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Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Index

A

Abuse. See also Medications for pain of opioids, 146–147

Acceptance, new emphasis on, 44

Access to opioid analgesics, 142–148

abuse of opioids, 146–147

effectiveness of opioids as pain relievers, 144–145

need for education, 145–146

opioid use and costs of care, 147–148

patient access to opioids, 143–144

Access to pain care, 127–128

Accreditation Council for Graduate Medical Education (ACGME), 193, 200, 210

Acetaminophen, 130

Activities of daily living, effects of pain on, 86, 139

Acupuncture, 135–136, 208

Acute pain, 1, 32–33, 277

better treatment for, 100

choice of a treatment approach for, 124, 126

common sources of, 29

Addiction, 36, 277

Adequacy of pain control, in hospitals and nursing homes, 140–141

Adherence to drug regimen, problems with, 131

Adjusting to pain. See Pain adjustment

Advance directives, campaigns to educate about, 188

Advocates, for patients with chronic pain, 24, 31, 34, 115, 184, 190, 224, 228, 239

Afghanistan conflict, 81, 157–158

African Americans, disparities in prevalence and care for, 67–70, 310

Agency for Healthcare Research and Quality (AHRQ), 6, 12–13, 56, 61, 72, 99, 101, 143, 189, 249, 253–254, 304

Aging, conditions associated with, 79

Alaska Natives, disparities in prevalence and care for, 72–73

Allodynia, 35, 277

Allostatic load, 37, 277

Alternative medicine. See Complementary and alternative medicine (CAM) services

Alzheimer’s Association, 189

Alzheimer’s disease, campaigns to educate about, 188–189

Alzheimer’s Disease Education and Referral Center, 189

American Academy of Family Physicians, 197

American Academy of Neurology, 199, 249

American Academy of Orofacial Pain, 120

American Academy of Orthopedic Surgeons, 303

American Academy of Pain Management, 120

American Academy of Pain Medicine, 120, 123

American Association of Colleges of Nursing, 202

American Association of Naturopathic Physicians, 209

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

American Association of Orthopaedic Medicine, 209

American Back Society, 120

American Board of Anesthesiology, 121, 198

American Board of Medical Specialties (ABMS), 198–199, 210

American Board of Pain Medicine (ABPM), 198

American Cancer Society (ACS), 57, 143, 188, 239

American Chronic Pain Association, 34, 189

American College of Emergency Physicians, 203

American Dental Association (ADA), 207

American Diabetes Association, 57

American Geriatrics Society, 143

Foundation for Health in Aging, 189

American Headache Society, 120

American Heart Association, 239

American Holistic Medical Association, 208–209

American Indians, disparities in prevalence and care for, 72–73

American Medical Association (AMA), 120 Pain and Palliative Medicine Specialty Section Council, 191

American Medical Directors Association, 143

American Neurological Association, 199

American Nurses Association (ANA), 203

American Nurses Credentialing Center, 203

American Pain Foundation (APF), 145, 189, 300

American Pain Society, 120, 143, 203

Clinical Centers of Excellence Awards Program, 161

American Physical Therapy Association, 207

American Productivity Audit telephone survey, 86

American Psychological Association (APA), 205–206

Committee on Accreditation, 210

American Recovery and Reinvestment Act, 245

American Society for Pain Management Nursing, 120, 203

American Society of Interventional Pain Physicians, 120

American Society of Regional Anesthesia and Pain Medicine, 120

American Urological Association, 248

Analgesia, 31, 71, 76, 277

Analgesic Clinical Trials, Innovations, Opportunities, and Networks (ACTION) initiative, 231–232, 246

Anesthetic interventions, for treating people with pain, regional, 131

Anger, 4, 42

Annex 5-1. See “Mechanisms, Models, Measurement, and Management in Pain Research Funding Opportunity Announcement” Antianxiety medication, 78

