of drug abuse and overdose are the legitimate needs of patients who suffer from chronic pain. Two distinct public health crises are simultaneously plaguing this country—chronic pain and opioid addiction—but the two have been conflated in the media and in policy initiatives. People living with chronic pain and their caregivers have been misperceived as drivers of the opioid epidemic, rather than legitimate patients who suffer from a real disease—the disease of chronic pain— and require comprehensive assessment and real treatments. The result has been to further stigmatize these patients and to compromise the quality of their care.1 In 2011, the prestigious Institute of Medicine (IOM) issued its report Relieving Pain in America.2 Commissioning studies and surveys to establish the prevalence of chronic pain, the IOM found that chronic pain afflicts over 100 million American adults, recognized the legitimacy and pervasiveness of this disease and recommended the development of a national strategy to address this urgent problem by the end of 2012.

Two distinct public health crises are simultaneously plaguing this country—chronic pain and opioid addiction—but the two have been conflated in the media and in policy initiatives.

2 — painsproject.org

It took almost five years before the Department of Health and Human Services (HHS) published the National Pain Strategy (NPS),3 which endorsed the IOM’s concerns and advocated the need for a “cultural transformation in the way pain is perceived, judged and treated.” HHS recommended a shift from the biomedical pain care model to a comprehensive biopsychological chronic disease management model, which would include assuring that people with chronic pain have timely access to safe and appropriate pain management, including opioid therapy, when needed. Like cancer and other major illnesses, the continuum of chronic pain that includes 100 million Americans is a bell-shaped curve: at one extreme are those who are regularly inconvenienced but able to manage their pain and to live full lives; at the other end are those who are completely disabled by unrelenting pain. As one participant said, “People lose notions of self…” For strategic reasons, the NPS Oversight Committee defined a sub-category of Americans living with chronic pain and labeled it as “high-impact chronic pain, i.e. pain associated with substantial restriction of work, social and selfcare activities for six (6) months.” To date, there has been no definitive determination of the exact number of Americans who live with high-impact chronic pain. However, most agree that there are between 25 and 30 million Americans in this category. Clearly, there is a movement in the scientific community to define medical conditions more succinctly. Similarly, policymakers and others encourage directing resources to those with the greatest need. The decision to create this new category was hoped to be politically efficacious. Many of those living with chronic pain have been outraged by this decision and expressed fear that it will pit chronic pain patients against one another. Some members of the NPS Oversight Committee and the NIH Interagency Pain Research Coordinating Committee expressed concern about

this new category being used in a subjective manner that could keep some people living with chronic pain from having access to certain therapies or medications. However, in the end, it was decided that, strategically, the new category could motivate HHS to move forward more quickly with what many saw as a “more manageable” public health problem. This does not appear to be the case. Reflecting a lack of coordination and consistency in the federal government’s policies toward chronic pain, just days before HHS’ announcement of its long-awaited National Pain Strategy, the Centers for Disease Control (CDC) issued its “Guideline for Prescribing Opioids for Chronic Pain.”4 Contravening one of the core recommendations of HHS, CDC advocated restricting the use of opioids for the treatment of chronic pain and limiting both dosage strength and duration of prescriptions. HHS’ proposed comprehensive strategy was drowned out by the CDC Guideline. Although the Guideline was only a voluntary recommendation, in the year and a half since its issuance, over 50 laws have been enacted in 30 states restricting the availability of opioids,5 insurance companies have begun to deny coverage for opioid analgesics,6 and prescription benefit managers have begun restricting the dosage and duration of pain prescriptions.7 The immediate impact of these changes has been to deny legitimate patients relief from their chronic pain. Whether these restrictions will have any effect on opioid addiction and overdoses remains to be seen.

