[House Report 106-378]
[From the U.S. Government Publishing Office]



106th Congress                                            Rept. 106-378
                        HOUSE OF REPRESENTATIVES
 1st Session                                                     Part 2

======================================================================



 
                   PAIN RELIEF PROMOTION ACT OF 1999

                                _______


                October 18, 1999.--Ordered to be printed

                                _______
                                

  Mr. Bliley, from the Committee on Commerce, submitted the following

                              R E P O R T

                             together with

                            ADDITIONAL VIEWS

                        [To accompany H.R. 2260]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Commerce, to whom was referred the bill 
(H.R. 2260) to amend the Controlled Substances Act to promote 
pain management and palliative care without permitting assisted 
suicide and euthanasia, and for other purposes, having 
considered the same, report favorably thereon with amendments 
and recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     5
Background and Need for Legislation..............................     5
Hearings.........................................................     6
Committee Consideration..........................................     6
Committee Votes..................................................     6
Committee Oversight Findings.....................................     7
Committee on Government Reform Oversight Findings................     7
New Budget Authority, Entitlement Authority, and Tax Expenditures     7
Committee Cost Estimate..........................................     7
Congressional Budget Office Estimate.............................     7
Federal Mandates Statement.......................................    10
Advisory Committee Statement.....................................    10
Constitutional Authority Statement...............................    10
Applicability to Legislative Branch..............................    10
Section-by-Section Analysis of the Legislation...................    11
Changes in Existing Law Made by the Bill, as Reported............    12
Additional Views.................................................    17

                               Amendment

    The amendments (stated in terms of the page and line 
numbers of the introduced bill) are as follows:
    Page 4, strike line 21 and all that follows through page 5, 
line 2, and insert the following:

    ``(b) Definition.--For purposes of this section, the term 
`palliative care' means the active, total care of patients 
whose disease or medical condition is not responsive to 
curative treatment or 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.''.

  Page 7, strike line 9 and all that follows through line 14 
and insert the following:

  ``(g) Definition.--For purposes of this section, the term 
`palliative care' means the active, total care of patients 
whose disease or medical condition is not responsive to 
curative treatment or 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.''.

  The following shows the text of the bill as reported:

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 section:

``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 disease or medical condition is not responsive to 
curative treatment or 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 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 disease or medical condition is not responsive to 
curative treatment or 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 upon the date of the enactment of this Act, whichever 
occurs later.

                          Purpose and Summary

    H.R. 2260, the Pain Relief Promotion Act of 1999 (PRPA) 
amends the Controlled Substances Act (21 U.S.C. 801, CSA) to 
promote pain management and palliative care without permitting 
assisted suicide and euthanasia. The bill provides that the use 
of controlled substances for alleviating pain and discomfort is 
a legitimate medical purpose, even where the use of these drugs 
may have the effect of increasing the risk of death. The bill 
also clarifies the standard that the use of controlled 
substances with the intent of assisting in a suicide is not 
authorized by the Controlled Substances Act and provides that 
the Attorney General, in implementing the Act, must employ a 
uniform standard in enforcement of the Act, without regard to 
State law permitting assisted suicide or euthanasia. PRPA also 
authorizes an increase in the existing authorization of Health 
Resources and Services Administration (HRSA) grants for 
education and training of health care professionals, and 
creates a new Agency for Health Care Policy and Research 
(AHCPR) research program aimed at improving the quality of care 
for patients suffering from chronic or end-of-life pain.