Anxiety, 4, 41

Arthritis, improvements in, 118

Asian Americans

disparities in prevalence and care for, 71–72, 310

language problems for, 65

Assessment

dimensions of pain, 236–237

ongoing, and monitoring of pain and pain-related states, 238

of pain, 8, 138, 164–165, 262–263

of psychological traits and states related to pain adjustment, 237–238

Assistance with Pain Treatment, 122

Association of American Medical Colleges, 194

Australia

national cost of pain in, 92–93

public education campaign on low back pain, 97, 185–186

Avoidance, about pain, 88

B

Back Beliefs Questionnaire (BBQ), 185–186

Barriers to effective pain care, 8–9, 152–157

cultural attitudes of patients, 156–157

geographic barriers, 157

insurance coverage, 156

magnitude of the problem, 9, 153

provider attitudes and training, 153–156

regulatory barriers, 157

written public testimony on, 294

Barriers to improving pain care

clinician-level barriers, 45–46

overview of, 45–47

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

patient-level barriers, 46–47

potential savings from improvements in, 100

system-level barriers, 45

Basic knowledge

biomarkers and biosignatures, 221–222

conclusion, 223

expanding, 220–223

opportunities in psychosocial research, 223

other promising basic research, 222–223

Behavioral Risk Factor Surveillance System survey, 147

Behavioral therapy, 132–133, 299

Beliefs, 42, 71, 277

about pain, 183, 185

Best Pharmaceuticals for Children Act, 78

Biofeedback, 132, 226

Biological changes, caused by pain, 31

Biological factors in pain, 24

Biomarkers and biosignatures, 220–222

Biomarkers Consortium, 247

“Biopsychosocial model,” 35, 42, 115, 127, 227, 277

education in, 183, 219–220

Blueprint for transforming pain prevention, care

education, and research, 14–17, 269–275

immediate goals, 272–273

near-term and enduring goals, 273–275

Brain, role in the causes and persistence of pain, 38–40

Brennan, F., et al., 34

Brief Pain Inventory, 237

Brigham and Women’s Pain Management Center, 161

British Pain Society, 219

Bureau of Health Professions, 210

Bureau of Labor Statistics, 80

C

Canada, public education campaign on low back pain, 186

Cancer patients, 314

disparities in prevalence and care for, 84

fear in, 43

Cardiovascular patients, 131

Care of people with pain, 113–177. See also Barriers to improving pain care

barriers to effective pain care, 153–157

blueprint for transforming, 14–17, 269–275

conclusion, 161

findings and recommendations, 161–165

issues in pain care practice, 137–152

models of pain care, 158–161, 227–228

outcomes-based, 298

overtreating, 299

potential savings from improvements in, 100

treatment modalities, 129–137

treatment overview, 115

Cartesian model, of mind-body separation, 35

Catastrophic injuries and diseases, x, 81. See also Pain catastrophizing

Causes of pain, 34–44

the brain’s role, 38–40

cognitive context, 42–44

the complexity of chronic pain, 34–36

emotional context, 40–42

genetic influences, 36–37

nerve pathways, 38

pain in childhood, 37

Center for Studying Health System Change, 148

Centers for Disease Control and Prevention (CDC), 12–13, 56, 99, 189, 253

Centers for Medicare and Medicaid Services (CMS), 11–13, 82–83, 210, 249, 254

Minimum Data Set, 83

Centers of Excellence in Primary Care Education, 203

Central sensitization, 33

Cerebrovascular disease, 82

Certifying physicians, 198, 210

Challenges. See Education challenges; Research challenges

Children

causes and persistence of pain in, 37

disparities in prevalence and care for, 77–78, 192

