Relieving pain in America

CHARGE TO THE COMMITTEE AND STUDY APPROACH Section 4305 of the 2010 Patient Protection and Affordable Care Act required the Secretary, Department of Health and Human Services (HHS), to enter into an agreement with the IOM for activities “to increase the recognition of pain as a significant public health problem in the United States.” Accordingly, HHS, through the National Institutes of Health (NIH), requested that the IOM conduct a study to assess the state of the science regarding pain research, care, and education and to make recommendations to advance the field (see Chapter 1 for the committee’s statement of task). This report responds to the committee’s charge by providing a blueprint for transforming the way pain is understood, assessed, treated, and prevented. It provides recommendations for improving the care of people who experience pain, the training of clinicians who treat them, and the collection of data on pain in the United States. The report does not provide an exhaustive review of the literature examining the science of pain and its diagnosis and treatment. Nor does the report present a clinical algorithm for the diagnosis and treatment of patients with pain. Rather, it describes the scope of the problem of pain and provides an overview of needs for care, education, and research. The committee’s recommendations are based on both scientific evidence and expert judgment. Several important underlying principles informed the committee’s approach to its charge. These principles are presented in Box S-1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research SUMMARY 3 Copyright © National Academy of Sciences. All rights reserved. BOX S-1 Underlying Principles s ! MORAL IMPERATIVE. Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions. s #HRONIC PAIN CAN BE A DISEASE IN ITSELF. Chronic pain has a distinct pathology, causing changes throughout the nervous system that often worsen over time. It has significant psychological and cognitive correlates and can constitute a serious, separate disease entity. s 6ALUE OF COMPREHENSIVE TREATMENT. Pain results from a combination of biological, psychological, and social factors and often requires comprehensive approaches to prevention and management. s .EED FOR INTERDISCIPLINARY APPROACHES. Given chronic pain’s diverse effects, interdisciplinary assessment and treatment may produce the best results for people with the most severe and persistent pain problems. s )MPORTANCE OF PREVENTION Chronic pain has such severe impacts on all aspects of the lives of its sufferers that every effort should be made to achieve both primary prevention (e.g., in surgery for a broken hip) and secondary prevention (of the transition from the acute to the chronic state) through early intervention. s 7IDER USE OF EXISTING KNOWLEDGE While there is much more to be learned about pain and its treatment, even existing knowledge is not always used effectively, and thus substantial numbers of people suffer unnecessarily. s 4HE CONUNDRUM OF OPIOIDS The committee recognizes the serious problem of diversion and abuse of opioid drugs, as well as questions about their longterm usefulness. However, the committee believes that when opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, postoperative, and procedural pain, as well as for patients near the end of life who desire more pain relief. s 2OLES FOR PATIENTS AND CLINICIANS The effectiveness of pain treatments depends greatly on the strength of the clinician–patient relationship; pain treatment is never about the clinician’s intervention alone, but about the clinician and patient (and family) working together. s 6ALUE OF A PUBLIC HEALTH AND COMMUNITY BASED APPROACH. Many features of the problem of pain lend themselves to public health approaches—concern about the large number of people affected, disparities in occurrence and treatment, and the goal of prevention cited above. Public health education can help counter the myths, misunderstandings, stereotypes, and stigma that hinder better care. THE NEED FOR A CULTURAL TRANSFORMATION IN THE WAY PAIN IS VIEWED AND TREATED Pain serves a vital function as a warning sign of injury or infection, but once its warning role is over, continued pain is maladaptive. Chronic pain results in many changes in the peripheral and central nervous systems that aid in its persistence. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research 4 RELIEVING PAIN IN AMERICA Copyright © National Academy of Sciences. All rights reserved. Because of those physiological changes, some types of chronic pain are diseases in their own right. All people are at risk of chronic pain. It can come about with age (e.g., arthritis), from genetic predisposition (e.g., migraine), as a component of another chronic disease (e.g., cancer, heart disease), as a result of surgery (e.g., severed nerves), or following an injury (e.g., low back pain, neck pain). Pain is a uniquely individual, subjective experience. Why one person suffers an injury and reports modest pain and another with a similar injury reports serious pain depends on many factors: genetic characteristics, general health status and comorbidities, pain experiences from childhood on, the brain’s processing system, the emotional and cognitive context in which pain occurs, and cultural and social factors. Because pain often produces psychological and cognitive effects— anxiety, depression, and anger among them—interdisciplinary, biopsychosocial approaches are the most promising for treating patients with persistent pain. But for most patients (and clinicians), such care is a difficult-to-attain ideal, impeded by numerous structural barriers—institutional, educational, organizational, and reimbursement-related. Costly procedures often are performed when other actions should be considered, such as prevention, counseling, and facilitation of self-care, which are common features of successful treatment. In addition, adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and societal stigma consciously or unconsciously applied to people reporting pain, particularly when they do not respond readily to treatment. In the committee’s view, remediating the mismatch between current knowledge and its application will require a cultural transformation in the way clinicians and the public view pain and its treatment. Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it. It also means that health professions education programs should include a substantial amount of learning about pain and its diversity, and that people with chronic pain should be recognized by family, employers, health insurers, and others as having a serious condition. It means that people with chronic pain have an important role to play in managing their disease in an informed, productive way. And finally, it means that the biomedical research community should pursue pain research with the same vigor expended on other serious and disabling chronic conditions. FINDINGS AND RECOMMENDATIONS The findings and recommendations presented in this report revolve around a single conclusion: Chronic pain alone affects the lives of approximately 100 million Americans, making its control of enormous value to individuals and society. To reduce the impact of pain and the resultant suffering will require a transformation in how pain is perceived and judged both by people with pain and by the health care pro Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research SUMMARY 5 Copyright © National Academy of Sciences. All rights reserved. viders who help care for them. The overarching goal of this transformation should be gaining a better understanding of pain of all types and improving efforts to prevent, assess, and treat pain. The committee’s recommendations and the findings that support them fall into four areas that serve to structure the main chapters of the report: pain as a public health challenge, care of people with pain, education challenges, and research challenges.3