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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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181 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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183 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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184 RELIEVING PAIN IN AMERICA 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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185 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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186 RELIEVING PAIN IN AMERICA 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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187 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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188 RELIEVING PAIN IN AMERICA • 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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189 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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206 RELIEVING PAIN IN AMERICA 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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207 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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208 RELIEVING PAIN IN AMERICA 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. REFERENCES AAMC (Association of American Medical Colleges). 2010. 2010 GQ medical school graduation questionnaire: All schools summary report—final. Washington, DC: Association of American Medical Colleges.
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211 EDUCATION CHALLENGES ABMS (American Board of Medical Specialties). 2010. AMBS maintenance of certification: Ten years strong & growing. 2010 ABMS certificate statistics. Chicago, IL: ABMS. ACGME (Accreditation Council for Graduate Medical Education). 2007. ACGME program require- ments for graduate medical education in pain medicine. http://www.acgme.org/acWebsite/ downloads/RRC_progReq/sh_multiPainPR707.pdf (accessed March 26, 2011). ACGME. 2011. Reports—programs by specialty. http://www.acgme.org/adspublic/reports/program_ specialty_list.asp (accessed April 13, 2011). ACS (American Cancer Society). 2011. ACS National Cancer Information Center. http://www.cancer. org/aboutus/howwehelpyou/helpingyougetwell/cancer-information-services (accessed June 8, 2011). ACS, Framework Convention Alliance, and Campaign for Tobacco-free Kids. 2008. How do you sell death. http://www.cancer.org/acs/groups/content/@internationalaffairs/documents/document/ acspc-024669.pdf (accessed March 22, 2011). ADA (American Dental Association). 2007. Guidelines for teaching the comprehensive control of pain and sedation to dentists and dental students. http://www.ada.org/sections/professionalResources/ pdfs/anxiety_guidelines.pdf (accessed June 3, 2011). Alzheimer’s Association. 2011. 10 Signs of Alzheimer’s. http://www.alz.org/alzheimers_disease_10_ signs_of_alzheimers.asp (accessed September 13, 2011). American Association of Colleges of Nursing. 2008. The essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing. American Chronic Pain Association. 2011. ACPA consumer guide to pain medications and treat- ments 2011. Rocklin, CA: American Chronic Pain Association. http://www.theacpa.org/uploads/ ACPA_Consumer_Guide_2011%20final.pdf (accessed March 18, 2011). American College of Emergency Physicians, American Pain Society, Emergency Nurses Association, and American Society for Pain Management Nursing. 2010. Optimizing the treatment of pain in patients with acute presentations. http://www.ampainsoc.org/advocacy/downloads/APS10_ Optimizing%20PositionPaper.pdf (accessed January 27, 2011). American Geriatrics Society. 2011. Foundation for health in aging. http://www.healthinaging.org/ public_education/pef/alzheimers_caregiver.php (accessed March 22, 2011). American Pain Foundation. 2011. Pain conditions. http://www.painfoundation.org/learn/pain-conditions/ (accessed March 20, 2011). American Psychological Association. 2011. Health-care reform. http://www.apa.org/health-reform/ pain.html (accessed March 27, 2011). ANA (American Nurses Association). 2005. ANCC announces new certification for pain man- agement nurses. http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/ PressReleases/2005/pr09208536.aspx (accessed January 27, 2011). ANA. 2011. What is nursing? http://www.nursingworld.org/EspeciallyForYou/StudentNurses/ WhatisNursing.aspx (accessed January 28, 2011). Arnstein, P., and B. St. Marie. 2010. Managing chronic pain with opioids: A call for change. http:// www.nphealthcarefoundation.org/programs/ (accessed January 15, 2011). Berry, D. L., D. J. Wilkie, C. R. Thomas, Jr., and P. Fortner. 2003. Clinicians communicating with patients experiencing cancer pain. Cancer Investigation 21(3):374-381. Blumenthal, D., M. Gokhale, E. G. Campbell, and J. S. Weissman. 2001. Preparedness for clinical practice: Reports of graduating residents at academic health centers. Journal of the American Medical Association 286(9):1027-1034. Borneman, T., M. Koczywas, V. Sun, B. F. Piper, C. Smith-Idell, B. Laroya, G. Uman, and B. Ferrell. 2011. Effectiveness of a clinical intervention to eliminate barriers to pain and fatigue manage - ment in oncology. Journal of Palliative Medicine 14(2):197-215. Bostrom, M. 1997. Summary of the Mayday Fund Survey: Public attitudes about pain and analgesics. Journal of Pain Symptom Management 13(3):166-168.