Chiropractic spinal manipulation, 135, 208

Choice of a treatment approach, 124–127

environmental factors affecting, 125

individual-related factors affecting, 125

pain-related factors affecting, 125

Chronic fatigue syndrome, 75

Chronic pain, 1, 32–33, 278, 295

choice of a treatment approach for, 126–127

common sources of, 29

complexity of, 34–36, 300

as a disease in itself, 4, 26

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

growing public understanding of, 63

inversely related to socioeconomic status, 74–75

life-cycle factors associated with the development of, 30

reductions in complications associated with, 100

Chronic Pain Policy Coalition, 219

City of Hope National Medical Center, 204

Clinical Centers of Excellence Awards Program, 161

Clinical pharmacy specialist, 129

Clinical Trials Transformation Initiative, 231

Clinician-level barriers, to improved pain care, 45–46

Clinicians, roles for, 3, 22

CME credit, 193, 195–196

Cognitive-behavioral therapy, 43, 132, 207, 226, 278

Cognitive context, of the causes and persistence of pain, 42–44

Cognitive impairments, disparities in prevalence and care for people with, 82–83

Collaboration, need to support, 9, 163–164

Collins, Francis S., 240

Commission on Accreditation of Rehabilitation Facilities, 123

Commissioned paper, 283, 301–337

Committee on Accreditation (of the APA), 210

Committee on Advancing Pain Research, Care, and Education, 301

Agendas for Public Sessions, 284–291

charge to, 2

description of, x, 281, 339–348

Committee on Dental Accreditation (CODA), 206

Common Fund (of the NIH), 241

Community-based approach, value of, 3

Comparative effectiveness research (CER), 228, 232–234

Competency-based education, 197

Complementary and alternative medicine (CAM) services

education in, 208–209

reduced costs associated with, 93

for treating people with pain, 93, 134–136

Complexity of pain, 8, 24–26. See also Unknown causes of pain

Comprehensive Pain Center of Sarasota, Florida, 161

Comprehensive Severity Index (CSI), 235

Comptroller General of the United States, 248

Concerns about opioid analgesic use, 142–148

abuse of opioids, 146–147

effectiveness of opioids as pain relievers, 144–145

need for education, 145–146

opioid use and costs of care, 147–148

patient access to opioids, 143–144

Consumer Price Index (CPI), Medical Care inflation index of, 302

Control variables, in the economic costs of pain, 306–307

Cost models for selected pain conditions incremental, 316–317

indirect, 323–324

Costs of pain and its treatment, 91–95. See also Direct costs; Economic costs of pain; Emotional cost of pain; Incremental costs; Indirect costs

to families, 94–95

to the nation, 56, 91–93

opioid use and, 147–148

and savings from a public health approach, 100

Counseling, 4

Cowan, Penny, 34

Cowley, Terrie, 184, 217, 224

COX inhibitors, 225

Credentialing physicians, 198

Croft, P., et al., 95

Cross-fertilization of ideas, 45, 121

Cross-sectional analysis, 314

Cultural attitudes of patients, a barrier to effective pain care, 156–157

Cultural transformation, 47–49

and barriers to improved pain care, 45–47

need for, 44–49, 209, 250–251

in the way pain is viewed and treated, 3–4

Current partnership activities, 245–248

D

Daily living. See Activities of daily living

Data on the economic costs of pain, 304–307

control variables, 306–307

dependent variables, 305–306

key independent, 305

sample, 304–305

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Data sources and methods, 281–291. See also Economic Costs of Pain in the United States, The

