6
A Blueprint for Transforming Pain
Prevention, Care, Education, and Research
Progress occurs when courageous, skillful leaders seize the opportunity to change things for the better.
—Harry S Truman
This report has provided an overview of the causes, impact, prevalence, and scope of pain; presented pain as a public health problem; identified barriers to high-quality and accessible pain care; delineated specific groups that may be undertreated for pain; outlined strategies for improving the training of pain researchers; and described opportunities for public–private partnerships and collaborations in pain research, care, and education. The report has also identified challenges in educating patients, the public, and providers with respect to pain and examined the current state of basic knowledge about pain and ways in which pain research is funded and organized. In reviewing the evidence in these areas, the report has identified knowledge gaps, barriers, opportunities to move the field forward, and ways to transform how pain is understood and treated.
The committee’s goal in preparing this report was to provide a broad overview of the topics included in its charge (see Chapter 1, Box 1-1) and delineate a direction and priorities for achieving change. The committee recognizes that other groups, such as the Interagency Pain Research Coordinating Committee and the Pain Consortium of the National Institutes of Health (NIH), will make use of the broad direction provided by this report and undertake their own processes to improve the understanding of pain and its treatment.
As discussed in Chapter 2, pain is experienced by virtually everyone yet is unique in its perception and experience for each person. Accordingly, broad recommendations such as those offered by the committee can yield general change, but not improvement that will be palpable to every affected individual. A standard clinical algorithm for diagnosing and treating every patient lies well beyond the scope of this report (and may not be achievable in any event). The committee did not analyze the complexities of individual pain conditions and diseases associated with pain. Nor did it analyze in depth the controversies surrounding opioid abuse and diversion. However, the committee hopes that its findings and recommendations will be transformative for the lives of many of the approximately 100 million American adults experiencing chronic pain and those with acute pain as well.
The committee determined that transforming pain prevention, care, education, and research will require carefully planned and coordinated actions by numerous leaders and organizations. Many actors should contribute to the formation of a new national pain strategy. For example, the NIH Pain Consortium should be strengthened and its activities expanded. A comprehensive strategy will ensure that actions to address the problem of pain will be both efficient and effective.
The recommendations in this report are designed to assist policy makers; federal agencies within and outside the Department of Health and Human Services; state and local health departments; primary care practitioners; pain specialists; other health professionals; health care provider organizations; health professions associations; private insurers; researchers; funders; educators; pain advocacy and awareness organizations; the public; and, most important, people living with pain and their families, friends, and colleagues. The ultimate goal is to improve outcomes of care and return people to their maximum level of functioning. The basis for the committee’s recommendations consists of scientific evidence, direct testimony, and the expert judgment of the committee’s diverse membership. Principles underlying the recommendations were presented in Chapter 1 (Box 1-2). They include
- pain management as a moral imperative,
- chronic pain as sometimes a disease in itself,
- the value of comprehensive treatment,
- the need for interdisciplinary approaches,
- the importance of prevention,
- wider use of existing knowledge,
- recognition of the conundrum of opioid use,
- collaborative roles for patients and clinicians, and
- the value of a public health- and community-based approach.
This chapter organizes the recommendations presented in Chapters 2 through 5 into a blueprint for action by identifying them as either immediate or near-term
and enduring. The immediate recommendations are those the committee believes should be initiated now and completed before the end of 2012. The near-term and enduring recommendations build on these immediate actions, should be completed before the end of 2015, and should be maintained as ongoing efforts. Table 6-1 presents the recommendations in these two categories, along with the relevant actors and the recommendations’ key elements. (Note that the numbering scheme used in Chapters 2 through 5 is preserved here.)
The committee wishes to emphasize that the comprehensive population health-based strategy set forth in Recommendation 2-2 should inform actions taken in response to, or consistent with, all of the other recommendations. The strategy should be comprehensive in scope, inclusive in its development, expeditious in its implementation, and practical in its application. Most important, the strategy must be far-reaching. As evidenced in this report, pain is a major reason for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Further, pain costs the country $560-635 billion a year according to a new, conservative estimate developed as part of this study. Given the burden of pain in terms of human lives, dollars, and social consequences, actions to relieve pain should be undertaken as a national priority.
Perez, T., P. Hattis, and K. Barnett. 2007. Health professions accreditation and diversity: A review of current standards and processes. Battle Creek, MI: W.K. Kellogg Foundation. http://www.jointcenter.org/healthpolicy2/hpi-lib/Accreditation.pdf (accessed June 6, 2011).
