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Summary1
Acute and chronic pain affects large numbers of Americans, with ap-
proximately 100 million2 U.S. adults burdened by chronic pain alone. The
annual national economic cost associated with chronic pain is estimated
to be $560-635 billion. Pain is a uniquely individual and subjective expe-
rience that depends on a variety of biological, psychological, and social
factors, and different population groups experience pain differentially. For
many patients, treatment of pain is inadequate not just because of uncertain
diagnoses and societal stigma, but also because of shortcomings in the
availability of effective treatments and inadequate patient and clinician
knowledge about the best ways to manage pain. Some answers will come
from exciting new research opportunities, but changes in the care system
also will be needed in order for patients’ pain journeys to be shorter and
more successful. In the committee’s view, addressing the nation’s enormous
burden of pain will require a cultural transformation in the way pain is
understood, assessed, and treated. This report provides recommendations
intended to help achieve this transformation.
1This summary does not include references. Citations for the discussion presented in the summary
appear in the subsequent report chapters.
2 Because of a computational error, the initial publication of the report Relieving Pain in America
contained an erroneous estimate of the number of adults who experience chronic pain in the United
States. A re-analysis of the study by Tsang and colleagues (2008), as well as the independent assess -
ment by Gaskins and Richards (Appendix C), yield an estimate of approximately 100 million U.S.
adults who experience chronic pain and not 116 million as stated in the original report. The text of
the report has been revised to show this corrected estimate.
1
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2 RELIEVING PAIN IN AMERICA
Pain is a universal experience. Common chronic pain conditions affect ap-
proximately 100 million U.S. adults at a cost of $560-635 billion annually in
direct medical treatment costs and lost productivity. Pain’s occurrence, severity,
duration, response to treatment, and disabling consequences vary from person to
person because pain, like other severe chronic conditions, is much more than a
biological phenomenon and has profound emotional and cognitive effects. Pain
can be mild and easily handled with over-the-counter medications; it can be acute
and recede with treatment; it can be recurrent over months or years; or it can be
chronic and debilitating, requiring almost constant attention and accommodation.
Many shortfalls in pain assessment and treatment persist despite humanity’s
intimate familiarity with pain throughout history, modern appreciation for the
complexity of its origins and the diversity of its effects, and the not insubstantial
risk that any one person may have serious or chronic pain at some point. In gen -
eral, these shortfalls arise through gaps in policy, treatment, attitudes, education,
and research. Why and how these gaps might be remedied was the focus of the
Institute of Medicine’s (IOM’s) Committee on Advancing Pain Research, Care,
and Education.
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 edu -
cation 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.
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3
SUMMARY
BOX S-1
Underlying Principles
• moral imperative. Effective pain management is a moral imperative, a
A
professional responsibility, and the duty of people in the healing professions.
• hronic pain can be a disease in itself. Chronic pain has a distinct pathology,
C
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.
• alue of comprehensive treatment. Pain results from a combination of bio-
V
logical, psychological, and social factors and often requires comprehensive
approaches to prevention and management.
• eed for interdisciplinary approaches. Given chronic pain’s diverse effects,
N
interdisciplinary assessment and treatment may produce the best results for
people with the most severe and persistent pain problems.
• mportance of prevention. Chronic pain has such severe impacts on all
I
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.
• ider use of existing knowledge. While there is much more to be learned
W
about pain and its treatment, even existing knowledge is not always used
effectively, and thus substantial numbers of people suffer unnecessarily.
• he conundrum of opioids. The committee recognizes the serious problem
T
of diversion and abuse of opioid drugs, as well as questions about their long-
term 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.
• oles for patients and clinicians. The effectiveness of pain treatments de-
R
pends greatly on the strength of the clinician–patient relationship; pain treat-
ment is never about the clinician’s intervention alone, but about the clinician
and patient (and family) working together.
