Pain in the United States A Review of Our Country’s Experience with Pain Sean Mackey, MD, PhD More than 100 million Americans suffer from chronic pain, a condition that costs between $560 and $635 billion dollars per year in medical expenses and lost productivity, according to the recently
released report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, from the Institute of Medicine (IOM) of the National Academies. The IOM’s involvement in examining pain as a public health problem was mandated by the U.S. Congress’ 2010 Patient Protection and Affordable Care Act, which required the Department of Health and Human Services (HHS) to enlist the IOM’s help. HHS charged the IOM with assessing the state of the science regarding pain and recommending how to advance the field. HHS directed the IOM to carry out five specific goals and be guided by seven underlying principles.
• Review and quantify the public health significance of pain. • Identify barriers to appropriate pain care and strategies to reduce such barriers. • Identify demographic groups and special populations; discuss related research needs, barriers to completing needed research, and opportunities to reduce such barriers. • Identify and discuss what scientific tools and technologies are available. • Discuss opportunities for public-private partnerships in the support and conduct of pain research, care, and education.
• Pain management is a moral imperative; pain needs to be better assessed and treated using interdisciplinary and comprehensive approaches. • Although pain is often a symptom of a disease, when pain becomes chronic, it can become a disease in itself. • Large amounts of existing knowledge about effective pain treatment need to be better disseminated. • Pain is better prevented than treated; more resources should be directed at effectively preventing chronic pain. • Use of opioids is a conundrum; their benefits and potential adverse effects need to be balanced. • Collaboration between patients and clinicians needs improvement. • Public health- and community-based approaches to pain care are of great value. • In response to the mandate, the IOM formed a nineteenmember committee whose overriding conclusion is that effectively treating pain is a moral imperative. The committee’s report presents a detailed blueprint for improving the state 26 27
San Francisco Medicine April 2012
of pain care, education, and research in the U.S. and beyond to the global community. Members of the committee represented multiple fields of medicine, ethics, epidemiology, psychology, and public health. The committee used varied methods to obtain and process information, including reviewing literature and conducting public workshops intended to obtain key stakeholders’ perspectives. In these workshops the committee discussed numerous important topics: data collection; public–private partnerships; cultural views of pain; financing and resources for pain care; basic science of pain and approaches to pain treatment; regulation of pain drugs; and personal testimony from people living with pain, their caregivers, and other stakeholders. Via a website, the IOM sought public input and read more than 2,000 responses. Realizing better data about pain’s economic burden was needed, the committee commissioned a research paper to better assess this burden.
In addition to specifying the quantity of American pain sufferers and the huge direct and indirect medical cost, the report made clear that pain is a uniquely individual and subjective experience—one not often directly related to the amount of nociception or injury observed.
Due to the complexity of chronic pain and the challenges in treating it, the committee agreed that a comprehensive and interdisciplinary (e.g., biopsychosocial) approach is the most important and effective one to pursue. Unfortunately, such care is difficult to obtain because of structural barriers, including financial and payment disparities. To address the complexities of this national health care crisis, the IOM committee called for a cultural transformation as to how government agencies, private foundations, health care associations and payors, health care professionals, patients, and the public prevent, assess, treat, and understand pain. Accordingly, the committee’s report outlined sixteen recommendations grouped under four key areas—public health challenges, pain care, education of providers, and research—and specified a blueprint for accomplishing the four recommendations listed below by the end of 2012. The HHS Secretary should create a comprehensive, population-level strategy for pain prevention, treatment, management, and research. This strategy should contain the following elements: www.sfms.org