                  Background and Need for Legislation

    Two critical events have led to the call for legislation 
addressing palliative care and assisted suicide. First, on 
October 27, 1997, Oregon became the first and only State to 
legalize physician assisted suicide by lethal doses of 
controlled substances. Second, the Attorney General of the 
United States ruled on June 5, 1998, that such usage is now 
part of the ordinary practice of medicine in Oregon and, 
therefore, exempt from the Controlled Substances Act of 1970 
and Drug Enforcement Agency (DEA) jurisdiction.
    On April 30, 1997, after a vote of 398-16 in the House and 
a unanimous vote in the Senate, the President signed the 
Assisted Suicide Funding Restriction Act of 1997 (Public Law 
105-12), which prohibited the use of Federal funds to cause a 
patient's death. The President, in signing the bill, 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.''
    In a letter responding to the inquiry of Judiciary 
Committee Chairman Henry J. Hyde, dated November 5, 1997, the 
Administrator of the DEA, Thomas K. Constantine, made a 
determination that physician assisted suicide with the use of 
Federally controlled substances violates the CSA. Under the DEA 
ruling, doctors given the special Federal license under the CSA 
to prescribe Federally controlled substances could not 
prescribe them for the purpose of assisting in a suicide. 
Constantine agreed with the sentiment of many Members of 
Congress that administering a drug to deliberately cause 
someone to die is not a ``legitimate medical purpose'' within 
the meaning of the Controlled Substances Act.
    However, in a letter dated June 5, 1998, Attorney General 
Janet Reno made a determination that, contrary to Mr. 
Constantine's position, physician assisted suicide falls within 
the course of professional practice in those States that have 
legalized assisted suicide. Under the Attorney General's 
ruling, the Federal CSA is enforceable against the use of 
controlled substances for assisted suicide only to the extent 
that States have not authorized assisted suicide. Thus, while 
Federal law forbids the use of Federal funds for assisted 
suicide without regard to whether States legalize this 
practice, critics charged that this ruling rendered Federal law 
and policy on assisted suicide subordinate to and a mere 
function of State law and policy.
    The CSA provides a uniform national standard for the 
control of potentially dangerous drugs, and a system of 
enforcement and penalties. Because some of these drugs can help 
alleviate pain and treat illness or injury when dispensed under 
strictly controlled conditions, physicians and pharmacists may 
apply to the DEA for a special Federal license to administer 
them. Thus, while physicians receive their licenses to practice 
medicine from State medical boards, they receive this separate 
DEA registration to prescribe controlled substances from the 
Federal DEA. The DEA registration allows them to prescribe 
these Federally controlled drugs for ``legitimate medical 
purposes.'' Under the current statutory scheme of the CSA, 
physicians must be prepared to explain to DEA officials their 
use of these drugs, and they lose theirregistration and even 
risk criminal penalties if they prescribe such drugs for any purpose 
other than a ``legitimate medical purpose.''

                                Hearings

    The Committee on Commerce has not held hearings on the 
legislation.

                        Committee Consideration

    On October 13, 1999, the Full Committee met in open markup 
session and proceeded to the immediate consideration of H.R. 
2260 without objection. The Full Committee ordered H.R. 2260 
reported to the House, amended, by a voice vote, a quorum being 
present.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House requires 
the Committee to list the record votes on the motion to report 
legislation and amendments thereto. There were no record votes 
taken in connection with ordering H.R. 2260 reported. An 
amendment by Mr. Greenwood to strike all after the enacting 
clause and insert in lieu thereof the text of H.R. 2188, the 
Conquering Pain Act of 1999, was withdrawn by unanimous 
consent. An amendment by Mr. Stupak to expand the definition of 
``palliative care'' to include medical conditions other than 
end-of-life was agreed to by a voice vote. A motion by Mr. 
Bliley to order H.R. 2260 reported to the House, amended, was 
agreed to by a voice vote, a quorum being present.

                      Committee Oversight Findings

    Pursuant to clause 3(c)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee has not held oversight 
or legislative hearings on this legislation.

           Committee on Government Reform Oversight Findings

    Pursuant to clause 3(c)(4) of rule XIII of the Rules of the 
House of Representatives, no oversight findings have been 
submitted to the Committee by the Committee on Government 
Reform.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee finds that H.R. 
2260, the Pain Relief Promotion Act of 1999, would result in no 
new or increased budget authority, entitlement authority, or 
tax expenditures or revenues.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
section 402 of the Congressional Budget Act of 1974.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
provided by the Congressional Budget Office pursuant to section 
403 of the Congressional Budget Act of 1974:
                                     U.S. Congress,
                               Congressional Budget Office,
                                  Washington, DC, October 18, 1999.
Hon. Tom Bliley,
Chairman, Committee on Commerce, U.S. House of Representatives, 
        Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office (CBO) 
has prepared the enclosed cost estimate for H.R. 2260, the Pain 
Relief Promotion Act of 1999.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contacts are Mark 
Grabowicz (for effects on spending by the Department of 
Justice), Cyndi Dudzinski (for costs to the Health Resources 
and Services Administration), Jeanne De Sa (for costs to the 
Agency for Health Care Policy and Research), Lisa Cash Driskill 
(for the state and local impact), and John Harris (for the 
private-sector impact).
            Sincerely,
                                          Barry B. Anderson
                                    (For Dan L. Crippen, Director).
    Enclosure.

