Major changes needed to end inadequate pain management for millions, say Stanford authors of IOM study

- By Krista Conger

Philip Pizzo

Philip Pizzo

More than 100 million American suffer chronic pain, and the condition costs the United States around $600 billion each year in medical expenses and lost productivity, according to a report released today by the National Academies’ Institute of Medicine. The report concludes that the effective treatment of pain demands a cultural transformation on the part of patients, physicians and researchers.

“This is a challenge that is affecting our nation, with a significant number of people affected and with a great economic toll,” said the dean of the Stanford School of Medicine, Philip Pizzo, MD, who chaired the Committee on Advancing Pain Research, Care and Education, which prepared the report, at a news conference this morning in Washington, D.C. “Most importantly, it is something affecting individuals at a deeply personal level. We feel that there is a moral imperative that we seek to do something about this problem as it relates to America.”

Another committee member, Sean Mackey, MD, PhD, chief of Stanford’s division of pain management, added: “We need to change the way we approach and treat patients with pain,” said “Chronic pain is a disease that affects more people than heart disease, diabetes and cancer combined, and yet we spend only a small portion of the budget of the National Institutes of Health on understanding its cause or how to treat it. Our hope is that this report will serve as a wake-up call to our country.”

The 19-member committee included physicians from several medical specialties, researchers, educators and patients. They met for over a year to conduct the study, which was mandated by Congress and sponsored by the NIH. The report outlined “short-term” goals, which should begin immediately and be fully implemented by the end of 2012, and “enduring” goals, which should be implemented by the end of 2015.

According to the report, “Pain is a major reason for visits to physicians, a major reason for taking medications, a major cause of disability and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars and social consequences, action to relieve pain should be undertaken as a national priority.”

“It is clear that pain is a major public health problem in America,” said Pizzo, in a news release from the IOM. Pizzo is also the Carl and Elizabeth Naumann Professor of Pediatrics and a professor of microbiology and immunology. “All too often, the prevention and treatment of pain are delayed, inaccessible or inadequate. Patients, health-care providers and our society need to overcome misperceptions and biases about pain,” he added.

The report states that a critical short-term goal will be to develop a nationally coordinated approach to prevent, treat and manage pain, to increase research efforts to understand the biology of acute and chronic pain and to find ways to reduce or eliminate disparities in pain care. Other, short-term goals include naming one of the existing National Institutes of Health to take the lead in pain research, and to find ways to encourage collaboration between primary care physicians, pain specialists and centers such as Stanford’s Pain Management Center.

The report covers both acute and chronic pain, though chronic pain is less well understood and can be very difficult to treat. It can be the result of an ongoing condition such as cancer or diabetes, or it can occur when the acute pain of an injury or surgery fails to resolve. In some cases, the pain persists despite the lack of an obvious physical cause. In addition, the experience of pain is subjective; how people respond to pain can be affected by their genetic and psychological background and their previous pain experiences. 

Sean Mackey

“Although pain can be a symptom of another condition, it can also be a disease in its own right,” said Mackey, who is also an associate professor of anesthesia at the Stanford University School of Medicine.

“It can continue and even be amplified in the absence of obvious injury. Differences in how patients experience pain, coupled with resulting changes in the nervous system, can lead to extensive suffering. And yet physicians and even patients want to associate the amount of pain with the degree of injury.”

As a result, much pain is often poorly managed and can lead to multiple physician appointments, lost work hours and disability claims as the patient struggles in a health-care system in which pain medicine is rarely taught and the perception of pain can be entangled with cultural bias against showing weakness.

The report also specifies long-term, or “enduring,” goals, to be implemented by the end of 2015. These include, among other things, to promote the self-management of pain by patients; to provide educational opportunities for physicians (particularly those in primary care) to learn about how to treat and manage their patients’ pain and for medical students to specialize in pain; to revise reimbursement policies of public and private insurance companies to encourage coordinated pain care; and to encourage interdisciplinary pain research and the development of new agents for pain control.

“As a physician who cares for patients with acute and chronic pain, and as someone who is very interested in the educational mission, I fervently hope that this report makes an impact,” said Mackey. “We need to look very critically at how we currently assess, research, treat and educate the public and physicians about pain. And then we need to do it better.”

“Some of the barriers are related to social perception,” said Pizzo. “It’s not in your head, is a message that we want to convey. There is a need for cultural transformation to overcome some of these social and societal barriers, including the way that reimbursements work. There is an incredible need for new knowledge and understanding about pain. Our hope is that this report will lead to action.” 

“There is a need for we as a nation, and we as a community, to recognize the dynamics of pain,” Pizzo said, explaining that pain is not something that a patient “should be blamed for or viewed that they made up.”

 “This is not someone who is seeking attention, but someone who is suffering,” Pizzo added, pointing out, “All too often when there is an absence of knowledge, there is a culture of blame.” 

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