• alue of a public health and community-based approach. Many features
V
of the problem of pain lend themselves to public health approaches—concern
about the large number of people affected, disparities in occurrence and treat-
ment, 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 per-
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4 RELIEVING PAIN IN AMERICA
sistence. 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 ap-
proaches 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 knowl-
edge 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
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5
SUMMARY
pain is perceived and judged both by people with pain and by the health care
providers who help care for them. The overarching goal of this transformation
should be gaining a better understanding of pain of all types and improving ef -
forts 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
Pain as a Public Health Challenge
Pain affects millions of Americans; contributes greatly to national rates of
morbidity, mortality, and disability; and is rising in prevalence. Substantial dis -
parities exist in the prevalence, seriousness, and adequate treatment of pain that
affect the vulnerable populations of traditional public health concern. Pain exacts
enormous costs both economically and in the toll it takes on people’s lives. Analy-
sis performed for the committee revealed that the annual economic cost of chronic
pain in the United States is at least4 $560-635 billion. This estimate combines the
incremental cost of health care ($261-300 billion) and the cost of lost productivity
($297-336 billion) attributable to pain. The federal Medicare program bears fully
one-fourth of U.S. medical expenditures for pain; in 2008, this amounted to at
least $65.3 billion, or 14 percent of all Medicare costs. In total, federal and state
programs—including Medicare, Medicaid, the Department of Veterans Affairs,
TRICARE, workers’ compensation, and others—paid out $99 billion in 2008 in
medical expenditures attributable to pain. Lost tax revenues due to productivity
losses compound that expense.
Finding 2-1. Pain is a public health problem. Pain is a significant public health
problem. Chronic pain alone affects approximately 100 million U.S. adults.
Pain reduces quality of life, affects specific population groups disparately, costs
society at least $560-635 billion annually (an amount equal to about $2,000 for
everyone living in the United States), and can be appropriately addressed through
population health-level interventions.
3 The findings and recommendations are numbered according to the chapter of the report in which
they appear. Thus, for example, recommendation 2-1 is the first recommendation in Chapter 2. Note
that some of the findings and recommendations are presented here in abbreviated form. The full ver-
sions are included in the respective chapters.
4 The $560-635 billion range is a conservative estimate because it excludes the cost of pain affecting
institutionalized individuals (including nursing home residents and corrections inmates), military
personnel, children under age 18, and personal caregivers (such as spouses who miss work while
caring for people with pain), as well as the lost productivity of workers younger than 24 and older
than 65. The estimate also excludes the emotional cost of pain.
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6 RELIEVING PAIN IN AMERICA
Finding 2-2. More consistent data on pain are needed. While it is known
that pain affects millions of Americans, the committee acknowledges the lack
of consistent data with which to describe the nature and extent of the problem
or to identify subpopulations that will benefit most from future interventions.
Improvements in state and national data are needed to (1) monitor changes in the
incidence and prevalence of acute and chronic pain; (2) document rates of treat -
ment or undertreatment of pain; (3) assess the health and societal consequences
of pain; and (4) evaluate the impact of related changes in public policy, pay -
ment, and care. Pain data need to be based on standardized questions, preferably
using existing international standards, to facilitate comparisons over time and
across populations. These data would be useful for a wide range of stakeholders,
including policy makers, health care providers, health professions educators,
professional licensing authorities, pain advocacy and awareness organizations,
and researchers.
Recommendation 2-1. Improve the collection and reporting of data
on pain. The National Center for Health Statistics, the Agency for Health-
care Research and Quality, other federal and state agencies, and private
organizations should improve and accelerate the collection and reporting
of data on pain. Data should be collected in the following domains:
• t
he incidence and prevalence of pain;
• i
nterference with activities of daily living and work, as well as dis-
ability, related to pain;
• u
tilization of clinical and social services as a result of pain;
• c
osts of pain and pain care, including indirect costs of lost employ-
ment and public- and private-sector costs for disability payments;
and
• t
he effectiveness of treatment in reducing pain and pain-related
disability, determined through research on the comparative effec-
tiveness of alternative treatments (including in different patient
populations), to identify people most likely to benefit (or not) from
specific treatment approaches.
