The pursuit of balance in drug control law and public policy

Beginning just before the year 2000, a major public policy initiative focused on pain relief and drug control law began. The central or governing principle of the initiative was ''balance,'' which was characterized as ''the dual imperative of governments to establish a system of controls to prevent abuse, trafficking, and diversion of narcotic drugs while, at the same time, ensuring their medical availability.''69 Inherent in the initiative appeared to be a genuine concern that there was currently, and had been for some time, an imbalance produced by a disproportionate emphasis on preventing or punishing drug diversion and a lack of emphasis on access to opioids for pain relief. The evaluation guide was intended to provide a tool with which to measure the level of imbalance in a jurisdiction's laws and policies. It identified eight criteria for provisions that may tend to enhance pain management, e.g. prescription amount alone is recognized as insufficient to determine the legitimacy of prescribing, and nine criteria for provisions that may tend to impede pain management, e.g. medical use of opioids is implied to be outside legitimate professional practice. In the United States, the University of Wisconsin Pain and Policy Studies Group conducted evaluations of the states in 2000 and 2003 and grades were assigned on a scale of A-F. In neither year did any state receive either an "A'' or an "F," with "C'' being average.70 In the three years between the two evaluations, 14 states improved their grades, 36 remained the same, and one (Ohio) had a negative change.

During the same period, the Pain and Policy Studies Group collaborated with the WHO to prepare a similar guide that was international in scope.71 The stated purpose of this document was to enable governments "to determine whether their national drug control policies have established the legal and administrative framework to ensure the medical availability of opioid analgesics, according to international treaties and the recommendations of the International Narcotics Control Board (INCB) and the World Health Organization (WHO).'' The INCB had implicitly endorsed the principle of balance in public policy in an earlier report when it stated: "...an efficient national drug control regime must involve not only a programme to prevent illicit trafficking and diversion, but also a programme to ensure the adequate availability of narcotic drugs for medical and scientific purposes.''72 The INCB officially endorsed the WHO guidelines for policy assessment in 2001, and in 2005 reiterated its request that individual nations examine the extent to which their laws and regulations allow the medical use of opioids and develop plans for addressing problems revealed by such an examination.73

Rumania has become the first country to initiate a government-sponsored program to conduct a comprehensive assessment of drug control policy to address regulatory barriers and improve access to opioids by collaborating with the Pain and Policy Studies Group on recommendations for changing the country's regulatory policies for opioids.74 However, perhaps prompted to some extent by the WHO report and previous statements by the INCB, Italy eliminated a complex triplicate prescription form for opioids. The question that remains open, even when governmental policies are made more conducive to good pain management, is the extent to which clinicians will change their traditionally ultra-conservative approach to opioid analgesics, which has been shaped for so long by the history of unbalanced policies focused on drug diversion.

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