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2
Pain as a Public Health Challenge
Public health is what we, as a society do collectively to assure the
conditions for people to be healthy.
—IOM, 1988, p. 19
Pain can be conceptualized as a public health challenge for a number of
important reasons having to do with prevalence, seriousness, disparities, vulner-
able populations, the utility of population health strategies, and the importance
of prevention at both the population and individual levels.
First is the extent of the problem: pain affects tens of millions of Ameri -
cans and contributes substantially to morbidity, mortality, disability, demands
on the health care system, and significant economic burdens for the nation.
The prevalence of chronic pain is growing and likely to continue to do so. (See
Chapter 1.)
Second, there are substantial disparities in pain prevalence and seriousness
and rates of undertreatment across population groups. Inadequately treated pain is
more common in vulnerable populations—including the elderly, children, racial
and ethnic minorities, and others—that are a traditional concern of public health
agencies and programs.
Third, because pain is ubiquitous across the population, imposes a differen -
tial burden on vulnerable subgroups, and is affected by conditions in the social,
physical, and economic environments, a comprehensive pain prevention and
55
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56 RELIEVING PAIN IN AMERICA
management strategy at the population health level is needed. It is not sufficient
to treat pain merely on a case-by-case basis in physicians’ offices and other health
care settings.
Fourth, pain is costly to the nation—not just in terms of health care expen -
ditures and disability compensation but also in terms of lost school days, lost
productivity and employment, reduced incomes, and, indeed, lost potential and
quality of life.
Fifth, pain raises societal issues that extend beyond individuals and their
suffering. Specifically, the opioid medications that are effective for many people
with pain also are subject to misuse and abuse, and ensuring that they are avail-
able for those who need them and not available to abusers necessitates cross-
governmental efforts at all levels.
Sixth, the public’s health is greatly influenced by the graduates of the nation’s
health professions training programs, many of which are heavily supported with
public monies. From initial education through continuing education programs,
health professionals need to learn more about the importance of pain prevention,
ways to prevent the transition from acute to chronic pain, how to treat pain more
effectively and cost-effectively, and how to prevent other physical and psycho -
logical conditions associated with pain.
Seventh, the ability to reduce pain’s impact on the public’s health can be
strengthened as a result of new knowledge generated by the nation’s vital research
establishment through basic, clinical, and translational research; epidemiologic
studies; and analysis of care patterns and costs.
Finally, public health offers an infrastructure and a forum for developing
strategies for preventing and addressing pain. Multiple federal agencies—such as
the Centers for Disease Control and Prevention (CDC), Food and Drug Admin-
istration (FDA), National Institutes of Health, Agency for Healthcare Research
and Quality (AHRQ), Surgeon General, and Departments of Veterans Affairs and
Defense—can interact with state and local public health agencies and private-
sector partners to develop and implement public education efforts and other
population-based interventions.
The Department of Health and Human Services’ (HHS) vision and strategic
framework on multiple chronic conditions is an example of a multipronged ef -
fort to accomplish much of what a coordinated national initiative on pain might
do (HHS, 2010b). The starting point for the HHS initiative was recognition of
the high human and economic costs of multiple chronic diseases, many of which
include a substantial pain component. Problems that result from having several
chronic diseases mirror in many ways the challenges experienced by people
with severe chronic pain: “poor functional status, unnecessary hospitalizations,
adverse drug events, duplicative tests, and conflicting medical advice” (HHS,
2010b, p. 2). The kind of systems thinking and stakeholder involvement that went
into the HHS strategic framework parallels what the public health community
could accomplish in pain care.
