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.