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Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011.

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Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.

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3Care of People with Pain

Appointment after appointment, test after test, and of course, nothing to really confirm [the diagnosis]. . . . Having pain that I did not understand, as a physical therapist, fearing some dreadful disease was hard enough. . . . So, in addition to pain, I had anxiety and depression. . . . The medication that finally gave me better relief was pulled off the market recently by the FDA.

—A person with chronic pain1

While pain care has grown more sophisticated, the most effective care still is not widely available. Some cases of acute pain can be successfully treated but are not; others could be dealt with promptly, but agonizing delays occur. And most people with severe, persistent pain still do not receive—and often are not offered—systematic relief or the comprehensive, integrated, evidence-based assessment and treatment that pain care clinicians strive to provide.

Currently available treatments have limited effectiveness for most people with severe chronic pain. For many such individuals, pain management on a daily basis takes place outside any health care setting. They must respond to and attempt to control their own pain while they are at home, at work or school, or in their communities as they go about their lives as actively as they can, or think they can. From that vantage point, the assistance provided by health professionals is largely a matter of guiding, coaching, and facilitating self-management. The clinician’s approach clearly must be patient-centered—that is, specific to the individual—to be effective. Because skills in guiding and coaching are not specifically emphasized in medical education, few physicians are sufficiently prepared to perform this support role, although some health professionals from other disciplines, such as nursing or psychology, may be. Worse, even those physicians and other health professionals who are sufficiently prepared encounter obstacles because of the way health care is typically organized, reimbursed, marketed, and evaluated—namely, around specialization, procedural interventions, and a hierarchy of care management.

To a great degree, as this chapter describes, effective pain care involves a number of individuals, beginning with the patient, and various treatments. First and foremost is self-management—that is, the patient’s attempts to manage pain and prevent flare-ups or additional injury. Beyond self-management, the health care sector provides pain care through primary care, specialty care, and pain centers, each of which may offer diverse treatment approaches, including medications, interventional procedures, surgery, psychological therapies (not typically available in primary care), rehabilitative and physical therapy, and complementary and alternative therapies. This chapter describes these approaches in general terms. People with pain frequently consult various types of providers, often sequentially but sometimes concurrently, and use many different therapies as they seek relief, knowledge, and understanding. This chapter also examines selected issues and barriers in pain care, including how clinicians assess pain; issues around the use of opioid medications; the perverse incentives incorporated in most health insurance coverage; and patient-level issues, such as unrealistic expectations or reluctance to report pain. Finally, the chapter describes some emerging models of effective pain care, including those of the Department of Veterans Affairs, the Department of Defense, quality improvement practitioners, and award-winning programs.

The resources available to help the tens of millions of Americans with acute and chronic pain are few and stretched thin. Nor is the path to maximum achievable relief straightforward or clear of pitfalls. Small measures will not significantly improve pain care. Rather, as discussed in Chapter 1, a cultural transformation in how pain is perceived, diagnosed, and managed will be necessary to make the best care currently possible—care we know how to provide—accessible to Americans in pain.

TREATMENT OVERVIEW

Is it too much to ask that we, the patients, no longer be bound to a system where no one professional takes responsibility for the patient—a system of unbelievable referrals with unscientific, unproven treatments (and hope) sold to the patient by each referring physician. In many cases, patients end up worse and more and more destitute, yet they grasp for hope with each referral.

—A chronic pain advocate2

Numerous factors—involving the type of pain, one’s background and personal traits, and the family and social environments—affect an individual’s treatment plan. In many different cases, especially for people with complex, chronic pain conditions, biopsychosocial care (taking into account patients’ unique biologic and genetic constitution, their psychological and emotional composition and reaction, and the societal and environmental framework within which they reside and function) has been shown to be advantageous. In all cases, a trusting relationship between patient and clinician fosters clear communication intended to improve outcomes.

Steps in Care

When confronted with pain, some people seek professional help early on, probably from a primary care clinician, while others attempt, at least initially, to handle the situation on their own. If the pain persists, however, affecting physical functioning and quality of life, a person is likely to seek treatment—and should do so—in case the pain is functioning in its warning role as described in Chapter 1.

At least initially, a clinician probably will assume pain is a symptom of some underlying condition and prescribe analgesics, while focusing on discovering what the underlying problem might be. But if a cause cannot be found, if early treatments fail to bring improvement, and if pain persists for several months, it may progress to the point where it becomes a disease in itself, that is, an abnormal condition that impairs or disrupts normal bodily functioning (this is almost always chronic pain). Then, regardless of the initiating process, cause, or underlying disease, the clinician must focus on management of the pain condition in order to assist in restoring the individual to a better state of health. This is not to say that all pain is a serious disease. When pain is a disease in itself, however, it requires comprehensive assessment, care planning, and treatment.

Many factors affect the initial pain experience:

  • the severity, frequency, and extent of the pain itself;
  • the underlying disease process or pathology, if there is one;
  • genetic factors;
  • people’s attitudes, emotional makeup, and beliefs and the meaning of the experience for them (for example, an accident victim might associate pain with a companion’s loss of life);
  • knowledge and beliefs about the effectiveness and availability of treatments;
  • environmental circumstances, such as the advice of family and colleagues, the burdens of work, other life stressors, and physical aspects of the home (e.g., stairs); and
  • responses of physicians and other health professionals (encouragement to engage in exercise or other self-management efforts versus suspicion or denigration of the patient’s coping efforts).

In sum, the pain experience has diverse contributors and wide-ranging effects. Likewise, there are numerous ways to assess and treat it. A simple medical model, in which a physician attempts to diagnose, treat, and “cure” the cause of pain, often is too limited an approach, and the physician applying this approach is stymied at the outset when the cause cannot be found. Instead, a biopsychosocial framework takes into account the rich range of potential causes, effects, and treatment strategies.

Pain care is available in many settings, and a patient’s journey may include any or all of the following steps, in sequence or in any order and with any number of repeat visits with the same or new clinicians and advisors:

  • self-management, perhaps in consultation with family and friends— whose prior experience and knowledge, whether accurate or not, will play a key role—but with little systematic guidance or intervention from a clinician;
  • primary care, where practitioners may employ a variety of management strategies, including use of prescription drugs and suggestions for exercise, physical therapy, or weight loss, perhaps after some consultation with specialists;
  • specialist care, from a professional in diagnosing and treating an underlying disease (cancer, heart disease) causing the pain or from a pain specialist; and
  • a pain center, where an interdisciplinary approach may be offered.

Almost every patient is likely to engage in self-management, and almost everyone—even those consulting with a pain specialist—should benefit from the involvement of a primary care practitioner (or medical home) who is able to help coordinate care across the full spectrum of providers (IOM, 1996). Such coordination of care helps prevent people from seeking relief from multiple providers and treatment approaches that may leave them frustrated and angry and worse off both physically and mentally, and from falling into a downward spiral of disability, withdrawal, and hopelessness. Certainly, fragmentation hinders the development of a strong, mutually trusting relationship with a single health professional who takes responsibility for coordinating care. This relationship is one of the keys to successful pain treatment.

Self-Management

Self-management is almost always the first step in a person’s journey to relieving pain, and is one that is returned to repeatedly. Because severe pain strongly influences virtually all aspects of a person’s quality of life, and because treatment often is insufficient and involves several specialties and professions, the burden of controlling pain falls most heavily on people in pain and their families.

Self-management succeeds partly because it helps patients believe in their own capacity to control their pain (Keefe et al., 2008). Pain beliefs correlate with outcomes, and patients function better when they have some control, are not severely disabled, and avoid “catastrophizing” pain—that is, exaggerating its threat and believing they cannot control it (see also Chapter 1) (Keefe et al., 2000).

Self-management of pain may be viewed as including both informal efforts undertaken by people with pain, perhaps following the advice of non professionals or written or online sources of information, and structured activity, guided by a health professional or by an established protocol and intended to enhance the person’s capacity for self-management. In self-management programs, patients become educated about their condition and active participants in their treatment, “engaging in active problem-solving, decision-making, developing good use of health resources, and taking actions to manage their pain” (National Institute of Nursing Research, 2011, p. 1). To illustrate, back pain self-management efforts might include brief rests, resumption of normal activities, strengthening exercises, structured physical activity, application of heat and cold, use of over-the- counter medications and topical ointments and creams, sleep, yoga, and caution in lifting and carrying. The following examples illustrate the range of self-management options:

  • A Stanford University program, initially established for patients with arthritis, includes exercise, muscle relaxation techniques, distraction, sleep aids, education about pain and negative emotions, and cooperation with clinicians and employers (Lorig et al., 2008). This program showed modest but statistically significant improvements in self-reported pain but no differences in health care utilization.
  • A psychoeducational pain control program for cancer patients, using coaching by nurses, showed significant decreases in pain intensity ( Miaskowski et al., 2004).
  • A self-management program of cognitive-behavioral therapy and diet interventions for women with irritable bowel syndrome, using advanced practice nurses, reduced abdominal pain symptoms (Heitkemper et al., 2004).
  • A model program run by pain clinicians from several disciplines encouraged new pain center patients to participate in a 2-day, 8-hour group educational program before individual counseling with a pain specialist (for which the two pain clinics involved had lengthy waiting lists). Patients received information about pain and its treatment and learned a variety of self-management skills. Half (52 percent) of the attendees decided to forego a clinical appointment and manage their pain on their own. Results indicated statistically significant increases in the use of various self-management strategies and improved satisfaction, as well as other overall positive effects (Davies et al., 2011).
  • Participants in a lay-person-led self-management group intervention for back pain patients in primary care, evaluated in a randomized trial, achieved significantly less worry about their pain, more confidence in self-care, and less self-reported disability (Von Korff et al., 1998).

A substantial body of research supports the effectiveness of such programs. For example, a meta-analysis of 17 self-management education programs for arthritis found that they achieved small but statistically significant reductions in pain ratings and reports of disability (Warsi et al., 2003).

The above examples illustrate that self-management need not take place by itself but can be combined with treatment directed by a health professional. To illustrate further, pain self-management combined with the use of anti depressants led to significantly less pain in patients with both musculoskeletal pain and depression (Kroenke et al., 2009b). A program for cancer patients called “ Passport to Comfort,” with four education sessions on assessing and managing fatigue and pain, was found to lead to improvements in physical and psychological well-being ( Borneman et al., 2011). And a program of manual therapy, exercise, and education for chronic low back pain showed a significant treatment effect, maintained at 1-year follow-up (Moseley, 2002). Such combination programs use various settings and media; a review of rates of participation in arthritis self-management programs in the San Francisco Bay area showed that small group programs were most highly attended. Convenience in scheduling and location is also important; offering self-management programs “multiple times in diverse settings and continuously over many years” produced 40 percent participation rates among the target group (Bruce et al., 2007, p. 852).

For some people with pain, education alone may be the most effective treatment by a health professional. But as Chapter 4 describes, patient education is no easy matter, especially given deficits in health literacy (see Chapter 2) and challenges in framing messages that are specific and appropriate to individual circumstances. For example, the message delivered to an adult experiencing chronic pain caused by osteoarthritis of the spine should differ markedly from that for a person with multiple myeloma, for whom a new pain can be a truly catastrophic harbinger of permanent paralysis.

Primary Care

Primary care is where people obtain accessible, comprehensive, coordinated health care. The primary care fields of medicine are general internal medicine, general pediatrics, family medicine, and (in some views) obstetrics-gynecology. Whether functioning as individual practitioners, in integrated teams of health professionals, or in what are now termed medical homes or accountable care organizations with medical and financial responsibility for the health of a patient population, primary care clinicians provide a wide range of services and assist people in making decisions about specialty services and elective procedures (see Chapter 4). Primary care physicians also are responsible for the majority of pain medicine prescriptions. Indeed, in 2007, analgesics were the drug category most frequently mentioned in data on office visits to physicians. In 2008, analgesics constituted 10.1 percent of all drugs prescribed for adults (ranking a close second to antidepressants, at 10.8 percent) (Gu et al., 2010).

It is no wonder, then, that primary care practitioners are an early step in the pain care journey, treating 52 percent of chronic pain patients in the United States based on a national mail survey of primary care physicians, physician pain specialists, chiropractors, and acupuncturists (Breuer et al., 2010). Typically, primary care is where people first report pain to the health care system; thus the primary care practitioner’s response may be crucial in providing timely relief and preventing acute pain from progressing to a persistent or chronic state (Dobkin and Boothroyd, 2008). Doubtless, many primary care practitioners become extraordinarily adept at providing pain care, but this is not the uniform experience. As discussed later in this chapter, patients experience a number of barriers to optimal pain care within the primary care system.

Specialty Care

Although most people with pain do not need a pain specialist’s care, the potential demand for these services far outstrips the supply. At least 116 million American adults have common chronic pain conditions, but only 3,488 physicians were board certified in pain care between 2000 and 2009; thus there are more than 33,000 people with chronic pain for every specialist (this figure can be compared, for example, with the U.S. average of 264 patients treated by each radiation oncologist in 2003 [Lewis and Sunshine, 2007]). As a result, most pain care must (and should) be provided by primary care practitioners. In a national survey conducted in the late 1990s, fully four-fifths of people currently experiencing severe pain said they had never been referred to a specialized pain program or clinic (American Pain Society, 1999).