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PAIN AS A PUBLIC HEALTH CHALLENGE
This is not to say that the committee believes pain management services
should be the sole responsibility of any one public health entity or of public health
personnel. Instead, the committee acknowledges the understanding promulgated
in The Future of the Public’s Health in the 21st Century that a contemporary
public health system calls for “the contributions of other sectors of society that
have enormous power to influence health” (IOM, 2002a, p. 2). With respect to
improving pain management, those sectors include
the health care delivery system, for pain prevention, assessment, treat-
•
ment, and follow-up;
health professions educational institutions, for improvements in educa-
•
tion, mentoring, and modeling of good pain care;
businesses and employers, which influence group health insurance cover-
•
age policies;
the research establishment, for stimulating new understandings of pain
•
that may lead to prevention, early intervention, and new treatments that
are more effective and less problematic;
state and federal policy makers, who must craft policies related to pa-
•
tient safety, dispensing of opioid drugs, regulation of clinicians’ scope
of practice, workers’ compensation programs, drug marketing, insurance
coverage of pain services, and many others;
voluntary health organizations, especially those consumer-oriented
•
groups devoted to pain conditions, but also groups for which pain is a
significant problem for their primary constituents, such as the American
Cancer Society, the American Diabetes Association, the National Alli-
ance on Mental Illness, and many others;
the pharmaceutical and device industries, as they attempt to develop
•
new, more effective, and more targeted analgesics;
accrediting and licensing bodies, which set the educational and practice
•
standards for clinicians; and
the news and information media, which can affect public opinion and
•
increase understanding of acute and chronic pain.
The variety of entities potentially involved in a broad-based effort to improve pain
prevention and management across U.S. society offers promising opportunities
for the kinds of public–private partnerships envisioned in the charge to this com -
mittee (see Chapter 1).
Recently released goals and objectives for Healthy People 2020—“the health
agenda for the nation,” issued by HHS—appear to anticipate a larger public
health role in pain management. Under the Medical Product Safety topic is a
new objective—“Increase the safe and effective treatment of pain”—although this
objective does not explicitly frame a comprehensive or strategic approach to pain,
and three of its four subparts remain under development (Box 2-1).
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58 RELIEVING PAIN IN AMERICA
BOX 2-1
Healthy People 2020 Pain Relief Objectives
Medical Product Safety (MPS) Objective 2: Increase the safe and effective treat-
ment of pain
MPS 2.1 educe the proportion of patients suffering from untreated pain
R
due to a lack of access to pain treatment
MPS 2.2 Reduce the number of nonFDAapproved pain medications*
MPS 2.3 Reduce serious injuries from the use of pain medicines
MPS 2.4 Reduce deaths from the use of pain medicines
*This is the only objective that, as of Healthy People’s December 2010 release, was not
considered “developmental”; however, the committee was unable to obtain a list of non-FDA-
approved pain medications from the FDA.
Medical Product Safety Objective 2.2—“Reduce the number of non-FDA-
approved pain medications”—needs additional clarification. The intent of this
objective is not to address “off-label” uses of drugs for pain,1 but to focus on
drugs whose use predated current strict FDA oversight and that the FDA has
never approved. The committee was unable to obtain a list of these drugs from
the FDA and believes that decisions to withdraw specific medications could have
unintended consequences that would be detrimental to patients. Therefore, such
decisions should be evidence based, transparent, and made in consultation with
clinicians who treat people with pain.
Only two other Healthy People 2020 objectives relate to pain. One focuses
on reducing disability from arthritis and the other on reducing nonmedical use of
prescription drugs, including pain relievers (HHS, 2010a).
Pain—especially severe, chronic pain—interferes with multiple aspects of
the individual’s life and has many consequences. The remainder of this chap-
ter begins by summarizing data from national surveys, as well as independent
research studies, to provide insight into the large number of people with pain
1 Many FDA-approved medications are used for pain “off-label” (that is, they are approved drugs,
but not approved specifically for pain or approved only in specified doses), and these constitute a
significant share of clinicians’ pain care resources, especially for children and the elderly, groups
usually omitted in clinical trials. Off-label use of prescription drugs, in general, is common; an
estimated 21 percent of office-based physicians’ overall use of commonly prescribed drugs is off-label
(Radley et al., 2006). Examples of drugs used off-label for pain care are antiseizure drugs used for
migraine and nerve pain, antidepressants for chronic pain, beta-blockers for migraine, and opioids
for people with only mild or infrequent pain (Consumers Union, 2007).
