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4
Education Challenges
Education, Education, Education. Educate more physicians on proper
diagnosis and proper pain management. Educate the person living with
pain and their family on addiction versus physical dependency and proper
storage of medication. Educate the public and press about the realities of
pain medication and people living with pain.
—A person with chronic pain1
Earlier chapters of this report reveal a disturbing discrepancy. On the one
hand, pain is extremely widespread in American society, exacts a huge toll in suf-
fering and disability, and imposes extraordinary costs on the health care system
and the nation’s economy (Chapter 2). On the other hand, all too often treatment
is delayed, disorganized, inaccessible, or ineffective (Chapter 3). Much of this
gap between need and performance results from inadequate diffusion of knowl-
edge about pain. Many members of the public, people with pain themselves,
and many health professionals are not adequately prepared to take preventive
action, recognize warning signs, initiate timely and appropriate treatment, or
seek specialty consultation when necessary with respect to pain. The avoidable
negative consequences are that more people than necessary experience pain, acute
pain often is not optimally treated and progresses unnecessarily to chronic pain,
1 Quotation from response to committee survey.
179
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180 RELIEVING PAIN IN AMERICA
chronic pain is not systematically addressed, and the health and quality of life of
large numbers of people are severely impaired.
Improving care for people with acute or chronic pain requires broad improve-
ments in education, especially with regard to
• the multiple causes and effects of pain,
• the range of treatments available to help people obtain relief, and
• the need to consider chronic pain as a biopsychosocial disorder.
Education efforts should be directed to people with pain, the general public,
and health professionals. Each of these audiences has distinct needs for greater
knowledge, and each presents its own education challenges. In addition, educa -
tion programs need to be high quality and evidence based, and in their planning
draw on such sources as the successful examples highlighted in this chapter,
inasmuch as the history of both patient and public education efforts is littered
with failed, ineffective, and poorly implemented programs.
PATIENT EDUCATION
I had to relearn how to live.
—Gwenn Herman,
Pain Connection-Chronic Pain Outreach Center, Inc.2
People with acute or chronic pain often are unaware of their treatment op -
tions or may hold inaccurate or value-laden beliefs about pain that obstruct the
path to treatment and relief (Chapter 3). They deserve information that can help
them understand and address their condition.
The optimal timing, content, and goals of patient education will vary depend-
ing upon the type of pain (acute or chronic), the availability and effectiveness of
treatment, and the educational and literacy levels of the patient. Consider the case
of acute pain. Although there are only limited opportunities to provide effective
pain education to patients who experience unanticipated pain as a result of an
injury or medical emergency, acute pain is an appropriate target of patient edu-
cation. For example, the fear of pain or the experience of poorly controlled pain
with outpatient procedures can affect a person’s willingness to undergo needed
medical or dental treatment. Education about the likelihood of pain, including its
possible magnitude, is therefore important to informed decision making, includ -
2 Quotation from testimony to the committee, November 2010.
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EDUCATION CHALLENGES
ing decisions about options for preventing or managing pain. There is ample
opportunity to educate people who will undergo elective surgery or outpatient
procedures about the likelihood and magnitude of acute pain they may experience
and to inform them about the availability of methods to prevent or relieve this
pain. Postoperative patients surveyed about their information needs placed a high
value on information about pain and pain management plans following surgery
and discharge (Kastanias, 2009).
With respect to chronic pain, the committee believes education for patients
should encompass such topics as those listed in Table 4-1. While the table addresses
strictly patient education, families, too, should be seen as an appropriate target for
educational efforts. Education for people with chronic pain should not be a one-
time effort; as pain progresses, as treatments have greater or dwindling effects, as
new treatments become available, the educational process should continue. One
advantage of education is that it can enable people with pain to handle many pain-
related problems themselves, without having to rely on medical care.
People with chronic pain have substantial unmet educational needs. For ex-
ample, while three-fourths of people with chronic pain who visited an emergency
department reported a desire for information about pain treatment options or
referrals to pain specialists, only half reported receiving such information (Todd
et al., 2010). There is evidence that appropriate education can improve satisfac -
tion with care and outcomes of people with pain (Merelle et al., 2008).