Organization of the specialty. Pain medicine (the physician specialty of pain care) and pain care in general constitute a “highly active” field, distinguished by rising numbers of peer-reviewed publications and professional associations and interest groups (Dubois et al., 2009). The American Medical Association (AMA) recognizes pain medicine as a discrete specialty, represented in the AMA house of delegates by the American Academy of Pain Medicine.

Most pain physicians come to the field from anesthesiology or, to a lesser extent, physical and rehabilitation medicine, occupational medicine, and psychiatry and neurology. (The specialty breakdown of pain medicine is discussed in greater detail in Chapter 4.) Few pain specialists come from primary care disciplines. This is an unfortunate gap because greater interchange would be helpful given that, in light of the paucity of pain specialists, the bulk of clinical pain care must take place either through primary care or through routine medical care provided by the cardiologists, oncologists, and neurologists who manage most of the care for people with heart disease, cancer, and neurologic disorders, respectively.

Several health professional associations that focus on pain are influential sources of information about pain and pain care. Individuals are free to join as many associations as they wish, provided they meet the qualifications for membership. Relatively large groups (among which memberships overlap), with about 4,000 to 6,000 members each, are the American Academy of Pain Management (consisting of anesthesiologists, chiropractors, physical therapists, psychologists, and others), the American Society of Regional Anesthesia and Pain Medicine ( anesthesiologists), and the International Association for the Study of Pain ( researchers and physicians, whose U.S. chapter is the American Pain Society). Somewhat smaller groups include the American Society of Interventional Pain Physicians (anesthesiologists), the American Academy of Pain Medicine (physicians), and the American Back Society (physicians, chiropractors, and physical therapists). Relatively small groups include the American Headache Society (physicians), the American Society for Pain Management Nursing, and the American Academy of Orofacial Pain (primarily dentists and physical therapists).

Certification of pain specialists. Physicians already board certified in anesthesiology, physical medicine and rehabilitation, or psychiatry/neurology can become board certified in pain medicine. During the 2000–2009 decade, pain medicine certificates were issued to 1,874 anesthesiologists, 1,337 physiatrists, and 277 psychiatrists and neurologists, based on a common curriculum and a jointly developed examination administered by the American Board of Anesthesiology (American Board of Medical Specialties, 2010).

Practice patterns reflect training. A pain specialist trained as an anesthesiologist is likely to provide different perspectives and treatments from those of a psychiatrist, neurologist, or internist. For example, a study of medication care provided to fibromyalgia patients by primary care physicians, rheumatologists, neurologists, and psychiatrists found no statistically significant differences among disciplines in outcomes of care, satisfaction, or costs of care, but did find significant differences in the types of medications most often prescribed (McNett et al., 2011). The historical predominance of anesthesiology in the pain medicine field—for example, many early pain clinics were established by anesthesiologists using nerve block techniques (Manchikanti, 2000, p. 133)—may affect the scope of services available to patients.

The confusing state of pain medicine has led some physicians and organizations to support the development of a new, inclusive pain care specialty not under the aegis of any particular medical discipline (Dubois et al., 2009). Perceived advantages of creating an independent pain specialty are a more coherent voice and the ability to advocate for a consistent training curriculum and promote greater continuity of care. For example, a unified specialty would be better positioned to persuade third-party payers to adopt reimbursement practices that are aligned with best pain care practices. Other than the logistical difficulties, possible disadvantages of creating an independent pain specialty might include loss of the cross-fertilization enabled by the involvement of several specialty groups with a history of and experience with providing pain care.

Interdisciplinary teams. Ideally, most patients with severe persistent pain would obtain pain care from an interdisciplinary team, as opposed to a specialist who might focus on a narrow range of treatments and have a restricted view of how pain is affecting the patient. The interdisciplinary model incorporates assessment and diagnosis, not just therapy. It is an integrated, coordinated, and multimodal approach to care targeting multiple dimensions of the chronic pain experience— including disease management, reduction in pain severity, improved functioning, and emotional well-being and health-related quality of life—that is developed through a comprehensive evaluation by multiple specialists (usually physicians, nurses, psychologists or other mental health professionals, rehabilitation specialists, and/or complementary and alternative medicine [CAM] therapists). In the primary care setting, the team most often includes a primary care practitioner, nurse, and mental health clinician. In specialty and tertiary care settings, this team approach most often emphasizes psychological, pharmacological, and rehabilitation approaches.

An interdisciplinary approach is hardly unique to pain care. It also is used, to beneficial effect, in palliative care, rehabilitation, critical care, mental health, and geriatrics (Paice, 2005). Interdisciplinary approaches for chronic pain have been supported by numerous studies from many different countries and study populations, including

Several examples illustrate the effectiveness of team approaches to pain care. An initiative within the Department of Veterans Affairs is testing the value of a collaborative support team involving a case manager and specialist consultant, who communicate with primary care providers by their preferred method— generally e-mail or telephone (Dobscha et al., 2007). Another example comes from England, where a randomized controlled trial found that implementing a cognitive- behavioral intervention consisting of up to six group therapy sessions was effective and cost-effective in managing subacute and chronic low back pain in primary care (Lamb et al., 2010). A Department of Veterans Affairs intervention called Assistance with Pain Treatment, led by a psychologist care manager and an internist, reduced pain among primary care patients through clinician and patient education, assessment, symptom monitoring, feedback to clinicians, and referrals to specialists (Dobscha et al., 2009). For pain associated with sickle-cell disease, useful models include day hospitals and other alternatives to emergency departments (EDs) that focus on multipronged assessment and continuous, individualized care (Benjamin, 2008). An example not involving a team per se would be a strong referral network giving primary care practitioners access to multimodal treatment resources for direct consultation and for referral of at-risk patients, including those at psychosocial risk.

Specialists often differ significantly in the ways they practice. Even in multidisciplinary settings, pain specialists may collaborate actively, or they may seldom embrace collaboration or may even exclude patients whose pain cannot be managed through the specialist’s preferred modality or type of intervention. In any event, given the low numbers of pain specialists, they should serve not only as direct care practitioners but also as resources to help educate primary care practitioners about how to assist patients with relatively easy-to-manage pain.

Pain Centers

Primary care physicians and specialists who are uncomfortable treating pain or whose efforts are unsuccessful may refer patients to pain centers. In a truly interdisciplinary pain center, a coordinated team of health professionals performs a comprehensive assessment of the pain problem and its impact on the patient and family, and then implements a management plan that usually involves several therapeutic modalities. These modalities may include medications; physical therapy; psychological therapies, such as cognitive-behavioral therapy; and other treatments designed to intervene in the biological, psychological, and social aspects of the pain experience.

The number of pain centers grew in the latter part of the 20th century, largely in academic medical centers and other hospital and nonhospital settings, focused on serving patients with complex pain problems. However, not all care that takes place in pain centers is interdisciplinary, and some “pain clinics” make no attempt to provide a broad range of modalities. Indeed, formal criteria do not exist for defining what a “pain clinic,” “pain center,” or “pain program” is, and thus these terms can be confusing or mean different things to different providers or constituencies. The Commission on Accreditation of Rehabilitation Facilities currently accredits only about 122 pain treatment facilities offering interdisciplinary approaches. Only three of these thus far are veterans’ facilities, despite the Department of Veterans Affairs’ important role in pain care. The American Academy of Pain Management accredits some 46 individuals and centers (American Academy of Pain Management, 2011). A tightening of accreditation standards during the late 1990s and 2000s may have led to reductions in the number of accredited centers, although many centers function without accreditation and refer to themselves as “pain clinics,” adding to the confusion. In addition, reluctance on the part of insurance carriers to reimburse multimodal pain center care can challenge the viability of some interdisciplinary pain centers.

Outcome data on the effectiveness of care provided by pain centers are severely limited, whether effectiveness is measured in terms of lower pain severity scores or improved functioning, such as return to work. Not all pain centers are subject to review or oversight, and quality likely varies markedly from center to center. The outcome data that do exist on the effectiveness of multidisciplinary pain center care show consistent benefits; for example, such care is more effective than surgery in helping people with back problems return to work and increase their activity (Boris-Karpel, 2010). Even modest benefits could be considered an impressive result given that patients usually are referred to a pain center only after other treatments have failed, and their pain is at a severe and recalcitrant level.

People generally visit pain centers after a lengthy experience with pain— 7 years on average according to an early study (Flor et al., 1992). By this point, pain has permeated most aspects of a person’s life and for many has led to emotional distress or psychiatric conditions, so that care clearly must address psychosocial needs (Turk et al., 2010). This is not to imply that psychological factors caused the pain; in most patients with both pain and psychiatric conditions, the pain came first (Fishbain et al., 2010). As discussed in Chapter 1, however, a preexisting mental health problem may affect pain severity (Arnow et al., 2006). In some cases, successfully treating the pain relieves the emotional distress, while in other cases both conditions require treatment.

Choice of a Treatment Approach

The choice of a treatment approach depends first and foremost on whether the pain being experienced by the patient is acute or chronic. For each of these broad categories of pain, multiple factors must then be considered.

Acute Pain

As described in Chapter 1, acute pain is of recent onset, is likely to be short in duration, and is usually caused by an identifiable injury or disease. Acute pain is most often a symptom or result of tissue injury, a surgical procedure, inflammation, childbirth, or a brief disease process (Zeller et al., 2008). When acute pain is predictable, as with surgery, childbirth, or removal of a chest tube, health professionals can reduce distress by providing patients with information about typical steps and feelings they are likely to experience (Puntillo and Levy, 2004). Diagnosing the reason for acute pain is essential for selecting an optimal treatment regimen, which should take into account factors related to the pain itself, the individual, and his or her environment (Box 3-1). Initial acute pain management may include

Box Icon

BOX 3-1

Factors Affecting the Choice of Treatment for Pain. the known likely source of pain, such as an arthritic joint; the location, intensity, frequency, duration, and recurrence pattern of the pain;

  • pharmacologic therapy, for example, with analgesic drugs;
  • advice, reassurance, or distraction delivered by a health professional;
  • formal psychological interventions, including stress and tension reduction and cognitive-behavioral interventions;
  • physical therapies, such as resting the affected part of the body, application of heat or ice, manual and massage therapies, and structured physical activity; and
  • local electrical stimulation, nerve blocks, or trigger point injections to treat muscle spasms.

Chronic Pain

A common source of frustration for chronic pain patients, their families, and clinicians is that it is often impossible with today’s knowledge to predict which treatment or combination of treatments will work best in an individual case, even when the factors listed in Box 3-1 are fairly well known. Many patients are not told, or do not readily comprehend, that the road to finding the right combination of treatments for them may be a long one with many different approaches to treatment until the right match is found. This lack of mutual understanding—reflecting inadequate patient–clinician communication and sometimes inadequate clinician education and training—can lead patients to change practitioners repeatedly (doctor-shop) or try a series of unsubstantiated remedies.

Mutual understanding between clinicians and patients is important in pain care. For example, a trusting relationship with a practitioner was found to improve outcomes for patients treated with a placebo for pain (Kaptchuk et al., 2008). The clinician’s understanding of the impact of the painful disorder on the physical, emotional, and social aspects of the person’s life is critical to making the best management and treatment decisions. Even a single structured, 30-minute communication/education session with a health professional can help a patient overcome misperceptions about pain and pain care (Smith et al., 2010). Gaining this understanding often requires a relationship with the patient beyond brief consultations, a delicate balancing act for clinicians who want to encourage realistic hope in the face of what may be a series of treatment failures.

Similarly, while people with pain should be encouraged to engage in “self-management,” they should not be burdened with the impression that failing to control the pain is somehow their fault or responsibility. It is possible that more intense and focused attention to the individual, similar to care management or disease management, could point the way out of this dilemma. People who present frequently for pain care and receive many different treatments might, like other frequent users of health care, benefit from a strong commitment by a team or practitioner focused on comprehensive care, rehabilitation, and increased functioning (Gawande, 2011).

In general, an integrative approach to persistent and severe pain is beneficial, but even an integrative approach may fail large numbers of patients. In addition, the history of pain care suggests that it may be wise to temper enthusiasm for any single approach. Just as pain care has evolved in recent years from being routinely overlooked, to utilizing treatment with opioids or other single-modality interventions, to applying today’s integrative model, future biomedical advances and an improved understanding of social factors will bring further changes.