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PAIN AS A PUBLIC HEALTH CHALLENGE
conditions and the differential impacts of pain on various population groups.
The chapter then examines the seriousness of pain by describing its effects on
daily activities, productivity, and quality of life, as well as its link with suicide;
this section also includes a discussion of differences in the seriousness of pain
by race/ethnicity and sex. Finally, the chapter reviews data on the financial costs
of pain and its treatment before turning to a discussion of an expanded focus on
public health’s role in pain prevention and treatment.
SCOPE OF THE PROBLEM
I have been told to “suck it up”; I have been asked if I was having
trouble at home; I have been accused of being a “druggy” (drug seeking
female). I have also found some practitioners who could “read the tea
leaves,” so to speak, and TELL ME how much pain I must be in, based on
my physical exam.
—A person with chronic pain2
Neuropathic pain has reached an epidemic. More than 6 million
Americans have unrelenting nerve pain. Now it will increase tremendously
because of the epidemic of diabetes.
—Tina Tockarshewsky, The Neuropathy Association,
an advocate for people with chronic pain3
Data Sources and Limitations
Obtaining a definitive picture of the extent and significance of pain is dif -
ficult. Current data on the incidence, prevalence, and consequences of pain are
not consistent or complete, in part because in many cases pain is treated as
a symptom, and what is collected is data on underlying conditions or events
(see Box 2-2). For example, data on health care utilization are organized by
diagnoses (e.g., arthritis or spinal disorders), but the extent to which the pain
of these conditions drove people to the health care system is unclear. Similarly,
2 Quotation from response to committee survey.
3 Quotation from oral testimony to the committee, November 2010.
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60 RELIEVING PAIN IN AMERICA
BOX 2-2
Key Shortcomings of Data on Pain Prevalence in the United States
• here is no standardization of methods, definitions, and survey questions
T
regarding pain used in population-based studies across and within agencies.
• xisting international standards for questions on some aspects of pain (e.g.,
E
low back pain) are not used by U.S. population-based health surveys, hindering
cross-national comparisons.
• ational populationbased health surveys usually do not include people in the
N
military or those living in nursing homes, chronic care facilities, or corrections
facilities.
• n most cases, painrelated questions in national populationbased health
I
surveys are asked only of adults.
• vailable data relate to only a few conditions (e.g., arthritis, low back pain).
A
• eneral items on pain (e.g., pain in the last month) do not describe types of
G
pain.
• cute and chronic pain are not distinguished in available data.
A
• ongitudinal data on consequences of pain are not available, and the data
L
often are old.
• omplete data for population subgroups are unavailable because of these
C
weaknesses (although some differences among subgroups—women, Ameri-
can Indians, those with lower levels of education or income—appear clear).
the reason for a physician visit is recorded as, for example, “knee symptoms”
or “back symptoms,” and while some or all of these visits may have been
prompted by pain, it is impossible to know. In constructing the picture of pain
provided in this chapter, the committee could not rely solely on large epidemio-
logic studies or clinical trials. Such data simply are not available to describe
the full impact of pain from different causes, in different population groups,
or with different impacts. Instead, the committee assembled a variety of types
of data from different types of sources that, taken together, suggest the broad
outlines of the problem.
Furthermore, data on pain from different U.S. federal sources often do not
agree. They are based on different survey questions and methodologies; some
sources rely solely on self-report, while others also check medical records. Seek -
ing insights from cross-national studies can be helpful, but the possibility of
cultural differences in pain expression and expectations of treatment cannot be
ignored, nor can differences in data collection methods that could affect compari -
sons. Moreover, since chronic pain in particular has a lengthy trajectory, longitu -
dinal data on its consequences—medical, financial, social, and otherwise—would
be a valuable resource, but these data are not available. As a result of such limita-
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PAIN AS A PUBLIC HEALTH CHALLENGE
tions, the profile in this chapter cannot be said to be complete, but rather strongly
suggestive of the dimensions of pain in the United States.