H.R. 2260--Pain Relief Promotion Act of 1999

    Summary: H.R. 2260 would increase an existing authorization 
of appropriations to the Health Resources and Services 
Administration (HRSA) for the purpose of making grants to 
public and private entities to educate and train health care 
professionals in palliative care. The bill also would direct 
the Agency for Health Care Policy and Research (AHCPR) to 
develop a program to improve palliative care, and would 
prohibit the use of controlled substances for assisted suicide 
or euthanasia, regardless of any state law authorizing such 
activity.
    Assuming appropriation of the necessary amounts, CBO 
estimates that implementing H.R. 2260 would result in 
additional discretionary spending of about $24 million over the 
2000-2004 period. Enacting this legislation could affect direct 
spending and receipts, so pay-as-you-go procedures would apply; 
however, CBO estimates that the amounts involved would be less 
than $500,000 a year.
    H.R. 2260 contains both an intergovernmental and a private-
sector mandate as defined in the Unfunded Mandates Reform Act 
(UMRA). CBO estimates that the bill would result in no costs to 
state, local, or tribal governments, so the threshold 
established in UMRA ($50 million in 1996, adjusted annually for 
inflation) would not be exceeded. CBO also estimates that the 
costs of the private-sector mandate would fall below the 
threshold established in UMRA ($100 million in 1996, adjusted 
for inflation).
    Estimated cost to the Federal Government: The estimated 
budgetary impact of H.R. 2260 is shown in the following table. 
The costs of this legislation fall within budget function 550 
(health).

----------------------------------------------------------------------------------------------------------------
                                                               By fiscal years, in millions of dollars--
                                                     -----------------------------------------------------------
                                                         2000        2001        2002        2003        2004
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level.......................           7           7           7           2           2
Estimated Outlays...................................           3           6           7           5           3
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: For the purposes of this estimate, CBO 
assumes that the bill will be enacted early in fiscal year 
2000, that the necessary amounts will be provided for each 
year, and that outlays will follow historical spending rates 
for these activities.

Spending subject to appropriation

    The estimated change in spending subject to appropriation 
has two components: (1) an increase in the existing 
authorization of HRSA grants for education and training of 
health care professionals, and (2) a new AHCPR research program 
aimed at improving the quality of care for terminally ill 
patients.
    The existing HRSA grant program received an appropriation 
of $21 million for fiscal year 1999 (a full-year appropriation 
for fiscal year 2000 has not yet been enacted). This program is 
part of a larger HRSA activity which has a current 
authorization of such sums as necessary through fiscal year 
2002. H.R. 2260 would increase the existing target level of $23 
million a year (within that ``such sums'' authorization) by $5 
million. The agency would use the additional funds to award 
grants to public and private entities to develop, implement, 
and evaluate education and training programs in palliative 
care.
    H.R. 2260 would direct AHCPR to develop a research program 
to improve palliative care, mainly through the collection and 
dissemination of guidelines for providing such care. CBO 
estimates that implementing this provision would cost about $1 
million in fiscal year 2000 and $2 million annually thereafter, 
assuming the appropriation of the necessary amounts. (The 
agency received an appropriation of $100 million for 1999 and 
has not yet received a full-year appropriation for 2000.)