No Longer Silent To give voice to these forgotten patients, the PAINS Project8 launched No Longer Silent and convened a meeting on October 13, 2017 in Washington, DC in an effort to allow those who live with chronic pain and those who treat them to be heard. As Dr. Richard Payne, the Medical Director of the PAINS Project, explained in his call to the meeting, the purpose of the initiative is to bring together “patients, leaders across medical societies, policy groups and media to build bridges and share ideas on how to better understand chronic pain so that it can be understood without the traditional stigmas and more fittingly treated and managed.” The meeting was supported by grants from the US Cancer Pain Relief Committee, the Mayday Fund, and the Milbank Foundation, and was months in the planning, with considerable assistance from Global Prairie Public Relations and YI Media Advisors. Emmy-award winning journalist Jeanne Meserve Dr. Richard Payne moderated the Roundtable discussion. Dr. Payne opened the discussion for a panel of primary stakeholders, including chronic pain patient Jonathan Bell, pain specialist Dr. Lynn Webster and policymaker, Dr. Vanila Singh, Chief Medical Officer for the Office of the Assistant Secretary of Health at HHS. These principal panelists were joined around the table by journalists, clinicians, patient advocates, researchers, government officials and other patients. (The full list of participants is attached as Appendix 2.) painsproject.org — 3

Surrounded by policymakers, media and clinicians, patient Jonathan Bell most eloquently defined the problem: I have sickle cell anemia. Every day is a struggle, not knowing what I will be able to do. My disease produces episodes of severe and almost intolerable pain and I never know when or what will trigger it. Getting out of bed. Getting caught in the rain. Traveling on a plane. Standing up too quickly. My pain score can go from 0 to 10 instantaneously and without warning. Fifteen years ago, my doctors finally got me on a stable program of opioid painkillers. I could get up in the morning. I had a quality of life with my wife and children. My visits to the hospital almost stopped. My dosage hadn’t changed in years. I had no problems with the medication. My pain was under control. I had a life. I could cut the grass. In January 2017, my doctors told me that the guidelines had changed and they had to cut my dosage in half. My pain increased immediately. I have tried every alternative—acupressure, over-thecounter medications—but none of them worked. I finally found out that I could make an application to go back to my old regimen, but it expires in December and I don’t know what I will do then. I don’t want to be on opioids, but nothing else works.


“Jonathan Bell’s is not an uncommon story,” explained Dr. Lynn Webster, who has been treating people living with chronic pain and patients with drug abuse problems for three decades. “People who have been well-controlled are now being rejected by doctors. People in pain are difficult to treat and, now, doctors are afraid even to try, afraid to be accused of overprescribing opioids. They are not being paranoid—there has been a 500% increase in prosecutions.9 In this environment, it is easier for doctors to simply refuse to treat patients in chronic pain.” As the IOM reported, 100 million Americans suffer from chronic pain and the cost to society for their healthcare and loss of their productivity exceeds $500 billion a year. But, the individual cost to the person in pain cannot be quantified. Chronic pain patients are difficult to diagnose and manage. And most physicians are not trained to treat them. As several clinicians around the table admitted, “I received almost no training in medical school on how to deal with chronic pain patients and none at all after that. These are time-consuming and difficult patients and doctors just don’t have the time or the patience to deal with them.” One clinician shamefully confessed that as a resident in an inner-city ER, he initially enthusiastically treated patients with sickle cell or HIV who complained of chronic pain. Within weeks, however, “in his mind, these patients had all become drug seekers.” With new genomic tests, complex medications and tech-based treatments capturing the fascination of practitioners and medical schools, there is even less room in the academic curriculum or in continuing education to teach about treating patients in pain. As one panelist commented, “the average med student gets ten (10) hours of training on pain management; students in veterinary school get ten times that much.” As many panelists agreed, pain is simply not a priority in medical education.

Dr. Lynn Webster

All stakeholders agreed that insufficient resources are devoted to better education, more research, alternative treatments or reducing the stigma of the disease of chronic pain. And sadly, the effect of the war on opioids is to largely remove the availability of opioid treatment for these patients. As one clinician observed, “there are not enough tools, not enough science, and both the doctors and the patients are being stigmatized by the media.” “Primary care doctors have too much administrative work to do and not enough time to spend with their patients. And they are not trained to deal with patients in pain.” As Dr. Webster and other panelists described, many doctors are now afraid to prescribe opioids because they will be investigated and possibly prosecuted.