The major sources of U.S. population health data including information on
pain are two large, ongoing surveys conducted by the National Center for Health
Statistics (NCHS), an agency within CDC. The first is the National Health Inter-
view Survey (NHIS), an ongoing, cross-sectional household interview survey
of approximately 35,000 U.S. households collectively containing about 87,500
persons. It is large enough to enable analysis of health information for many
demographic and socioeconomic groups. The second is the National Health
and Nutrition Examination Survey (NHANES), which collects data through in-
person interviews and physical examinations of a representative sample of about
5,000 Americans annually. The NHANES includes demographic, socioeconomic,
dietary, and health-related questions; medical, dental, and physiological measure -
ments; and laboratory tests.
Data from national population-based surveys such as the NHIS are very lim-
ited in scope. For example, arthritis and pain questions included in the NHIS 2009
adult questionnaire were restricted to eight pain sites, asked about pain during the
past 30 days, and did not distinguish between acute and chronic or persistent pain
or among types of arthritis (e.g., rheumatoid arthritis, gout). Patterns in the preva-
lence of these pain conditions based on the NHIS questions may not reflect differ-
ences in levels of activity limitation, quality of life, or access to appropriate pain
care. Most important, pain-related conditions such as lupus, sickle-cell disease,
ankylosing spondylitis, and other conditions may not be captured in these data.
Moreover, both the NHIS and the NHANES use samples of civilian, non-
institutionalized populations. They do not include people with chronic pain who
are in the military or live in corrections facilities, nursing homes, or other chronic
care facilities.
In addition to the NHIS and NHANES, the Medical Expenditure Panel
Survey (MEPS), a project of AHRQ, surveys U.S. families and individuals, their
medical providers (doctors, hospitals, pharmacies, etc.), and employers. The
MEPS collects data on the use of health services, their costs, how they are paid
for, and health insurance coverage. Pain data are obtained from both self-reports
and providers’ reports. Given the limitations of and the very high-level picture
provided by these national data sets, this chapter includes findings from a large
number of smaller-scale, independent studies in an attempt to round out the pic -
ture of pain and its effects.
Overall Prevalence
The most prominent feature of pain that qualifies it as a public health prob -
lem is its sheer prevalence, as well as its apparent increase (discussed in the next
section). Of course, estimates of the current prevalence of pain in a population
vary depending on the definitions and methods used. Nevertheless, an interna -
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62 RELIEVING PAIN IN AMERICA
TABLE 2-1 Age-Adjusted Rates of U.S. Adults Reporting Pain in the Last 3
Months, Selected Causes, 2009
Cause of Pain U.S. Average, Adults 18 and Over (%)
Severe headache or migraine 16.1
Low back pain 28.1
Neck pain 15.1
Knee pain 19.5
Shoulder pain 9.0
Finger pain 7.6
Hip pain 7.1
SOURCE: CDC and NCHS, 2010.
tional group of researchers using the World Health Organization’s (WHO) World
Mental Health Survey instrument in 10 developed countries has estimated that
some 37 percent of adults in these populations (age-standardized) have common
chronic pain conditions (Tsang et al., 2008). In the United States, the prevalence
rose to 43 percent, amounting to approximately 100 million adults in 2010—a
conservative estimate as neither acute pain nor children are included.
Recent NCHS data suggest substantial rates of pain from various common
causes. The percentage of Americans 18 and older who, in 2009, reported pain
during the 3 months prior to the survey is shown in Table 2-1. Low back pain was
the most frequently reported pain condition. A review of multiple epidemiologic
studies of pain prevalence in various populations reveals two clear and consistent
messages:
• Musculoskeletal pain, especially joint and back pain, is the most com-
mon single type of chronic pain.
• Most people with chronic pain have multiple sites of pain (Croft et al.,
2010).