OCR for page 212
212 RELIEVING PAIN IN AMERICA Breuer, B., R. Cruciani, R. K. Portenoy. 2010. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey. Southern Medical Journal 103(8):738-747. Brushwood, D. B. 2001. From confrontation to collaboration: Collegial accountability and the ex - panding role of pharmacists in the management of chronic pain. Journal of Law, Medicine, & Ethics 29(2001):69-93. Buchbinder, R. 2008. Self-management education en masse: Effectiveness of the back pain: Don’t take it lying down mass media campaign. Medical Journal of Australia 189(10):S29-S32. Buchbinder, R., and D. Jolley. 2004. Population based intervention to change back pain beliefs: Three year follow up population survey. British Medical Journal 328(7435):321. Buchbinder, R., D. Jolley, and M. Wyatt. 2001a. 2001 Volvo award winner in clinical studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine 26(23):2535-2542. Buchbinder, R., D. Jolley, and M. Wyatt. 2001b. Population based intervention to change back pain beliefs and disability: Three part evaluation. British Medical Journal 322(7301):1516-1520. Burchiel, K. 2010. How should pain medicine be taught? Workgroup report. The first national pain medicine summit—final summary report. Pain Medicine 11:1452-1453. California Health and Human Services Agency and California Council of the Alzheimer’s Association. 2011. California’s State Plan for Alzheimer’s Disease: An Action Plan for 2011-2021 . http:// www.caalz.org/PDF_files/CA%20State%20Plan.pdf (accessed June 2, 2011). Campaign for Tobacco-free Kids. 2011. Public education campaigns reduce tobacco use. http://www. tobaccofreekids.org/research/factsheets/pdf/0051.pdf (accessed March 21, 2011). Cantor, D. 2007. Uncertain enthusiasm: The American Cancer Society, public education, and the problems of the movie. Bulletin of the History of Medicine 81:39-69. CDC (Centers for Disease Control and Prevention). 2006. New report finds pain affects millions of Americans. http://www.cdc.gov/nchs/pressroom/06facts/hus06.htm (accessed March 24, 2011). CDC. 2011. National public health performance standards program. http://www.cdc.gov/nphpsp/ essentialServices.html (accessed March 22, 2011). Clark, N. M., and M. R. Partridge. 2002. Strengthening asthma education to enhance disease control. Chest 121(5):1661-1669. Claxton, R., S. Marks, R. Buranosky, D. Rosielle, and R. M. Arnold. 2011. The educational impact of weekly e-mailed fast facts and concepts. Journal of Palliative Medicine 14(4):475-481. Cooper, R. A. 2009. Workforce reorientation. Integrative medicine and the health of the public: A summary of the February 2009 summit. Washington, DC: The National Academies Press. Pp. 124-125. Darer, J. D., W. Hwang, H. H. Pham, E. B. Bass, and G. Anderson. 2004. More training needed in chronic care: A survey of U.S. physicians. Academic Medicine 79(6):541-548. Davis, D., R. Galbraith, and American College of Chest Physicians, Health and Science Policy Com - mittee. 2009. Continuing medical education effect on practice performance: Effectiveness of continuing medical education. American College of Chest Physicians evidence-based educa - tional guidelines. Chest 135(3S):42S-48S. Department of Veterans Affairs. 2011. VA centers of excellence in primary care education. http:// www.va.gov/oaa/rfp_coe.asp (accessed January 30, 2011). DeVore, S., and R. W. Champion. 2011. Driving population health through accountable care organiza- tions. Health Affairs 30(1):41-50. Drexler, M. 2008. New approaches to neurological pain: Planning for the future . http://www. painandhealth.org/didyouknow.html (accessed January 27, 2011). Elman, I., J.-K. Zubieta, and D. Borsook. 2011. The missing P in psychiatric training. Archives of General Psychiatry 68(1):12-20. Feder, J. L. 2011. At Martin’s Point in Maine, primary care teams for chronic disease patients. Health Affairs 30(3):394-396.