TABLE 6-1a Blueprint for Transforming Pain Prevention, Care, Education, and Research
IMMEDIATE: Start now and complete before the end of 2012 | ||
Recommendation | Actors | Key Elements of Recommendation |
2-2. Create a comprehensive population health-level strategy for pain prevention, treatment, management, and research | Secretary of Health and Human Services (HHS) | Involve multiple federal, state, and private-sector entities, such as the National Institutes of Health (NIH), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Health Resources and Services Administration (HRSA), Centers for Medicare and Medicaid Services (CMS), Department of Defense (DoD), Department of Veterans Affairs (VA), outcomes research community and other researchers, credentialing organizations, pain advocacy and awareness organizations, health professions associations (including pain specialty professional organizations), private insurers, health care providers, state health departments, Medicaid programs, and workers’ compensation programs |
3-2. Develop strategies for reducing barriers to pain care | HHS Secretary, AHRQ, CMS, HRSA, Surgeon General, Office of Minority Health, Indian Health Service, VA, DoD, large health care providers (e.g., accountable care organizations) | Key part of the strategy envisioned in Recommendation 2-2 |
3-4. Support collaboration between pain specialists and primary care clinicians, including referral to pain centers when appropriate | CMS, VA, DoD, health care providers, pain specialists, pain centers, primary care practitioners, pain specialty professional organizations, primary care professional associations, private insurers | The pain specialist role includes serving as a resource for primary care practitioners |
Recommendation | Actors | Key Elements of Recommendation |
5-1. Designate a lead institute at the National Institutes of Health responsible for moving pain research forward, and increase the support for and scope of the Pain Consortium | NIH | Involve pain advocacy and awareness organizations; foster public-private partnerships |
NEAR-TERM AND ENDURING: Build on immediate recommendations, complete before the end of 2015, and maintain as ongoing efforts | ||
Recommendation | Actors | Key Elements of Recommendation |
2-1. Improve the collection and reporting of data on pain | National Center for Health Statistics (NCHS) (part of CDC), AHRQ, CMS, VA, DoD, state and local health departments, private insurers, outcomes research community, other researchers, large health care providers, designers of electronic medical records | Based on Recommendation 2-2; foster public–private partnerships; includes subpopulations at risk for pain and undertreatment of pain, characteristics of acute and chronic pain, and health consequences of pain (morbidity, mortality, disability, related trends) |
3-1. Promote and enable self-management of pain | Health professions associations (including pain specialty professional organizations), pain advocacy and awareness organizations, health care providers | Requires the development of better and more evidence-based patient education products |
3-3. Provide educational opportunities in pain assessment and treatment in primary care | CMS, VA, DoD, graduate medical education (GME) and continuing medical education (CME) primary care programs (backed by accreditation, licensure, and certification authorities and examiners), nurse practitioner and physician assistant training programs, researchers, health care providers | Improved health professions education requires a stronger evidence base on clinical effectiveness and more interdisciplinary training and care |
Recommendation | Actors | Key Elements of Recommendation |
3-5. Revise reimbursement policies to foster coordinated and evidence-based pain care | CMS, VA, DoD, Medicaid programs, private insurers, health care providers, health professions associations (including pain specialty professional organizations), pain advocacy and awareness organizations | Requires the development of more evidence on clinical effectiveness and collaboration between payers and providers |
3-6. Provide consistent and complete pain assessments | Health care providers, primary care practitioners, pain specialists, other health professions, pain clinics and programs, World Health Organization (WHO) | WHO should add pain to the International Classification of Diseases, Tenth Edition (ICD-10) |
4-1. Expand and redesign education programs to transform the understanding of pain | FDA, CDC, AHRQ, CMS, Surgeon General, DoD, VA, pain advocacy and awareness organizations, health professions associations (including pain specialty professional organizations), private insurers, health care providers | Focus is on patient education and public education; includes pain prevention |
4-2. Improve curriculum and education for health care professionals | CMS, HRSA Bureau of Health Professions, accrediting organizations,b undergraduate and graduate health professions training programs (backed by licensure and certification authorities and examiners) | CMS’s role is that of payer for GME; include interdisciplinary training |
4-3. Increase the number of health professionals with advanced expertise in pain care | Pain medicine fellowship programs and graduate education programs in dentistry, nursing, psychology and other mental health fields, rehabilitation therapies, pharmacy, and other health professions | Requires more effort to attract young health professionals to pain programs; also requires collaboration between educators and clinicians |
Recommendation | Actors | Key Elements of Recommendation |
5-2. Improve the process for developing new agents for pain control | FDA, NIH, pharmaceutical manufacturing and research industry, academically based biomedical research community, private funders of pain research | Based on Recommendation 5-1; involves developing new and faster ways to evaluate and approve new pain therapies, e.g., novel forms of patient stratification in clinical trials and novel investigative endpoints |
5-3. Increase support for interdisciplinary research in pain | NIH, AHRQ, CDC, DoD, VA, pharmaceutical manufacturing and research industry, private funders of pain research, academically based biomedical research community, pain advocacy and awareness organizations | Based on Recommendation 5-1; basic, translational, and clinical studies should involve multiple agencies and disciplines; focus on knowledge gaps |
5-4. Increase the conduct of longitudinal research in pain | NIH, AHRQ, CDC, DoD, VA, pharmaceutical manufacturing and research industry, Patient-Centered Outcomes Research Institute, private funders of pain research, academically based biomedical research community, outcomes research community, pain advocacy and awareness organizations | Based on Recommendation 5-1; includes translational, population health, and behavioral aspects of pain care (social and multimodal aspects, not just medications and other single modalities); focus is on real-world situations (comparative effectiveness, not just efficacy); foster public–private partnerships |
5-5. Increase the training of pain researchers | NIH, NCHS, AHRQ, CMS, academic medical institutions | Includes more interdisciplinary training |
a The committee prepared this table based on the recommendations but with a focus on their implementation. The table lists a range of potential actors and key elements of each recommendation.
b Accrediting organizations include the Liaison Committee on Medical Education, Commission on Osteopathic College Accreditation, Accreditation Council for Graduate Medical Education, Commission on Dental Accreditation, Commission on Collegiate Nursing Education, National League for Nursing Accreditation Commission, American Psychological Association Committee on Accreditation, Council on Education for Public Health, Council on Social Work Education, and Council for Higher Education Accreditation (Perez et al., 2007).