December 4, 2000

United States Senate
Washington, DC 20510

Dear Senator:

I am writing on behalf of the American Psychological Association (APA) in reference to H.R. 2260, the "Pain Relief Promotion Act," which will soon be considered for inclusion in Conference Report 106-1004 (to accompany the Certified Development Company Program Improvement Act of 1999, H.R. 2614). While it is not the purpose of this letter to argue for or against this legislation, the APA is concerned about the possible impact of the bill on the quality of life of people in pain and those near the end of life. As you review this bill and consider the implications for your constituents, we hope you will consider several key points derived from research on behavioral and social science issues.

APA is the largest scientific and professional organization in the United States and is the world's largest association of psychologists. APA's membership includes more than 159,000 researchers, educators, clinicians, consultants, and students. Our mission is to advance psychology as a science, as a profession, and as a means of promoting human welfare. The APA is invested in promoting quality of life throughout the life span and thus very interested in end-of-life issues. Many psychologists are trained in providing behavioral interventions that can decrease pain and other symptoms that cause suffering. Accordingly, APA's Board of Directors recently established a Working Group on Assisted Suicide and End-of-Life Decisions to facilitate the involvement and contribution of psychology and of psychologists in the dialogue surrounding end-of-life decision making.

Research on Pain and Suffering

• Although tens of millions of dollars have been spent in the last decade, health care providers still lack sufficient training about how best to reduce severe pain. Subsequently, pain is generally undertreated.

• The presence of physical pain can lead to or intensify clinical depression and anxiety. Therefore, alleviating pain is important in providing proper mental health care.

• In addition, the experience of pain and suffering is related to the psychological aspects of a person's life so the amelioration of psychological issues and stressors can decrease pain and suffering.

• The proper treatment of psychological conditions, such as clinical depression, has been shown to decrease the desire of some people to end their lives.

Research on the Use of Controlled Substances to Manage Pain

The title of the bill notwithstanding, available data indicate that language included in the legislation will continue to keep pain management at improperly low levels.

• Evidence from states that have enacted laws with similar language suggest that only in rare circumstances will pain management improve under such provisions, and there is the distinct possibility of pain management becoming worse.

• In states with additional regulatory oversight, prescribing of scrutinized controlled substances dramatically decreases following rule changes, while prescriptions of other less effective medications suddenly increase.

• Despite claims that the bill does not increase regulatory oversight, research has unequivocally and repeatedly indicated that even perceived regulatory scrutiny leads to fear of prescribing powerful pain medications.

Additional Issues to Consider

There are a number of common ethical and legal practices in the field of end-of-life care that may become illegal under the proposed act. Controlled substances are often used to reduce suffering when a person is receiving a procedure that is known to lead to death.

• For example, when a person has requested that a ventilator be turned off (either the person's own or that of a loved one), it is standard practice to sedate the person with controlled substances so that he or she does not experience the panic associated with air hunger. Withholding controlled substances in such situations would increase fear and suffering.

APA urges that findings from behavioral and social science research be considered in any legislation crafted to improve end-of-life care and the alleviation of pain and suffering. It should be noted that there are other bills that take into account this research, and we encourage you to consider them as you decide upon the route the government should take in improving the quality of life of those in pain and those who are dying.

If you have any questions or would like additional information, please contact Camille Preston, Ph.D., of APA's Public Policy Office at (202) 336 - 6153.

Sincerely,