Sometimes, especially in cases of severe persistent pain, a person may have
to learn that certain limitations and discomforts appear to be permanent. Someone
facing the prospect of lifelong discomfort, disability management, and self-care
challenges will require emotional support along with accurate information. The
prospect of a permanent reduction in health status and quality of life is not unique
to persistent pain. It also confronts people who have other chronic diseases (such
as diabetes, asthma, end-stage renal disease, multiple sclerosis, and some cancer
and heart disease conditions), and the rich experience of patient education about
these other diseases can be mined to improve strategies and expand the supply of
materials for patient education about pain. Patient education programs and mate -
rials, like treatment choices (Chapter 3), need to be age-appropriate, geared to the
person’s and family’s level of comprehension and general health literacy, cultur-
ally and linguistically competent, and supported by timely opportunities to ask
questions and receive authoritative and useful answers. Families and other per-
sonal caregivers deserve information about how to obtain stress relief—including,
in the case of people who are terminally ill, respite care—because they, too, are
part of the patient’s milieu and need to be able to remain in peak form. Given the
importance of patient education on pain, it would be useful to have educational
modules—available through different media, such as Internet links (which could
also benefit clinicians), pamphlets, and audio connections translated into various
languages or geared to different health literacy levels or age groups—that could
be selected for individual patients.
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182 RELIEVING PAIN IN AMERICA
TABLE 4-1 Patient Education: Essential Topics
Essential Patient Education Topic Reason Why the Topic Is Essential
Steps people can take on their own—such To prevent pain from progressing (that is,
as relaxation strategies, exercises, or weight secondary prevention), to provide quick relief,
loss—to prevent or obtain relief, help prevent to empower people to manage their own care as
acute pain from progressing to chronic pain, appropriate, and to avoid unnecessary health care
and help prevent chronic pain conditions from expenditures
worsening
Differences between pain that is protective To advise people why pain that is not protective
(adaptive) and pain that is not protective should be treated
(maladaptive)
Reasons why the need for relief is important, To persuade people to obtain early treatment
especially the possibility that poorly managed when necessary
acute pain will progress to chronic pain
When and how emergency or urgent care To encourage seeking immediate intervention,
should be obtained which sometimes can prevent pain from severely
worsening
Treatment-related pain (such as postoperative To enable patients to be informed consumers
pain) and major categories of available pain
therapies, along with the main advantages
and disadvantages of each (such as potential
benefits and risks of opioids)
Different types of health professionals who To provide information about a full range of
may be able to help, and how they may help available services, to promote individual choice
Treatments health insurers may or may not To equip people to make choices that are
reimburse or may reimburse only partially cost-effective for them and prepare them for
reimbursement problems
Ways in which family, employer, colleagues, To empower patients to marshal support from
friends, school, and other contacts can those who are willing and able to help them
help prevent the pain from progressing or
becoming prolonged
How pain is measured, including the To enable patients to place their pain in a context
difference between numeric (“subjective,” or health professionals will recognize and serve as
intensity) scales and functional (“objective,” an informed member of their own health care
or disability) assessments team
The fact that pain involves a complex mind– To provide patients with an understanding of the
body interaction, rather than being strictly need to address both dimensions of their pain and
physical (biological) or strictly emotional with appropriate, rather than unrealistically high,
(psychological) expectations
The right to pain care, including access to To alert patients to the possible need to advocate
medications that are medically necessary and on their own behalf
properly used
Self-management techniques (surveyed in To furnish patients with enough information to
Chapter 3) obtain some relief on their own and contribute
meaningfully to their own care
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EDUCATION CHALLENGES
Because severe pain affects so many aspects of a person’s life, people
with pain and their families can feel overwhelmed. Education can help them
devise ways of improving those circumstances that can be improved and coping
with more lasting restrictions. Various types of education programs evaluated
or in use by voluntary health organizations have benefited people with pain,
including
• information on ways to control and cope with pain (American
Chronic Pain Association, 2011; American Pain Foundation, 2011;
PainKnowledge.org, 2011);
• psychosocial supports for people with pain and their personal caregivers,
with a strong patient education component (Porter et al., 2010); and
• encouragement in the use of self-management strategies (Oliver et al.,
2001; Moseley, 2003; Trautmann and Kröner-Herwig, 2010).