“the pendulum has, perhaps, swung too far. There have been unintended consequences...” Compounding the problem is that the few available effective non-opioid analgesics are often not available because they are expensive and insurance companies won’t cover them.10 And in most cases, there is no coverage for alternative therapies, because the insurers claim that there is no evidence to support that they work. As one speaker after another reflected, since so little research is being supported, the evidence is not being produced, the insurers then claim the treatments can’t be justified, and it is the patients who are caught in this vicious circle. painsproject.org — 5

In a self-reflective moment, one government official asked herself whether “chronic pain voices were being heard.” Her reply: “the pendulum has, perhaps, swung too far. There have been unintended consequences. Things are out of balance and now we are seeing more” chronic pain patients, like Jonathan Bell, struggling to access the medications they have relied upon and have used responsibly. Perhaps there is some hope. As part of the overall response to the opioid crisis, the federal government has adopted a multi-prong strategy which includes support for cutting edge research in pain and treatments and the development of better practices for pain management. The government representatives described the serious efforts being undertaken by NIH, FDA, VA, DOD and HHS to address the needs of those in chronic pain in the midst of efforts to combat the opioid crisis. But in state after state,11 either through government actions or changes in insurance coverage, policies are being adopted that place severe limits on dosage, the duration of opioid prescriptions and number of refills.12 While there are some exceptions for patients in chronic pain in the newly adopted rules, the reality is Jonathan Bell’s. The new restrictions make it almost impossible to overcome the presumption against long term use of opioids and lack of data.


Lindsay Natiw is on active duty in the Army. She suffers from fibromyalgia. People just don’t get that your skin hurts. Every day, I wake up exhausted. Only someone who has lived this knows what I am going through. With every new doctor, it is an uphill battle while they get up to speed about this disease and how to treat it. Each time, I am starting again at the bottom and trying to climb my way up. I have been suffering, almost untreated, for 12 years. Chronic pain patients have long been seen by many doctors and society as malingerers. The current “crisis” has recast them in an even worse light, as engaging in “drug seeking behavior.” Since less than 20% of the public think that chronic pain is a major health problem,13 it should not be surprising that the medical communities adopt this view. The problem is even worse for adolescents, whose problems are almost invariably seen as “psychological” and their claimed need for analgesia a product of their intended drug abuse. As Dr. Lonnie Zeltzer, Director of the UCLA Pediatric Pain Program, explained, “Adolescents in chronic pain grow up to be adults in chronic pain.”

Agreement At the end of the discussion, the stakeholders agreed: 1. There is an urgent need to change the cultural perceptions about people who live with chronic pain—that chronic pain is a medical disease, not a social disease. 2. There is an urgent need for education of physicians, patients and the public about the proper use of pain medication and that opioids are an essential part of the treatment plan for many patients suffering from chronic pain. 3. There is a need for the development of evidence-based data on the effectiveness of other nonpharmacological treatments for chronic pain. 4. There is a need for appropriate reimbursement for the costs of treating chronic pain.

For these things to happen, there must be a clear differentiation between the terrible problem of drug abuse and the legitimate needs of the 100 million adults suffering from chronic pain. The media plays an essential role in educating the public and policy makers and creating the context for the proper treatment of patients living with chronic pain. More balanced reporting, including narratives about the struggles of those living with chronic pain, especially high-impact chronic pain, is required to change public perception and pain policy in the U.S. and for millions of Americans to receive comprehensive chronic pain care. To achieve this more balanced reporting, the following must occur: 1. Relationships between leaders in pain and the national media need to be established. 2. Access to evidence-based information about both the science of pain and the science of addiction should be facilitated for representatives of the media. 3. Access to experts and pain patients and their advocates must be established.

“Comprehensive and high quality management, including the judicious use of opioids, will improve the lives of millions of people in chronic pain, will save money and will positively impact the opioid problem.”

Dr. Richard Payne concluded, “Comprehensive and high quality management, including the judicious use of opioids, will improve the lives of millions of people in chronic pain, will save money and will positively impact the opioid problem.” This will require a more critical view by the press of health policy and a more informed and nuanced public narrative about both public health crises.

painsproject.org — 7

painsproject.org

Appendix 1 Recent State Legislation regarding Chronic Pain • •

56 laws passed in 32 states between 01/01/2016–10/05/2017 13 directly targeting prescription limits or liability of physicians

