After years of consultations with academic pain specialists over the increasingly contentious issue of proper pain management with opioids versus the DEA's concerns about prescription drug abuse and diversion, the agency last summer posted the pain FAQ. While criticized by some pain patients' advocates and physicians with experience with unfounded prosecutions, the pain FAQ at a minimum represented an acknowledgment by the drug-fighting agency that prescribing even large amounts of opioids for pain management falls within the scope of legitimate medical practice.

But weeks later, the pain FAQ vanished, pulled from the DEA's web site without explanation. The agency also requested, without forewarning or explanation, that academic medical organizations that had participated in creation of the pain FAQ also pull down their copies of the Guidelines. Only after a rising storm of criticism from pain treatment advocates and the offended academics alike did the agency deign to explain that it felt the pain FAQ positions were too constraining on the government's power to investigate and prosecute physicians.

Now, the embattled agency has formally requested comments on the question of the proper prescribing of opioid pain medications. Leading pain physicians were quick to respond to news of the request, as would be expected, but so was the National Association of Attorneys General, representing the top law enforcement officers in each state. They were not pleased with the agency.

In a January 19 letter signed by 30 attorneys general -- more than half -- the organization pronounced itself "concerned" about the DEA's recent actions regarding pain medication policy and "surprised" that the agency had suddenly shifted its views, especially without consulting them. That concern included fears that "state and federal policies are diverging with respect to the relative emphasis on ensuring the availability of prescription pain medications to those who need them."

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Noting its own adoption of a 2003 resolution seeking balance in promoting pain relief and preventing prescription drug abuse, the NAAG called the pain FAQ reflective of "a consensus among law enforcement agencies, health care practitioners, and patient advocates that the prevention of drug abuse is an important societal goal that can and should be pursued without hindering proper patient care." Its replacement with a tougher DEA interim policy statement in November "emphasizes enforcement, and seems likely to have a chilling effect on physicians engaged in the legitimate practice of medicine," they group wrote.

The unexpected display of thoughtfulness from the attorneys general is worth quoting at length: "As Attorneys General have worked to remove barriers to quality care for citizens of our states at the end of life, we have learned that adequate pain management is often difficult to obtain because many physicians fear investigations and enforcement actions if they prescribe adequate levels of opioids or have many patients with prescriptions for pain medications. We are working to address these concerns while ensuring that individuals who do divert or abuse drugs are prosecuted. There are many nuances of the interactions of medical practice, end of life concerns, definitions of abuse and addiction, and enforcement considerations that make balance difficult in practice. But we believe this balance is very important to our citizens, who deserve the best pain relief available to alleviate suffering, particularly at the end of life."

The attorneys general concluded by noting the DEA's solicitation for comments and pointedly asking DEA administrator Karen Tandy for an early March meeting -- the AGs will be in Washington for their annual conference -- to discuss their concerns.

If the DEA is catching flak from its friends, it is also hearing from some former friends. Dr. Russell Portenoy, chair of the Department of Pain Medicine and Palliative Care at New York's Beth Israel Medical Center and the lead expert in the joint collaboration between academic pain specialists and the DEA that led to the pain FAQ, told the American Medical News this week that he had "little enthusiasm" for any further involvement with the agency.

Dr. David Joranson of the University of Wisconsin's Pain and Policy Studies Group was a little bit more forgiving. He told the American Medical News that it appeared the DEA had new people working on prescription drug diversion and they needed to be educated. "I think everyone in the pain field -- clinicians, administrators and patients -- should take the DEA request very seriously," he said.