Standardized questions, fields, and protocols for surveys and electronic
health records should be developed, and pain-related data should be col-
lected at regular intervals.
Finding 2-3. A population-based strategy for reducing pain and its conse -
quences is needed. The committee finds that, to effect changes that will reach
the millions of American adults living with pain, account for differences in the
experience of pain among population groups, and address selected environmental
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7
SUMMARY
factors that contribute to the consequences of pain, a population health-level
strategy is needed.
Recommendation 2-2. Create a comprehensive population health-
level strategy for pain prevention, treatment, management, and
research. The Secretary of the Department of Health and Human Ser-
vices should develop a comprehensive, population health-level strategy
for pain prevention, treatment, management, education, reimbursement,
and research that includes specific goals, actions, time frames, and re -
sources. This strategy should
• D
escribe how efforts across government agencies, including public–
private partnerships, can be established, coordinated, and integrated
to encourage population-focused research, education, communica -
tion, and community-wide approaches that can help reduce pain and
its consequences and remediate disparities in the experience of pain
among subgroups of Americans.
• I
nclude an agenda for developing physiological, clinical, behav-
ioral, psychological, outcomes, and health services research and
appropriate links across these domains (consistent with Recom -
mendations 5-1 through 5-4).
• I
mprove pain assessment and management programs within the
service delivery and financing programs of the federal government.
• P
roceed in cooperation with the Interagency Pain Research Coordi-
nating Committee and the National Institutes of Health’s Pain Con -
sortium and reach out to private-sector participants as appropriate.
• I
nvolve the relevant federal agencies and departments (National
Institutes of Health, Centers for Disease Control and Prevention,
Food and Drug Administration, Centers for Medicare and Medi-
caid Services, Agency for Healthcare Research and Quality, Health
Resources and Services Administration, Indian Health Service, De -
partment of Defense, and Department of Veterans Affairs); private-
sector entities (pain advocacy and awareness organizations; health
professions associations; health care providers; health professions
educators; private insurers; and accreditation, certification, and ex -
amination organizations); and state-level entities.
• I
nclude ongoing efforts to enhance public awareness about the ature
n
of chronic pain and the role of self-care in its management.
The development of this strategy should be completed by the end of 2012.
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8 RELIEVING PAIN IN AMERICA
Care of People with Pain
Currently, large numbers of Americans receive inadequate pain prevention,
assessment, and treatment, in part because of financial incentives that work
against the provision of the best, most individualized care; unrealistic patient
expectations; and a lack of valid and objective pain assessment measures. Clini-
cians’ role in chronic pain care is often a matter of guiding, coaching, and assist-
ing patients with day-to-day self-management, but many health professionals lack
training in how to perform this support role, and there is little reimbursement
for their doing so. Primary care is often the first stop for patients with pain, but
primary care is organized in ways that rarely allow clinicians time to perform
comprehensive patient assessments. Sometimes patients turn to, or are referred to,
pain specialists or pain clinics, although both of these are few in number. Unfortu-
nately, patients often are not told, or do not understand, that their journey to find
the best combination of treatments for them may be long and full of uncertainty.
Finding 3-1. Pain care must be tailored to each person’s experience. Pain
management takes place through self-management, primary care, specialty care,
and pain centers. However, the majority of care and management should take
place through self-management and primary care, with specialty services being
focused on recalcitrant or more complex cases. Accordingly, individualization
of pain management is necessary throughout the health care system. Health care
providers need to foster pain care that is patient-centered and, when necessary,
comprehensive and interdisciplinary. Financing, referral, records management,
and other systems need to support this flexibility.
Recommendation 3-1. Promote and enable self-management of pain.
Health care provider organizations should take the lead in developing
educational approaches and materials for people with pain and their
families that promote and enable self-management. These materials
should include information about the nature of pain; ways to use self-
help strategies to prevent, cope with, and reduce pain; and the benefits,
risks, and costs of various pain management options. Approaches and
materials should be culturally and linguistically appropriate and avail -
able 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.