OCR for page 213
213 EDUCATION CHALLENGES Federation of State Medical Boards. 2010. A guide to the Essentials of a Modern Medical and Osteopathic Practice Act. Euless, TX: Federation of State Medical Boards. www.fsmb.org/pdf/ GRPOL_essentials.pdf (accessed June 3, 2011). Ferrell, B. 2005. Ethical perspectives on pain and suffering. Pain Management Nursing 6(3):83-90. Fineberg, I. C., N. S. Wenger, and K. Brown-Saltzman. 2006. Unrestricted opiate administration for pain and suffering at the end of life: Knowledge and attitudes as barriers to care. Journal of Palliative Medicine 9:873-883. Follett, K. 2010. What mechanisms do we need to establish the competency of a physician who wishes to practice pain medicine? Workgroup report. The first national pain medicine summit—final summary report. Pain Medicine 11(10):1455-1457. France, C. R., K. S. Masters, C. D. Belar, R. D. Kerns, E. A. Klonoff, K. T. Larkin, T. W. Smith, S. Suchday, and B. E. Thorn. 2008. Application of the competency model to clinical health psychology. Professional Psychology: Research and Practice 39(6):573-580. Gallagher, R. 2003. Physician variability in pain management: Are the JCAHO standards enough? Pain Medicine 4(1):1-3. Gallagher, R. 2010. What should all physicians know about pain medicine? Workgroup report. The first national pain medicine summit—final summary report. Pain Medicine 11:1450-1452. George, S. Z., D. S. Teyhen, S. S. Wu, A. C. Wright, J. L. Dugan, G. Yang, M. E. Robinson, and J. D. Childs. 2009. Psychosocial education improves low back pain beliefs: Results from a cluster randomized trial (NCT00373009) in a primary prevention setting. European Spine Journal 18(7):1050-1058. Giovino, G. A., F. J. Chaloupka, A. M. Hartman, K. G. Joyce, J. Chriqui, C. T. Orleans, K. Wende, C. Tworek, D. Barker, J. T. Gibson, J. Yang, J. Hinkel, K. M. Cummings, A. Hyland, B. Fix, M. Paloma, and M. Larkin. 2009. Cigarette smoking prevalence and policies in the 50 states: An era of change—The Robert Wood Johnson Foundation ImpacTeen Tobacco Chart Book. Buffalo, NY: University at Buffalo, State University of New York. Good, M.-J. D., C. James, B. J. Good, and A. E. Becker. 2002. The culture of medicine and racial, ethnic, and class disparities in healthcare. Russell Sage Foundation Working Paper, No. 199. New York: Russell Sage Foundation. Gooddy, W. 1992. Foreword. In Migraine (revised and expanded), author O. Sacks. New York: Vintage Books. Gross, D. P., A. S. Russell, R. Ferrari, M. C. Battié, D. Schopflocher, R. Hu, G. Waddell, and R. Buchbinder. 2010. Evaluation of a Canadian back pain mass media campaign. Spine 35(8):906-913. Grumbach, K., and T. Bodenheimer. 2004. Can health care teams improve primary care practice? Journal of the American Medical Association 291:1246-1251. Gunnarsdottir, S., H. S. Donovan, R. C. Serlin, C. Voge, and S. Ward. 2002. Patient-related barriers to pain management: The Barriers Questionnaire II (BQ-II). Pain 99:385-396. Gustin, S. M., S. L. Wilcox, C. C. Peck, G. M. Murray, and L. A. Henderson. 2011. Similarity of suffering: Equivalence of psychological and psychosocial factors in neuropathic and non- neuropathic orofacial pain patients. Pain 152(4):825-832. Health Psychology Network. 2011. Chronic pain. http://www.healthpsychology.net/Chronic%20Pain. htm (accessed March 27, 2011). IASP (International Association for the Study of Pain). 1997. Curriculum on pain for students in psychology. Seattle, WA: IASP. IOM (Institute of Medicine). 1997. Approaching death: Improving care at the end of life. Washington, DC: National Academy Press. IOM. 2001a. Improving palliative care for cancer. Washington, DC: National Academy Press. IOM. 2001b. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