Rising Rates of Chronic Pain
An increase in pain prevalence has been recorded for some types of pain in
the U.S. population,4 and chronic pain rates are likely to continue to rise, for at
least five reasons.
First, the aging of the U.S. population means that a growing number of Ameri-
cans will experience the diseases with which chronic pain is associated—diabetes,
cardiovascular disorders, arthritis, and cancer, among others (Cherry et al., 2010).
4 Rising rates of chronic pain are not unique to the United States. A U.K. report, for example, notes
that the prevalence of chronic pain is rising sharply: “chronic pain is two to three times more common
now than it was 40 years ago” (U.K. Department of Health, 2009, p. 34).
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PAIN AS A PUBLIC HEALTH CHALLENGE
Second is the rising prevalence of obesity, which is associated with chronic
conditions that have painful symptoms (diabetes-associated neuropathy, for ex -
ample), as well as orthopedic problems, including cartilage degradation (Richettel
et al., 2011). As a result, more Americans will have joint replacement surgeries
and at younger ages (Harms et al., 2007; Changulani et al., 2008); these surgeries,
in themselves, can cause acute and sometimes persistent pain that interferes with
a full recovery and a resumed quality of life. While it may be readily understood
that increased weight places a greater burden on a person’s bones and joints—
back, knees, hips—obesity also is associated with higher rates of other types of
pain, notably migraine (Peterlin et al., 2009).
Third, progress in saving the lives of people with catastrophic injuries related
to work, sports, vehicle crashes, or military combat who in previous times would
have died creates a group of relatively young people at high risk of lifelong
chronic pain. Similarly, modern medicine can help many people with serious
illnesses survive longer, but the cost of survival may be debilitating pain. As one
example, cancer chemotherapy can cause neuropathic pain.
Fourth, all surgical patients are at risk of both acute and chronic pain as a
result of their procedure. Today, about 60 percent of surgical procedures in U.S.
community hospitals are performed on an outpatient basis, and persistent prob -
lems with adequate pain control after ambulatory surgery are well documented.
People may be discharged before their level of pain can be adequately assessed,
or they may be unable to implement the prescribed pain management strategy at
home. The greatest risk is that undermanaged acute postsurgical pain may evolve
into chronic pain (Rawal, 2007; Schug and Chong, 2009).
Fifth, greater public understanding of chronic pain syndromes and the devel-
opment of new treatments may cause many people who have not sought help or
who previously gave up on treatment to reenter the health care system. Likewise,
those who gain health care coverage under the recent health care reform legisla -
tion may newly seek care. In the past, many of these people were invisible to the
system, so while their emergence does not affect the true number of people with
chronic pain, it increases the size of the population under management.
A study of chronic low back pain conducted in North Carolina found “an
alarming increase in the prevalence of chronic [low back pain] from 1992 to 2006
. . . across all population subgroups.” The prevalence for the total population stud -
ied more than doubled over the period, from about 4 to more than 10 percent, and
for women (all ages) and men aged 45-54, prevalence nearly tripled (Freburger
et al., 2009). Although these data are from a single state, a similar growth pattern
has been seen in national data for users of the Department of Veterans Affairs
health system, which show an annualized increase in prevalence of low back pain
of about 5 percent per year, larger than increases in three other conditions studied
(depression, diabetes, and hypertension) (Sinnott and Wagner, 2009). Further
evidence of rising pain prevalence in the United States, based on NHANES data,
is shown in Table 2-2. (The NHANES collected these data only through 2004.)