• E
nhanced 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
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SUMMARY
and ill-informed attitudes about people with pain, and stereotyping and
biases that contribute to disparities in pain care.
• O
ther 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 com -
munities at a disadvantage.
• S
ystem and organizational barriers, many of them driven by current re-
imbursement policies, obstruct patient-centered care. Examples of these
barriers are minimal capacity for frequent visits when necessary; lim-
ited 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 prac-
tice, psychosocial and rehabilitative services, in-depth patient interviews
and education, and time spent planning and coordinating care.
• A
comprehensive, strategic approach can succeed in addressing these
barriers and help close the gap between empirical evidence regarding
the efficacy of pain treatments and current practice.
• R
egulatory, 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. Strate-
gies also should focus on ways to improve pain care for these groups.
Recommendation 3-3. Provide educational opportunities in pain as-
sessment 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 collabora-
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10 RELIEVING PAIN IN AMERICA
tion of pain specialists with primary care practitioners and teams when
primary care providers have exhausted their expertise and the patient’s
pain persists.
Recommendation 3-5. Revise reimbursement policies to foster coor-
dinated and evidence-based pain care. Payers and health care orga-
nizations should work to align payment incentives with evidence-based
assessment and treatment of pain. Optimal care of the patient should be
the focus.
Recommendation 3-6. Provide consistent and complete pain assess-
ments. Health care providers should provide pain assessments that are
consistent and complete and documented so that patients will receive the
right care at the right place and the right time.
Education Challenges
The optimal timing, content, and goals of patient education about pain vary
with individual circumstances. Fundamental to treatment is education regarding
self-management to minimize flare-ups, decrease day-to-day discomfort, and
maximize functioning. In addition, public education about pain can be highly
beneficial in promoting
• i
ndividual and community actions to prevent injuries,
• a
dvocacy for appropriate acute and chronic pain treatment, and
• s
upport for improved pain prevention and control policies.
Educational programs for the many types of health care professionals who
play a role in pain prevention and treatment—nurses, psychologists, physicians,
dentists, pharmacists, physical therapists, and complementary and alternative
medicine practitioners—vary in the amount and quality of information on pain
they contain. In medical education, pain generally has received little attention,
which has contributed to the problem of undertreatment. The need for improved
education about pain is especially acute for primary care providers—the front-
line clinicians for most people’s acute or chronic pain problems.
Finding 4-1. Education is a central part of the necessary cultural transforma -
tion of the approach to pain. The committee finds that the federal government is
in a position to contribute to substantial improvements in patient and professional
education about pain.
Recommendation 4-1. Expand and redesign education programs
to transform the understanding of pain. Federal agencies and other
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11
SUMMARY
relevant stakeholders should expand education programs to transform
patient and public understanding of pain. In concert with Recommenda-
tion 2-2, federal agencies, in partnership with health professions asso -
ciations, payers, pain advocacy and awareness organizations, and other
relevant stakeholders, should develop education programs for patients,
the public, and health care providers that are designed to promote a
transformation in their expectations, beliefs, and understanding about
pain, its consequences, its management, and its prevention.
Recommendation 4-2. Improve curriculum and education for health
care professionals. The Centers for Medicare and Medicaid Services,
the Health Resources and Services Administration, accrediting or-
ganizations, and undergraduate and graduate health professions train -
ing programs should improve pain education curricula for health care
professionals.
Recommendation 4-3. Increase the number of health profession-
als with advanced expertise in pain care. Educational programs for
medical, dental, nursing, mental health, physical therapy, pharmacy, and
other health professionals who will participate in the delivery of pain
care should have increased capacity to train providers who can offer
advanced pain care.
Research Challenges
In recent years, biomedical research has made remarkable strides in under-
standing of the basic biological and psychological underpinnings of pain. A
principal current opportunity may be to use what has been learned across a broad
spectrum of fields—from genomic and cellular through behavioral mechanisms—
to develop innovative therapies that are simultaneously more targeted to the
individual and more comprehensive in meeting patient needs.