commissioned paper, 283, 301–337

description of the study committee, 281

and limitations, 59–61

literature review, 282

need to improve, 6, 101–102, 123–124

public meetings, 282–291

shortcomings of, 60

Databases, 234–236

Grey Literature, 282

Workers’ Compensation, 304

Deficits, in problem-solving ability, 88

Dementia, 83

Dentistry, education in, 204, 206–207

Department of Defense, 13, 56, 81, 114, 246, 253

model of pain care, 160

Department of Health and Human Services (HHS), 2, 7, 20, 56, 102

Department of Veterans Affairs, 5, 13, 56, 80–82, 93, 114, 122, 206, 246, 253

Centers of Excellence in Primary Care Education, 203

model of pain care, 158–160

Pain Research Program, 242

Dependent variables, for the economic costs of pain, 305–306

Depression, xi, 4, 41, 70, 88, 118

Descartes, René, 34

Diagnosing pain. See Pain diagnoses

Direct costs

for medical care for pain diagnoses, 312–313

for selected pain conditions, 337

Disability. See Functional disability; Pain-related disability; Work disability

Discussion, on the economic costs of pain, 313–314

Disease. See also Catastrophic injuries and diseases

chronic pain as, 3, 22, 26

chronic pain developing into, ix

validation accorded by, x

Disparities in prevalence and care. See also Health disparities

by age group, 77–80

of pain in children, 77–78

of pain in the elderly, 78–80

Drug Enforcement Administration (DEA), 97, 297

Drugs for pain. See Medications for pain

Duke University, 231

Dysmenorrhea, 33

E

Economic costs of pain

control variables, 306–307

data on, 304–307

dependent variables, 305–306

key independent, 305

sample, 304–305

written public testimony on, 296

Economic Costs of Pain in the United States, The, 301–337

background, 302

conclusion, 303

data, 302, 304–307

discussion, 313–314

estimation strategy, 307–309

Education

competency-based, 197

Internet-based, 197

potential savings from improvements in, 100

Education challenges, 10, 179–216

about opioid analgesic use, need for, 145–146

blueprint for transforming, 10–11, 14–17, 269–275

in complementary and alternative medicine (CAM), 208–209

conclusion, 209

in dentistry, 206–207

findings and recommendations, 209–210

for the health professions, 56, 163, 204–209

nurse education, 201–204

patient education, 180–184

for patients, 180–184

in pharmacy, 208

in physical and occupational therapy, 207–208

physician education, 190–201

of primary care physicians, 196–198

in psychology, 204–206

public education, 184–190

tools useful in reaching the public, 187–188

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Educational background, disparities in prevalence and care by, 73–75

Effectiveness, of opioids as pain relievers, 144–145

Effects of pain

on activities of daily living, 86

on productivity, 86–87

on quality of life, 87–88

on the risk of suicide, 88–89

Elderly, disparities in prevalence and care for, 78–80

Electronic health record systems, 101

Electronic prescription monitoring system, calls for, 298

Emergency Nurses Association, 203

Emotional context, of the causes and persistence of pain, 40–42

Emotional cost of pain, 5

Emotional support, importance of, 95

End of life

disparities in prevalence and care for people at, 85

pain and suffering at, 141–142, 188

Endometriosis, 75, 78

Enduring goals, for transforming pain prevention, care, education, and research, 271, 273–275

English as a second language, disparities in prevalence and care for patients with, 65–66

Environments

as factors in pain, 36

unhealthy, 37

unsafe, 96

Epidemiology, of pain, 264–265

Estimation strategy for the economic costs of pain, 307–309

health care expenditure models, 307–308

indirect cost models, 308–309

Ethnicity. See Racial and ethnic factors

Evidence-based pain care. See Pain care

Exercise, in pain management, 133–134

Existing knowledge, wider use of, 3, 22

Expenditure models, total, for selected pain conditions, 319–320

Expenditures, for selected pain conditions, 318

Experiences providing pain treatment, written public testimony on, 294

F

Families

costs of pain and its treatment to, 94–95

viewed as entities, 94

Fatalism, “deeply-rooted value and belief in,” 71

Fatigue, xi. See also Chronic fatigue syndrome

Federal agencies. See also individual agencies and departments

role of, 56

Federal research funding, obtaining, 244–245

Federation of State Medical Boards, Medical and Osteopathic Practice Act (model), 191

Ferrell, Betty, 202

Fibromyalgia, 75, 121, 137, 153

Fifth vital sign approach, 139–141

Findings and recommendations, 4–13, 100

audiences for, 23, 57

in caring for people with pain, 8–10, 161–165

conclusions, 4, 13

education challenges, 10–11, 209–210

public health challenges, 5–7, 100–103

research challenges, 11–13, 250–254

First National Pain Medicine Summit, 191

Food and Drug Administration (FDA), 12–13, 56, 99, 142, 224, 230, 252

Office of Critical Path Programs, 231

Regulatory Science Initiative, 224

Foundation for Health in Aging, 189

Functional disability, 310–314

Functional neuroimaging, to investigate pain, 39

Functioning, hampered by pain, xi, 139–140

Future of the Public’s Health in the 21st Century, The, 57

G

Gaskin, Darrell J., 301–337

Gender

differences in the seriousness of pain by, 89–90

disparities in prevalence and care by, 75–77

Generalized linear model, hourly wages

models for selected pain conditions, 332–333

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Genetic factors in pain, 36–37, 221–222, 260

Genomic data, 233, 235

Geographic barriers, to effective pain care, 80, 157

Glial cells, 222, 260

“Global Year Against Acute Pain,” 219

Goals, for transforming pain prevention, care, education, and research, 270–271, 273–275

