Pain as a Public Health Challenge

Pain affects millions of Americans; contributes greatly to national rates of morbidity, mortality, and disability; and is rising in prevalence. Substantial disparities exist in the prevalence, seriousness, and adequate treatment of pain that affect the vulnerable populations of traditional public health concern. Pain exacts enormous costs both economically and in the toll it takes on people’s lives. Analysis performed for the committee revealed that the annual economic cost of chronic pain in the United States is at least³ $560–635 billion. This estimate combines the incremental cost of health care ($261–300 billion) and the cost of lost productivity ($297–336 billion) attributable to pain. The federal Medicare program bears fully one-fourth of U.S. medical expenditures for pain; in 2008, this amounted to at least $65.3 billion, or 14 percent of all Medicare costs. In total, federal and state programs—including Medicare, Medicaid, the Department of Veterans Affairs, TRICARE, workers’ compensation, and others—paid out $99 billion in 2008 in medical expenditures attributable to pain. Lost tax revenues due to productivity losses compound that expense.

Finding 2-1. Pain is a public health problem. Pain is a significant public health problem. Chronic pain alone affects at least 116 million U.S. adults. Pain reduces quality of life, affects specific population groups disparately, costs society at least $560–635 billion annually (an amount equal to about $2,000 for everyone living in the United States), and can be appropriately addressed through population health-level interventions.

Finding 2-2. More consistent data on pain are needed. While it is known that pain affects millions of Americans, the committee acknowledges the lack of consistent data with which to describe the nature and extent of the problem or to identify subpopulations that will benefit most from future interventions. Improvements in state and national data are needed to (1) monitor changes in the incidence and prevalence of acute and chronic pain; (2) document rates of treatment or undertreatment of pain; (3) assess the health and societal consequences of pain; and (4) evaluate the impact of related changes in public policy, payment, and care. Pain data need to be based on standardized questions, preferably using existing international standards, to facilitate comparisons over time and across populations. These data would be useful for a wide range of stakeholders, including policy makers, health care providers, health professions educators, professional licensing authorities, pain advocacy and awareness organizations, and researchers.

Recommendation 2-1. Improve the collection and reporting of data on pain. The National Center for Health Statistics, the Agency for Healthcare Research and Quality, other federal and state agencies, and private organizations should improve and accelerate the collection and reporting of data on pain. Data should be collected in the following domains:

• the incidence and prevalence of pain;
• interference with activities of daily living and work, as well as disability, related to pain;
• utilization of clinical and social services as a result of pain;
• costs of pain and pain care, including indirect costs of lost employment and public- and private-sector costs for disability payments; and
• the effectiveness of treatment in reducing pain and pain-related disability, determined through research on the comparative effectiveness of alternative treatments (including in different patient populations), to identify people most likely to benefit (or not) from specific treatment approaches.

Standardized questions, fields, and protocols for surveys and electronic health records should be developed, and pain-related data should be collected at regular intervals.

Finding 2-3. A population-based strategy for reducing pain and its consequences is needed. The committee finds that, to effect changes that will reach the millions of American adults living with pain, account for differences in the experience of pain among population groups, and address selected environmental factors that contribute to the consequences of pain, a population health-level strategy is needed.

Recommendation 2-2. Create a comprehensive population health-level strategy for pain prevention, treatment, management, and research. The Secretary of the Department of Health and Human Services should develop a comprehensive, population health-level strategy for pain prevention, treatment, management, education, reimbursement, and research that includes specific goals, actions, time frames, and resources. This strategy should

• Describe how efforts across government agencies, including public–private partnerships, can be established, coordinated, and integrated to encourage population-focused research, education, communication, and community-wide approaches that can help reduce pain and its consequences and remediate disparities in the experience of pain among subgroups of Americans.
• Include an agenda for developing physiological, clinical, behavioral, psychological, outcomes, and health services research and appropriate links across these domains (consistent with Recommendations 5-1 through 5-4).
• Improve pain assessment and management programs within the service delivery and financing programs of the federal government.
• Proceed in cooperation with the Interagency Pain Research Coordinating Committee and the National Institutes of Health’s Pain Consortium and reach out to private-sector participants as appropriate.
• Involve the relevant federal agencies and departments (National Institutes of Health, Centers for Disease Control and Prevention, Food and Drug Administration, Centers for Medicare and Medicaid Services, Agency for Healthcare Research and Quality, Health Resources and Services Administration, Indian Health Service, Department of Defense, and Department of Veterans Affairs); private-sector entities (pain advocacy and awareness organizations; health professions associations; health care providers; health professions educators; private insurers; and accreditation, certification, and examination organizations); and state-level entities.
• Include ongoing efforts to enhance public awareness about the nature of chronic pain and the role of self-care in its management.

The development of this strategy should be completed by the end of 2012.