From a scientific standpoint, the future of pain research is exciting because
of advances in a number of relevant and diverse research fields and the devel-
opment of new research techniques. This excitement is tempered, however, by
knowledge that federal research dollars to address the problem of pain are in short
supply and likely to decrease. Pain is a topic of interest to virtually every NIH
institute and center, but not a central concern of any one of them. The committee
believes one of the existing NIH institutes should be designated the lead institute
for pain. The committee further believes that the NIH Pain Consortium needs to
take a stronger leadership role in effecting the necessary transformation in how
pain research is conducted by fostering coordination across institutes and centers,
by ensuring that study section decision making on pain proposals is improved,
and by exploring a range of potential public–private initiatives.
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12 RELIEVING PAIN IN AMERICA
Pain research should not be confined to NIH. As this report details, pain-
related research is needed across public health entities, involving, for example,
the Centers for Disease Control and Prevention’s epidemiological and public
education expertise, the Agency for Healthcare Research and Quality’s quality
improvement initiatives, the Health Resources and Services Administration’s ex -
pertise in professional education and service delivery for vulnerable populations,
and the Centers for Medicare and Medicaid Services’ research and demonstration
programs related to reimbursement policies.
Finding 5-1. Research to translate advances into effective therapies for pain is
a continuing need. The committee finds that significant advances have been made
in understanding the basic mechanisms of nociception and pain, leading to new
potential targets for future pain assessment and treatment strategies. Furthermore,
recent advances in the neurosciences, biomarkers, and the behavioral sciences have
validated a comprehensive approach to the management of pain that includes the
individual’s inherent biology, behavior, and psychological makeup and reactions,
as well as environmental influences. However, data and knowledge gaps in pain
research remain that have prevented such research advances from being translated
into safe and effective therapies. Addressing these gaps will require a cultural
transformation in the view of and approach to pain research, involving basic,
translational, and clinical researchers; federal funding and regulatory agencies;
and private organizations. This cultural transformation is reflected in the following
recommendations.
Recommendation 5-1. Designate a lead institute at the National
Institutes of Health responsible for moving pain research forward,
and increase the support for and scope of the Pain Consortium.
The National Institutes of Health should designate a specific institute to
lead efforts in advancing pain research. At the same time, the National
Institutes of Health should increase financial resources and staffing
support for and broaden the scope of the Pain Consortium and engage
higher-level staff from the institutes and centers in the consortium’s
efforts. The Pain Consortium should exert more proactive leadership in
effecting the necessary transformation in how pain research is conducted
and funded.
Recommendation 5-2. Improve the process for developing new agents
for pain control. Academia and industry should develop novel agents for
the control of pain. This does not mean simply recycling current drugs.
What is required is basic and clinical science research to discover new
classes of pain therapeutics and more efficient ways of developing them.
Also required is that regulatory agencies, especially the Food and Drug
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13
SUMMARY
Administration, develop new and expeditious ways to evaluate and ap-
prove new pain therapies.
Recommendation 5-3. Increase support for interdisciplinary re-
search in pain. Federal agencies, such as the National Institutes of
Health, Agency for Healthcare Research and Quality, Centers for Dis -
ease Control and Prevention, Department of Defense, and Department
of Veterans Affairs, as well as private funders of pain research, should
increase support for interdisciplinary research and research training—
across agencies and professions—on pain-related diseases and the defi-
ciencies noted in Finding 5-1.
Recommendation 5-4. Increase the conduct of longitudinal research
in pain. Public and private funders should increase support for longitu-
dinal research in pain, including comparative effectiveness research and
novel randomized controlled trials, to help ensure that patients receive
care that works best in both the short and long terms.