OCR for page 214
214 RELIEVING PAIN IN AMERICA IOM. 2003. The future of the public’s health in the 21st century. Washington, DC: The National Academies Press. IOM. 2004. Improving medical education: Enhancing the behavioral and social science content of medical school curricula. Washington, DC: The National Academies Press. IOM. 2010. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Jones, R., 2006. General practitioners with special interests: Evolution and evaluation. Journal of Health Services Research and Policy 11:106-109. Karani, R., and D. E. Meier. 2003. Results from the Last Acts Campaign: How can we improve? Supportive Oncology 1(1):69-72. Kastanias, P., 2009. What do adult surgical patients really want to know about pain and pain manage- ment? Pain Management Nursing 10(1):22-31. Kerns, R. D., S. Barry, L. M. E. Frantsve, and J. C. Linton. 2009. Life-long competency development in clinical health psychology. Training and Education in Professional Psychology 3(4):212-217. Kotler, P. R., and N. R. Lee. 2008. Social marketing: Influencing behaviors for good, 3rd ed. Thousand Oaks, CA: Sage Publications. Kreitzer, M. J., B. Kligler, and W. C. Meeker. 2009. Health professions education and integrative health care. Unpublished paper commissioned for the IOM Summit on Integrative Health Care and the Health of the Public. Washington, DC: IOM. LeMone, P., K. M. Burke, G. Bauldoff, and J. Bostick. 2011. Clinical handbook for medical-surgical nursing: Critical thinking in patient care. Upper Saddle River, NJ: Prentice Hall. Lewis, S. L., M. Heitkemper, S. R. Dirksen, P. G. O’Brien, and L. Bucher. 2011. Medical-surgical nursing: Assessment and management of critical problems, 7th ed. Maryland Heights, MO: Mosby. Lippe, P. M., C. Brock, J. David, R. Crossno, and S. Gitlow. 2010. The first national pain medicine summit—final summary report. Pain Medicine 11:1447-1468. Loder, E. 2006. The public health paradox of migraine. Headache Care 3(1):21-29. Loder, E., A. Witkower, P. McAlary, M. Huhta, and J. Matarrazzo. 2003. Rehabilitation hospital staff knowledge and attitudes regarding pain. American Journal of Physical Medicine and Rehabili- tation 82(1):65-68. Massachusetts Pain Initiative. 2011. Legislative issues and access to care council. http:// masspaininitiative.org/index.cfm?p=p.12&title=Councils#Legis (accessed March 22, 2011). May, F., D. Simpson, L. Hart, D. Rowett, and D. Perrier. 2009. Experience with academic detailing services for quality improvement in primary care practice. Quality and Safety in Health Care 18:225-231. Mayday Fund. 2009. A call to revolutionize chronic pain care in America: An opportunity in health care reform. Report of the Special Committee on Pain and the Practice of Medicine . New York: Mayday Fund. McCaffery, M., and B. R. Ferrell. 1996. Correcting misconceptions about pain assessment and use of opioid analgesics: Educational strategies aimed at public concerns. Nursing Outlook 44(4):184-190. McCaffery, M., B. R. Ferrell, and C. Pasero. 2000. Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Management Nursing 1(3):79-87. McCleary, L., J. A. Ellis, and B. Rowley. 2004. Evaluation of the pain resource nurse role: A resource for improving pediatric pain management. Pain Management Nursing 5(1):29-36. Meng, K., B. Seekatz, H. Roband, U. Worringen, H. Vogel, and H. Faller. 2011. Intermediate and long-term effects of a standardized back school for inpatient orthopedic rehabilitation on illness knowledge and self-management behaviors: A randomized controlled trial. Clinical Journal of Pain 27(3):248-257.