One possible change, for example, is more attention to psychosocial factors. Current treatment options sometimes have only limited effectiveness; require the motivation and patience of the individual to adhere to exercise or physical therapies or other regimens that are part of a multimodal approach; and, in the case of many pain medications, have unpleasant side effects. The biopsychosocial approach, combining physical and emotional factors in assessing and treating chronic pain, offers a uniquely valuable clinical perspective (Flor and Hermann, 2004). This mind–body perspective is now generally accepted by pain researchers (Gatchel et al., 2007) and has been found useful by clinicians in various disciplines, such as osteopathic medicine (Penney, 2010), rheumatology (Johnson, 2009), and physiotherapy (George, 2008). It has improved the pain care of patients with conditions ranging from multiple sclerosis (Kerns et al., 2002) and muscular dystrophy (Miró et al., 2009) to low back pain (Guzmán et al., 2002), exercise-induced shoulder pain (George et al., 2008), and musculoskeletal pain in general (Vranceanu et al., 2009). It benefits populations ranging from children (von Baeyer, 2007)—partly because children with pain often have parents with pain (Schanberg et al., 2001)—to the elderly (Zagaria, 2008). As an example of the application of this approach, evidence that psychological factors predispose patients to persistent pain following surgery could lead to routine screening for psychological risk factors for pain and timely interventions designed to prevent their adverse effects. The growing literature showing that cultural factors influence pain and patients’ engagement in pain treatments (see Chapter 2) similarly could lead to increased efforts to deliver care in more culturally appropriate and competent ways.

The committee notes how best practices evolve with new knowledge. Two examples illustrate this point. A hundred years ago, tuberculosis was a disease with a complex complement of psychosocial correlates equal to that of chronic pain today, and 50 years ago, peptic ulcers were believed to be caused by emotional stress. When tuberculosis could be cured with antibiotics and the H. pylori bacterium was identified as the main and treatable cause of most peptic ulcers, these diseases largely emerged from their psychosocial contexts.

Access to Pain Care

Not all Americans have the same access to pain care. As discussed in Chapter 2, significant numbers are at risk of undertreatment, especially those from racial and ethnic minorities, women, and the elderly. Lack of insurance, insurance limits, employment pressures, and other factors also can reduce access.

In addition, EDs are a common site of pain care. A busy hospital ED would appear to be one of the least promising care sites for chronic pain patients, given the multiple factors involved in assessing such pain and devising a treatment strategy and the desirability of developing a continuing patient–clinician partnership. In 2007, almost half of ED patients presented with pain that was severe (22 percent) or moderate (23 percent) (Niska et al., 2010) (chest or abdominal pain was the leading reason for the visit among those aged 15–64, while chest or abdominal pain plus shortness of breath was the leading reason for the visit among those 65 and older).

Such frequent use of EDs for pain care may in part reflect difficulties in surmounting financial, geographic, and cultural barriers affecting access to ambulatory care; for many Americans, EDs are a safety-net provider (IOM, 2007a). In addition, EDs are open all hours and are legally bound to turn no one away without a clinical assessment. They provide diagnostic and screening services (such as x-rays, head scans, and cultures), procedures (such as splints, wraps, and laceration repairs), medications, and admission to the hospital when necessary.

Other than EDs, hospitals are a site of pain care, often because of the acute pain that may follow a surgical procedure. There were 10 million inpatient surgeries and 17.4 million hospital outpatient surgeries in 2009 (AHA, 2011). Between 10 and 50 percent of people having common surgical operations— groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery—go on to experience chronic pain, often due to damage to nerves in the surgical area during the procedure (Kehlet et al., 2006). Today’s shorter hospital stays—down, on average, from 7.2 days in 1989 to 5.4 days in 2009 (AHA, 2011)—and the trend toward outpatient surgery may not permit sufficient opportunity to assess patients’ postsurgical pain or establish an appropriate course of postoperative analgesia (perhaps one that can be administered at home), shown to be effective in hip and knee replacement, for example (Schug and Pogatzki-Zahn, 2011). Hospitals also are challenged to manage the high rate of unscheduled admissions (between 14 and 26 percent) due to uncontrolled pain among cancer patients.

However, the logic of health care financing focuses some hospitals on implementing pain care initiatives to reduce lengths of stay or to prevent admissions. For example, an initiative to better manage chest pain reduced the average length of stay in one hospital from 2.36 to 1.88 days and saved the hospital almost $320,000 in the first year (Gottlieb et al., 2010). A model is being developed to predict which patients are most likely to have severe pain so that resources can be targeted toward them; they tend to be orthopedic or general surgical patients, as opposed to medical patients (Levitan, 2010), and patients with severe acute pain following surgery (Schug and Pogatzki-Zahn, 2011).

TREATMENT MODALITIES

We cannot successfully treat the complexity of pain without treating the whole patient. Insurance companies will pay for useless, expensive procedures and surgeries but won’t pay for simple cognitive-behavioral therapy and physical rehab therapy.

—A clinical pharmacy specialist3

Many forms of treatment are used to help patients who present with pain. Treatment modalities frequently used by physician pain specialists and other practitioners include

  • medications,
  • regional anesthetic interventions,
  • surgery,
  • psychological therapies,
  • rehabilitative/physical therapy, and
  • CAM.

Medications

The range of medications used for pain is expansive (Turk et al., 2011). The most common are nonopioid analgesic drugs (acetaminophen; nonsteroidal anti-inflammatory drugs, including COX-2 inhibitors; ibuprofen; and aspirin), opioids, and a plethora of so-called “adjuvant analgesic drugs” that encompass medications used for other indications that also are used to manage pain. Most often these adjuvant medications are in the anticonvulsant (Dworkin et al., 2010) or psychotropic classes (Attal et al., 2006; Kroenke et al., 2009a). A few additional drug classes and compounds further illustrate the range: mu-opioid agonists, serotonin and norepinephrine reuptake inhibitors, and muscle relaxants (Arnold et al., 2000).

The rising rate of reported chronic pain (see Chapter 2) has been accompanied by a rise in the rate of adults reporting the use of prescription drugs for pain, the most controversial of which are the opioids. National Health and Nutrition Examination Survey (NHANES) data show that during the 7-year period 1988–1994, 3.2 percent of Americans reported using opioids for pain (2.8 percent of men and 3.6 percent of women). During the 4-year period 2005–2008, by contrast, 5.7 percent of the population was using these drugs (5.2 percent of men and 6.2 percent of women), including 7 percent of people 65 and older.4

In 2007, about 2.3 billion drugs were provided or prescribed during patients’ visits to their physicians, according to physician-provided reports to the National Ambulatory Medical Care Survey.5 Aspirin (usually thought of as an analgesic, but also an antiplatelet agent) was mentioned most frequently by the physicians, associated with 55 million patient visits. Other pain medications among the 20 drugs most frequently mentioned were ibuprofen, acetaminophen-hydrocodone, and acetaminophen (Hsiao et al., 2010).

Similarly, data from the National Hospital Ambulatory Medical Care Survey indicate that in hospital EDs, the most common drug category used is analgesics, which accounted for 36 percent of drugs reported in 2007 ( Niska et al., 2010). 6 The most common drugs mentioned in connection with ED visits were three analgesics: ibuprofen, acetaminophen-hydrocodone, and acetaminophen. Five other analgesics were among the top 20 drugs mentioned: keterolac, morphine, hydromorphone, acetaminophen-oxycodone, and aspirin. Acetaminophen- hydrocodone, an opioid anti-inflammatory drug compound, was mentioned in reports of 26 million physician office visits and 13 million ED visits. When patients were discharged from the ED, the leading drugs prescribed were acetaminophen (alone or with hydrocodone or oxycodone) and ibuprofen (Hsiao et al., 2010).

Issues and problems in developing new drugs for pain conditions, many of which relate to the high costs of drug development, are discussed in Chapter 5. Briefly, they include the unfavorable economics of developing drugs that may help only a small number of people, problems in finding the required animal models, lower international prices, competition from generics, high failure rates of new drugs in clinical trials, and tough new regulatory standards. Indeed, much pain medication development in the last decade has not involved novel therapies but merely reformulated existing drugs.

It is also important to recognize that some medications may actually cause pain. For example, the statins—an important class of drugs that reduces cholesterol and thus the morbidity and mortality from heart disease—were used by an estimated 8.2 million Americans aged 40 and older in 1999–2002 (Buettner et al., 2008). Between 9 and 20 percent of statin users reported muscle pain, including lower extremity pain and low back pain. Similarly high rates were confirmed in a study using NHANES data. The additional significance of these findings is that painful side effects may reduce cardiovascular patients’ willingness to adhere to their cholesterol drug regimen.

Regional Anesthetic Interventions

Regional anesthetic interventions are invasive and include a variety of treatments, such as sacroiliac joint injections; epidural steroid injections to manage radicular pain (pain radiating along a nerve as a result of irritation of the spinal nerve root, such as sciatica); cervical, thoracic, and lumbar facet joint nerve blocks; or implantation of devices that deliver analgesic medications directly to the spinal canal (Manchikanti et al., 2010).

The usefulness of some of these therapies may be doubtful. A systematic review of interventional therapies for low back and radicular pain concluded: “Few non-surgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials” (Chou et al., 2009a, p. 1078). A systematic review of 18 randomized controlled trials found no strong evidence for or against using injection therapy to treat subacute or chronic low back pain (Staal et al., 2008). However, the reviewers suggest that some specific types of patients might benefit. That said, a review of 30 trials determined that corticosteroid injections (and traction) were not found to be beneficial and are not recommended for lumbosacral radicular syndrome (Luijsterburg et al., 2007). Finally, a global discussion of pain treatments notes that the implantation procedures of spinal cord stimulation and intrathecal drug delivery systems—so-called “pain pumps”—require routine monitoring, replacement of devices over time, refilling of drug reservoirs, and a balancing of high costs and maintenance requirements against benefits (Turk et al., 2011).

Surgery

Surgical therapies overlap with interventional techniques, such as implantation of spinal cord stimulation systems and spinal analgesic infusion pumps, but include more invasive procedures, such as spinal decompression procedures (e.g., laminectomies, discectomy), disc replacement, and spinal fusion, which are used to treat neck, low back, and radicular pain. Joint replacement surgery is another frequently used surgical intervention for pain. Others include nerve decompression (e.g., for carpal tunnel syndrome or trigeminal neuralgia) and ablative surgeries that disrupt the flow of nociceptive pain in the nervous system, such as nerve section (neurectomy or rhizotomy) and cordotomy. Surgery usually is undertaken only after other treatments fail, and different procedures vary in their effectiveness (Chou et al., 2009b).

Access to high-cost treatments such as spine surgery or hip, knee, and shoulder replacement surgeries varies by race and geography. Even with less-than- universal access to these procedures, however, their frequency has grown markedly. Medicare data show that between 2000–2001 and 2005–2006, the number of hip replacements grew by 15 percent, the number of knee replacements by 48 percent, and the number of shoulder replacements by 67 percent. A portion of these surgeries results from Americans’ increased longevity; people outlive their joints and need to have them replaced.

As with many other procedural interventions, wide geographic differences exist in the rates at which such procedures are performed. These differences are associated with service availability and practice patterns and preferences within the local health care system (Gawande, 2009) and are not an indicator of treatment efficacy. As Table 3-1 indicates, rates among cities varied four-fold during 2005–2006 for hip replacements, ten-fold for shoulder replacements, and nearly four-fold for knee replacements. Likewise, African Americans are only a little more than half as likely as whites to receive any of these elective procedures.

TABLE 3-1. U.S. Cities with Lowest and Highest Rates of Joint Replacement Surgeries per 1,000 Medicare Beneficiaries, 2005–2006.

TABLE 3-1

U.S. Cities with Lowest and Highest Rates of Joint Replacement Surgeries per 1,000 Medicare Beneficiaries, 2005–2006.

These geographic and racial differentials raise important questions about both potential overuse and underuse: Is everyone who could benefit being offered a procedure, or are some people having “a procedure that they might choose to delay or forgo if they had received balanced information on risks and benefits?” (Fisher et al., 2010, p. 1). Fisher and colleagues offer potential explanations for the differentials: that physicians in some areas may be stronger advocates for a procedure, leading to overuse; that some geographic areas may lack the skilled clinicians or sophisticated hospital facilities required, leading to underuse; or that the black–white differential may reflect individual preferences, since there is evidence that African Americans with severe osteoarthritis of the knee prefer more conservative, nonsurgical treatment (Figaro et al., 2004).

Psychological Therapies

Psychological therapies include cognitive-behavioral treatment, behavioral treatment alone, biofeedback, meditation and relaxation techniques, and hypnosis. These therapies reflect the biopsychosocial model of pain discussed earlier and are supported by a long line of psychological research (Kerns et al., 2011).

