Appendix J

NATIONAL MEDICAL ASSOCIATION (NMA) RECOMMENDATIONS
FOR THE SAFE AND EFFECTIVE MANAGMENT OF PAIN

Pain is a common feature of many diseases, including cancer, HIV/AIDS, and sickle cell. Whether acute or chronic, untreated or under treated pain can diminish a patient's quality of life. For ethnic and racial minorities, this problem is even more acute because of stereotyping. To this end, the NMA recommends the following policies for the safe and effective management of pain:

Education
A pain management curriculum should be integrated throughout medical and related health education programs at the undergraduate and postgraduate continuing medical education levels. As part of this curriculum development, there will be a concerted effort to increase the number of culturally competent specialists in the area of pain management. This curriculum should also be promoted through collaborations with historically black colleges and universities.

Health education programs for the public should include appropriate instruction and understanding of pain management, prevention of abuse and addiction.

Special attention should be directed toward adolescents and secondary education students through a structured curriculum regarding proper use of prescription medications and prevention of abuse.

A concerted effort will be made to provide training for law enforcements officials, state controlled substances authorities, the judicial community and business leaders.

Research
More focus must center on the collection of data by race and ethnicity to allow better identification of the reasons for healthcare disparities in pain management, with a focus on their elimination.

More research should be directed toward pain management of diseases, which disproportionately affect minorities, women, and children.

African-American patients and researchers should participate in clinical trials on new treatments for pain management. These trials should also be actively promoted.

Physician Practice
Incorporate into practice medical record documentation of the four A's of treatment outcomes:

• Analgesia
• Activities of Daily Living
• Adverse Effects
• Aberrant Drug Taking Behaviors.

Perform an adequate history and physical examination to include a social history that specifically addresses:

• A history of substance abuse
• A list of all controlled substances prescribed and by whom
• Mental health disorders and treatment.

Develop collaborations with local pharmacies and law enforcement officials in order to provide early detection of aberrant drug taking behaviors. Adopt standards for prescriptions, which include:

• Tight control of prescription pads
• The use of tamper-resistant pads
• Writing out in words the quantity and strength of the medication to be dispensed as well as spelling out the number
• Do not include on preprinted prescription pads the medical license or controlled substance registration number.

Physicians should record in the medical record signs of drug abuse, such as inflamed nares, a perforated nasal septum, skin tracks, and skin lesions caused by subcutaneous injection.

Recognize and record behavior suggestive of addiction, such as loss of control, compulsive use, and use despite harm.

Toxicology should be used when there is a suspicion of diversion or aberrant drug-taking to identify the presence of the prescribed drug, as well as any other illicit drugs in body fluids. If diversion of prescription drugs is suspected, the local police department should be notified.

An excerpt from "Managing Pain: The Challenge in Underserved Populations: Appropriate Use versus Abuse and Diversion"
The Journal of the National Medical Association, 2004, Vol. 96, no.9, September

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