OCR for page 215
215 EDUCATION CHALLENGES Merelle, S. Y. M., M. J. Sorbi, L. J. Van Doornen, and J. Passchier 2008. Lay trainers with migraine for a home-based behavioral training: A 6-month follow-up study. Headache 48(9):1311-1325. Meyers, F. J., S. E. Weinberger, J. P. Fitzgibbons, J. Glassroth, F. D. Duffy, C. P. Clayton, and the Alliance for Academic Internal Medicine Education Redesign Task Force. 2007. Redesigning residency training in internal medicine: The consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Academic Medicine 82(12):1211-1219. Mezei, L., and B. B. Murinson. In press. Assessment of pain education in North American medical schools. Journal of Pain. Moseley, G. L. 2003. Joining forces—combining cognition-targeted motor control training with group or individual pain physiology education: A successful treatment for chronic low back pain. Journal of Manual and Manipulative Therapy 11(2):88-94. Moseley, G. L. 2004. Evidence for a direct relationship between cognitive and physical change dur- ing an education intervention in people with chronic low back pain. European Journal of Pain 8(1):39-45. Murinson, B. B., E. Nenortas, R. S. Mayer, L. Mezei, S. Kozachik, S. Nesbit, J. A. Haythornthwaite, and J. N. Campbell. 2011. A new program in pain medicine for medical students: Integrat - ing core curriculum knowledge with emotional and reflective development. Pain Medicine 12(2):186-195. Notcutt, W., and G. Gibbs. 2010. Inadequate pain management: Myth, stigma, and professional fear. Postgraduate Medical Journal 86:453-458. Nutting, P. A., B. F. Crabtree, W. L. Miller, K. C. Stange, E. Stewart, and C. Jaén. 2011. Transforming physician practices to patient-centered medical homes: Lessons from the national demonstration project. Health Affairs 30(3):439-445. Office on Smoking and Health. 2010. Cigarette use among high school students—United States, 1991-2009. Morbidity and Mortality Weekly Report 59(26):797-801. Oliver, J. W., R. L. Kravitz, S. H. Kaplan, and F. J. Meyers. 2001. Individualized patient education and coaching to improve pain control among cancer outpatients. Journal of Clinical Oncology 19(7):2206-2212. O’Rorke, J. E., I. Chen, I. Genao, M. Panda, and S. Cykert. 2007. Physicians’ comfort in caring for patients with chronic nonmalignant pain. American Journal of Medical Sciences 333(2):93-100. Paice, J. A., C. Barnard, J. Creamer, and K. Omerod. 2006. Creating organizational change through the Pain Resource Nurse program. Joint Commission Journal on Quality and Patient Safety 32(1):24-31. PainKnowledge.org. 2011. Important news about PainKnowledge.org. http://www.painknowledge. org/ (accessed June 2, 2011). Partners for Understanding Pain. 2002. Survey shows myths, misunderstandings about pain common among Americans. http://www.theacpa.org/uploads/documents/Partners%20for%20Understanding% 20Pain%20Electronic%20Press%20Kit1.pdf (accessed March 21, 2011). Porter, L. S., F. J. Keefe, J. Garst, D. H. Baucom, C. M. McBride, D. C. McKee, L. Sutton, K. Car- son, V. Knowles, M. Rumble, and C. Scipio. 2010. Caregiver-assisted coping skills training for lung cancer: Results of a randomized clinical trial. Journal of Pain and Symptom Management 41:1-13. Ridsdale, L. 2008. A new GP with special interest headache service: Observational study. British Journal of General Practice 58:478-483. Robert Wood Johnson Foundation. 2003. Means to a better end: A report on dying in America today. Princeton, NJ: Robert Wood Johnson Foundation. Rochmann, D. L. 1998. Students’ knowledge of pain: A survey of four schools. Occupational Therapy International 5(2):140-154. Scudds, R. J., R. A. Scudds, and M. J. Simmonds. 2001. Pain in the physical therapy (PT) curriculum: A faculty survey. Physiotherapy Theory and Practice 17(4):239-256.
