THE FOLLOWING IS A POST FROM: (I THINK IT’S RELEVANT AND HOPE IT EDUCATES.)
: AUGUST 2011 | VOLUME: 9:08
Declaring that the diagnosis and treatment of pain in America are woefully inadequate, the Institute of Medicine (IOM) is urging a multifaceted approach to transforming virtually all aspects of pain management. Recommendations include increasing federal and private funding for research into new pain medications and therapies, offering additional training and education for primary care physicians and clinicians and reforming payment policies so physicians can be reimbursed for spending additional time with patients and for interdisciplinary collaborations with therapists and other specialists.
Overall, the IOM report estimates that acute and chronic pain afflict at least 116 million adults in the United States annually and are responsible for $560 billion to $635 billion in direct medical costs and lost productivity—a conservative estimate that does not include costs associated with people who are institutionalized, in the military or younger than 18 years.
“Given the large number of people who experience pain and the enormous cost in terms of both dollars and the suffering experienced by individuals and their families, it is clear that pain is a major public health problem in America,” said Philip Pizzo, MD, dean of medicine and professor of pediatrics, microbiology and immunology at Stanford University School of Medicine, Palo Alto, Calif., and chair of the IOM Committee on Advancing Pain Research, Care, and Education. “Pain is an experience that affects virtually every one of our citizens. For many patients, chronic pain becomes a disease itself,” Dr. Pizzo said at a briefing releasing the report in June.
According to the report, chronic pain requires direct treatment and should not be sidelined “while clinicians attempt to identify some underlying condition that may have caused it.” The biomedical research community should pursue pain research with the same vigor it extends to other serious and disabling chronic conditions.
The report calls for a “cultural transformation” in how clinicians and the public view pain and pain treatment. All too often, patients with pain are treated with suspicion and skepticism, which hinders effective treatment and care. Many physicians also are hesitant to prescribe pain medications, especially opioids, to patients because of concerns about abuse and diversion as well as fear of attracting the attention of law enforcement authorities.
“There’s abuse on both sides,” Dr. Pizzo said. “There is abuse that occurs when individuals are drug seeking and abuse that occurs in that people who need pain medications may not have access because physicians won’t prescribe or the state has regulatory barriers,” he said. Nevertheless, when used as prescribed and appropriately monitored, opioids can be safe and effective, especially for acute, postoperative and procedural pain, according to the report.
Recommendations for Research
Even though chronic pain affects one in three people in the United States, federal research efforts into pain are fragmented and underfunded. The report asks the National Institutes of Health (NIH) to designate an institute responsible for coordinating and advancing pain research.
“There’s a huge disconnect between what we’re spending on pain research—somewhere between $200 [million] and $300 million per year—and what the problem of pain is costing the nation,” said committee member Charles E. Inturrisi, PhD, professor of pharmacology, Weill Cornell Medical College, New York City, and immediate past president of the American Pain Society. “We need much more funding at the NIH level, because that’s the major source for new targets and new approaches.”
Because the cause and experience of pain is highly personal, the report recommends a “multifactorial” research approach including an analysis of genetics, psychological and environmental factors and social and cultural histories as well as the development of objective metrics for defining response. Promising research areas include identifying biomarkers and biosignatures for pain and pain responses, further characterizing ion channels for pain blocks and targeting glial cells to modify or eliminate pain.
Although the FDA approved nearly 100 new drugs from 2005 to 2009, only a handful of these were for chronic pain conditions, specifically arthritis and fibromyalgia. To this end, the report also requests that researchers devote more resources to developing novel pain control agents and that the FDA develop “new and expeditious ways” to evaluate and approve new pain therapies.
“We recommend stronger public–private partnerships to advance pain research and to reduce regulatory barriers to bringing effective pain treatments to market,” said Sean Mackey, MD, PhD, chief of the Pain Management Division, Stanford University School of Medicine, and another committee member.
Randomized controlled trials (RCTs) remain the gold standard for determining the safety and efficacy of new drugs, but the report acknowledges “significant problems” in using RCTs in pain research, namely their limited ability to predict effectiveness in larger populations. In particular, older adults with comorbidities and who take multiple medications often are excluded from RCTs, yet they are among those who experience pain the most.
“I think we need new, novel approaches. For example, it’s important that we do population-based effectiveness research,” said Dr. Inturrisi. “That would include what we call real-world patients with all of their comorbidities so that we can begin to identify patient characteristics and perhaps even biomarkers that predict better outcomes. These will then help us to design better drugs and better therapeutics.”
Recommendations for Training
According to the report, the patient and the primary care physician or clinician should conduct most of the pain care and management, reserving referrals to specialty services for recalcitrant or more complex cases. But many health care professionals are not adequately trained in pain care and management. For instance, only five of the nation’s 133 medical schools have required courses on pain, and just 17 offer elective courses. In addition to expanding education and training, the report recommends that licensing and certification exams should include pain-related assessments.
Pain specialists were not upset by the emphasis placed on self-care and primary care. “The extent and amount of pain is so widespread, there is much more there than can be dealt with solely by pain specialists,” said Standiford Helm, MD, president of the American Association of Interventional Pain Physicians (ASIPP).
Recommendations for Reimbursement
The report also calls on Medicare, Medicaid, private health plans and workers’ compensation programs to expand patient-centered pain care treatment and to cover interdisciplinary pain care management efforts. The report notes, however, that current reimbursement systems do not efficiently pay for these approaches, and most health care organizations are not organized to support integrated patient management.
Examples of “barriers” in billing and coverage include minimal capacity for frequent physician visits when needed, limited time allocated for comprehensive patient assessment and lack of reimbursement for needed specialty care services, interdisciplinary practice, psychosocial and rehabilitative services and time spent in planning and coordinating care.
“We often want to get cognitive-behavioral or physical therapy consultations to see if helping patients deal with the stress of having chronic pain or reconditioning will help,” Dr. Helm said. “But insurance coverage is a barrier to these services.”
Although it welcomed the report’s recommendations, the ASIPP noted that the study did not fully include interventional pain procedures in the diagnosis and treatment of chronic pain conditions. “The report doesn’t give enough weight to interventional pain procedures as a modality to reduce pain and increase function,” Dr. Helm said.
Other professional associations and advocacy groups generally lauded the report’s findings. “We hope that this landmark report sounds the siren call for greater attention to pain issues by both public and private sector policymakers and by the nation as a whole,” said a statement jointly issued by 35 organizations, including the American Academy of Neurology, the American Academy of Pain Management, the American Pain Foundation and the American Pain Society. “We hope the recommendations of the report lay a clear path toward much-needed improvements in pain research, care, education, and treatment.”