Direct spending and revenues

    Persons who violate the bill's provisions regarding the use 
of controlled substances to assist in suicide could face 
revocation of their license to prescribe controlled substances. 
Upon revocation of an individual's license, the Drug 
Enforcement Administration could seize any such substances in 
their possession. Thus, enacting H.R. 2260 could lead to the 
seizure of more assets and their forfeiture to the United 
States, but we estimate that any such increase would be less 
than $500,000 annually in value. Proceeds from the sale of any 
such assets would be deposited as revenues into the Assets 
Forfeiture Fund of the Department of Justice and spent from 
that fund, generally in the same year. Thus, the changes in 
direct spending from the Assets Forfeiture Fund would match any 
increase in revenues to that fund.
    Violators of the bill's provisions also could be subject to 
criminal fines, so the federal government might collect 
additional fines if the bill is enacted. Collections of such 
fines are recorded in the budget as governmental receipts 
(revenues), which are deposited in the Crime Victims Fund and 
spent in subsequent years. CBO expects that any additional 
receipts and direct spending would be negligible.
    Pay-as-you-go considerations: The Balanced Budget and 
Emergency Deficit Control Act sets up pay-as-you-go procedures 
for legislation affecting direct spending or receipts. Enacting 
H.R. 2260 could affect both direct spending and receipts, but 
CBO estimates that any such effects would be less than $500,000 
a year.
    Estimated impact on State, local, and tribal governments: 
H.R. 2260 contains an intergovernmental mandate as defined in 
UMRA, but CBO estimates that complying with the mandate would 
impose no costs on state, local, or tribal governments, and 
thus would not exceed the threshold established in that act 
($50 million in 1996, adjusted annually for inflation).
    In October 1997, an Oregon law that legalized doctor-
assisted suicide for terminally ill patients went into effect. 
Since that time, the interaction of the Federal Controlled 
Substances Act with that state law has been controversial. As 
it currently stands, under both Oregon and federal law, it is 
acceptable for doctors in Oregon to use federally controlled 
substances for the purposes set forth in state law. H.R. 2260 
would direct the Attorney General to give no force and effect 
to such a state law when determining whether the federal 
registration of a doctor under the Controlled Substances Act is 
consistent with the public interest. This would be a preemption 
of the Oregon ``Death with Dignity Act'' because it would limit 
the options available to doctors acting under that state law. 
Because the state would not be required to take any action, the 
preemption would have no cost. The bill also would authorize $5 
million for education and training in palliative care for 
health care professionals, many of whom are employed by state 
and local facilities.
    Estimated impact on the private sector: H.R. 2260 would 
create a new private-sector mandate for physicians registered 
to prescribe or administer federally controlled substances by 
prohibiting the use of such substances in physician-assisted 
suicides. The bill would require the Drug Enforcement 
Administration to treat the use of controlled substances for 
physician-assisted suicide as a violation of the Controlled 
Substances Act in all states, including Oregon, which is the 
only state that currently allows the practice. Doctors who 
violate the prohibition would lose their registration, would 
have to give up their stocks of controlled substances, and 
could face criminal prosecution. Because the bill would affect 
only doctors in Oregon, the costs associated with the mandate 
would fall below the $100 million (adjusted for inflation since 
1996) threshold established in UMRA.
    Previous CBO estimate: On September 24, 1999, CBO 
transmitted a cost estimate for H.R. 2260, as ordered reported 
by the House Committee on the Judiciary on September 14, 1999. 
The two versions of the bill are similar and the cost estimates 
are identical.
    Estimate prepared by: Federal Costs: DOJ--Mark Grabowicz. 
HRSA--Cyndi Dudzinski. AHCPR--Jeanne De Sa. Impact on State, 
Local, and Tribal Governments: Lisa Cash Driskill. Impact on 
the Private Sector: John Harris.
    Estimate approved by: Peter H. Fontaine, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for this legislation is provided in 
Article I, section 8, clause 3, which grants Congress the power 
to regulate commerce with foreign nations, among the several 
States, and with the Indian tribes.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    This section provides the short title of the legislation, 
the ``Pain Relief Promotion Act of 1999''.

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


Section 101. Reinforcing existing standard for legitimate use of 
        controlled substances

    This section amends the Controlled Substances Act to 
clarify that doctors and other licensed health care 
professionals are authorized to dispense, distribute, or 
administer controlled substances for the legitimate medical 
purpose of alleviating a patient's pain or discomfort even if 
the use of these drugs may increase the risk of death. This 
section also clarifies the current law that the administration, 
dispensing, or distribution of a controlled substance for the 
purpose of assisting a suicide is not authorized by the 
Controlled Substances Act.
    This section also provides that the Attorney General in 
implementing the Controlled Substances Act shall not give force 
or effect to any State law permitting assisted suicide or 
euthanasia, and that the provisions of the bill are effective 
upon enactment with no retroactive effect.

Section 102. Education and training programs

    This section authorizes the Attorney General to incorporate 
the recommendations of the Secretary of Health and Human 
Services (the Secretary) to carry out educational and research 
training programs for law enforcement personnel on the 
necessary and legitimate use of controlled substances in pain 
management and palliative care.