Care of People with Pain

Currently, large numbers of Americans receive inadequate pain prevention, assessment, and treatment, in part because of financial incentives that work against the provision of the best, most individualized care; unrealistic patient expectations; and a lack of valid and objective pain assessment measures. Clinicians’ role in chronic pain care is often a matter of guiding, coaching, and assisting patients with day-to-day self-management, but many health professionals lack training in how to perform this support role, and there is little reimbursement for their doing so. Primary care is often the first stop for patients with pain, but primary care is organized in ways that rarely allow clinicians time to perform comprehensive patient assessments. Sometimes patients turn to, or are referred to, pain specialists or pain clinics, although both of these are few in number. Unfortunately, patients often are not told, or do not understand, that their journey to find the best combination of treatments for them may be long and full of uncertainty.

Finding 3-1. Pain care must be tailored to each person’s experience. Pain management takes place through self-management, primary care, specialty care, and pain centers. However, the majority of care and management should take place through self-management and primary care, with specialty services being focused on recalcitrant or more complex cases. Accordingly, individualization of pain management is necessary throughout the health care system. Health care providers need to foster pain care that is patient-centered and, when necessary, comprehensive and interdisciplinary. Financing, referral, records management, and other systems need to support this flexibility.

Recommendation 3-1. Promote and enable self-management of pain. Health care provider organizations should take the lead in developing educational approaches and materials for people with pain and their families that promote and enable self-management. These materials should include information about the nature of pain; ways to use self-help strategies to prevent, cope with, and reduce pain; and the benefits, risks, and costs of various pain management options. Approaches and materials should be culturally and linguistically appropriate and available in both electronic and print form.

Finding 3-2. Significant barriers to adequate pain care exist. The committee finds that multiple and significant barriers to pain care and management exist in the primary care setting.

• Enhanced continuing education and training are needed for health care professionals to address gaps in knowledge and competencies related to pain assessment and management, cultural attitudes about pain, negative and ill-informed attitudes about people with pain, and stereotyping and biases that contribute to disparities in pain care.
• Other barriers include the magnitude of the pain problem, including its extremely high prevalence, which makes effective action difficult on a national scale; certain provider attitudes and training, which impede the delivery of high-quality care; insurance coverage, because fully one-third of all Americans are uninsured or underinsured; cultural attitudes of patients, many of whom do not recognize the need to address pain early on; and geographic barriers, which place residents of rural communities at a disadvantage.
• System and organizational barriers, many of them driven by current reimbursement policies, obstruct patient-centered care. Examples of these barriers are minimal capacity for frequent visits when necessary; limited time for conduct of comprehensive assessments; inadequate patient education initiatives; difficulties in accessing specialty care; and lack of reimbursement for needed specialty care services, interdisciplinary practice, psychosocial and rehabilitative services, in-depth patient interviews and education, and time spent planning and coordinating care.
• A comprehensive, strategic approach can succeed in addressing these barriers and help close the gap between empirical evidence regarding the efficacy of pain treatments and current practice.
• Regulatory, legal, educational, and cultural barriers inhibit the medically appropriate use of opioid analgesics.

Recommendation 3-2. Develop strategies for reducing barriers to pain care. The population health-level strategy referred to in Recommendation 2-2 should include identifying and developing comprehensive approaches to overcoming existing barriers to pain care, especially for populations that are disproportionately affected by and undertreated for pain. Strategies also should focus on ways to improve pain care for these groups.

Recommendation 3-3. Provide educational opportunities in pain assessment and treatment in primary care. Health professions education and training programs, professional associations, and other groups that sponsor continuing education for health professionals should develop and provide educational opportunities for primary care practitioners and other providers to improve their knowledge and skills in pain assessment and treatment, including safe and effective opioid prescribing.

Recommendation 3-4. Support collaboration between pain specialists and primary care clinicians, including referral to pain centers when appropriate. Pain specialty professional organizations and primary care professional associations should work together to support the collaboration of pain specialists with primary care practitioners and teams when primary care providers have exhausted their expertise and the patient’s pain persists.

Recommendation 3-5. Revise reimbursement policies to foster coordinated and evidence-based pain care. Payers and health care organizations should work to align payment incentives with evidence-based assessment and treatment of pain. Optimal care of the patient should be the focus.

Recommendation 3-6. Provide consistent and complete pain assessments. Health care providers should provide pain assessments that are consistent and complete and documented so that patients will receive the right care at the right place and the right time.

Education Challenges

The optimal timing, content, and goals of patient education about pain vary with individual circumstances. Fundamental to treatment is education regarding self-management to minimize flare-ups, decrease day-to-day discomfort, and maximize functioning. In addition, public education about pain can be highly beneficial in promoting

• individual and community actions to prevent injuries,
• advocacy for appropriate acute and chronic pain treatment, and
• support for improved pain prevention and control policies.

Educational programs for the many types of health care professionals who play a role in pain prevention and treatment—nurses, psychologists, physicians, dentists, pharmacists, physical therapists, and complementary and alternative medicine practitioners—vary in the amount and quality of information on pain they contain. In medical education, pain generally has received little attention, which has contributed to the problem of undertreatment. The need for improved education about pain is especially acute for primary care providers—the front-line clinicians for most people’s acute or chronic pain problems.

Finding 4-1. Education is a central part of the necessary cultural transformation of the approach to pain. The committee finds that the federal government is in a position to contribute to substantial improvements in patient and professional education about pain.

