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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, vulnerable 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 Americans 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 differential burden on vulnerable subgroups, and is affected by conditions in the social, physical, and economic environments, a comprehensive pain prevention and



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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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57 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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59 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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61 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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63 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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65 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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103 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. REFERENCES Access Economics. 2007. The high price of pain: The economic impact of persistent pain in Australia. 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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