• *Relieving Pain in America*

    Below are my notes from skimming Relieving Pain in America, by the IOM (2011). The report covers the following topics, among others:

    • What pain is, who gets it, its impact on health
    • The prevalence and cost of pain and its treatment
    • Types of pain care
    • Opioid abuse
    • Pain care under different types of insurance and systems, including the Department of Veterans Affairs
    • Education and research challenges
    • Problems with RCTs in studying pain and what’s been done about them

    All of the following are quotes. I’ve left out links to references since you can freely download the report and find them yourself.*

    • Acute and chronic pain affects large numbers of Americans, with approximately 100 million U.S. adults burdened by chronic pain alone. [Page 1 and similar on many other pages]
    • Section 4305 of the 2010 Patient Protection and Affordable Care Act required the Secretary, Department of Health and Human Services (HHS), to enter into an agreement with the IOM for activities “to increase the recognition of pain as a significant public health problem in the United States.” [Page 2]
    • [S]ome types of chronic pain are diseases in their own right. […] Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it. [Page 4]
    • [T]he annual economic cost of chronic pain in the United States is at least $560-635 billion. This estimate combines the incremental cost of health care ($261-300 billion) and the cost of lost productivity ($297-336 billion) attributable to pain. The federal Medicare program bears fully one-fourth of U.S. medical expenditures for pain; in 2008, this amounted to at least $65.3 billion, or 14 percent of all Medicare costs. In total, federal and state programs—including Medicare, Medicaid, the Department of Veterans Affairs, TRICARE, workers’ compensation, and others—paid out $99 billion in 2008 in medical expenditures attributable to pain. Lost tax revenues due to productivity losses compound that expense. [Page 5]
    • National Health and Nutrition Examination Survey (NHANES) data show that during the 7-year period 1988- 1994, 3.2 percent of Americans reported using opioids for pain (2.8 percent of men and 3.6 percent of women). During the 4-year period 2005-2008, by contrast, 5.7 percent of the population was using these drugs (5.2 percent of men and 6.2 percent of women), including 7 percent of people 65 and older. [Page 130]
    • A meta-analysis found [rehabilitation/physical therapy] programs achieved significant reductions in both pain intensity and use of pain medications (Hoffman et al., 2007). […] Rehabilitative/physical therapy has increasingly been found to reduce pain even in end-of-life situations, such as advanced cancer (Chang et al., 2007). […] A systematic review of 18 randomized controlled trials showed that physical conditioning programs “seem to be effective in reducing the number of sick days for some workers with chronic back pain, when compared to usual care” (Schonstein et al., 2003, p. 1). […] A meta-analysis of 20 studies showed that exercise had a statistically significant effect in reducing disability for work over the long term but not over the short or intermediate term (Oesch et al., 2010). […] In a systematic review of 43 studies of exercise for chronic low back pain, the researchers concluded that only 6 showed statistically significant and clinically important results in improving functioning, and only 4 showed such results in reducing pain intensity (van Tulder et al., 2007). [Pages 133-134]
    • Health professionals’ general awareness of the importance of pain and recognition of the need to ask patients about it have been buttressed by efforts of the Joint Commission to establish and enforce pain management standards (Phillips, 2000). Beginning in 2001, following the lead of pain medicine professional associations and the Department of Veterans Affairs, the then Joint Commission on Accreditation of Healthcare Organizations introduced a new hospital accreditation standard that requires monitoring of patients’ pain level as a “fifth vital sign.” […] The Joint Commission’s effort quickly led to clinically appropriate increases in opioid use in postanesthesia care units (Frasco et al., 2005). It also led many health facilities to implement routine efforts to relieve patients of pain immediately, identify and address causes of pain, initiate treatments other than medication, and prevent postsurgical acute pain from developing into chronic pain. […] In a veterans’ outpatient clinic, monitoring pain as a fifth vital sign failed to improve pain management as the assessment was not followed up with recommended treatment, even for patients reporting substantial pain (Mularski et al., 2006). Similarly, in a study of eight veterans’ facilities in the Los Angeles area, documentation of pain—necessary for pain care planning—was frequently absent from the medical records of patients with moderate and severe pain (Zubkoff et al., 2010). Taken together, these studies suggest the need to exercise careful clinical judgment based on a comprehensive patient assessment instead of merely monitoring pain (meeting, in a sense, the letter of the law and not the spirit), using opioids to the exclusion of other treatment approaches, or routinely using these powerful medications when their use is not clinically indicated. [Pages 138-139]
    • Despite the many variables involved in people’s responses to pain, different measures of pain can yield consistent results. For low back pain, high degrees of correlation have been found among three different types of measures: a patient’s global assessment of response to therapy (often a score given by the patient from zero to 4), a well-validated questionnaire about the extent of pain-related disabilities, and use of a “visual analog” or graphic rather than a numeric scale to report pain levels (Sheldon et al., 2008). [Page 140]
    • The April 2011 White House comprehensive action plan on prescription drug abuse notes that “. . . any policy in this area must strike a balance between our desire to minimize abuse of prescription drugs and the need to ensure access for their legitimate use” (The White House, 2011, pp. 1-2). While most of the plan’s provisions relate to substance abuse, it does include some measures to assess the adequacy and effectiveness of pain treatment and to “facilitate appropriate prescribing, including development of Patient-Provider Agreements and guidelines” (The White House, 2011, p. 4). The same day the White House action plan was released, the Food and Drug Administration (FDA) announced that it will require an Opioids Risk Evaluation and Mitigation Strategy (REMS) (Okie, 2010; FDA, 2011) for all extended release and long-acting opioid medications. [Pages 142-143]
    • A reasonable degree of access to pain medication—such as the stepped approach of the World Health Organization’s Pain Relief Ladder for cancer—has been considered a human right under international law since the 1961 adoption of the U.N. Single Convention on Narcotic Drugs (Lohman et al., 2010; WHO, 2011). Similarly, countries are expected to provide appropriate access to pain management, including opioid medications, under the International Covenant on Economic, Social, and Cultural Rights, which guarantees “the highest attainable standard of physical and mental health” (Brennan et al., 2007, p. 213). [Page 143]
    • Certainly in recent years, opioid prescriptions for chronic noncancer pain have increased sharply (Dhalla et al., 2009; Chapman et al., 2010). According to the White House action plan, between 2000 and 2009, the number of opioid prescriptions dispensed by retail pharmacies grew by 48 percent—to 257 million (The White House, 2011). But are patients who really need opioids able to get them? Twenty-nine percent of primary care physicians and 16 percent of pain specialists report they prescribe opioids less often than they think appropriate because of concerns about regulatory repercussions (Breuer et al., 2010). […] The effectiveness of opioids as pain relievers, especially over the long term, is somewhat unclear. [A lit review follows, omitted here. Pages 143-144]

    * Plus, this “research notebook” post is principally for a future me. Delighted if you also find it of value, but I’m clearly not trying to write a complete piece for a general audience here.


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