[Congressional Record Volume 145, Number 90 (Wednesday, June 23, 1999)]
[Senate]
[Pages S7532-S7534]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. NICKLES (for himself, Mr. Lieberman, Mr. Lott, Mr. 
        Abraham, Mr. Allard, Mr. Brownback, Mr. Coverdell, Mr. Enzi, 
        Mr. Hagel, Mr. Inhofe, Mr. Craig, and Mr. Sessions):
  S. 1272. A bill to amend the Controlled Substances Act to promote 
pain management and palliative care without permitting assisted suicide 
and euthanasia, and for other purposes; to the Committee on Health, 
Education, Labor, and Pensions.


                   Pain Relief Promotion Act of 1999

  Mr. NICKLES. Mr. President, end-of-life issues are some of the most 
complicated our society wrestles with today, as medical technology 
dramatically advances and life expectancies continue to increase. Many 
of us have relatives, or know someone, who has grappled with grave and 
terminal illnesses. Doctors, caregivers, and family members work 
together in such situations, not just in an effort to save a loved 
one's life, but to give them the comfort and palliative care they 
deserve. However, love and concern can often come up against a 
confusing and complicated set of Federal and state laws which govern 
and influence care and treatment decisions in such situations.
  Today I, along with Senators Lieberman, Lott, Abraham, Allard, 
Brownback, Coverdell, Enzi, Hagel, Helms, Inhofe, and Craig, introduce 
the Pain Relief Promotion Act of 1999. This comprehensive legislation 
will restore the uniform national standard of the Controlled Substances 
Act (CSA) to all 50 states. The Pain Relief Promotion Act will:
  Affirm and support aggressive pain management as a ``legitimate 
medical purpose'' for the use of federally-controlled substances--even 
in cases where such use may unintentionally hasten death as a side-
effect (``principle of double effect'').
  Encourage practitioners to dispense and distribute federally-
controlled substances as medically appropriate to relieve pain and 
other distressing symptoms, by clarifying that such conduct is 
consistent with the Controlled Substances Act.
  Provide that a state law authorizing or permitting assisted suicide 
or euthanasia does not change the federal government's responsibility 
to prevent misuse of federally-controlled, potentially dangerous, 
drugs. The Federal government's responsibility to prevent such misuse 
in states which have not legalized assisted suicide is already conceded 
by the Attorney General and would not change.
  Provide education and training to law enforcement officials and 
health professionals on medically accepted means for alleviating pain 
and other distressing symptoms for patients with advanced chronic 
disease or terminal illness, including the legitimate use of federally-
controlled substances.
  Establish a ``Program for Palliative Care Research and Quality'' 
within the Agency for Health Care Policy and Research (AHCPR) to 
develop and advance scientific understanding of palliative care, and 
collect, disseminate and make available information on pain management, 
especially for the terminally ill health professionals and the general 
public.
  Authorize $5 million for a grant program within the Health Resources 
and Services Administration (HRSA) to

[[Page S7533]]