Recommendation 4-1. Expand and redesign education programs to transform the understanding of pain. Federal agencies and other relevant stakeholders should expand education programs to transform patient and public understanding of pain. In concert with Recommendation 2-2, federal agencies, in partnership with health professions associations, payers, pain advocacy and awareness organizations, and other relevant stakeholders, should develop education programs for patients, the public, and health care providers that are designed to promote a transformation in their expectations, beliefs, and understanding about pain, its consequences, its management, and its prevention.

Recommendation 4-2. Improve curriculum and education for health care professionals. The Centers for Medicare and Medicaid Services, the Health Resources and Services Administration, accrediting organizations, and undergraduate and graduate health professions training programs should improve pain education curricula for health care professionals.

Recommendation 4-3. Increase the number of health professionals with advanced expertise in pain care. Educational programs for medical, dental, nursing, mental health, physical therapy, pharmacy, and other health professionals who will participate in the delivery of pain care should have increased capacity to train providers who can offer advanced pain care.

Research Challenges

In recent years, biomedical research has made remarkable strides in understanding of the basic biological and psychological underpinnings of pain. A principal current opportunity may be to use what has been learned across a broad spectrum of fields—from genomic and cellular through behavioral mechanisms— to develop innovative therapies that are simultaneously more targeted to the individual and more comprehensive in meeting patient needs.

From a scientific standpoint, the future of pain research is exciting because of advances in a number of relevant and diverse research fields and the development of new research techniques. This excitement is tempered, however, by knowledge that federal research dollars to address the problem of pain are in short supply and likely to decrease. Pain is a topic of interest to virtually every NIH institute and center, but not a central concern of any one of them. The committee believes one of the existing NIH institutes should be designated the lead institute for pain. The committee further believes that the NIH Pain Consortium needs to take a stronger leadership role in effecting the necessary transformation in how pain research is conducted by fostering coordination across institutes and centers, by ensuring that study section decision making on pain proposals is improved, and by exploring a range of potential public–private initiatives.

Pain research should not be confined to NIH. As this report details, pain-related research is needed across public health entities, involving, for example, the Centers for Disease Control and Prevention’s epidemiological and public education expertise, the Agency for Healthcare Research and Quality’s quality improvement initiatives, the Health Resources and Services Administration’s expertise in professional education and service delivery for vulnerable populations, and the Centers for Medicare and Medicaid Services’ research and demonstration programs related to reimbursement policies.

Finding 5-1. Research to translate advances into effective therapies for pain is a continuing need. The committee finds that significant advances have been made in understanding the basic mechanisms of nociception and pain, leading to new potential targets for future pain assessment and treatment strategies. Furthermore, recent advances in the neurosciences, biomarkers, and the behavioral sciences have validated a comprehensive approach to the management of pain that includes the individual’s inherent biology, behavior, and psychological makeup and reactions, as well as environmental influences. However, data and knowledge gaps in pain research remain that have prevented such research advances from being translated into safe and effective therapies. Addressing these gaps will require a cultural transformation in the view of and approach to pain research, involving basic, translational, and clinical researchers; federal funding and regulatory agencies; and private organizations. This cultural transformation is reflected in the following recommendations.

Recommendation 5-1. Designate a lead institute at the National Institutes of Health responsible for moving pain research forward, and increase the support for and scope of the Pain Consortium. The National Institutes of Health should designate a specific institute to lead efforts in advancing pain research. At the same time, the National Institutes of Health should increase financial resources and staffing support for and broaden the scope of the Pain Consortium and engage higher-level staff from the institutes and centers in the consortium’s efforts. The Pain Consortium should exert more proactive leadership in effecting the necessary transformation in how pain research is conducted and funded.

Recommendation 5-2. Improve the process for developing new agents for pain control. Academia and industry should develop novel agents for the control of pain. This does not mean simply recycling current drugs. What is required is basic and clinical science research to discover new classes of pain therapeutics and more efficient ways of developing them. Also required is that regulatory agencies, especially the Food and Drug Administration, develop new and expeditious ways to evaluate and approve new pain therapies.

Recommendation 5-3. Increase support for interdisciplinary research in pain. Federal agencies, such as the National Institutes of Health, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Department of Defense, and Department of Veterans Affairs, as well as private funders of pain research, should increase support for interdisciplinary research and research training— across agencies and professions—on pain-related diseases and the deficiencies noted in Finding 5-1.

Recommendation 5-4. Increase the conduct of longitudinal research in pain. Public and private funders should increase support for longitudinal research in pain, including comparative effectiveness research and novel randomized controlled trials, to help ensure that patients receive care that works best in both the short and long terms.

Recommendation 5-5. Increase the training of pain researchers. With the support of training grants from the National Institutes of Health, academic institutions should increase the training of basic, translational, behavioral, population, and clinical pain researchers. This training should recognize the interdisciplinary benefits of research on pain and pain management. Agencies such as the National Center for Health Statistics, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services should support the training of researchers interested in secondary analysis of pain-related data collected by these agencies.