                  TITLE II--PROMOTING PALLIATIVE CARE


Section 201. Activities of Agency for Health Care Policy and Research

    This section amends the Public Health Services Act (42 
U.S.C. 299 et seq.) by authorizing a program responsibility for 
the Agency for Health Care Policy and Research in the 
Department of Health and Human Services to develop and advance 
the scientific understanding of palliative care. The Agency is 
directed to collect and disseminate protocols and evidence-
based practices for palliative care with priority for 
terminally ill patients.

Section 202. Activities of Health Resources and Services Administration

    This section amends the Public Health Services Act by 
authorizing a program for education and training in palliative 
care in the Health Resources and Services Administration of the 
Department of Health and Human Services. This section 
authorizes the Secretary, in consultation with the 
Administrator for Health Care Policy and Research to award 
grants, cooperative agreements and contracts to health 
professions schools, hospices, and other public and private 
entities to develop and implement palliative care education and 
training programs for health care professionals in palliative 
care.
    This section requires the applicant for the award to 
include three educational and informational components in the 
program: (1) the program must have a component that addresses a 
means for alleviating pain and discomfort, especially in 
terminally ill patients, including the use of controlled 
substances; (2) the program must provide information and 
education on the applicable law on controlled substances; and 
(3) the information and education must provide recent findings 
and developments in the improvement of palliative care. Health 
professional schools, residency training programs, continuing 
education, graduate programs in the health professions, 
hospices, and other sites as determined by the Secretary will 
be used as program sites.
    This section also requires the Secretary to evaluate the 
grant, cooperative agreement or contracted programs. Further, 
it mandates that the Secretary shall include one or more 
individuals with expertise and experience in palliative care in 
each peer review group involved in the selection of the 
palliative care awards. Finally, this section defines the term 
``palliative care'' and authorizes an additional $5,000,000 
annually for the palliative care award program with the grant 
cycle to begin with the Fiscal Year 2000.

Section 203. Effective date

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

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

                       CONTROLLED SUBSTANCES ACT


                  TITLE II--CONTROL AND ENFORCEMENT

           *       *       *       *       *       *       *



Part C--Registration of Manufacturers, Distributors, and Dispensers of 
Controlled Substances; Piperidine Reporting

           *       *       *       *       *       *       *



                       registration requirements

  Sec. 303. (a) * * *

           *       *       *       *       *       *       *

  (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.

           *       *       *       *       *       *       *


          Part E--Administrative and Enforcement Provisions

           *       *       *       *       *       *       *


  Sec. 502. (a) The Attorney General is authorized to carry out 
educational and research programs directly related to 
enforcement of the laws under his jurisdiction concerning drugs 
or other substances which are or may be subject to control 
under this title. Such programs may include--
          (1) * * *

           *       *       *       *       *       *       *

          (5) studies or special projects to develop more 
        effective methods to prevent diversion of controlled 
        substances into illegal channels; [and]
          (6) studies or special projects to develop 
        information necessary to carry out his functions under 
        section 201 of this title[.]; and
          (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.

           *       *       *       *       *       *       *

                              ----------                              


                      PUBLIC HEALTH SERVICE ACT

           *       *       *       *       *       *       *


                 TITLE VII--HEALTH PROFESSIONS EDUCATION

           *       *       *       *       *       *       *


          PART D--INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES

           *       *       *       *       *       *       *


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 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 disease or medical condition is not responsive to 
curative treatment or 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. [754.] 755. QUENTIN N. BURDICK PROGRAM FOR RURAL INTERDISCIPLINARY 
                    TRAINING.

  (a) Grants.--The Secretary may make grants or contracts under 
this section to help entities fund authorized activities under 
an application approved under subsection (c).

           *       *       *       *       *       *       *


SEC. [755.] 756. ALLIED HEALTH AND OTHER DISCIPLINES.

  (a) In General.--The Secretary may make grants or contracts 
under this section to help entities fund activities of the type 
described in subsection (b).

           *       *       *       *       *       *       *


SEC. [756.] 757. ADVISORY COMMITTEE ON INTERDISCIPLINARY, COMMUNITY-
                    BASED LINKAGES.

  (a) Establishment.--The Secretary shall establish an advisory 
committee to be known as the Advisory Committee on 
Interdisciplinary, Community-Based Linkages (in this section 
referred to as the ``Advisory Committee'').