make grants and contracts for the development and implementation of 
programs to provide education and training in palliative care. It 
states that physicians entrusted by the federal government with the 
authority to prescribe and dispense federally-controlled substances may 
not abuse that authority by using them for assisted suicide; however, 
it strongly affirms that it is a ``legitimate medical purpose'' to use 
these federally-controlled substances to treat patient's pain and end-
of-life symptoms, even in light of the unfortunate and unintended side 
effect of possibly hastening a patient's death.
  Recognize that this policy promoting pain control does not authorize 
the use of federally-controlled substances for intentional assistance 
in suicide or euthanasia.
  Restore the uniform national standard that federally-controlled 
substances can not be used for the purpose of assisted suicide by 
applying the current law in 49 states to all 50 states. This bill does 
not create any new regulatory authority for the DEA.
  This is a straight-forward, very positive bill that would merely 
apply what is current law in 49 states to all 50 states, without 
increasing the federal regulatory authority of the Drug Enforcement 
Administration (DEA). The bill has been endorsed by organizations 
including the National Hospice Organization, American Society of 
Anesthesiologists, American Academy of Pain Management, and former 
Surgeon General Dr. C. Everett Koop. And, today I was informed that the 
House of Delegates of the American Medical Association voted to support 
the bill.
  A variety of provisions in this legislation is in direct response to 
the June 5, 1998, letter by the Attorney General, allowing Oregon to 
use federally-controlled substances for assisted suicide, a decision 
that was in direct opposition to an earlier policy determination by her 
own Drug Enforcement Administration.
  It is significant to remember that in 1984 Congress passed amendments 
to strengthen the Controlled Substances Act, due to specific concerns 
regarding the use of prescription drugs in lethal overdoses. Congress's 
view was that while the states are the first line of defense against 
misuse of prescription drugs, the federal government must enforce its 
own objective standard as to what constitutes such misuse--and it must 
have the authority to enforce that standard when a state cannot or will 
not do so.
  Again, Congress clearly spoke on the issue of assisted suicide when 
it passed the Assisted Suicide Federal Funding Restriction Act of 1997 
by a nearly unanimous vote. Signing the bill President Clinton said it 
``will allow the Federal Government to speak with a clear voice in 
opposing these practices,'' and warned that ``to endorse assisted 
suicide would set us on a disturbing and perhaps dangerous path.''
  It is time for Congress to speak again.
  Federal law is clearly intended to prevent use of these drugs for 
lethal overdoses, and contains no exception for deliberate overdoses 
approved by a physician. The DEA currently pursues cases where a 
physician's negligent use of controlled substances has led to the death 
of a patient, it was inappropriate for the Attorney General to allow 
for the intentional use of controlled substances to cause the death of 
a patient. The Pain Relief Promotion Act will clarify federal law, to 
affirm use of controlled substances to control pain and reject their 
deliberate use to kill patients.
  This legislation is overdue. Already physicians have used these 
federally controlled substances to cause the death of their patients. 
There is no role for the Federal government in providing assisted 
suicide.
  I urge my colleagues to support and enact this urgently needed 
bipartisan legislation.
  Mr. President, I ask unanimous consent that the text of the bill and 
letters, of support be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1272

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Pain Relief Promotion Act of 
     1999''.

 TITLE I--USE OF CONTROLLED SUBSTANCES CONSISTENT WITH THE CONTROLLED 
                             SUBSTANCES ACT

     SEC. 101. REINFORCING EXISTING STANDARD FOR LEGITIMATE USE OF 
                   CONTROLLED SUBSTANCES.

       Section 303 of the Controlled Substances Act (21 U.S.C. 
     823) is amended by adding at the end the following:
       ``(i)(1) For purposes of this Act and any regulations to 
     implement this Act, alleviating pain or discomfort in the 
     usual course of professional practice is a legitimate medical 
     purpose for the dispensing, distributing, or administering of 
     a controlled substance that is consistent with public health 
     and safety, even if the use of such a substance may increase 
     the risk of death. Nothing in this section authorizes 
     intentionally dispensing, distributing, or administering a 
     controlled substance for the purpose of causing death or 
     assisting another person in causing death.
       ``(2) Notwithstanding any other provision of this Act, in 
     determining whether a registration is consistent with the 
     public interest under this Act, the Attorney General shall 
     give no force and effect to State law authorizing or 
     permitting assisted suicide or euthanasia.
       ``(3) Paragraph (2) applies only to conduct occurring after 
     the date of enactment of this subsection.''.

     SEC. 102. EDUCATION AND TRAINING PROGRAMS.

       Section 502(a) of the Controlled Substances Act (21 U.S.C. 
     872(a)) is amended--
       (1) by striking ``and'' at the end of paragraph (5);
       (2) by striking the period at the end of paragraph (6) and 
     inserting ``; and''; and
       (3) by adding at the end the following:
       ``(7) educational and training programs for local, State, 
     and Federal personnel, incorporating recommendations by the 
     Secretary of Health and Human Services, on the necessary and 
     legitimate use of controlled substances in pain management 
     and palliative care, and means by which investigation and 
     enforcement actions by law enforcement personnel may 
     accommodate such use.''.

                  TITLE II--PROMOTING PALLIATIVE CARE

     SEC. 201. ACTIVITIES OF AGENCY FOR HEALTH CARE POLICY AND 
                   RESEARCH.

       Part A of title IX of the Public Health Service Act (42 
     U.S.C. 299 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 906. PROGRAM FOR PALLIATIVE CARE RESEARCH AND QUALITY.

       ``(a) In General.--The Administrator shall carry out a 
     program to accomplish the following:
       ``(1) Develop and advance scientific understanding of 
     palliative care.
       ``(2) Collect and disseminate protocols and evidence-based 
     practices regarding palliative care, with priority given to 
     pain management for terminally ill patients, and make such 
     information available to public and private health care 
     programs and providers, health professions schools, and 
     hospices, and to the general public.
       ``(b) Definition.--For purposes of this section, the term 
     `palliative care' means the active total care of patients 
     whose prognosis is limited due to progressive, far-advanced 
     disease. The purpose of such care is to alleviate pain and 
     other distressing symptoms and to enhance the quality of 
     life, not to hasten or postpone death.''.