Gooddy, William, 191

Grey Literature database, 282

Guidelines for Teaching the Comprehensive Control of Pain and Sedation to Dentists and Dental Students, 207

H

Headaches, 136

fiscal challenge of caring for, 149

migraines, 87

Healing, pain persisting after, 35

Health. See also Pain as a public health challenge

impact of pain on physical and mental, 31–32

influence of occupational rank on, 74

Health and Retirement Study, 68, 72

Health care expenditure models, estimation strategy for, 307–308

Health disparities, 265–266

Health literacy, 66

low rates of, 66

Health Psychology Network, 205

Health Resources and Services Administration, 11, 210

Healthcare Effectiveness Data and Information Set (HEDIS), 149–150

Healthy People 2020, 57–58

Pain Relief Objectives, 58

Heart surgery, complications following, 84

Heckman selection models, 309

Helplessness, about pain, 88

Herman, Gwenn, 180

Hip replacement surgeries, 132

Hispanics

disparities in prevalence and care for, 70–71, 310

language problems for, 65–66

HMO Research Network, 234

Hopelessness, about pain, 88

Hospice patients, 85, 141–142

Hospitals, adequacy of pain control in, 140–141

Hourly wage reductions

for adults with selected pain conditions, 327

due to selected pain conditions, 336

Hourly wages models, for selected pain conditions, logistic regression and generalized linear, 332–333

Hours worked. See also Missed hours models for adults with selected pain conditions, 312, 326

Hurricanes, 157

Hydrocodone, 130

Hyperalgesia, 35, 278

Hypnosis, 132–133, 226

I

Ibuprofen, 130

Imaging, to investigate pain, 38–39

Immediate goals, for transforming pain prevention, care, education, and research, 270, 272–273

Impact of pain, written public testimony on, 295

Improving pain care, written public testimony on, 294

Income, disparities in prevalence and care by, 73–75

Incremental cost models, for selected pain conditions, dependent and independent variables used in, 316–317

Incremental costs

of health care, 308–311

of medical expenditures, by source of payment, 322

of medical expenditures for selected pain conditions, 321

of number of days of work missed because of selected pain conditions, 334

of number of hours of work missed because of selected pain conditions, 335

Independent factors, in the economic costs of pain, 305

Indian Health Service (IHS), 72, 96

Indirect cost models

estimation strategy for, 308–309

for selected pain conditions, dependent and

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

independent variables used in, 323–324

Indirect costs

associated with reductions in wages due to selected pain conditions, 336

of health care, 311–312

Inflammation, causing pain, 33

Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 231, 246

Injection therapy, 131

Injuries, causing pain, 33

Insomnia, 88

Institute for Healthcare Improvement, 160

Institute of Medicine (IOM), ix–x, 2, 20, 55, 97, 194, 232, 243, 303

Committee on Care at the End of Life, 143

publications from, 23, 69, 199

Insurance coverage, a barrier to effective pain care, 148, 156, 298–299

Insurance incentives, 148–150

Integrative approach, 126

Interagency Pain Research Coordinating Committee, 7, 103, 269

Interdisciplinary approaches, xi, 278. See also Collaboration

need for, 3–4, 22, 42, 197–198, 227–228

teams using, 121–124

International Association for the Study of Pain (IASP), 25, 47, 120, 205, 219, 239