Alaska 1. Voluntary No Opioid Directive Act (Enacted 07/25/2017) https://custom.statenet.com/public/resources.cgi?id=ID:bill:AK2017000H159&ciq=ncsl9&client_md=36fc16bae6fdb4074a2a088b64f34d25&mode=current_text a. The 7-day and 4-day limits outlined in the state legislature should not be interpreted as minimums for prescribing opioids for acute pain b. The CDC has stated that 3 days is the minimum that will satisfy most cases of acute pain c. Doctors should use their personal judgment and not interpret the 7-day/4-day limits as minimums Hawaii 2. Opioid Therapy Informed Consent Process (enacted 07/03/2017) http://custom.statenet.com/public/resources.cgi?id=ID:bill:HI2017000S505&ciq=ncsl9&client_md=65e3b5e96fc96bf7783ab6caa89438a7&mode=current_text

a. Requires execution of an opioid therapy informed consent process between patient/prescriber before beginning an opioid therapy that may cause dependency b. Limits initial prescription to 7 consecutive days except for specialized conditions c. Specialized conditions include: i. Pain experienced by the patient in post-operative care ii. Chronic pain and pain management iii. Substance abuse or opioid dependence iv. Cancer v. Pain experienced while the patient is in palliative care vi. Pain experienced while the patient is in hospice care Indiana 3. Prescribing and Dispensing of Opioids (enacted 04/26/2017) https://custom.statenet.com/public/resources.cgi?id=ID:bill:IN2017000S226&ciq=ncsl9&client_md=a224f1c098b554d1b89a019600402b41&mode=current_text

a. Limits the opioid prescription to 7 days for an adult who is being prescribed an opioid for the first time b. 7 days for a prescription for a child under 18 (unless for specific circumstances) c. Requires a prescriber to issue a prescription for an opioid in a lesser amount if requested by specific individuals and to document that request (partial fill rules) 4. Controlled Substances (enacted 03/21/2016) http://custom.statenet.com/public/resources.cgi?id=ID:bill:IN2016000S214&ciq=ncsl9&client_md=c84534d35839cc51f1ead1cc7ebfc823&mode=current_text

a. Prohibits Medicaid reimbursement for Subutex, Suboxone, or a similar trade name or generic of the drug if the drug was prescribed for the treatment of pain or pain management and the drug is only indicated for addiction treatment b. Requires that the office of the secretary develop best treatment practices


Louisiana 5. Drugs and Controlled (enacted 06/12/2017) http://custom.statenet.com/public/resources.cgi?id=ID:bill:LA2017000H192&ciq=ncsl9&client_md=2ee07f2177214edfc891ed6007eb20f7&mode=current_text

a. Provides a 7-day limit on prescriptions with exceptions b. Exceptions i. Chronic pain management ii. Palliative care iii. Cancer iv. Hospice v. Substance abuse or opioid dependence c. Authorizes a prescription to be filled for a lesser quantity than the maximum prescribed amount Maine 6. Opioid Medication Prescribing Limits Laws (enacted 06/16/2017) http://custom.statenet.com/public/resources.cgi?id=ID:bill:ME2017000S338&ciq=ncsl9&client_md=69016854c13a49ed6e5f902e77555c34&mode=current_text

a. Aggregate amount of opioid medication prescribed to a patient may not be in excess of 100 morphine milligram equivalents per day b. DHHS must adopt rules establishing reasonable exceptions to those limits 7. Immunity from Liability for Disclosure of Information (enacted 04/19/2016) http://custom.statenet.com/public/resources.cgi?id=ID:bill:ME2015000S671&ciq=ncsl9&client_md=bc03d7747ce0314e2dab1cf87926a7fe&mode=current_text

a. Provides immunity from liability for disclosure of information to the Controlled Substances Prescription Monitoring Program by the prescriber, includes sharing with other states and Canadian provinces to prevent fraud b. Related to MaineCare Maryland 8. Health Care Providers—Prescription Opioids—Limits on Prescribing (enacted 05/25/2017) http://custom.statenet.com/public/resources.cgi?id=ID:bill:MD2017000H1432&ciq=ncsl9&client_md=a19d3fe000035c638dc271a2919af4fb&mode=current_text

a. Requires healthcare providers to prescribe a certain dosage and a certain quantity of an opioid unless the opioid is prescribed to treat a certain disorder or certain pain b. Requires the dosage, quantity, and duration of certain prescribed opioids to be based on certain guidelines c. Provides that a violation of a certain provision of the act is grounds for disciplinary action by the health occupations board Massachusetts 9. Substance Abuse and Prevention (enacted 03/14/2016) https://custom.statenet.com/public/resources.cgi?id=ID:bill:MA2015000H4056&ciq=ncsl9&client_md=6ca1da9ac1f9ea8c02add2f33d6111ed&mode=current_text

a. Dispenser may dispense less than the recommended amount if the patient requests b. Prescribers must have adequate training before becoming registered to prescribe controlled substances and they must discuss the dangers of opioids before prescribing with their patient c. No liability for not prescribing an opiate