As noted in Chapter 1, a person’s beliefs about pain correlate with pain
treatment outcomes. For example, one study found that people with cancer tend
to receive inadequate analgesics and have greater pain if they harbor beliefs
such as that cancer pain is inevitable, that side effects of analgesic drugs are
unmanageable, that “good patients” do not complain about pain, and that pain
distracts physicians from treating the cancer (Gunnarsdottir et al., 2002). Correct-
ing such beliefs and misperceptions should be an important educational goal.
Education programs also can reduce symptoms and improve functioning. A
program consisting of four educational sessions for people with cancer showed
“significant immediate and sustained effects . . . on pain and fatigue barriers”
among patients who received the intervention, compared with a usual care control
group, as well as increased knowledge and measurable improvements in quality
of life (Borneman et al., 2011, p. 197). Among people with low back pain, one-
on-one education with a physiotherapist led to improved physical functioning,
as measured by both straight-leg raise and forward bending. The researchers at -
tributed approximately 77 percent of the leg-raise improvement and 60 percent of
the bending improvement to a change in cognition, especially the belief that pain
means tissue damage, and to reduced catastrophizing (Moseley, 2004).
Psychosocial education appears to be especially useful. In a German study
involving “back schools” for rehabilitation in patients with low back pain, those
who received education in the biopsychosocial model showed greater knowledge
about their illness and better self-management than those who received more tra -
ditional education (Meng et al., 2011). A study of U.S. soldiers completing their
training showed that a psychosocial education program improved their knowledge
about the effects of low back pain—a malady frequently faced by soldiers—and
their ability to cope with it (George et al., 2009).
Patient education assists people with pain and their families, as well as spe-
cific high-risk groups, such as soldiers in the example discussed above or people
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diagnosed with cancer. The next section addresses public education, which can
help in the prevention and treatment of pain in the general population.
PUBLIC EDUCATION
We need respectability brought to these conditions.
—Terrie Cowley, The TMJ Association, Ltd.,
An advocate for people with chronic pain3
Why educate the general public about pain? The committee identified five
reasons why public education about pain could be highly beneficial:
• People who have received such education can take steps to avoid pain,
such as practicing proper stretching and lifting techniques, and can en -
gage in timely and useful self-management when pain strikes.
• Educated people can give appropriate advice and assistance to family
members, friends, and colleagues of people with pain, especially by
advising them to refrain from telling injured individuals to simply “bear
with it” or “suck it up.”
• In interactions with health care providers, educated people can advocate
for and accept appropriate treatment of acute and chronic pain they or
family members experience.
• An educated public can act at the community level to minimize hazards
that contribute to pain-producing injuries among students (such as in
sports programs) and in the general community (such as unshoveled
walkways or sidewalks in disrepair).
• Educated citizens can advocate for improved pain prevention and control
policy measures, such as reasonable sports helmet requirements, lawful
access to medically necessary opioid medications, and health insurer
reimbursement of interdisciplinary pain care.
Data with which to measure the extent and accuracy of public knowledge
about the science and treatment of pain are limited. A 2002 national telephone
survey of 1,000 adults found that “most Americans have little understanding of
pain and its treatment” (Partners for Understanding Pain, 2002, p. 2). Specifically,
survey respondents tended to overestimate physicians’ training in pain; under-
estimate the extent to which pain affects people under age 65; and believe that
3 Quotation from testimony to the committee, November 2010.
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EDUCATION CHALLENGES
most people complain about pain only to obtain drugs, avoid work, or garner
attention. Similarly, a landmark 1997 survey of the public sponsored by the
Mayday Fund found that many Americans had only limited knowledge about pain
and its treatment, believing, for example, that pain medications are dangerous and
should be avoided if possible (Bostrom, 1997).