A meta-analysis found positive effects for psychological approaches in reducing pain intensity, improving functioning and quality of life, and curtailing depression (Hoffman et al., 2007). Another meta-analysis, limited to treatment of arthritis, also found that patients receiving psychosocial interventions reported significantly lower pain levels (Dixon et al., 2007). A 10-year study involving more than 1,000 pain patients showed that between one in three and one in seven patients benefited from a 4-week inpatient cognitive-behavioral treatment program (Morley et al., 2008). On the other hand, a meta-analysis of 30 randomized controlled trials involving chronic low back pain showed that while behavioral therapy was more effective than usual care in the short term, it was no more effective than group exercise in the intermediate to long term (Henschke et al., 2010). One brief survey of the evidence supports the notion of individualization of psychological therapies:

There is insufficient evidence to recommend any one (psychological) therapeutic approach or modality over another. It is reasonable to consider the possibility that patients with different characteristics might derive benefits from treatments with different foci and targets. (Turk et al., 2011, p. 16)

Rehabilitative/Physical Therapy

Rehabilitative/physical therapy is undertaken in inpatient, ambulatory care, and home-based settings. Inpatient pain rehabilitation programs are interdisciplinary, include a physical medicine and rehabilitation component, and provide education as well as treatment. A meta-analysis found such programs achieved significant reductions in both pain intensity and use of pain medications ( Hoffman et al., 2007). Rehabilitation methods available to patients living at home or in other settings include stretching, strengthening, and mobility exercises. Heat therapy and mechanical traction also have been used. Rehabilitative/physical therapy has increasingly been found to reduce pain even in end-of-life situations, such as advanced cancer (Chang et al., 2007), although consistent adherence to exercise regimens may be difficult for many patients. Exercise also has been shown to be effective in reducing persistent pain due to osteoarthritis of the knee (Fransen and McConnell, 2009).

A systematic review of 18 randomized controlled trials showed that physical conditioning programs “seem to be effective in reducing the number of sick days for some workers with chronic back pain, when compared to usual care” (Schonstein et al., 2003, p. 1). The programs must comprise cognitive-behavioral treatment and intensive aerobic physical training (for muscle strength, endurance, and coordination), relate to the person’s work, and be directed by a physiotherapist or interdisciplinary team. The review found no evidence to support exercise programs for acute back pain.

A meta-analysis of 20 studies showed that exercise had a statistically significant effect in reducing disability for work over the long term but not over the short or intermediate term (Oesch et al., 2010). The analysts did not find support for any particular exercise approach over others. In a systematic review of 43 studies of exercise for chronic low back pain, the researchers concluded that only 6 showed statistically significant and clinically important results in improving functioning, and only 4 showed such results in reducing pain intensity (van Tulder et al., 2007). The authors comment that many studies focus only on the statistical significance of results rather than on clinical importance, so some studies misleadingly label findings as positive.

Physical modalities of therapy include physical and functional restoration techniques, massage ultrasound, and neurostimulators (such as transcutaneous electrical nerve stimulation, or TENS). Other modalities include dry land physical therapy and aquatherapy.

Complementary and Alternative Medicine

Definitions of CAM differ. For example, a study of CAM in hospices identified practices as diverse as massage therapy, supportive group therapy, music therapy, pet therapy, and guided imagery or relaxation, not all of which are usually associated with CAM (Bercovitz et al., 2011). Acupuncture, chiropractic spinal manipulation, magnets, massage therapy, and yoga often are considered CAM pain treatments. According to the National Institutes of Health’s (NIH) National Center for Complementary and Alternative Medicine, additional CAM therapies used for pain include dietary supplements, such as glucosamine and chondroitin intended to improve joint health; various herbs; acupuncture; and mind–body approaches, such as meditation and yoga (NIH and NCCAM, 2010).

CAM holds special appeal for many people with pain for several reasons:

  • deficits in the way that many physicians treat pain, using only single modalities without attempting to track their effectiveness for a particular person over time or to coordinate diverse approaches;
  • the higher preponderance of pain in women (see Chapter 2), given that “women are more likely than men to seek CAM treatments” (IOM, 2005, p. 10); and
  • a welcoming, less reserved attitude toward people with pain on the part of CAM practitioners and an apparent willingness to listen to the story of a patient’s pain journey.

Whatever the reasons, pain is a common complaint presented to CAM practitioners (NIH and NCCAM, 2010). In 2007, 44 percent of people with pain or neurologic conditions sought help from CAM practitioners (Wells et al., 2010). In 2002, three-fifths of people who turned to CAM for relief of back pain found a “great deal” of benefit as a result (Kanodia et al., 2010). The National Center for Complementary and Alternative Medicine’s strategic plan, released in February 2011, supports the development of better strategies for managing back pain, in particular.

However, a single CAM practice, like a single type of medical treatment, may not be as beneficial as an integrated approach. It is unclear which types of patients—defined on the basis of pain condition, attitude, or other characteristics— stand to benefit most from CAM treatments for pain.

For which pain conditions are CAM treatments most often used? In the 2007 National Health Interview Survey (NHIS), adults reported using CAM in the previous year most often to treat various musculoskeletal problems. Just over 17 percent of adults—more than 14 million Americans—used CAM for back pain/problems, almost 6 percent (5 million) for neck pain/problems, 5 percent for joint pain/stiffness (5 million), and 44 percent specifically for arthritis (3 million). An additional 1.5 million used CAM for other musculoskeletal problems, 1 million for severe headache or migraine, 11 million for “regular headaches,” and 0.8 million for fibromyalgia (Barnes et al., 2008). Rates of reported use of CAM for these conditions had remained relatively unchanged since 2002. Even among children, NHIS data show that CAM therapies are used most often for back or neck pain (7 percent of all children).7

CAM treatments lie outside the traditional medical model, and research on their effectiveness for specific pain conditions is incomplete but accumulating. For example, reviews of research on acupuncture, massage, and chiropractic spinal manipulation for chronic low back pain suggest these therapies may be beneficial, whereas results are mixed as to whether the popular dietary supplements glucosamine and chondroitin sulfate can relieve osteoarthritis pain. Evidence regarding the effectiveness of static magnets, widely marketed for pain control, does not support their use. Systematic reviews show that spinal manipulation for low back pain is more effective than sham manipulation, bed rest, or traction, but not more effective than analgesics, physical therapy, exercise, or “back-school” education (Tan et al., 2007). Evidence also supports the use of massage therapy for low back and shoulder pain and suggests it may benefit patients with fibromyalgia and neck pain.

Acupuncture appears to affect several mechanisms in the brain and spinal cord, including those involved in pain and inflammation. A systematic review supports its use in postoperative pain management (Sun et al., 2008). Likewise, a German clinical trial involving more than 3,000 patients with chronic low back pain found that acupuncture improved functioning (Witt et al., 2006). A systematic review of 11 studies suggests that acupuncture may be clinically valuable in treating tension headaches (Linde et al., 2009).

Research on acupuncture has been controversial. Of interest, a systematic review of 23 clinical trials found moderate evidence that acupuncture and sham acupuncture are, in roughly equal measure, more effective than no treatment for chronic low back pain (Yuan et al., 2008). This finding is consistent with evidence from a rigorous German study (Haake et al., 2007). The success of sham acupuncture, in which needles are inserted in the body but not at acupuncture points and usually not with stimulation, has led to debates among researchers and clinicians about the value of placebos (Berman et al., 2010) (see the next section). Some critics of studies finding a lack of efficacy for acupuncture contend that the study findings are based only on criteria of Western medicine, not those of traditional Chinese medicine (Chiang et al., 2010).

Evidence on the effectiveness of CAM in treating children’s pain is not yet robust, although the available findings suggest that hypnosis, music therapy, acupuncture, laughter therapy, and massage therapy have been beneficial for acute procedural pain in children (Evans et al., 2008). A systematic review found sufficient evidence to support only one CAM approach in children—the use of self-hypnosis/guided imagery/relaxation for recurrent headache (Tsao and Zeltzer, 2005). A review of 23 randomized controlled trials and 8 meta-analyses on acupuncture for children found “evidence of some efficacy and low risk,” with the greatest effectiveness found in preventing postoperative nausea (Jindal et al., 2008, p. 431). The authors caution, however, that “because acupuncture’s mechanism is not known, the use of needles in children becomes questionable” (Jindal et al., 2008, p. 432). A study of 45 children found their expectations for benefits from CAM to be fairly low, and those of their parents only somewhat higher (Tsao et al., 2005).

Note on the Use of Placebos

Placebos conceivably could be considered a form of treatment of pain, especially in light of the shortcomings of other modalities or other benefits they bring in their own right. Even though placebos are believed to have no specific pharmacologic effects, researchers and clinicians have found that some people with pain have reduced symptoms after taking them and that at times, a placebo performs as well as—or better than—other treatments (see the above discussion of sham acupuncture). Furthermore, a placebo effect has been observed in the management of a variety of nonpain disorders, suggesting that placebos have an effect that is yet to be fully understood on a scientific basis. A recent survey showed that many physicians already use placebos, in one form or another, in clinical practice (Tilburt et al., 2008), although the ethics of such use, when it involves deception, are rigorously disputed (Nichols et al., 2005). Certainly placebo should not be used as a diagnostic tool or to validate whether a patient’s reported pain “is real or not.”

Neuroimaging studies show that placebos reduce activation of opioid neural transmission in pain-sensitive regions of the brain, which suggests that they do have biological effects (Qiu et al., 2009). According to Tracey (2010, p. 1277), the “placebo effect” is “a genuine psychobiological event attributable to the overall therapeutic context in which a treatment is given, which itself comprises many factors such as patient-physician interaction and treatment environment.”

One factor in the success of a placebo—or any pain treatment, for that matter—is the prescriber’s empathy or skill in communicating with the patient. Evidence suggests that for patients treated with placebo pills, a positive relationship with a practitioner improves outcomes (Kaptchuk et al., 2008) and, in a sense, engages the brain to help in pain control by instilling optimism and confidence. Because placebo use could undermine trust, Kaptchuk and colleagues (2010) told patients they were receiving a placebo, and the treatment still produced statistically significant improvements in terms of mean global improvement scores, reduced symptom severity, and adequate relief at both an 11-day midpoint and 21-day endpoint (Kaptchuk et al., 2010).

SELECTED ISSUES IN PAIN CARE PRACTICE

It’s a relief to finally have names for my conditions after suffering most of my life with a myriad of symptoms.

— A woman with fibromyalgia, vulvodynia, and interstitial cystitis8

Issues in pain care discussed in this section of the chapter are difficulties in measuring pain, the adequacy of pain control in hospitals and nursing homes, pain and suffering at the end of life, access to opioids and concerns about their use, insurance incentives, and the reporting of pain.

Difficulties in Measuring Pain

As discussed in Chapter 1, the experience of pain is influenced by a range of physical, psychosocial, and behavioral factors. There is growing consensus that these factors include many of those listed earlier in Box 3-1: (1) genetic composition; (2) physical pathology associated with a trauma or disease; (3) alterations in the peripheral and central nervous system attributable to the initial insult (peripheral and central sensitization); (4) psychological contributors, including prior pain history and available coping resources (e.g., emotional support, financial resources, acquired coping skills); and (5) environmental influences (e.g., response by significant others, disability compensation, features inherent in the workplace). All of these factors likely interact and are important considerations in measuring pain.

The general goals of a pain evaluation, from both the clinician’s and the patient’s point of view, are to (1) arrive at a medical diagnosis, (2) determine whether additional diagnostic testing is needed, (3) make a judgment about the extent to which medical data adequately explain the patient’s symptoms and the severity of his or her apparent incapacitation, (4) determine whether there is any appropriate treatment (i.e., treatment directed toward reversing a pathophysiologic process) that has a reasonable chance of helping, (5) determine whether there are any symptomatic treatments that should be prescribed if a reversal of pathophysiology is not possible, and (6) establish the objectives of treatment. The depth of assessment in these areas will depend on the circumstances. For example, a trauma patient in an ED will receive a much different assessment from that of a person with a 5-year history of back pain being evaluated at an interdisciplinary pain clinic.

A large number of measures have been developed with which to assess mood and physical functioning. Reliable and validated self-report measures of pain and of emotional and physical functioning are available for different populations. These measures are age- and disease-appropriate and appropriate at the level at which patients—for example, children or nursing home residents—are able to communicate. In addition to self-report measures, clinicians make their own careful observations of the patient, and, depending on circumstances, may call on other clinicians, such as physical or occupational therapists, to evaluate objective factors such as range of motion.

Health professionals’ general awareness of the importance of pain and recognition of the need to ask patients about it have been buttressed by efforts of the Joint Commission to establish and enforce pain management standards (Phillips, 2000). Beginning in 2001, following the lead of pain medicine professional associations and the Department of Veterans Affairs, the then Joint Commission on Accreditation of Healthcare Organizations introduced a new hospital accreditation standard that requires monitoring of patients’ pain level as a “fifth vital sign.” This means that physicians and nurses are expected to measure hospital patients’ pain as regularly as they measure the four traditional vital signs: blood pressure, pulse rate, temperature, and respirations.

Under this approach, patients are asked to assess their pain on a numeric scale from zero (no pain) to 10 (worst possible pain). These pain intensity scores indicate whether, and how quickly, pain needs to be treated and can be tracked over time to assess healing and effects of treatment. The Joint Commission’s effort quickly led to clinically appropriate increases in opioid use in postanesthesia care units (Frasco et al., 2005). It also led many health facilities to implement routine efforts to relieve patients of pain immediately, identify and address causes of pain, initiate treatments other than medication, and prevent postsurgical acute pain from developing into chronic pain.