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64 RELIEVING PAIN IN AMERICA
TABLE 2-2 Trends in Pain Prevalence, United States, 1999-2004
NHANES NHANES NHANES
People Who Reported Pain in 1999-2000 2001-2002 2003-2004
Previous Month (%) (%) (%)
Age 20 and over 22.2 25.7 27.7
Ages 20 to 44 15.7 19.5 19.6
Ages 45 to 64 28.5 31.7 35.6
Age 65 and over 33.1 34.2 36.3
Men 19.4 23.8 24.8
Women 24.8 27.4 30.4
White (not Hispanic) 24.4 28.6 30.6
Black (not Hispanic) 17.5 21.5 19.1
Mexican American 16.3 13.3 19.6
Below 100% of poverty level 26.3 28.6 29.0
100% to <200% of poverty level 25.4 30.7 29.0
≥200% of poverty level 20.0 23.6 27.9
SOURCE: Unpublished data from the National Health and Nutrition Examination Survey, 1999-2004.
In nearly every demographic group, there has been a steady increase in reporting
of pain prevalence across these surveys.
The potential impact of the growing prevalence of pain on the health care
system is substantial. Although not all people with chronic low back pain are
treated within the health care system, many are, and “back problems” are one of
the nation’s 15 most expensive medical conditions. In 1987, some 3,400 Ameri-
cans with back problems were treated for every 100,000 people; by 2000, that
number had grown to 5,092 per 100,000. At the same time, health care spending
for these treatments had grown from $7.9 billion to $17.5 billion. Thorpe and col-
leagues (2004) estimate that low back pain alone contributed almost 3 percent to
the total national increase in health care spending from 1987 to 2000. While about
a quarter of the $9.5 billion increase could be attributable to increased population
size, and close to a quarter was attributable to increased costs of treatment, more
than half of the total (53 percent) was attributable to a rise in the prevalence of
back problems.
DISPARITIES IN PREVALENCE AND CARE
IN SELECTED POPULATIONS
An important message from epidemiologic studies cited by Blyth and col -
leagues (2010) is “the universal presence across populations of characteristic
subgroups of people with an underlying propensity or increased risk for chronic
pain, in the context of a wide range of different precipitating or underlying dis -
eases and injuries” (p. 282). These vulnerable subgroups are most often those
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PAIN AS A PUBLIC HEALTH CHALLENGE
of concern to public health.5 Increased vulnerability to pain is associated with
the following:
• having English as a second language,
• race and ethnicity,
• income and education,
• sex and gender,
• age group,
• geographic location,
• military veterans,
• cognitive impairments,
• surgical patients,
• cancer patients, and
• the end of life.
Many of these same groups also are at risk of inadequate treatment. Unfortu-
nately, there have been no systematic national studies of rates of undertreatment
among population groups, and the picture of undertreatment must be assembled
from disparate pieces and small-scale studies. These assemblages do not provide
a comprehensive view, but are consistent across population groups and settings.
In fact, “most studies that have evaluated the potential for disparities in pain
treatment on the basis of racial or ethnic differences have found them” (Portenoy
et al., 2004, p. 326). Clearly, however, there is a need for more assessment of
individual and group-related factors involved in seeking treatment for pain. Fac-
tors that discourage people from seeking treatment might include not only the
typical and well-documented access barriers, such as lack of a usual source of
care, but also “low levels of trust in clinicians, poorer expectations of treatment
outcomes, language barriers and communication difficulties” (Dobscha et al.,
2009, p. 1078). Under health care reform, increased access to health insurance
may reduce rates of undertreatment, but the number of clinical, provider, and
patient factors involved complicates the situation.
English as a Second Language
Census 2000 indicated that nearly three-quarters of Asian Americans spoke
a language other than English at home, and almost 4 million Asian Americans
were “low-English proficient” (Ro et al., 2009). Language problems are faced by
many other groups as well. The largest group with such problems is the Hispanic
population, with 28.1 million who speak Spanish at home and 13.8 million
who speak English “less than very well” (Shin and Bruno, 2003). Non-English
5 The nomenclature used for different national, ethnic, and racial groups in this section of the report
is that of the original sources.
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102 RELIEVING PAIN IN AMERICA
seriousness, and trajectories of pain, as well as the effectiveness of pain
treatments. This information can guide decision makers, including pub -
lic and private payers, and foster more efficient and effective pain care.