OCR for page 216
216 RELIEVING PAIN IN AMERICA Schuetz, B., E. Mann, and W. Everett. 2010. Educating health professionals collaboratively for team- based primary care. Health Affairs 29(8):1476-1480. Strong, J., L. Tooth, and A. Unruh. 1999. Knowledge about pain among newly graduated occupational therapists: Relevance for curriculum development. Canadian Journal of Occupational Therapy 66(5):221-228. Sullivan, M. D., B. Gaster, J. Russo, L. Bowlby, N. Rocco, N. Sinex, J. Livovich, H. Jasti, and R. Arnold. 2010. Randomized trial of web-based training about opioid therapy for chronic pain. Clinical Journal of Pain 26(6):512-517. Todd, A. K., P. Cowan, N. Kelly, and P. Homel. 2010. Chronic or recurrent pain in the emergency department: National telephone survey of patient experience. Western Journal of Emergency Medicine 11(5):408-415. Trautmann, E., and B. Kröner-Herwig. 2010. A randomized controlled trial of Internet-based self- help training for recurrent headache in childhood and adolescence. Behaviour Research and Therapy 48(1):28-37. Trossman, S. 2006. Improving pain management: Call to action. American Nurse Today, December, pp. 29-30. Ulrich, L. P. 1999. The Patient Self-Determination Act: Meeting the challenges in patient care. Washington, DC: Georgetown University Press. United Council for Neurologic Subspecialties. 2011. About UCNS. http://www.ucns.org/go/home (accessed March 24, 2011). Upshur, C. C., R. S. Luckmann, and J. A. Savageau. 2006. Primary care provider concerns about management of chronic pain in community clinic populations. Journal of General Internal Medicine 21(6):652-655. Waddell, G., M. O’Connor, S. Boorman, and B. Torsney. 2007. Working backs Scotland: A public and professional health education campaign for back pain. Spine 32(19):2139-2143. Wakefield, M. A., B. Loken, and R. C. Hornik. 2010. Use of mass media campaigns to change health behaviour. Lancet 376(9748):1261-1271. Walker, B. F., R. Muller, and W. D. Grant. 2003. Low back pain in Australian adults: The economic burden. Asia-Pacific Journal of Public Health 15(2):79-87. Weinberger, S. E., L. G. Smith, and V. E. Collier. 2006. Redesigning training for internal medicine. Annals of Internal Medicine 144(12):927-932. Werner, E. L., C. Ihlebaek, E. Laerum, M. E. A. Wormgoor, and A. Indahl. 2008. Low back pain media campaign: No effect on sickness behavior. Patient Education and Counseling 71(12):198-203. White House Commission on Complementary and Alternative Medicine Policy. 2002. Final report. http://www.whccamp.hhs.gov/pdfs/fr2002_document.pdf (accessed June 3, 2011). Wiest, F. C., T. G. Ferris, M. Gokhale, E. G. Campbell, J. S. Weissman, and D. Blumenthal. 2002. Preparedness of internal medicine residents and family practice residents for treating common conditions. Journal of the American Medical Association 288(20):2609-2614. Wolff, M. S., T. H. Michel, D. E. Krebs, and N. T. Watts. 1991. Chronic pain—Assessment of ortho - pedic physical therapists’ knowledge and attitudes. Physical Therapy 71(3):207-214.