Although the 1997 and 2002 surveys uncovered persistent deficits in public
understanding about pain, they are insufficient to serve as a platform for a major
public education effort today. The results are a decade or more old and are focused
largely on opioid-related issues that continue to evolve. Additional research into
public knowledge about pain would enable public health advocates to
• assess the overall need for public education,
• identify groups most in need of education and the most cost-effective
ways of reaching them,
• determine appropriate content domains, and
• craft messages or lessons.
Some existing campaigns, described in Box 4-1, illustrate how public educa-
tion on pain might take place. Some public health education campaigns outside
the pain field illustrate the potential for producing change in pain-related behavior.
BOX 4-1
Public Education Campaigns on Low Back Pain
Australia
Low back pain costs Australia more than AU$9 billion a year (which amounts
to approximately US$350400 per resident) (Walker et al., 2003). Partly to reduce
rapidly rising workers’ compensation costs for back pain, the state of Victoria
WorkCover Authority in the late 1990s conducted what is considered the first back
pain public education campaign, Back Pain: Don’t Take It Lying Down.
The 3year, $10 million multimedia effort, centered on primetime television
advertisements, helped convince people with pain not to fear remaining physically
active (Buchbinder et al., 2001a). Pre and postcampaign evaluations showed that
after the campaign, more people disagreed with certain inaccurate statements con-
tained in the Back Beliefs Questionnaire (BBQ), such as that back trouble requires
rest; that back trouble will eventually stop one from working; that there is no real
treatment for back pain; and that once one has had back trouble, there is always a
weakness. The desired beliefs were maintained for at least 3 years after the cam-
paign ended and were held more widely in Victoria than in neighboring New South
continued
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BOX 4-1 Continued
Wales (Buchbinder and Jolley, 2004). General practitioners’ beliefs also improved,
and claims for back injuries fell by 15 percent (Buchbinder et al., 2001b).
The Victoria campaign messages were disseminated through television, radio,
billboards, posters, seminars, workplace visits, and news articles. The messages
included the following:
• ack pain is not a serious problem.
B
• eople with back pain should continue their usual activities and exercise,
P
without resting for long periods or leaving work unnecessarily.
• eople with back pain should maintain a positive attitude.
P
• rays are not useful, and surgery may not help.
X
• mployees should remain at work.
E
Underlying the Victoria campaign were specific, informed convictions about
disease prevention. Campaign organizers focused on improving beliefs in a
majority of the population that had been somewhat undecided (“had intermedi-
ate beliefs”) instead of trying to improve “the poorest beliefs” held by only a few
people. They also thought that influencing attitudes communitywide could produce
sustained behavioral change and that even expensive mass media campaigns
would ultimately be more cost-effective than one-on-one education (Buchbinder,
2008).
Scotland
Influenced by the Australian experience, National Health Service authorities in
Scotland also conducted a media campaign on back pain, involving 1,777 radio
announcements that reached three in five of the country’s adults. The effort further
included leaflets, as well as information packets distributed to health professionals
and employers. The campaign produced a positive effect on public and profes-
sional attitudes, as most people became aware of the benefits of staying active
for those with back pain. However, the Scottish campaign, which was far smaller
in scale than its Australian counterpart, did not reduce disability claims or worker
absenteeism (Waddell et al., 2007).
Norway and Canada
Back pain campaigns modeled on the Australian and Scottish efforts have
taken place in parts of Norway and in the province of Alberta, Canada. The
Norwegian effort was relatively small and, like the Scottish campaign, improved
beliefs but not workers’ compensation claims (Werner et al., 2008). The Alberta
effort also was small, involving mostly radio announcements, and produced little
effect on beliefs and no appreciable change in work behavior or health care utiliza-
tion (Gross et al., 2010). As the evaluators of the Alberta campaign emphasized,
mass media campaigns must be large in order to influence behavior significantly.
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EDUCATION CHALLENGES
Tobacco use in the United States has fallen dramatically, for example, partly as a
result of systematic public education. Between 1991 and 2009, use levels among
high school students declined by 34 percent for “ever smoked cigarettes,” by 29
percent for current cigarette use, and by 43 percent for current frequent cigarette
use (Office on Smoking and Health, 2010). Among adults, smoking rates declined
by 24 percent between 1992-1993 and 2006-2007 (Giovino et al., 2009). Local
combinations of a well-designed public education campaign, community and
school-based programs, strong enforcement efforts, and smoking cessation pro-
grams have reduced smoking among youth by as much as 40 percent (Campaign
for Tobacco-free Kids, 2011). Mass media tobacco control campaigns are associ -
ated with both declines in youth uptake of smoking and adult smoking cessation
(Wakefield et al., 2010).