     SEC. 202. ACTIVITIES OF HEALTH RESOURCES AND SERVICES 
                   ADMINISTRATION.

       (a) In General.--Part D of title VII of the Public Health 
     Service Act (42 U.S.C. 294 et seq.), as amended by section 
     103 of Public Law 105-392 (112 Stat. 3541), is amended--
       (1) by redesignating sections 754 through 757 as sections 
     755 through 758, respectively; and
       (2) by inserting after section 753 the following section:

     ``SEC. 754. PROGRAM FOR EDUCATION AND TRAINING IN PALLIATIVE 
                   CARE.

       ``(a) In General.--The Secretary, in consultation with the 
     Administrator for Health Care Policy and Research, may make 
     awards of grants, cooperative agreements, and contracts to 
     health professions schools, hospices, and other public and 
     private entities for the development and implementation of 
     programs to provide education and training to health care 
     professionals in palliative care.
       ``(b) Priorities.--In making awards under subsection (a), 
     the Secretary shall give priority to awards for the 
     implementation of programs under such subsection.
       ``(c) Certain Topics.--An award may be made under 
     subsection (a) only if the applicant for the award agrees 
     that the program carried out with the award will include 
     information and education on--
       ``(1) means for alleviating pain and discomfort of 
     patients, especially terminally ill patients, including the 
     medically appropriate use of controlled substances;
       ``(2) applicable laws on controlled substances, including 
     laws permitting health care professionals to dispense or 
     administer controlled substances as needed to relieve pain 
     even in cases where such efforts may unintentionally increase 
     the risk of death; and
       ``(3) recent findings, developments, and improvements in 
     the provision of palliative care.
       ``(d) Program Sites.--Education and training under 
     subsection (a) may be provided at or through health 
     professions schools, residency training programs and other 
     graduate programs in the health professions, entities

[[Page S7534]]

     that provide continuing medical education, hospices, and such 
     other programs or sites as the Secretary determines to be 
     appropriate.
       ``(e) Evaluation of Programs.--The Secretary shall 
     (directly or through grants or contracts) provide for the 
     evaluation of programs implemented under subsection (a) in 
     order to determine the effect of such programs on knowledge 
     and practice regarding palliative care.
       ``(f) Peer Review Groups.--In carrying out section 799(f) 
     with respect to this section, the Secretary shall ensure that 
     the membership of each peer review group involved includes 
     one or more individuals with expertise and experience in 
     palliative care.
       ``(g) Definition.--For purposes of this section, the term 
     `palliative care' means the active total care of patients 
     whose prognosis is limited due to progressive, far-advanced 
     disease. The purpose of such care is to alleviate pain and 
     other distressing symptoms and to enhance the quality of 
     life, not to hasten or postpone death.''.
       (b) Authorization of Appropriations; Allocation.--
       (1) In general.--Section 758 of the Public Health Service 
     Act (as redesignated by subsection (a)(1) of this section) is 
     amended in subsection (b)(1)(C) by striking ``sections 753, 
     754, and 755'' and inserting ``section 753, 754, 755, and 
     756''.
       (2) Amount.--With respect to section 758 of the Public 
     Health Service Act (as redesignated by subsection (a)(1) of 
     this section), the dollar amount specified in subsection 
     (b)(1)(C) of such section is deemed to be increased by 
     $5,000,000.

     SEC. 203. EFFECTIVE DATE.

       The amendments made by this title take effect October 1, 
     1999, or on the date of the enactment of this Act, whichever 
     occurs later.
                                  ____



                                National Hospice Organization,

                                     Arlington, VA, June 11, 1999.
     Hon. Don Nickles,
     U.S. Senate,
     Washington, DC.
       Dear Senator Nickles: The National Hospice Organization has 
     recently endorsed your bill, ``The Pain Relief Promotion Act 
     of 1999.''
       Your legislation would provide a mechanism for health care 
     professionals to collect, review and disseminate vital 
     practice protocols and effective pain management techniques 
     within the health care community and the public. In addition, 
     increased educational efforts focused within the health 
     professions community about the nature and practice of 
     palliative care are important components of your initiative.
       Our 2,000 member hospices provide what Americans say they 
     want if they were confronted with a terminal illness--to die 
     in their home, free of pain, and with emotional support for 
     themselves and their loved ones. For over 20 years, hospices 
     have been in the forefront of managing the complex medical 
     and emotional needs of the terminally ill. It is unfortunate 
     that we continue to see individuals living and dying in 
     unnecessary pain when the clinical and medical resources 
     exist but widespread education is lacking.
       Your legislation is a step toward a better awareness of 
     effective pain management techniques and should ultimately 
     change behavior to better serve the needs of terminally ill 
     patients and their families.
           Sincerely,
                                                   Karen A. Davie,
     President.
                                  ____