The full impact of the fifth vital sign approach is not entirely clear, however, as studies have indicated effects ranging from beneficial and limited outcomes to negative consequences. While adherence to the standard has improved satisfaction with pain management, adverse drug reactions have increased (Vila et al., 2005). In selected trauma care centers, overmedication with opioids and sedatives—attributed by the researchers to compliance with the new standard— reportedly contributed to higher mortality rates, usually resulting from too great a reduction in blood pressure or compression of the airway (Lucas et al., 2007). In a veterans’ outpatient clinic, monitoring pain as a fifth vital sign failed to improve pain management as the assessment was not followed up with recommended treatment, even for patients reporting substantial pain (Mularski et al., 2006). Similarly, in a study of eight veterans’ facilities in the Los Angeles area, documentation of pain—necessary for pain care planning—was frequently absent from the medical records of patients with moderate and severe pain (Zubkoff et al., 2010). Taken together, these studies suggest the need to exercise careful clinical judgment based on a comprehensive patient assessment instead of merely monitoring pain (meeting, in a sense, the letter of the law and not the spirit), using opioids to the exclusion of other treatment approaches, or routinely using these powerful medications when their use is not clinically indicated.

Measuring pain intensity alone offers little insight into the quality or character of an individual’s pain experience (Ballantyne et al., 2009). Besides the fifth vital sign approach, clinicians use multiple mechanisms to measure pain. Assessing how much patients’ pain bothers them and affects functioning—that is, the extent to which pain interferes with activities of daily living, work, and other aspects of daily life—can be as or even more useful (see Chapter 2). Using changes in functioning to assess pain also may yield more consistent results across populations than descriptions of pain, which are more heavily influenced by culture (see Chapter 2). Efforts are now under way to use health-related quality-of-life measures to assess pain (Vetter, 2007).

While some clinicians rely primarily on either intensity measures or measures of functioning, advocates of indices of functioning generally recognize that they should be used only in conjunction with other measures. Exclusive reliance on measures of functioning and other “objective” measures of pain could result in insufficient attention to a person’s emotional response to pain, thereby alienating those who might already feel that the health care system is not responding adequately to their needs. Assessments of changes in function also must be tailored to the health care setting. For example, the ability to participate in rehabilitation and recovery activities is key to assessing changes in function in postoperative hospital care, the ability to perform activities of daily living is key in nursing homes, and social functioning is often central in outpatient settings. One difficulty that arises is that some people, such as those who are paralyzed, frail, terminally ill, or developmentally disabled, have only limited functioning to begin with.

Despite the many variables involved in people’s responses to pain, different measures of pain can yield consistent results. For low back pain, high degrees of correlation have been found among three different types of measures: a patient’s global assessment of response to therapy (often a score given by the patient from zero to 4), a well-validated questionnaire about the extent of pain-related disabilities, and use of a “visual analog” or graphic rather than a numeric scale to report pain levels (Sheldon et al., 2008).

Both intensity scores and indices of functioning, then, have limitations as measures of pain. Moreover, it remains unclear whether subjective measures of pain are fully informative. The lack of a single, universally accepted metric confounds clinicians’ efforts to assess an individual patient’s progression and response to treatment and researchers’ efforts to evaluate treatment modalities through clinical, cost-effectiveness, comparative effectiveness, or even health services research. Thus there exists a clear need for more objective measures for pain.

Adequacy of Pain Control in Hospitals and Nursing Homes

Hospitalized patients experience both acute and chronic pain; patients often experience acute pain following a surgical procedure, or they suffered from chronic pain prior to admission. In a recently reported national survey, most inpatients gave high marks to hospitals’ efforts to control their pain, whether acute or chronic (Hospital Care Quality Information from the Consumer Perspective, 2010). In a survey administered nationwide to 2.4 million patients discharged from 3,773 hospitals, 68 percent of patients who said they needed medicine for pain reported their pain was “always” well controlled, and 24 percent said it was “usually” well controlled. The same survey found equivalently high levels of satisfaction with other aspects of hospital care. (These “Hospital Compare” data derive from postdischarge surveys, so they exclude the experiences of patients who died during their hospital stay.) The survey is seen as providing a basis for improving pain care in hospitals (Gupta et al., 2009).

In another national survey, 67 percent of hospitalized patients reported that staff “always” managed pain well, 60 percent reported that staff “always” responded when help was needed, and 58 percent reported that staff “always” explained medicines and their side effects (Commonwealth Fund, 2008). An additional study found that 90 percent of hospital patients receiving medication for postsurgical pain were satisfied with their pain relief, although the researchers nevertheless concluded that “additional efforts are required to improve patients’ postoperative pain experience” (Apfelbaum et al., 2003, p. 534).

The Joint Commission’s fifth vital sign standard was initiated because hospital staff’s underrecognition of pain was believed to be a prominent cause of pain undertreatment. Since the standard was promulgated, staff recognition of pain appears to have been improving steadily. Even soon after the standard was in place, researchers testing its effects found that hospital staff recognized the presence of pain in 90 percent of patients experiencing it. At that time, attending physicians and house staff were more likely to recognize patients in pain (75 percent and 85 percent of patients, respectively) than were nurses (54 percent), regardless of patients’ pain levels. However, there was no association between documentation of pain in team members’ notes and patients’ satisfaction with pain management, or between pain score and patient satisfaction (Whelan et al., 2001). Much has likely improved since this early study, but it underscores that pain assessment is only the first step; it is what is done with that information that makes a difference to patients.

As discussed in Chapter 2, evidence indicates that nursing homes undertreat pain, especially in cognitively impaired and minority residents (Reynolds et al., 2008; Teno et al., 2001; Hutt et al., 2006). Previous research and expert opinion suggest that 45 to 80 percent of U.S. nursing home residents experience pain that contributes substantially to functional impairment or reduces quality of life ( Ferrell, 1995; American Geriatrics Society, 1998). Factors implicated in poor pain care by nursing homes include

  • cognitively impaired residents’ inability to articulate pain and some residents’ belief that their pain is untreatable or should be tolerated as just part of getting old;
  • insufficient knowledge about and training in pain and ways to reduce it among health professionals and other staff members working in long-term care settings;
  • the lack of standardized tools for assessing and treating pain in nursing homes;
  • health professionals’ concerns about side effects of medications, especially opioids, in frail individuals and possible adverse interactions with other drugs being taken (Reisman, 2007); and
  • possible reluctance of residents and families to complain to the institution’s staff.

Pain and Suffering at the End of Life

Pain and suffering are related but distinguishable concepts and not inextricably linked (Turk and Wilson, 2009). If pain is a complex biopsychosocial phenomenon, associated with tissue damage, suffering might best be described as “a specific state of distress that occurs when the intactness or integrity of the person is threatened or disrupted” (Cassell, 1999, p. 531). Quite commonly, however, pain and suffering co-occur in the context of terminal illness. Hospice pioneer Cecily Saunders coined the term “total pain” to describe this linkage (Clark, 2000). Opioids and other pain management strategies are important in addressing pain associated with terminal illness, but clinicians should be aware of the risk of exacerbating suffering when pain assessment and management lead to medical approaches alone without sufficient consideration of psychosocial and spiritual sources of distress (Kuupelomaki and Lauri, 1998).

Surveys of family members of people who have recently died find a wide range of satisfaction with pain management, associated with the place of care (Teno et al., 2004). When asked about the survey item, “Patient did not receive any or enough help with . . . pain,” 18 percent of family members of patients who had died in home hospice care answered “yes,” compared with 32 percent of family members who answered “yes” when their loved one had died in a nursing home without the benefit of hospice care. This result indicates that even in hospice and palliative care settings, the management of pain may be challenging, and implies that comprehensive approaches to assessment and management that address pain-related suffering are important.

Access to Opioid Analgesics and Concerns About Their Use

If I asked for prescription pain relief, I was treated like a common criminal. It was a terrible time in my life.

—A person with chronic pain9

Although opioid analgesics often are indicated for chronic severe pain, people with such pain and institutions such as nursing homes can have difficulty obtaining them for various reasons. Sometimes it is a clinician’s reluctance to prescribe; sometimes it is a pharmacy’s reluctance to carry the medications, ostensibly to protect against theft. The rise in opioid abuse, overdoses, and deaths over the past decade is of growing concern and may make it more difficult for people who need opioids for pain control to obtain them.

The April 2011 White House comprehensive action plan on prescription drug abuse notes that “. . . any policy in this area must strike a balance between our desire to minimize abuse of prescription drugs and the need to ensure access for their legitimate use” (The White House, 2011, pp. 1–2). While most of the plan’s provisions relate to substance abuse, it does include some measures to assess the adequacy and effectiveness of pain treatment and to “facilitate appropriate prescribing, including development of Patient-Provider Agreements and guidelines” (The White House, 2011, p. 4).

The same day the White House action plan was released, the Food and Drug Administration (FDA) announced that it will require an Opioids Risk Evaluation and Mitigation Strategy (REMS) (Okie, 2010; FDA, 2011) for all extended-release and long-acting opioid medications. Under the FDA requirement, manufacturers must develop education programs for all physicians prescribing these drugs that cover proper pain management and patient selection, as well as patient education programs in safe use and medication disposal. It is important that education programs mandated under the REMS approach not be so burdensome as to keep physicians from prescribing these medications altogether—particularly for those in severe pain or at the end of life.

Patient Access to Opioids

A reasonable degree of access to pain medication—such as the stepped approach of the World Health Organization’s Pain Relief Ladder for cancer—has been considered a human right under international law since the 1961 adoption of the U.N. Single Convention on Narcotic Drugs (Lohman et al., 2010; WHO, 2011). Similarly, countries are expected to provide appropriate access to pain management, including opioid medications, under the International Covenant on Economic, Social, and Cultural Rights, which guarantees “the highest attainable standard of physical and mental health” (Brennan et al., 2007, p. 213).

In the United States, many pain experts agree that physicians should prescribe opioids when necessary regardless of outside pressures as an exercise of their “moral and ethical obligations to treat pain” (Payne et al., 2010, p. 11). For some time, observers have attributed U.S. patients’ difficulty in obtaining opioids to pressures on physicians from law enforcement and risk-averse state medical boards. Federal and state drug abuse prevention laws, regulations, and enforcement practices have been considered impediments to effective pain management since 1994, when the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) adopted clinical practice guidelines on cancer pain (Jacox et al., 1994a,b).

Like AHRQ, the American Medical Directors Association (nursing home physicians) and American Geriatrics Society cite delays in access to prescribed opioids for nursing home patients, including those who are terminally ill, and the American Cancer Society has recognized the frequent inaccessibility of opioids necessary for treating some pain. The American Pain Society has developed evidence-based guidelines for controlling cancer pain, including the use of opioids when other treatments fail or when severe pain relief needs must be met immediately (Gordon et al., 2005). Fourteen years ago, the Institute of Medicine Committee on Care at the End of Life called for efforts to reduce regulatory barriers to pain relief at the end of life and termed some regulatory restrictions “outdated and flawed” (IOM, 1997, p. 56).

Certainly in recent years, opioid prescriptions for chronic noncancer pain have increased sharply (Dhalla et al., 2009; Chapman et al., 2010). According to the White House action plan, between 2000 and 2009, the number of opioid prescriptions dispensed by retail pharmacies grew by 48 percent—to 257 million (The White House, 2011). But are patients who really need opioids able to get them? Twenty-nine percent of primary care physicians and 16 percent of pain specialists report they prescribe opioids less often than they think appropriate because of concerns about regulatory repercussions (Breuer et al., 2010). A survey of clinical staff in an inpatient rehabilitation hospital found that while staff held generally progressive attitudes toward the treatment of pain, there was substantial ambivalence about the use of opioids. The authors note that “significant minorities of respondents indicate a belief that chronic morphine use frequently causes sedation or mental cloudiness and that sleep or sedation can be equated with pain relief” (Loder et al., 2003, p. 67).

In the wake of criticism of state medical boards’ actions against physicians who prescribed large amounts of opioids, the Federation of State Medical Boards developed a model policy in 1998—since adopted by many individual state boards—that supports use of opioids for pain management if appropriately documented by the treating physician (Federation of State Medical Boards of the United States, 2004). State medical boards generally are believed to be the best locus for sanctioning physicians for their opioid prescribing patterns, as opposed to criminal prosecution (Reidenberg and Willis, 2007). However, sanctions and prosecutions are rare: between 1998 and 2006, only 0.1 percent of practicing physicians were charged by prosecutors, medical licensing boards, or other administrative agencies with opioid-related prescribing offenses, providing “little objective basis for concern that pain specialists have been ‘singled out’ for prosecution or administrative sanctioning” (Goldenbaum et al., 2008, p. 2).