The back pain campaigns described in Box 4-1 and tobacco control cam -
paigns represent one type of public education—social marketing—which uses
simple messages, advertising techniques, and other marketing approaches to
persuade large numbers of people to change behavior or support changes in
public policy (Kotler and Lee, 2008). Other public education strategies include
more neutral informational and awareness-building efforts. Like social market -
ing, these efforts seek people out proactively. In the pain context, such efforts
could alert people to the range of available treatments and categories of health
professionals who treat pain, to available educational resources, or to the fact
that pain is both a physical and a psychosocial condition. These strategies also
might also focus on reducing risk factors for pain. For example, they could
remind people with frequent headaches to avoid using analgesics daily or near-
daily to minimize the development of medication-overuse headache (Loder,
2006).
Many educational tools are useful in reaching the public:
• website content, listservs, and social media;
• fact sheets distributed to target audiences, such as opinion leaders or
community meeting attendees;
• leaflets, to raise awareness and be retained as personal references;
• informational reports and studies;
• pamphlets distributed at schools, workplaces, churches, public meetings,
and other venues;
• signs at health facilities and in health professionals’ offices;
• media outreach;
• coalition building among stakeholders;
• surveys of public or professional attitudes used to garner media attention;
• wellness classes at health facilities, gyms, senior centers, and adult edu-
cation programs, for example;
• instructional videos; and
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• attempts to influence purveyors of popular culture, such as television and
movie scriptwriters.
An advantage of comprehensive educational efforts is that content can be far
more complex than simple messages delivered via the mass media. Also, most
of these approaches can be tailored to specific audiences, segmented by health
status, risk group, demographic characteristics, language skills, or preferred edu -
cational media. Some educational initiatives could target nonhealth professionals
who receive people’s initial reports of pain, such as employers, teachers, and
clergy (Chapter 3), or third-party payers and others who influence the course of
pain care. An additional advantage of public education overall is that it can draw
people into public decision-making processes, for example, by encouraging them
to ask their employer to make sure that their health insurance plan sufficiently
covers pain management or advocate that their local public schools have an injury
prevention policy, especially in sports programs.
Illustrating the capacity of public education about health issues, the Ameri -
can Cancer Society (ACS) has been effective in its long-term efforts to promote
cancer screening and early detection. ACS began as a public education orga -
nization in an era when cancer was rarely talked about openly, and used film
and other media to engender emotion and gain support for cancer research and
care (Cantor, 2007). The organization maintains a nationwide 24-hour help line
and offers information about local resources, clinical trials, awareness building,
smoking cessation, and specific cancers (ACS, 2011). Additionally, ACS actively
advocates for public policies to increase cancer prevention, care, and research and
participates in prohealth coalitions (ACS et al., 2008).
Over a shorter time frame, end-of-life educational efforts have been similarly
instrumental in such areas as making more Americans aware of the importance
of advance directives (Ulrich, 1999; Patient Self-Determination Act, Public Law
101-508, Secs. 4206 and 4751 of Omnibus Budget Reconciliation Act of 1990).
Prominent among these end-of-life educational efforts was the Last Acts cam-
paign, a coalition-based enterprise that engaged in multiple public and profes -
sional education initiatives (Karani and Meier, 2003). For example, one Last Acts
product was a national report card indicating how well each state was protecting
end-of-life decisions and ensuring high-quality care for people with terminal ill -
nesses (Robert Wood Johnson Foundation, 2003).
Public education is undertaken by many other nonprofit organizations dedi -
cated to combating a single disease or constellation of health conditions. Typi -
cally, their efforts mix patient (and family) and public education. Alzheimer’s
disease, for example, is targeted by multiple groups that have both public and
patient education as part of their mission:
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EDUCATION CHALLENGES
• The Alzheimer’s Association maintains a website with access to such
materials as a chartbook and a list of ten warning signs of the disease
(Alzheimer’s Association, 2011).