                                                  American Academy


                                           of Pain Management,

                                        Sonora, CA, June 15, 1999.
     Senator Donald Nickles,
     Washington, DC.
       Dear Senator Nickles: The American Academy of Pain 
     Management, America's largest multidisciplinary pain 
     organization, applauds your efforts to end the pain and 
     suffering for Americans. The Board of Directors of the 
     American Academy of Pain Management supports The Pain Relief 
     Promotion Act of 1999. We share your belief that opioid 
     analgesics should be available for those unfortunately 
     suffering from the pain associated with terminal illnesses. 
     The alternatives to assisted suicide and euthanasia are 
     compassionate and appropriate methods for prescribers to 
     relieve pain without fear of regulatory discipline.
       The Pain Relief Promotion Act of 1999 provides for law 
     enforcement education, the development and dissemination of 
     practice guidelines, increased funding for palliative care 
     research, and safeguards for unlawful prescribers of 
     controlled substances. This bill appropriately reflects the 
     changing philosophy about pain control as a significant 
     priority in the care of those facing terminal illnesses.
       The American Academy of Pain Management thanks you for your 
     effort to improve the quality of life for Americans.
           Sincerely,
                                         Richard S. Weiner, Ph.D.,
     Executive Director.
                                  ____

                                                  American Society


                                         of Anesthesiologists,

                                    Washington, DC, June 16, 1999.
     Hon. Don Nickles,
     Assistant Majority Leader, U.S. Senate, Washington, DC.
       Dear Senator Nickles: In my capacity as President of the 
     American Society of Anesthesiologists, a national medical 
     association comprised of 34,000 physicians and other 
     scientists engaged or especially interested in the practice 
     of anesthesiology, I am pleased to offer our endorsement of 
     the Pain Relief Promotion Act of 1999, which I understand you 
     will introduce this week.
       Many ASA members engage in a pain management practice, and 
     such a practice regularly includes the treatment of 
     intractable pain, experienced by terminally or severely ill 
     patients, through the prescription of controlled substances. 
     As you are aware, a major concern among these practitioners 
     has involved the possible that aggressive treatment of 
     intractable pain involving increased risk of death--however 
     medically necessary to provide the patient with the best 
     possible quality of life--could be the subject of criminal 
     prosecution as involving alleged intent to cause death.
       ASA's House of Delegates has formally expressed the 
     Society's opposition to physician assisted suicide as 
     incompatible with the role of the physician. At the same 
     time, the Society believes anesthesiologists ``should always 
     strive to relieve suffering, address the psychological and 
     spiritual needs of patients at the end of life, add value to 
     a patient's remaining life and allow patients to die with 
     dignity''.
       We find your bill to be fully consistent with these 
     principles, in that (1) it denies support in federal law for 
     intentional use of a controlled substance for the purpose of 
     causing death or assisting another person in causing death, 
     but (2) it includes in federal law recognition that 
     alleviating pain in the usual course of professional practice 
     is a legitimate medical purpose for dispensing a controlled 
     substance that is consistent with public health and safety, 
     even if the use of such a substance may increase the risk of 
     death.
       ASA believes that the bill articulates an appropriate 
     standard for distinguishing between assisted suicide and 
     medically-appropriate aggressive treatment of severe pain. 
     Although we have some continuing concern whether law 
     enforcement officers will regularly recognize and honor this 
     critical distinction, we believe much can be accomplished 
     through the education and training programs contemplated by 
     section 102 of the bill. We look forward to the opportunity, 
     during congressional consideration of the bill, to work with 
     you and your staff to strengthen this provision to assure 
     that the these programs include input from medical 
     practitioners regularly engaged in a pain management 
     practice.
       If we can be of further assistance, please ask your staff 
     to contact Michael Scott in our Washington office, at the 
     address and telephone number listed above.
           Sincerely,
                                         John B. Neeld, Jr., M.D.,
     President.

                          ____________________