Recommendation 5-5. Increase the training of pain researchers. With
the support of training grants from the National Institutes of Health,
academic institutions should increase the training of basic, translational,
behavioral, population, and clinical pain researchers. This training should
recognize the interdisciplinary benefits of research on pain and pain man-
agement. Agencies such as the National Center for Health Statistics, the
Agency for Healthcare Research and Quality, and the Centers for Medi-
care and Medicaid Services should support the training of researchers
interested in secondary analysis of pain-related data collected by these
agencies.
CONCLUSION
With the goal of providing relief for pain in America, the committee
concludes this report by offering a blueprint for action toward transforming
prevention, care, education, and research (Chapter 6 and Table S-1 below).
This blueprint organizes the committee’s recommendations into two categories.
Recommendations categorized as immediate are those the committee believes
should be initiated now and completed before the end of 2012. Recommenda -
tions categorized as near-term and enduring build on these immediate actions,
should be completed before the end of 2015, and should be maintained as on -
going efforts. The comprehensive population health-based strategy set forth in
Recommendation 2-2 should inform actions taken in response to, or consistent
with, all of the other recommendations.
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14 RELIEVING PAIN IN AMERICA
TABLE S-1a Blueprint for Transforming Pain Prevention, Care, Education,
and Research
IMMEDIATE: Start now and complete before the end of 2012
Recommendation Actors Key Elements of Recommendation
2-2. Create a Secretary of Health and Involve multiple federal, state, and
comprehensive Human Services (HHS) private-sector entities, such as the
population health- National Institutes of Health (NIH),
level strategy for Food and Drug Administration
pain prevention, (FDA), Centers for Disease Control
treatment, and Prevention (CDC), Agency for
management, and Healthcare Research and Quality
research (AHRQ), Health Resources and
Services Administration (HRSA),
Centers for Medicare and Medicaid
Services (CMS), Department of
Defense (DoD), Department of
Veterans Affairs (VA), outcomes
research community and other
researchers, credentialing organizations,
pain advocacy and awareness
organizations, health professions
associations (including pain specialty
professional organizations), private
insurers, health care providers,
state health departments, Medicaid
programs, and workers’ compensation
programs
3-2. Develop HHS Secretary, AHRQ, CMS, Key part of the strategy envisioned in
strategies for HRSA, Surgeon General, Recommendation 2-2
reducing barriers to Office of Minority Health,
pain care Indian Health Service, VA,
DoD, large health care
providers (e.g., accountable
care organizations)
3-4. Support CMS, VA, DoD, health care The pain specialist role includes
collaboration between providers, pain specialists, serving as a resource for primary care
pain specialists pain centers, primary care practitioners
and primary care practitioners, pain specialty
clinicians, including professional organizations,
referral to pain primary care professional
centers when associations, private insurers
appropriate
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SUMMARY
TABLE S-1 Continued
Recommendation Actors Key Elements of Recommendation
5-1. Designate a NIH Involve pain advocacy and awareness
lead institute at the organizations; foster public–private
National Institutes of partnerships
Health responsible
for moving pain
research forward,
and increase the
support for and
scope of the Pain
Consortium
NEAR-TERM AND ENDURING: Build on immediate recommendations,
complete before the end of 2015, and maintain as ongoing efforts
Recommendation Actors Key Elements of Recommendation
2-1. Improve the National Center for Health Based on Recommendation 2-2; foster
collection and Statistics (NCHS) (part public–private partnerships; includes
reporting of data on of CDC), AHRQ, CMS, subpopulations at risk for pain and
pain VA, DoD, state and local undertreatment of pain, characteristics
health departments, private of acute and chronic pain, and health
insurers, outcomes research consequences of pain (morbidity,
community, other researchers, mortality, disability, related trends)
large health care providers,
designers of electronic
medical records
3-1. Promote Health professions Requires the development of better and
and enable self- associations (including more evidence-based patient education
management of pain pain specialty professional products
organizations), pain advocacy
and awareness organizations,
health care providers
3-3. Provide CMS, VA, DoD, graduate Improved health professions education
educational medical education (GME) requires a stronger evidence base