International Covenant on Economic, Social, and Cultural Rights, 143

Internet, education based on, 197, 252

Interstitial cystitis, 75, 137

InterTribal Council of Arizona, Inc., 72

Interviews. See Structured psychiatric interview methods

Ion channels, 222

Iraq conflicts, 81, 157–158

Issues in pain care practice, 137–152

access to opioid analgesics and concerns about their use, 142–148

adequacy of pain control in hospitals and nursing homes, 140–141

difficulties in measuring pain, 137–140

insurance incentives, 148–150

pain and suffering at the end of life, 141–142

the reporting of pain, 150–152

J

Jane B. Pettit Pain and Palliative Care Center, 161

Joint Commission on Accreditation of Healthcare Organizations, 138, 140

Joint pain, 79, 86

Joint replacement statistics, among Medicare beneficiaries, 132

Judgmentality, 46

K

Keywords searched, 282

Knee replacement surgeries, 132

Knowledge. See Basic knowledge; Existing knowledge; New knowledge

Korean conflict, 82

L

Lasker, Mary, 244

Last Acts campaign, 188

Liaison Committee on Medical Education, 210

Licensing physicians, 210

Life-cycle factors, associated with the development of chronic pain, 30

Lifesaving, progress in, 63

Limitations of clinical trials, initiatives to address, 230–232

Limitations on data, 59–61

Listening skills, of physicians, 193–194

Literature review, 201, 282

Logistic regression, hourly wages models for selected pain conditions, 332–333

Longitudinal research, need for, 13, 60–61, 253

Low back pain

chronic, 63–64

fiscal challenge of caring for, 148

public education campaigns on, 97, 185–186

M

Magnitude of the problem, of effective pain care, 153

Management of pain. See Pain management;

Self-management of pain

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Massachusetts Pain Initiative, 190

Massage, 135

Massage ultrasound, 134

Mayday Fund, 185, 189, 194, 246

McGill University, Pain Genetics Lab, 36

Measuring pain

difficulties in, 137–140

and objectivity, xi–xii

“Mechanisms, Models, Measurement, and Management in Pain Research Funding Opportunity Announcement,” 240–241, 259–267

biobehavioral pain, 261

diagnosis and assessment of pain, 262–263

epidemiology of pain, 264–265

genetics of pain, 260

health disparities, 265–266

models of pain, 262

molecular and cellular mechanisms of pain, 259–260

pain management, 263–264

research objectives, 259

translational pain research, 266–267

Mechanisms of pain, molecular and cellular, 259–260

Medicaid, 5, 93, 98, 147

low physician reimbursement rates in, 296

Medical and Osteopathic Practice Act (model), 191

Medical Care inflation index, of the Consumer Price Index (CPI), 302

Medical Expenditure Panel Survey (MEPS), 61, 91, 302, 304–305, 307, 310

Medical expenditures, for selected pain conditions, average incremental costs of, 321

Medical Product Safety Objectives, 57–58

Medical treatments, causing pain, 33

Medicare, 5, 93, 98, 150, 234

Medicare beneficiaries, joint replacement statistics among, 132

Medications causing pain, 130–131

Medications for pain, 20, 114, 120, 129–131.

See also Antianxiety medication abuse and misuse, 201

insurance coverage for, 84

“off-label” uses of, 58

prescribing for children, 77–78

Medicine. See Complementary and alternative medicine

Meditation, 132

MEDLINE, 282

Mental health, impact of pain on, 31–32

Methodology. See also Data sources and methods; Structured psychiatric interview methods

for the economic costs of pain, 91–93, 302

Migraine (Oliver Sacks), 191

Migraine headaches, 87

Mind-body separation, Cartesian model of, 35, 154

Minimum Data Set, 83

Missed days models, for selected pain conditions, 328–329

Missed hours models, for selected pain conditions, 330–331

Misuse. See Medications for pain

Models of pain, 262. See also Hourly wages models; Missed days models; Missed hours models

Models of pain care, 158–161. See also Cost models for selected pain conditions; Health care expenditure models; Indirect cost models; Quality improvement (QI) model

Department of Defense, 160

Department of Veterans Affairs, 158–160

other models, 160–161

“Monitoring the Future,” 146

Moral imperative, treating pain as, 3, 22

Moral judgment, 46

Multidimensional Pain Inventory, 237

Multimodal efforts, public health support for, 98–99

Musculoskeletal pain, 81, 118, 314

N

Nation, costs of pain and its treatment to, 91–93

National Alliance on Mental Illness, 57

National Ambulatory Medical Care Survey, 130

National Board of Medical Examiners, 193

National Cancer Institute (NCI), National Cooperative Drug Discovery Group, 247

National Center for Advancing Translational Sciences, 240

National Center for Complementary and Alternative Medicine, 134–135

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

National Center for Health Statistics (NCHS), 6, 13, 61, 101, 254, 304

National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set, 149

National Cooperative Drug Discovery Group, 247

National Data Bank for Rheumatic Diseases, 234

National Fibromyalgia Association, 189

National Health and Nutrition Examination Survey (NHANES), 61, 63–64, 67, 70, 77, 129, 131