Effectiveness of Opioids as Pain Relievers

The effectiveness of opioids as pain relievers, especially over the long term, is somewhat unclear:

  • In a meta-analysis of randomized controlled trials involving noncancer pain, researchers concluded that the “relative effectiveness and risk or benefit of opioids compared with other nonopioid drugs are still to be determined” (Furlan et al., 2006, p. 1593).
  • A meta-analysis of 43 studies of short-term opioid use among people over age 60 with chronic noncancer pain found reductions in pain intensity and improvements in physical functioning, but decreases in mental health functioning (Papaleontiou et al., 2010).
  • A meta-analysis of studies involving back pain did not show that opioids reduced pain, but the researchers concluded that these drugs “may be efficacious for short-term pain relief” (Martell et al., 2007, p. 116). They also found that substance use disorders are common in patients taking opioids for back pain, with as many as one-fourth of these patients showing aberrant medication-taking behavior.
  • Opioid use in a veterans’ setting increased among patients aged 18–30 from 3 percent in 2003 to 4.5 percent in 2007. According to the researchers, however, “Our study did not show an improvement in median pain scores following initiation of long-acting opioid therapy, and only one-quarter of patients showed response” (Wu et al., 2010, p. 138).
  • A systematic review of the use of nontramadol opioids in osteoarthritis patients concluded that the drugs should not be used routinely for that condition (Nuesch et al., 2009).

The long-term effects and effectiveness of opioid therapy are far from certain (Noble et al., 2008), and opioid therapy lasting longer than 90 days is characterized by diversity in the prescribed medications, dosages, and frequency of use (Von Korff et al., 2008). Some patients taking opioids on a long-term basis develop greater sensitivity to painful stimuli, a condition known as opioid-induced hyperalgesia (Chu et al., 2008). Changes in the functioning of sex hormones and the immune system also have been caused by long-term opioid use. Further, opioid use has been found to cause changes in gray matter that are not reversed an average of 4.77 months after cessation of use (Younger et al., 2011).

The research findings noted above need to be set against the testimony of people with pain, many of whom derive substantial relief from opioid drugs. This tension perhaps reflects the complex nature of pain as a lived experience, as well as the need for biopsychosocial assessments and treatment strategies that can maximize patients’ comfort and minimize risks to them and society. Regardless, the majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others.

Need for Education

As discussed in Chapter 4, patterns of opioid prescribing may reflect a need for better education of physicians in this area. In 2010, the American Pain Foundation (APF) sponsored a national online survey of 400 board-certified U.S. primary care physicians who “fairly commonly” prescribe opioids and found continued misperceptions about misuse and abuse of opioids (American Pain Foundation, 2010a). More than half of the physicians surveyed (56 percent) believed that few of their patients misuse or abuse their prescriptions, suggesting that almost half believed this might be a problem. However, data from a 2009 survey conducted by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) indicate that some 5 million Americans used pain relievers nonmedically in the month prior to the survey and that these medications generally were the result of a medical prescription (SAMHSA, 2010). The APF’s chief executive officer said of his organization’s study, “These survey results highlight common misunderstandings about these medications, which can be addressed in the health care provider’s office” (American Pain Foundation, 2010b, p. 1).

Abuse of Opioids

Ironically, while many people with pain have difficulty obtaining opioid medications, nonmedical users appear to obtain them far too easily (Arnstein and St. Marie, 2010), so much so that the diversion of opioid analgesics has become a national public health problem (FDA, 2010). Recent data on opioid abuse are disturbing. In the “Monitoring the Future” study of youth drug use and abuse for 2010, 1 in 12 high school seniors reported at least some nonmedical use of the opioid Vicodin and 1 in 20 of OxyContin (Johnston et al., 2011). And in 2007, the number of deaths for all age groups from opioid drug use—14,459—was almost twice the number involving cocaine and more than 5 times the number involving heroin (CDC, 2010b).

The 2009 SAMHSA survey further found that in the previous year, there had been some 2.2 million new users (12 years of age or older) of these drugs for nonmedical purposes. The average age of new users was 21 years. New non medical users (12 or older) of a single prescription opioid—OxyContin— numbered 584,000, up 22 percent in just one year. More than half (55 percent) of nonmedical users of prescription pain relievers obtained the drugs they used most recently “from a friend or relative for free”—that is, they did not buy or steal them. In four of five of these cases, the friend or relative obtained the drugs from just one doctor; that is, the person was not doctor-shopping to obtain multiple prescriptions. Finally, 18 percent of these nonmedical users obtained the drugs they used most recently through a prescription from their own doctor.

In a few states, unscrupulous activities by entities that identify themselves as pain clinics have included distribution of opioid medications in large quantities to drug abusers, many of whom end up as overdose victims (Collins, 2010; Horswell, 2010). Regulators and legislators are attempting to close or revamp these facilities, partly by developing or demanding tougher rules addressing standards of care, inspection, accreditation, and training (Gentry, 2011). Insufficiently regulated sources of opioids also include online distributors.

Opioid medications present some risk of abuse by patients as well. A structured review of 67 studies found that 3 percent of chronic noncancer pain patients regularly taking opioids developed opioid abuse or addiction, while 12 percent developed aberrant drug-related behavior (Fishbain et al., 2008). A recent analysis revealed that half of patients who received a prescription for opioids in 2009 had filled another opioid prescription within the previous 30 days, indicating that they were seeking and obtaining more opioids than prescribed by any single physician (NIH and NIDA, 2011).

In some geographic areas, opioid use is especially prevalent. In Utah in 2008, a Behavioral Risk Factor Surveillance System survey found that one in five adults had been prescribed an opioid during the past year, and 72 percent of these individuals reported having leftover medication, which potentially could be diverted for nonmedical use (CDC, 2010a).

Current voluntary strategies to reduce opioid abuse include

  • the clinician’s assessment in a history and physical exam that includes psychosocial factors, family history, and risk of abuse;
  • the clinician’s regular monitoring of the progress of patients on opioids and assessment for aberrant behavior that may indicate abuse;
  • random urine drug screening and pill counts for patients at risk;
  • state prescription drug monitoring programs (the U.S. Justice Department and other agencies have cooperated in forming an interstate information exchange for such programs);
  • new drug formulations intended to prevent abuse by (1) hindering the extraction of active ingredients through physical barrier mechanisms, (2) releasing agents that neutralize the opioid effects when products are tampered with, and (3) introducing substances that cause unpleasant side effects when drugs are consumed to excess (Fishbain et al., 2010); and
  • removing unused drugs from home medicine cabinets and disposing of them at “drug take-back” events (see Box 2-4 in Chapter 2) (Office of National Drug Control Policy, 2010).

Another control strategy that has gained traction is opioid “contracts” or “treatment agreements” between health care providers and patients, under which medication use by high-risk patients is closely monitored. In a study of a primary care clinic’s use of such contracts, three-fifths of patients adhered to the agreement (with a median follow-up of 23 months) (Hariharan et al., 2006). However, many pain experts have concluded that pain agreements/contracts do not necessarily improve the treatment of pain or minimize diversion and abuse of prescription drugs, particularly when used indiscriminately. A systematic review of the literature found only weak evidence to support either pain contracts or urine tests as a strategy for reducing opioid abuse (Starrels et al., 2010). Thus far at least, few primary care physicians prescribing opioids for chronic noncancer pain appear to be using urine testing or other strategies to reduce the risk of opioid abuse (Starrels et al., 2011). Clearly, this is an area where future research is needed.

Opioid Use and Costs of Care

Opioid use may increase the costs of care. An analysis of Medicaid data found that total costs for patients with opioid abuse or dependence were 68 percent higher than costs for a matched set of control patients (McAdam-Marx et al., 2010). Further, opioid abuse is associated with comorbidities that increase direct medical costs (Ghate et al., 2010). A “conservative estimate” of the cost to society of prescription opioid abuse in the United States is $9.5 billion in 2005 dollars (CDC, 2010b).

Insurance Incentives

The coverage policies of third-party payers can affect the quality and comprehensiveness of care received by people with pain. Payers in fee-for-service systems have a well-documented tendency to reimburse procedures more generously than psychosocial care or other nonprocedural treatments (Bodenheimer et al., 2009). This tendency generally is believed to contribute to the nationwide shortage of primary care physicians; to reduce value and cost-effectiveness in health care overall; and, with respect to pain management, to result in the overuse of some procedures and underuse of evidence-based strategies. Put another way, “Evidence is compelling that Americans receive a substantial amount of care that is inappropriate” (IOM, 2009, p. 89).

On the whole, payers do not encourage interdisciplinary team care, which, as discussed earlier, often is an effective pain management strategy. Further, payers frequently limit reimbursement for or do not cover psychosocial and rehabilitative care, which are essential components of comprehensive care. Some payers, such as state workers’ compensation programs, pay low rates for mental health care, and many insurers place lifetime or other limits on such care. Rehabilitation services also face insurance limits, especially under Medicare. In addition, many CAM therapies that are widely used in pain management often are not covered by health insurance.

These reimbursement limitations threaten the financial viability of comprehensive pain centers, even in hospitals. To illustrate, analysts for the Center for Studying Health System Change demonstrated a distortion in incentives by showing that the Virginia Mason Medical Center (VMMC), an integrated health care system in Seattle, Washington, would lose money by improving low back pain care and reducing costs:

Low back pain posed the most immediate fiscal challenge to VMMC. . . . VMMC believed that care could be improved by evaluating patients more quickly and by convincing physicians not to order MRIs for uncomplicated patients. A spine clinic was created that offered same-day access for an assessment visit. The plan is expected to reduce average commercial reimbursement per episode from $2,290 to $807 . . . with a reduction in margin from a $90 surplus to a $175 loss. (Ginsburg et al., 2007, p. 2)

Similarly, the analysts demonstrated how VMMC would suffer financially for improving the effectiveness and cost-effectiveness of migraine headache care:

Analysis of claims data suggested that expensive drugs prescribed for migraines were often dispensed in quantities that were too large and led to waste. Moreover, patients could avoid emergency department (ED) visits and expensive imaging procedures by having small “rescue” prescriptions on hand to take with onset of a migraine. . . . But ED visits (for insured patients) and MRIs are both profitable, with commercial margins of $180 and $450, respectively. Roughly 5 percent and 7 percent of VMMC members with a migraine diagnosis had ED visits or MRIs, respectively, so reducing these percentages (there is not a specific target) cost the organization positive margins that are used to cross-subsidize other services. (Ginsburg et al., 2007, p. 3)

At the primary care level, too, insurance incentives may inadvertently (albeit directly) discourage effective pain care. Evaluation and management codes, used to calculate payments for primary care visits, typically do not promote extensive one-on-one conversations with patients that can lead to effective, individualized care planning. Under current reimbursement approaches, it may be unreasonable to expect primary care practitioners to devote extensive resources to managing pain in patients simultaneously experiencing multiple health problems, such as diabetes, a history of family violence, and fibromyalgia. One way (among many) to help counter these skewed incentives would be to establish quality-of-care standards incorporating principles of biopsychosocial, interdisciplinary, multimodal pain care or evidence on the clinical effectiveness of different modalities. Currently, the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS), which comprises standards for managed care organizations and certain providers of care, begins to recognize the importance of pain care (NCQA, 2011, p. 8). HEDIS indicators of cost of care include “relative resource use for people with acute low back pain,” and the following HEDIS measures of effectiveness of care involve pain care, at least to some extent:

  • disease-modifying antirheumatoid drug therapy for rheumatoid arthritis;
  • osteoporosis management for women who have had a fracture;
  • avoidance of overuse of imaging studies for low back pain, as such studies have been determined to be appropriate only for patients with severe progressive neurological deficits or signs or symptoms of a serious or specific underlying condition (Chou et al., 2011);
  • some drug-monitoring practices (antidepressant medication management, annual monitoring for patients on persistent medications, medication recon ciliation postdischarge, potentially harmful drug–disease interactions in the elderly, and use of high-risk medications in the elderly); and
  • physical activity in older adults.

The HEDIS process and other mechanisms for monitoring the quality and cost-effectiveness of care provide opportunities for the pain management community. Within participating health care systems and institutional providers, pain management clinicians can work to improve pain care, thereby helping their institution meet the evolving standards of care. In the meantime, pain management experts—including consumers—can encourage monitoring programs to give greater attention to pain care when developing standards.

The Medicare program, too, could reasonably focus attention on pain as a quality-of-care issue. Some unique attributes of pain in the elderly that might be addressed by such quality measures include

  • difficulty using certain pain intensity scales;
  • increased vulnerability to neuropathic pain (but decreased vulnerability to acute pain involving visceral pathology);
  • prolonged recovery from tissue and nerve injury; and
  • differences, compared with younger adults, in relationships among psycho social factors (Gagliese, 2009).

The Reporting of Pain

Unlike the majority of medical complaints, pain is presented to practitioners in venues throughout the health care system and to diverse categories of people outside the system. Members of many groups play a role in pain care, starting from when they first hear about a person’s pain or notice it on their own. Any truly comprehensive program to improve pain care must therefore take into account the wide array of people who may be in a person’s network, providing information and advice that may or may not be constructive.