• The American Geriatrics Society’s Foundation for Health in Aging ad-
ministers a Patient Education Forum with online answers to such ques-
tions as: “What effect can Alzheimer’s disease have on a caregiver?”
and “How important is early detection and diagnosis of Alzheimer’s
disease?” (American Geriatrics Society, 2011).
• A California Alzheimer’s disease task force adopted a statewide plan
to reduce stigma, ensure that information clearinghouses have reliable
information, increase access to public information, and promote public
education (California Health and Human Services Agency and California
Council of the Alzheimer’s Association, 2011).
• The National Institute on Aging maintains an Alzheimer’s Disease Edu-
cation and Referral Center.
Educational efforts by these and many other organizations have helped make the
country more aware of Alzheimer’s disease and have assisted individuals and
their families in finding information and support.
Currently, public education about pain is not conducted in a large-scale, sys-
tematic, coordinated, and strategic way as in the tobacco, cancer, end-of-life, and
Alzheimer’s disease examples. Some organizations, such as the American Pain
Foundation and the Mayday Fund, certainly promote public awareness. Several
patient-oriented groups focused on single pain conditions or issues—such as the
National Fibromyalgia Association, Women with Pain Coalition, and American
Chronic Pain Association—take strong advocacy positions. The issue of access to
opioid medications has sparked numerous public advocacy efforts over the past
two decades. But neither the federal government nor a coalition of pain organiza-
tions that could assemble more resources has designed and undertaken a campaign
to increase public awareness of such topics as the pervasiveness of pain and the
need to treat it, the multiple causes and effects of pain, the fact that pain involves a
complex mind–body interaction, and the range of available and useful treatments.
Without such an effort, it appears unlikely that public awareness of these issues
will increase substantially in the near future or that the cultural transformation
envisioned by this committee (Chapter 1) can be achieved.
On the federal level, informing the public about pain has not received sus -
tained priority attention from the Centers for Disease Control and Prevention
(CDC), the Office of the Surgeon General, the Agency for Healthcare Research
and Quality (AHRQ), or the National Institutes of Health (NIH), although CDC,
AHRQ, and NIH all have displayed an appreciation for the importance of pain.
CDC, for example, has publicly released a fact sheet on pain (CDC, 2006); AHRQ
conducted an early study on back pain and publicized the results (Chapter 3); and
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principles of pain management emphasized in this report, including adherence to
the biopsychosocial model, integration of science and practice, interdisciplinary
methods, and explicit attention to culture and diversity.
Education and training in the specialty of clinical health psychology, and
by extension pain psychology, follow a graded and sequential series of learning
experiences beginning with doctoral training programs in clinical or counseling
psychology, followed by internship training and specialty training at the post-
doctoral level (Kerns et al., 2009). On an entirely volunteer basis, some psycholo-
gists pursue specialty board certification in clinical health psychology following a
more intensive process of continuing education and training beyond the doctoral
degree. However, only recently has the American Psychological Association be-
gun to accredit specialty training in clinical health psychology at the postdoctoral
level. Even so, pain psychology remains a subspecialty within the broader field
of clinical health psychology, and there are no explicit criteria for credentialing
psychologists with specific expertise in pain management.
Despite an apparently robust market for psychologists with this expertise,
the field has been slow to expand its capacity for education and training of
psychologists with competencies in pain management. One of the key challenges
is that doctoral training programs in clinical and counseling psychology may not
have faculty with this interest and expertise, thus limiting students’ exposure to
the field, including clinical practicum experiences and participation in research
laboratories or clinical research settings. The few students who do develop this
interest and expertise are likely to pursue internship and postdoctoral training in
the subspecialty area in academic medical environments that support this training.
In the past 10 years, for example, the Department of Veterans Affairs has con-
tinued to expand its predoctoral and postdoctoral psychology training programs,
and with this expansion and an increased emphasis on system improvements in
pain management for veterans (see Chapter 3), a growing number of training
opportunities for psychologists interested in pain management have emerged. A
small and growing number of subspecialty training opportunities in pain psychol-
ogy, focused on pain-relevant rehabilitation and health services research, also
have begun to emerge.