           *       *       *       *       *       *       *


SEC. [757.] 758. AUTHORIZATION OF APPROPRIATIONS.

  (a) In General.--There are authorized to be appropriated to 
carry out this part, $55,600,000 for fiscal year 1998, and such 
sums as may be necessary for each of the fiscal years 1999 
through 2002.

           *       *       *       *       *       *       *

  (b) Allocation.--
          (1) In general.--Of the amounts appropriated under 
        subsection (a) for a fiscal year, the Secretary shall 
        make available--
                  (A) * * *

           *       *       *       *       *       *       *

                  (C) not less than $22,631,000 for awards of 
                grants and contracts under [sections 753, 754, 
                and 755] section 753, 754, 755, and 756.

           *       *       *       *       *       *       *


          TITLE IX--AGENCY FOR HEALTH CARE POLICY AND RESEARCH

               Part A--Establishment and General Duties

           *       *       *       *       *       *       *


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 disease or medical condition is not responsive to 
curative treatment or 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.

           *       *       *       *       *       *       *


                            ADDITIONAL VIEWS

     The Pain Relief Promotion Act seeks to amend the 
Controlled Substances Act to promote pain management and 
palliative care without permitting assisted suicide and 
euthanasia. Section 101 of the bill specifically states that 
the use of controlled substances for alleviating pain and 
discomfort is a legitimate medical purpose, even where the use 
of these drugs may have the unintended effect of increasing the 
risk of death. The bill also reinforces the existing standard 
that the use of controlled substances with the intent of 
assisting in a suicide is not authorized by the Controlled 
Substances Act and provides that the Attorney General, in 
implementing the act, shall employ a uniform standard in 
enforcement of the Act, without regard to state law permitting 
assisted suicide or euthanasia.
    We do not endorse physician-assisted suicide. However, we 
have a number of concerns about this bill. The first relates to 
the lack of a subcommittee hearing or markup on the bill. 
Palliative care is an important and difficult issue for 
patients and families across the country, yet the Committee has 
not given this bill full and thorough consideration. The bill 
is supported by the American Medical Association and the 
National Hospice Organization, but opposed by the California 
Medical Association, the American Nurses Association, the 
Oncology Nursing Society, the National Association of 
Orthopaedic Nurses, the American Pain Foundation, and others. 
This contentious area of public policy demands careful 
subcommittee consideration and expert testimony by educated 
witnesses. H.R. 2260 clearly has not gone through the 
appropriate committee process.
    We are troubled that Title I of this bill raises the 
prospect of the Drug Enforcement Agency (DEA) ``second 
guessing'' a physician or a health care professional's intent 
in prescribing and using large doses of opiates for patients 
who are in severe pain. Title I of the bill could turn the DEA 
into a medical oversight body charged with investigating the 
``intent'' and ``purpose'' of a physician's care for a patient. 
The threat of investigation alone could scare health care 
professionals away from providing quality care to the neediest 
patients. This bill could inadvertently harm the 50 million 
American patients who suffer from serious pain and other 
distressing symptoms.
    Many sick patients require extremely large doses of pain 
medications to assure that they are comfortable and can 
maintain a high quality of life and interaction with their 
family. These large doses are not prescribed to assist in 
suicide, but to assure aggressive pain control and quality 
care. Many patients are able to tolerate the extremely high 
doses of controlled substances needed to manage their pain and 
other symptoms, but the same doses in another patient would be 
lethal.
    This gray area poses the problem. H.R. 2260 attempts to end 
the practice of assisted suicide, but it may just have the 
opposite effect. Many caregivers believe it could increase 
suicides, assisted and otherwise, by patients who can no longer 
bear the unrelieved pain caused when practitioners, threatened 
by possible DEA investigation into their intent in prescribing 
pain-killing medication, are deterred from providing necessary 
pain relief. Other caregivers do not believe this could result. 
Regular and full consideration by the Subcommittee would have 
given us an opportunity to resolve these differing views, and 
to produce better legislation.

                                   John D. Dingell.
                                   Edolphus Towns.
                                   Edward J. Markey.
                                   Ted Strickland.
                                   Lois Capps.
                                   Tom Barrett.
                                   Henry A. Waxman.
                                   Peter Deutsch.
                                   Sherrod Brown.
                                   Albert R. Wynn.
                                   Tom Sawyer.

                                  
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