Of course, a person’s complaint or report is only one sign that pain is a problem; as discussed earlier, loss of functioning and interference with daily life also indicate the presence of pain. Frequently, it is a person’s significant other or another close contact who observes a pain-related change. The response of this observer can be an important determinant of whether timely and effective treatment occurs.

Perhaps most frequently, people report pain to a primary care practitioner (family physician, general internist, general pediatrician, obstetrician-gynecologist, nurse practitioner, or physician assistant) or to a physician specialist (an orthopedist, oncologist, general surgeon, gastroenterologist, rheumatologist, psychiatrist, dermatologist, or other medical or surgical specialist) while being seen for a presumably “underlying” condition suspected of causing the pain. Thus, for example, people with chronic or recurring headaches may consult a neurologist. Depending on the severity of the pain, its site, local access to clinicians, insurance coverage, lifestyle, and pattern of health care use, people also may bring the complaint to one or more of the following:

  • hospital EDs;
  • medical center-based or free-standing ambulatory care clinics;
  • physiatrists (physicians specializing in physical and rehabilitation medicine) or physical therapists;
  • dentists;
  • psychotherapists, including psychiatrists, clinical psychologists, clinical social workers, and psychiatric/mental health nurses;
  • pharmacists;
  • chiropractors;
  • podiatrists;
  • occupational health nurses;
  • school nurses;
  • substance abuse clinics and drug and alcohol counselors; and
  • massage therapists, acupuncturists, and various other CAM practitioners (and vendors).

At acute-care hospitals, inpatients experiencing the onset of pain seek relief from attending physicians, hospitalists, bedside nurses, and pain and palliative care teams. Nursing home residents report their pain to nurses and nursing assistants, physical and occupational therapists, medical directors, and patient activity coordinators.

As noted earlier, the formal health care system is not alone in receiving complaints of acute or persistent pain or noticing pain in others (Thernstrom, 2010). For example:

  • People experiencing pain talk to their families, friends, and colleagues, trading suggestions and lessons learned.
  • Workers mention the problem to their supervisors and colleagues, who may offer a referral or suggest remedies, or may observe the problem on their own.
  • Athletes and people who exercise regularly at a gym consult athletic trainers.
  • Victims of natural disasters and disease outbreaks see physician volunteers, public health nurses, and emergency relief workers.
  • Students bring their problems to teachers, coaches, and resident housing fellows.
  • Active members of congregations seek guidance from clergy and other religious and spiritual advisers.
  • Today, many people seek answers through individual research conducted on the Internet or in libraries or published medical guides kept on house-hold bookshelves.
  • People also pay attention to popular magazines, newspaper columns, television talk shows, and televised medical dramas.

The consuming nature of severe pain leads people down many pathways in search of information, ideas, and of course relief of pain. As a result, suffering individuals are likely to receive conflicting and outdated information and advice that are not applicable to their individual situation, and may also be exposed to myths about pain and its treatment. Wider access to authoritative information about pain would help not only physicians and other health professionals but also many other categories of people respond appropriately to a person’s pain.

As noted in Chapter 2, although many people report pain in various ways, many others do not complain at all even when it would be appropriate for them to do so (Keefe et al., 2005). Cultural factors that may impede the reporting of pain include

  • a belief that pain has a divine purpose and should be endured as an expression of faith;
  • resignation to pain as something that cannot be alleviated;
  • concern that complaining about pain will be regarded as a sign of moral or physical weakness;
  • fear that pain will be regarded as completely psychological and hence not “real”;
  • confidence that pain is a single, limited mechanism that will not disrupt other aspects of health or quality of life;
  • an aversion to drugs—especially medications commonly used to relieve pain that may be addictive—coupled with the belief that these drugs are likely to be prescribed; and
  • among people whose main language is not English, linguistic differences that may confound the description of pain.

The nature of the patient’s relationship with a particular health professional also may impede the reporting of pain because of the patient’s

  • expectation that pain management is outside the professional’s scope of practice;
  • suspicion that the professional is uninterested in pain—a suspicion that may reflect the professional’s time pressures, lack of competence in pain treatment, or biases against or unfamiliarity with certain demographic groups of patients;
  • discomfort in communicating with the professional about sensitive topics or a belief that the professional will respond only to extreme expressions of pain;
  • previous negative experience with clinicians who trivialized pain, a belief that nothing can be done about the pain, or a desire for the professional to concentrate on an underlying disease; or
  • limited communication skills.

BARRIERS TO EFFECTIVE PAIN CARE

A physician told me last week, “We don’t usually prescribe any pain medication for fibromyalgia patients.” My answer: “I’m surprised more of them don’t commit suicide.”

—A person with fibromyalgia10

Based on the discussion in this and other chapters, the committee identified several important barriers to adequate pain care in the United States. These include the magnitude of the problem, provider attitudes and training, insurance coverage, cultural attitudes of patients, geographic barriers, and regulatory barriers.

Magnitude of the Problem

At least 116 million American adults experience pain from common chronic conditions, and additional millions experience short-term acute pain (Chapter 2). Many people could have better outcomes if they received incrementally better care as part of the treatment of the chronic diseases that are causing their pain. A nationwide health system straining to contain costs will be hard pressed to address the problem, however, unless early savings can be clearly demonstrated through reduced health care utilization and disability and fewer dollars wasted on ineffective treatments. The high prevalence of pain suggests that it is not being adequately treated, and undertreatment generates enormous costs to the system and to the nation’s economy (see Chapter 2).

Provider Attitudes and Training

A number of barriers to effective pain care involve the attitudes and training of the providers of care. First, health professionals may hold negative attitudes toward people reporting pain and may regard pain as not worth their serious attention. As discussed in detail in Chapter 2, patients can be at a particular disadvantage if they are members of racial or ethnic minorities, female, children, or infirm elderly. They also may have less access to care if they are perceived as drug seeking or if they have, or are perceived to have, mental health problems. A literature review showed that people with pain, especially women, often have attitudes and goals that are different from, and sometimes opposed to, the attitudes and goals of their practitioners; patients seek to have their pain legitimized, while practitioners focus on diagnosis and therapy (Frantsve and Kerns, 2007). Consumers testified before the committee that patients often believe practitioners trivialize pain, which makes them feel even worse. Researchers working with patient focus groups have noted the “perceived failures of providers to fully respect, trust, and accept the patient, to offer positive feedback and support, and to believe the participants’ reports of the severity and adverse effects of their pain” (Upshur et al., 2010, p. 1793).

Primary care practitioners often experience negative emotions—such as frustration, lack of appreciation, and guilt—in caring for people with pain. For example, even when 71 percent of primary care clinicians affiliated with the Department of Veterans Affairs felt confident of their ability to treat chronic pain, 73 percent said that patients with chronic pain are a major source of frustration (Dobscha et al., 2008). Efforts to improve primary care practitioners’ patient-centered communication skills, including demonstrating empathy and encouraging shared decision making, may help reduce this burden of negative emotions. Improving communication skills also could strike at the root cause of practitioners’ negative emotions by improving the effectiveness of pain treatment (Matthias et al., 2010). But “because physicians are oriented toward achieving cures, a chronic pain patient’s attending physician will sooner or later experience frustration” (Jackson, 2010, p. 37). Clinicians who become frustrated when they cannot “cure” or substantially relieve someone’s pain lose sight of the fact that even limited relief from the burden of pain may enable a person to revive skills, renew social interactions, and meet additional requirements of daily living—in themselves positive contributors to a person’s relief. Modest gains in pain relief that bring a person back toward a more normal life are vital clinical accomplishments.

Second, the profession and culture of medicine generally focus on biological rather than psychosocial causes and effects of illnesses. Medicine traditionally emphasizes mind–body dualism, views pain as a symptom, focuses on disease instead of illness, and has a bias toward cure rather than care—all perspectives that impede use of the biopsychosocial model, discussed earlier in this chapter, that best suits care for severe chronic pain (Crowley-Matoka et al., 2009). Typically, patients are encouraged to describe their experience only briefly and in terms most familiar to physicians, rather than present a narrative that fully explains the impact of pain in their lives (Morris, 2002). In the medical milieu, the cognitive and emotional experience of pain may not be sufficiently recognized.

A third important barrier to pain care is the need for expanded formal training in medical, nursing, and other health professions educational programs, as well as enhanced continuing education. Most people in pain are cared for by primary care physicians who likely received little initial training or experience in best practices in pain management. Even physicians in specialties such as oncology may be unaware of current models of pain care, unable or unwilling to assemble an interdisciplinary team when needed, unsure of how to proceed, and prevented by organizational or reimbursement policies from spending the time necessary to get to the bottom of a particular case. Surgeons do not routinely practice techniques to prevent acute (and potentially chronic) postoperative pain. And preventive approaches are underutilized almost universally. The nation also may have too few pain specialists. In addition, there are inadequate opportunities in the professional education system for interdisciplinary education about pain. Training should address gaps in knowledge; strengthen competencies related to pain assessment and management; and counter negative and ill-informed attitudes about people with pain, stereotyping, and bias. Chapter 4 addresses these and other education issues in detail.

Additionally, although pain is one of the most common reasons people seek treatment, clinicians may not ask about or thoroughly investigate pain. As discussed earlier, in part this is because patients do not raise the issue or downplay it for a variety of reasons, often cultural (Narayan, 2010). If the subject of pain is not raised in the clinical encounter, it surely cannot be adequately addressed. If health care providers do not know how to solicit information about a person’s experience with pain or how to treat pain when described, that is a failure of training; if they do know how to do so and yet do not, that is a failing of a different kind.

Fourth, evidence-based protocols and guidelines exist to assist primary care practitioners in treating people with chronic pain. The American College of Physicians (internal medicine physicians) and American Pain Society have issued a general guideline for treating low back pain (Chou et al., 2007). Guidelines on specific forms of treatment, such as medications for older patients, also are available to primary care practitioners (American Geriatrics Society, 2009). However, such protocols are used only rarely to treat pain in primary care practice. In one study, which used a protocol that classified pain patients by degree of disability, most participating primary care physicians reported increased confidence in treating pain after gaining familiarity with the protocol, but (as with clinical protocols in general) many physicians expressed reluctance to consult this or any other pain algorithm (Jamison et al., 2002).

Although protocols to guide primary care practitioners in providing pain care exist, there appear to be no evidence-based protocols to guide them in facilitating self-management and patient education. Yet as an article geared to family physicians points out with regard to chronic disease in general:

Support of patient self-management is a key component of effective chronic illness care and improved outcomes. Self-management support goes beyond traditional knowledge-based patient education to include processes that develop problem-solving skills, improve self-efficacy, and support application of knowledge in real-life situations that matter to patients. This approach also encompasses system-focused changes in the primary care environment. Family physicians can support self-management by structuring patient-physician interactions to identify problems from the patient perspective, making office environment changes that remove self-management barriers, and providing education individually and through available community self-management resources. (Coleman and Newton, 2005, p. 1503)

Finally, as discussed earlier, interdisciplinary, team approaches can facilitate high-quality pain care. Despite their demonstrated benefits, however, such team approaches are not consistently used in pain care.

In short, current clinical systems are not well designed to deal with severe acute and chronic pain. System and organizational barriers, such as the lack of capacity for frequent visits when necessary and the lack of time to conduct comprehensive assessments and patient education, obstruct individualized care. Much more could be done to educate clinicians, patients, and the public about pain and pain management, but education alone will be ineffective in the absence of systems that permit—or encourage—them to act on that knowledge. Overcoming these barriers will require changes to current reimbursement policies, discussed below.

Insurance Coverage

Costly team care, expensive medications, and procedural interventions—all common types of treatment for pain—are not readily obtained by the 19 percent of Americans under age 65 who lack health insurance coverage (Holahan, 2011) or by the additional 14 percent of under-65 adults who are underinsured (Schoen et al., 2008). Together, these groups make up one-third of the nation’s population. Lack of insurance coverage also may contribute to disparities in care. An inability to pay for pain care is especially prevalent among minorities and women (Green et al., 2011). As discussed above, even for people with insurance coverage, third-party reimbursement systems tend not to cover or to cover well psychosocial services and team approaches that represent the best care for people with the most difficult pain problems. Surmounting this barrier may require coordinated action by advocates for improvement.

Cultural Attitudes of Patients

Myths and stereotypes about chronic pain, people with chronic pain, and the drugs used to combat it are prevalent. Chapter 4 addresses the public and patient education efforts that might reduce some of these attitudinal barriers. Moreover, as discussed earlier, many patients do not report pain to health professionals for various reasons. They may have been rebuffed by clinicians in the past. Perhaps their clinician has tried (albeit unsuccessfully) to address the problem, and they want to be a “good patient” and not report the failure. They may fear the pain signals a serious problem they do not want to acknowledge or confront, or they may not want to distract the clinician from treating an underlying condition (Gunnarsdottir et al., 2002; Narayan, 2010). They may worry that they will be told they need surgery and not want to undergo it. Or they may harbor a tradition of stoicism. The military, for example, long has fostered an attitude of “no pain, no gain,” which has prevented service members from obtaining needed pain care (Office of the Army Surgeon General, 2010); such a culture of stoicism like-wise characterizes certain ethnic groups (Meghani and Houldin, 2007; see also Chapter 2). A 1993 survey of physicians with pain care responsibilities found that 62 percent believed their own patients’ reluctance to report pain was one of the principal barriers to better pain management (Von Roenn et al., 1993). Twenty years later, it is unlikely that this perception has changed significantly.