Dentistry
The Commission on Dental Accreditation (CODA) states that dental school
“graduates must be competent in providing oral health care within the scope of
general dentistry, as defined by the school, for the child, adolescent, adult, and
geriatric patient . . . including anesthesia, and pain and anxiety control. . . .”
(CODA Standard 2-25e, 2007). Pain management and control, particularly for
acute and postoperative pain, remain a core curriculum component that, histori -
cally, has affected the relationship between dental procedures and pain.
As a specialty, dentistry has long recognized the fear of the dental experi -
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EDUCATION CHALLENGES
ence. Dental education programs have therefore taken steps to decrease the pain
associated with dental care through several approaches, aided by the advent
of new anesthetics (local anesthesia, intravenous [IV] sedatives, and inhala-
tion agents such as nitrous oxide). In addition the American Dental Association
(ADA) and several other dental organizations have held comprehensive work-
shops on pain control. And through the active work of dental educators and the
dental community, Guidelines for Teaching the Comprehensive Control of Pain
and Sedation to Dentists and Dental Students provides training guidelines for
predoctoral dental programs, postdoctoral (residency) programs, and continuing
dental education (ADA, 2007). These efforts have allowed dentistry to evolve
from a specialty restricted to extracting problematic teeth; to one that restores
and maintains a person’s natural teeth; to one that promotes prevention of caries
and periodontal disease and the recognition that dental care can have an effect
on a person’s overall health.
As an example of postgraduate (residency) training that includes specific
competencies in pain management and anxiety control, oral and maxillofacial
surgery residencies typically include 4 months of training as an anesthesiology
resident. Residents must demonstrate competence in outpatient ambulatory sur-
geries utilizing IV sedation techniques and pain control. Acute pain control is
managed aggressively and has improved the overall experience of the patient.
Unfortunately, the development of chronic pain of the temporomandibular
joint (TMJ) or the orofacial region is poorly understood, and that type of pain is
poorly controlled. Management approaches vary among practitioners and may
highlight a variable etiology. However, there is growing evidence that the negative
affective, cognitive, and psychosocial state of chronic pain is universal, whether
it be non-neuropathic/nociceptive pain (TMJ chronic pain) or neuropathic pain
(trigeminal neuralgia), which suggests that cognitive-behavioral therapy may help
(Gustin et al., 2011).
Although predoctoral programs and continuing education in chronic orofacial
pain are limited, the ADA recently established accreditation standards for post-
graduate training in orofacial pain. A particular emphasis in this advanced training
program is the incorporation of interprofessional care.
Physical and Occupational Therapy
Rehabilitation therapies are an important part of pain care (Chapter 3).
Historically, however, physical therapists were not well prepared to help man -
age pain. In a survey of 119 physical therapists who belonged to the American
Physical Therapy Association’s Section on Orthopaedics, all but 4 percent said
they preferred not to work with patients likely to have chronic pain, 72 percent
said their entry-level education in pain management was very inadequate or less
than adequate to handle orthopedic patients, and pain knowledge scores were
found to be low (Wolff et al., 1991). In a faculty survey of slightly more than
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100 accredited physical therapy education programs in North America, the modal
amount of time spent on pain in the curriculum was 4 hours; most respondents
nevertheless believed pain was adequately covered, except for pain in the elderly
and children and cognitive-behavioral therapy (Scudds et al., 2001). Similarly, in
a survey of 201 seniors in occupational therapy programs, the mean score on a
10-item test about pain was 61 percent (Rochmann, 1998). And in an Australian-
based study of 35 recent occupational therapy graduates, the combined score
on a test including 69 questions about pain knowledge and attitudes was only
53 percent (Strong et al., 1999).
Pharmacy
Another health profession that has focused on pain is pharmacy. To improve
the use of analgesics to achieve “good therapeutic outcomes for patients,” some
pharmacists and physicians have created drug therapy management teams, or
even collaborative practice models (Brushwood, 2001). A few states authorize
collaborative practice in which physicians consult pharmacists about the use of
opioid medications, and both practitioners share accountability.