Pennsylvania 10. Limitations on Specified Drug Dispersion (enacted 11/02/2016)

http://custom.statenet.com/public/resources.cgi?id=ID:bill:PA2015000H1699&ciq=ncsl9&client_md=ad265b003cbeac14995598948c7e6e1d&mode=current_text

a. Provides for limitations on the dispensing of opioid drug products in hospital emergency departments and urgency care centers and to patients in observation status for duties of the Department of Health b. No more than 7 day supply c. No refills d. Must query the PDMP Tennessee 11. Controlled Substances (enacted 06/06/2017)

http://custom.statenet.com/public/resources.cgi?id=ID:bill:TN2017000H1207&ciq=ncsl9&client_md=9137f9b3a8ec1eacab3ce94ba862ac49&mode=current_text

a. Requires the Department of Health to identify the prescribers who are in the top of a certain percent of prescribers of opioids in the State, requires the identified prescriber to comply with certain requirements after being notified that such provider is a high volume opioid prescriber

Texas 12. Continuation and Functions of the Pharmacy Board (enacted 06/09/2017)

https://legiscan.com/TX/text/HB2561/id/1599378

a. Board, in consultation with the department and regulatory agencies shall identify prescribing practices that may be potentially harmful and patient prescription patterns that may suggest drug diversion and abuse b. Board may send electronic notification to the dispenser or prescriber if the information indicates the above c. Board may develop guidelines for determining whether a prescribing pattern of prescription pattern is harmful/subversive/abusive West Virginia 13. Denial of Prescription Drugs (enacted 03/23/2016)

http://custom.statenet.com/public/resources.cgi?id=ID:bill:WV2016000S627&ciq=ncsl9&client_md=d7aca3c382ee65bfed7003873ca834ef&mode=current_text

a. Limits disciplinary action on a healthcare provider with prescriptive authority for declining to prescribe or declining to continue to prescribe any controlled substance in certain circumstances b. Provides that the healthcare provider is not liable to a patient or third party c. Limits health care providers’ liability exposure for injuries sustained as a result of the use of a medical device or prescription drug


Appendix 2 Jonathan Bell PAINS-KC Citizen Leader Lives with sickle cell disease Michael Beyer YI Advisors Chester Buckenmaier, III Associate Professor and Director Defense & Veterans Center for Integrative Pain Management (DVCIPM) Myra Christopher Director PAINS Project Center for Practical Bioethics Clint Cole Research Intern PAINS Project Center for Practical Bioethics Larry Driver Professor, Department of Pain Medicine Division of Anesthesiology and Critical Care The University of Texas, MD Anderson Cancer Center Anna Fine Office of Health and Constituent Affairs FDA Katie Horton Research Professor GW Public Health Kum Kang YI Advisors Diederik Lohman Acting Director, Health and Human Rights Division Human Rights Watch Sherry McAllister Executive Vice President Foundation for Chiropractic Progress (F4CP) Richard Payne Medical Director, PAINS Project Professor of Medicine, Duke Cancer Institute Becky Priest Global Prairie Don Sapatkin Public Health Reporter: Addiction and Mental Health The Philadelphia Inquirer