Geographic Barriers

As noted in Chapter 2, America’s rural areas have shortages of primary care physicians and certainly have few pain care specialists. As a result, military veterans, farm workers, people who are chronically ill, and others living in rural areas are deprived of competent pain management or, like some wounded warriors from the Iraq and Afghanistan wars, must move with their families to an area where they can find suitable care (President’s Commission on Care for America’s Returning Wounded Warriors, 2007).

Regulatory Barriers

As described extensively in the preceding discussion of opioid use, regulatory and enforcement practices can reduce access to opioid analgesics for people with pain. These practices cause some practitioners to fear being unfairly prosecuted for prescribing opioids (Sullivan, 2004) and perhaps to stop prescribing them altogether. One aspect of this problem surfaced in the aftermath of Hurricanes Katrina and Rita in the Gulf Coast in 2005. Then, a lack of adequate electronic networking or efficient information exchange across databases prevented many dislocated hurricane victims from obtaining timely access to their usual and properly prescribed medications. Improved public health emergency planning efforts would allow patients with opioid prescriptions for severe pain (and other patients taking controlled substances as prescribed) who are displaced during a public health emergency to have their prescriptions filled without undue and harmful delays.

MODELS OF PAIN CARE

I fell on the ice at work two years ago, and have three areas needing surgery. . . . [The workers’ compensation system] keeps people in pain longer, it frustrates them, and injuries go untreated, frequently get worse, and become chronic. The system is so worried about fraud, that the victims with real pain and real issues do not get the treatment they need.

—A person with chronic pain11

This section describes the Department of Veterans Affairs and Department of Defense models of pain care, as well as some additional models.

Department of Veterans Affairs

Care of America’s military veterans provides an important large-scale model against which to assess current and future pain care services. Pain is a major issue in the veterans’ system: at least half of all male veterans who obtain primary care through the Department of Veterans Affairs and as many as three-fourths of all women veterans report pain (LaChappelle et al., in press) (see also Chapter 2).

Relatively early, in 1998, the department developed a brief but comprehensive National Pain Management Strategy that called for national coordination and national standards, including use of the fifth vital sign approach described earlier (VHA, 1998). The strategy represented an attempt to develop a comprehensive, multicultural, integrated, and systemwide effort to reduce acute and chronic pain associated with a wide range of injuries, illnesses, and conditions affecting veterans, including terminal conditions, and to improve veterans’ quality of life. Implementation of the strategy succeeded in reducing the prevalence of severe pain, increasing pain care planning, and increasing the distribution to patients of educational materials about pain (Cleeland et al., 2003).

Recently, after determining that large numbers of returning veterans of the Iraq and Afghanistan wars were experiencing persistent pain, the department issued a detailed Pain Management Directive (VHA, 2009). The department’s model has the potential to be far-reaching as a result of the number of Americans the department serves (5 million armed service veterans and 400,000 family members) and the number of facilities it operates (some 153 medical centers, 882 clinics, 136 nursing homes, and 45 residential rehabilitation facilities, as well as numerous other programs throughout the nation) (Congressional Budget Office, 2007). The directive prescribes a stepped approach to pain care such that increasingly aggressive modalities are introduced as milder methods fail to provide relief. The three steps are primary care, specialty care, and accredited pain centers. The model provides for management of most pain conditions in the primary care setting. Primary care practitioners’ efforts are supported by timely access to secondary consultations with specialists in pain medicine, behavioral health, physical medicine and rehabilitation, and palliative care. The approach recognizes that primary care practitioners treating veterans have shown a high level of interest in treating pain but low satisfaction with their ability to provide optimal care, and so are ripe for learning and support mechanisms to improve their ability to treat pain (Dobscha et al., 2008).

Secondary care and pain center, or tertiary, care are reserved for patients whose pain is not managed successfully at the primary care level, is more complex, or involves comorbidities, as well as for patients considered at risk for addiction or suicide, for example. Care at interdisciplinary pain centers includes advanced diagnostic and medical management, rehabilitation services for complex cases involving comorbidities (such as mental health disorders and traumatic brain injuries), and integrated services for patients with both chronic pain and substance use disorders.

The model further encompasses

  • treatment goals, education of practitioners, clinical protocols, and system-wide referrals;
  • system wide data collection, including questions on pain in veteran satisfaction surveys;
  • quality improvement, with increasing reliance on the department’s well-regarded electronic health record;
  • external evaluation, including reports of the department’s Health Analysis and Information Group;
  • health services research on such topics as geographic disparities and outcomes of care; and
  • use of “patient-aligned care teams,” usually including a nurse who coordinates services, to ensure that pain care is provided as part of the continuity of care. Teams also include practitioners in behavioral health and other specialty services.

Top-down and bottom-up elements both are included in the department’s approach. Top-down elements include systemwide action by the central administration to set standards of care and monitor performance. These top-down elements reflect the organization of veterans’ health as a closed system, so that referrals and practice—including adherence to stepped-care principles—can be guided by agency policy, an approach that is far more difficult to accomplish elsewhere in the pluralistic U.S. health care system. Bottom-up elements include action taken at the local level. There, champions are recruited; pain committees are formed; and these groups work together across the system as a community of practice in a network of frequent, rapid, and informal communication.

Department of Defense

A second, related model of care is provided by the Department of Defense, particularly the Army. In May 2010, an Army task force released, and vigorously publicized, a report containing more than 100 recommendations on pain management in the areas of tools, best practices, a focus on the patient and family, and a culture of awareness. The recommendations are intended to

. . . lead to a comprehensive pain management strategy that is holistic, interdisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain. . . . The recommendations rely heavily on an education and communication plan that crosses [Department of Defense and Veterans Health Administration] medical staff and patients. (Office of the Army Surgeon General, 2010)

To overcome the stigma that acknowledging one’s pain reflects “weakness of character,” the Army is emphasizing soldiers’ duty to obtain treatment for pain in order to remain sufficiently fit to accomplish their assigned mission. The Navy, too, is endeavoring to coordinate pain management efforts with the Department of Veterans Affairs’ stepped-care approach.

Other Models

The field of quality improvement (QI) provides another model for efforts to make pain care more effective. In health care, QI is a commitment by a provider or group of providers to improve the quality of care consistently, in measurable ways (IOM, 2007b). QI usually involves substantial effort to collect and analyze data in order to identify problems, monitor trends, and find ways to improve performance. For example, one QI approach is the “plan, do, study, act” cycle, promoted by the Institute for Healthcare Improvement.

St. Jude’s Children’s Research Hospital provides a model of the use of QI to improve pain care. After initially developing an institutional “pain standard of care,” St. Jude’s undertook a systematic evaluation of its performance in assessing and reducing pain intensity levels over 6 years (Oakes et al., 2008). The QI effort revealed patterns of success as well as continuing challenges. The researchers concluded (p. 667):

. . . no single strategy is likely to offer optimal pain management. Quality pain management requires an interdisciplinary approach combining the talents and dedication of every member of the health care team.

Additional models of care are offered by the American Pain Society’s Clinical Centers of Excellence Awards Program, which selects several pain management centers each year for recognition (American Pain Society, 2011). The Brigham and Women’s Pain Management Center in Boston won awards in both 2007 and 2011. The center serves 19,000 patients annually, providing expanded psychological, social work, and pharmacy services. It also has initiated palliative care and pelvic pain programs and conducts extensive research. The other 2011 award recipients were

  • Comprehensive Pain Center of Sarasota, Florida, a free-standing entity that provides multimodal, evidence-based services in a state where, the center’s staff emphasizes, eight people die each day from prescription drug abuse;
  • Jane B. Pettit Pain and Palliative Care Center, affiliated with Children’s Hospital of Wisconsin in Milwaukee, which integrates medical and mental health services, is dedicated to quality improvement, and maintains a sickle-cell clinic;
  • Rehabilitation Institute of Washington, in Seattle, which transitioned from an academic medical center to a free-standing facility that specializes in interdisciplinary cognitive-behavioral rehabilitation for injured workers and low back pain disability and provides language interpretive services for non-English speakers; and
  • University of New Mexico Project ECHO Pain Clinic in Albuquerque, which serves people with complex pain who are drawn from vulnerable urban and rural underserved populations.

CONCLUSION

Because people’s experience with pain touches the entire health care system and many aspects of American life, the committee believes it is an important public health and health care issue, but it is not yet an issue that our society is handling well. Multiple factors compromise the ability to provide high-quality treatment to people with pain, as this chapter has demonstrated. The diversity and importance of these factors suggest that, as discussed in Chapter 1, only a cultural transformation could substantially increase the accessibility and quality of pain care and thereby provide relief to many more Americans who need it.

FINDINGS AND RECOMMENDATIONS

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. Improving pain care will improve the effectiveness and cost-effectiveness of care and generate large savings by reducing the need for the most expensive types of treatments; reducing costly comorbidities, recognizing that patients with pain generate very large health care costs in general; avoiding costly public-sector disability payments; increasing the productivity of patients and families; and avoiding the negative effects of opioid misuse.
  • 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. Ways these organizations could work together include

  • joint meetings;
  • pain-related workshops and other educational opportunities sponsored by pain organizations at primary care national meetings, and awards and other forms of recognition to highlight exemplary models for how primary care clinicians and pain specialists can work together;
  • discussions among health professions associations and public and private payers to facilitate such consultations; and
  • clinical protocols for consultations between primary care clinicians and pain specialists, incorporating evidence-based practices. With support from specialists in creating an appropriate plan of treatment, the primary care team will be better informed about and willing to manage the patient’s pain care.

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. Medicare, Medicaid, workers’ compensation programs, and private insurers should

  • Create incentives to support and adequately reimburse primary care providers’ delivery of integrated, interdisciplinary pain assessment and treatment, as well as advanced specialty care for people with complex pain. The committee encourages demonstration projects of the Centers for Medicare and Medicaid Services to foster models of this kind of patient-centered pain management.
  • Recognize that patients with severe pain may require more frequent visits, as well as extended visits to allow for comprehensive assessment, treatment planning, and patient education. Reimbursement also should cover the physician’s time and effort for coordinating pain care outside of the face-to-face patient visit.
  • Consult with pain specialty organizations on ways to ensure that payment incentives are designed to encourage evidence-based best practices in the assessment and treatment of pain.
  • Create a database of providers for referrals.
  • Develop comprehensive pain management and research centers to promote interdisciplinary research that directly translates discoveries into effective clinical therapies.

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.

  • Pain assessment should focus on soliciting a careful history of the pain experience, the impact of pain on functioning and quality of life and emotional suffering, and the patient’s goals and values.
  • Pain assessment should be multifaceted and include self-report, observations by significant others, and careful examination by the health care provider.
  • In recognition of the prevalence and complexity of chronic pain and the fact that in some cases it is a disease entity in its own right, a specific disease category should be developed that would enable clinicians and researchers to better document and analyze this condition. Therefore, the World Health Organization should create a chronic pain category in the International Classification of Diseases, Tenth Edition.

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Footnotes

1

Quotation from response to committee survey.

2

Quotation from submission by Peter Reineke of stories from the membership of patient advocacy groups.

3

Quotation from response to committee survey.

4

Personal communication, J. Madans, Associate Director, Science, National Center for Health Statistics, Centers for Disease Control and Prevention, February 8, 2011.

5

The National Ambulatory Medical Care Survey is a national survey of nonfederal office-based physicians engaged primarily in direct patient care. It has been conducted continuously since 1989. Physician offices record data for a systematic random sample of patient visits, including symptoms, diagnoses, and medications ordered. See http://www​.cdc.gov/nchs/ahcd.htm.

6

The National Hospital Ambulatory Medical Care Survey collects data on the utilization and provision of services in nonfederal, short-stay hospital EDs (and other sites). ED staff complete patient record forms for a systematic random sample of patient visits, including reasons for the visit, diagnoses, and medications. See http://www​.cdc.gov/nchs/ahcd.htm.

7

Consensus standards have been developed for identifying core outcome domains for pediatric pain studies because children have different ways of expressing pain intensity or experiencing changes in functioning (McGrath et al., 2008).

8

Quotation from submission by Peter Reineke of stories from the membership of patient advocacy groups.

9

Quotation from response to committee survey.

10

Quotation from response to the committee survey.

11

Quotation from response to the committee survey.

Copyright © 2011, National Academy of Sciences.
Bookshelf ID: NBK92517

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