Complementary and Alternative Medicine (CAM)
Because complementary and alternative therapies are widely used in pain
care (see Chapter 3), the education of CAM practitioners is an important compo-
nent of health professions education about pain and pain management, although
systematic reviews of this training are scant. In general, education and training
of CAM practitioners are less formal than is the case for physicians, nurses,
and other conventional health professionals, in part because of the lack of ac -
creditation standards for CAM education programs, the existence of many small
proprietary training programs, and a chaotic set of state licensure regulations for
CAM practitioners (Kreitzer et al., 2009). Thus, for example, substantial varia -
tion has been found in pain education among chiropractors and acupuncturists
(Breuer et al., 2010).
Few educational programs in state-licensed CAM fields involved in pain
care—chiropractic, acupuncture, naturopathic medicine, traditional Chinese med-
icine, and massage therapy—appear to focus specifically on pain and pain man -
agement. However, several interdisciplinary undergraduate and graduate degree
or certificate programs have emerged that allow for a focus on pain in CAM
practice. For example, a collaborative program sponsored by Tufts University
School of Medicine and the New England School of Acupuncture provides an
opportunity for master’s students in acupuncture to enroll in a multidisciplinary
pain management program at Tufts (White House Commission on Complemen -
tary and Alternative Medicine Policy, 2002). Several organizations representing
CAM practitioners and others who offer pain treatment (e.g., the American
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209
EDUCATION CHALLENGES
Holistic Medical Association, American Association of Orthopaedic Medicine,
and American Association of Naturopathic Physicians) are able to contribute to
the education of relevant stakeholders.
CONCLUSION
Curricula for all health professions are full, and advocates of many important
causes compete for a greater share of students’ and clinicians’ valuable educa -
tional time. Yet despite the large role that care of patients with pain will play
in their daily practice, many health professionals, especially physicians, appear
underprepared for and uncomfortable with carrying out this aspect of their work.
These professionals need and deserve greater knowledge and skills so they can
contribute to the necessary cultural transformation in the perception and treatment
of people with pain.
FINDING AND RECOMMENDATIONS
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 rele-
vant stakeholders should expand education programs to transform patient
and public understanding of pain. In concert with Recommendation 2-2,
federal agencies, in partnership with health professions associations,
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 conse-
quences, its management, and its prevention. Programs should
• b
e endorsed by expert pain health professions organizations;
• s
trive to increase awareness of the significance of pain, its preven-
tion, the need to address acute and chronic pain in timely and ef -
fective ways, the biological and psychosocial aspects of pain, and
the need for comprehensive assessment of pain, as well as to instill
a balanced understanding of available treatments;
• i
ncorporate materials such as fact sheets and information that can
be made widely available, including on the Internet; and
• b
e specifically and appropriately targeted to patients, the public, and
providers to ensure understanding of the concepts being imparted.
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210 RELIEVING PAIN IN AMERICA
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 organizations,
and undergraduate and graduate health professions training programs
should improve pain education curricula for health care professionals.
• A
ccrediting organizations, such as the Liaison Committee on Medi-
cal Education and American Psychological Association Committee
on Accreditation, should establish specifically identifiable standard-
ized curriculum requirements for pain education.
• T
he Centers for Medicare and Medicaid Services should provide
financial support for advanced training in pain management.
• T
he Bureau of Health Professions should provide financial support
for training grants for the education of practitioners in pain assess-
ment and management.
• U
ndergraduate and graduate health professions training in programs
whose graduates will participate in pain care should include pain
education.
• R
elevant accrediting organizations (such as residency review com-
mittees and the Accreditation Council for Graduate Medical Edu-
cation) should establish specifically identifiable and standardized
curriculum requirements for pain education in graduate training
programs, such as primary care programs.
• T
raining should include education in interprofessional settings.
• A
ssessment of pain knowledge should be included in examina-
tions for licensure (e.g., the U.S. Medical Licensing Examination),
certification (the American Board of Medical Specialties), and
recertification.
• H
ealth care professionals should engage in ongoing pain education
through postgraduate continuing education programs.
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.
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