Finding 2-3. A population-based strategy for reducing pain and its conse -
quences is needed. The committee finds that, to effect changes that will reach
the millions of American adults living with pain, account for differences in the
experience of pain among population groups, and address selected environmental
factors that contribute to the consequences of pain, a population health-level
strategy is needed. A comprehensive and coordinated strategy would
• e
ncourage and foster the prevention of pain;
• h
eighten national concern about pain as a health care quality and safety
issue;
• u
se public health communication strategies to ensure that patients under-
stand their role in managing their own pain;
• i
dentify and attempt to remediate relevant environmental factors, espe-
cially those that adversely affect children and start them on a path to
chronic pain as adults; and
• i
nform members of the public about what chronic pain is, how they can
help loved ones who have it, and how they may be able to help prevent
it for themselves and others.
Recommendation 2-2. Create a comprehensive population health-
level strategy for pain prevention, treatment, management, and re-
search. The Secretary of the Department of Health and Human Services
should develop a comprehensive, population health-level strategy for
pain prevention, treatment, management, education, reimbursement, and
research that includes specific goals, actions, time frames, and resources.
This strategy should
• D
escribe how efforts across government agencies, including public–
private partnerships, can be established, coordinated, and integrated
to encourage population-focused research, education, communica -
tion, and community-wide approaches that can help reduce pain and
its consequences and remediate disparities in the experience of pain
among subgroups of Americans.
• I
nclude an agenda for developing physiological, clinical, behav-
ioral, psychological, outcomes, and health services research and
appropriate links across these domains (consistent with Recom -
mendations 5-1 through 5-4).
• I
mprove pain assessment and management programs within the
service delivery and financing programs of the federal government.
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PAIN AS A PUBLIC HEALTH CHALLENGE
• P
roceed in cooperation with the Interagency Pain Research Coordi-
nating Committee and the National Institutes of Health’s Pain Con -
sortium and reach out to private-sector participants as appropriate.
• I
nvolve the following agencies and entities:
— Federal agencies and departments
- National Institutes of Health
- Centers for Disease Control and Prevention
- Food and Drug Administration
- Centers for Medicare and Medicaid Services
- Agency for Healthcare Research and Quality
- Health Resources and Services Administration
- Indian Health Service
- Department of Defense
- Department of Veterans Affairs
— Private-sector entities
- Pain advocacy and awareness organizations
- Health professions associations
- Health care providers (e.g., accountable care organizations)
- Health professions educators, colleges, and training programs
- Private insurers
- Accreditation (e.g., Joint Commission, National Committee
for Quality Assurance), certification (e.g., American Board of
Medical Specialties), and examination (e.g., National Board
of Medical Examiners) organizations
— State-level entities
- Health professions licensing authorities
- Workers’ compensation programs
- Medicaid programs
- State health departments.
• I
nclude ongoing efforts to enhance public awareness about the nature
of chronic pain and the role of self-care in its management.
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Canberra, Australia: MBF Foundation in collaboration with the University of Sydney Pain
Management Research Institute.
AHRQ (Agency for Healthcare Research and Quality). 2011. National healthcare disparities report.
AHRQ Publication No. 11-0005. Washington, DC: ARHQ.
Alexander, J., and M. Manno. 2003. Underuse of analgesia in very young pediatric patients with
isolated painful injuries. Annals of Emergency Medicine 41(5):617-622.
American Geriatrics Society. 2009. Pharmacological management of persistent pain in older persons.
Journal of American Geriatrics Society 57(8):1331-1346.
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Anderson, K. O., C. R. Green, and R. Payne. 2009. Racial and ethnic disparities in pain: Causes and
consequences of unequal care. Journal of Pain 10(12):1187-1204.
Barber, J. B., and S. J. Gibson. 2009. Treatment of chronic non-malignant pain in the elderly: Safety
considerations. Drug Safety 32(6):457-474.
Barnes, P. M., P. F. Adams, and E. Powell-Griner. 2008. Health characteristics of the Asian adult
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