Vanila Singh Chief Medical Officer for the Office of the Assistant Secretary of Health U.S. Department of Health and Human Services Christina M. Spellman Executive Director The Mayday Fund Catlin O’Shaughnessy Coffrin Global Prairie Anne St. Peter Global Prairie Cindy Steinberg National Director of Policy and Advocacy US Pain Foundation Greg Terman President American Pain Society Dave Thomas Deputy Director Division of Clinical Neuroscience and Behavioral Research National Institute on Drug Abuse NIH Pain Consortium Doug Throckmorton Deputy Director Regulatory Programs FDA Bob Twillman Executive Director Academy of Integrative Pain Management Sarah Vander Schaaff Freelance Writer and Blogger Contributor to Wash Post Health & On Parenting, HuffPost Ed, Yahoo Parenting, Broadway World, Mental Health Advocate Amanda Vasil Global Prairie Michael “Buz” Waitzkin Deputy Director Duke Institute on Policy and Science Kaylie Wallace Global Prairie Lonnie K. Zeltzer Director UCLA Pediatric Pain Program


painsproject.org

References 1)

There is a substantial and growing body of both academic and anecdotal literature on the stigma associated with patients in chronic pain. See e.g. Goldberg,

“Pain, Objectivity and History: Understanding Pain Stigma,” Medical Humanities, December 2017; Cohen et al, “Stigmatization of Patients with Chronic Pain: The Extinction of Empathy,” Pain Medicine, no. 11 (2011); Lynn Webster, The Painful Truth, Ch. 4: Friendly Fire (2015); Zhang, “The Long History of Discrimination in Pain Medicine,” The Atlantic, Feb. 28, 2017.

2)

IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.

3)

https://iprcc.nih.gov/National-Pain-Strategy/Overview

4)

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

5)

See Appendix 1.

6)

See e.g. Madani, “Florida’s Largest Insurer to Stop Covering Oxycontin Amid Opioid Crisis,” U.S. News, Nov. 7, 2017.

7)

See e.g. Japsen, “CVS Health Increases Restrictions on Opioids,” Forbes, September 21, 2017.

8)

The Pain Action Alliance to Implement a National Strategy (PAINS) is a consortium of leaders from professional societies, patient advocacy organizations, policy

9)

The DEA’s actions against doctors between 2011 and 2016 increased five-fold (88/479). Michael Needleman. “Doctors Increasingly Face Charges for Patient

groups, consumers, third-party payers and the private sector and is a program of the Center for Practical Bioethics. http://painsproject.org/ Overdoses” CNN, July 31, 2017. 10) Thomas and Ornstein, “Amid Opioid Crisis, Insurers Restrict Pricey. Less Addictive Painkillers,” New York Times, Sept. 17, 2017. Reporting on Study by New York Times and ProPublica. 11) See footnotes 5, 6, 7 and 10 12) In a review of the IOM’s seminal 2011 report, a committee of the National Academies counseled against arbitrary regulatory restrictions on responsible prescribing for patients without effective alternatives to opioids. Bonnie, Kesselheim and Clark, “Both Urgency and Balance Needed in Addressing Opioid Epidemic: A Report from the National Academies of Science, Engineering and Medicine,” JAMA, August 1, 2017. National Academies of Sciences, Engineering, and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: National Academies Press; 2017. https://www.nationalacademies.org/opioidstudy. 13) Research America poll, April 8, 2013, http://www.researchamerica.org/news-events/news/chronic-pain-ranks-well-below-drug-addiction-major-health-problem-new-national

Contributor: Michael B. Waitzkin Michael B. Waitzkin is an attorney who practiced in Washington, DC for 30 years and has extensive experience in litigation and in counseling pharmaceutical companies, biotechs, startups, non-profits, government officials and biomedical researchers. He is currently on the faculty of Duke University, where he serves as Deputy Director of the Initiative for Science & Society and as Director of Graduate Studies for the MA in Bioethics & Science Policy.

He teaches courses on ethics and science policy in the law, medical and graduate schools. He received his legal training at Stanford Law School (JD 1974) and Yale Law School (LLM 1975 – Commonwealth Fellow in Law, Science & Medicine).

The Pain Action Alliance to Implement a National Strategy (PAINS) is a consortium of leaders from professional societies, patient advocacy organizations, policy groups, consumers, third-party payers and the private sector collaborating to achieve a common vision and mission. PAINS is a program of the Center for Practical Bioethics, a private, nonprofit organization that has a broad-based stream of revenues, including institutional memberships, endowments, grants and contributions from individuals, corporations and foundations (both public and private), and feefor-service. The Center brings a wealth of experience in coordinating national programs. Its staff includes nationally recognized leaders in chronic pain.

This copy is made available to you by:

Learn more at painsproject.org Published January 2018