opportunities in and continuing medical on clinical effectiveness and more
pain assessment and education (CME) primary interdisciplinary training and care
treatment in primary care programs (backed by
care accreditation, licensure,
and certification authorities
and examiners), nurse
practitioner and physician
assistant training programs,
researchers, health care
providers
continued
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16 RELIEVING PAIN IN AMERICA
TABLE S-1 Continued
Recommendation Actors Key Elements of Recommendation
3-5. Revise CMS, VA, DoD, Medicaid Requires the development of more
reimbursement programs, private insurers, evidence on clinical effectiveness and
policies to foster health care providers, health collaboration between payers and
coordinated and professions associations providers
evidence-based pain (including pain specialty
care professional organizations),
pain advocacy and awareness
organizations
3-6. Provide Health care providers, WHO should add pain to the
consistent and primary care practitioners, International Classification of
complete pain pain specialists, other health Diseases, Tenth Edition (ICD-10)
assessments professions, pain clinics
and programs, World Health
Organization (WHO)
4-1. Expand and FDA, CDC, AHRQ, CMS, Focus is on patient education and
redesign education Surgeon General, DoD, VA, public education; includes pain
programs to pain advocacy and awareness prevention
transform the organizations, health
understanding of professions associations
pain (including pain specialty
professional organizations),
private insurers, health care
providers
4-2. Improve CMS, HRSA Bureau CMS’s role is that of payer for GME;
curriculum and of Health Professions, include interdisciplinary training
accrediting organizations,b
education for health
care professionals undergraduate and graduate
health professions training
programs (backed by
licensure and certification
authorities and examiners)
4-3. Increase the Pain medicine fellowship Requires more effort to attract young
number of health programs and graduate health professionals to pain programs;
professionals with education programs in also requires collaboration between
advanced expertise in dentistry, nursing, psychology educators and clinicians
pain care and other mental health
fields, rehabilitation therapies,
pharmacy, and other health
professions
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SUMMARY
TABLE S-1 Continued
Recommendation Actors Key Elements of Recommendation
5-2. Improve FDA, NIH, pharmaceutical Based on Recommendation 5-1;
the process for manufacturing and research involves developing new and faster
developing new industry, academically ways to evaluate and approve new pain
agents for pain based biomedical research therapies, e.g., novel forms of patient
control community, private funders of stratification in clinical trials and novel
pain research investigative endpoints
5-3. Increase support NIH, AHRQ, CDC, DoD, Based on Recommendation 5-1; basic,
for interdisciplinary VA, pharmaceutical translational, and clinical studies
research in pain manufacturing and research should involve multiple agencies and
industry, private funders of disciplines; focus on knowledge gaps
pain research, academically
based biomedical research
community, pain advocacy
and awareness organizations
5-4. Increase NIH, AHRQ, CDC, DoD, Based on Recommendation 5-1;
the conduct of VA, pharmaceutical includes translational, population
longitudinal research manufacturing and research health, and behavioral aspects of pain
in pain industry, Patient-Centered care (social and multimodal aspects,
Outcomes Research Institute, not just medications and other single
private funders of pain modalities); focus is on real-world
research, academically situations (comparative effectiveness,
based biomedical research not just efficacy); foster public–private
community, outcomes partnerships
research community, pain
advocacy and awareness
organizations
5-5. Increase the NIH, NCHS, AHRQ, CMS, Includes more interdisciplinary training
training of pain academic medical institutions
researchers
a The committee prepared this table based on the recommendations but with a focus on their imple -
mentation. The table lists a range of potential actors and key elements of each recommendation.
b Accrediting organizations include the Liaison Committee on Medical Education, Commission on
Osteopathic College Accreditation, Accreditation Council for Graduate Medical Education, Com -
mission on Dental Accreditation, Commission on Collegiate Nursing Education, National League for
Nursing Accreditation Commission, American Psychological Association Committee on Accredita -
tion, Council on Education for Public Health, Council on Social Work Education, and Council for
Higher Education Accreditation (Perez et al., 2007).
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