National Health Interview Survey (NHIS), 61, 71, 86, 135, 303

National Hospital Ambulatory Medical Care Survey, 130

National Institute for Nursing Research, 239

National Institute of Neurological Disorders and Stroke, 243, 251

National Institute on Aging, 189

National Institute on Alcohol Abuse and Alcoholism, 240

National Institute on Drug Abuse, 240

National Institutes of Health (NIH), 12, 20, 56, 92, 99, 189, 218–219, 245, 253, 313

Common Fund, 241

National Center for Complementary and Alternative Medicine, 134

Pain Consortium, 7, 11–12, 103, 190, 240, 242–244, 251–252, 269–270

Roadmap for Medical Research, 237, 241

National Institutes of Health Reform Act, 240

National Nursing Home Survey (NNHS), 82

National Pain Management Strategy, 158

National Research Council, 303

National Violent Death Reporting System (NVDRS), 89

Native Hawaiian Health Care Systems Program, 96

Near-term goals, for transforming pain prevention, care, education, and research, 270, 273–275

Need for a cultural transformation, 44–49, 209, 250–251

the necessary cultural transformation, 47–49

overview of barriers to improved pain care, 45–47

in the way pain is viewed and treated, 3–4

Need to improve, data sources and methods, 6, 101–102, 123–124

Nerve pathways, and the causes and persistence of pain, 38

Nervous system, malfunctioning, 225

Neuroimaging, to investigate pain, 38–40, 137, 223

Neuromatrix theory, 38, 278

Neuropathic pain, 33–34, 222, 278 diabetic, 249

Neuropathy Association, The, 59

New analgesics, difficulty of developing, 224–225

New England School of Acupuncture, 208

New knowledge, 56

New Pathways to Discovery, 241

New York Academy of Medicine, Grey Literature database, 282

NMDA receptor pathways, drugs acting on, 300

Nociception, 36, 39, 68, 222, 278

Nonsteroidal anti-inflammatory drugs, 225

Norway, public education campaign on low back pain, 186

Nurse Practitioner Healthcare Foundation, 201

Nurses, 91, 201

education of, 201–204

Nursing homes, adequacy of pain control in, 69, 142

O

Obesity, and pain, 63, 226

Objectives

regarding the economic costs of pain, 302

of research, 259

Objectivity, x, 24. See also Measuring pain; Subjectivity

Observational studies, 234–236

Occupational rank, influence on health, 74

Occupational therapy. See Physical and occupational therapy

“Off-label” uses, of drugs for pain, 58

Office of Critical Path Programs, 231

Opioid use, 36, 56, 278. See also Access to opioid analgesics

the conundrum of, 3, 22, 144, 225

Opioids Risk Evaluation and Mitigation Strategy (REMS), 142–143

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Organization

alternative, in research, 241–243

of the report, 49

Orofacial pain, 207. See also Temporomandibular joint (TMJ) disorders

Osteoarthritis, 79

Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT), 231

Outcomes-based care, 298

Overtreating people with pain, 299

Oxycodone, 130, 146

P

Pain. See also Acute pain; Barriers to improving pain care; Chronic pain; Economic costs of pain; Joint pain; Low back pain; Musculoskeletal pain; Neuropathic pain; Orofacial pain; Prevalence of pain; Referred pain; Seriousness of pain; Translational pain in animals, 223

causes and persistence of, 34–44

complexity of, 8, 24–26, 220

definitions of, 1, 24–26, 278

impact on physical and mental health, 31–32

maladaptive coping strategies, 94

the picture of, and risk, 27

protection from and relief of, ix

romanticizing, ix

statistics on, 28

typology of, 32–34

universality of, 2, 19, 55–56

as a warning, 24

Pain adjustment, assessment of states related to, 237–238

Pain and Palliative Medicine Specialty Section Council (of the AMA), 191

“Pain apathy,” 193

Pain as a public health challenge, 55–111

the costs of pain and its treatment, 91–95

data sources and limitations, 59–61

disparities in prevalence and care in selected populations, 64

findings and recommendations, 100–103

overall prevalence, 61–64

potential roles for public health, 95–100

present crisis in, xii

scope of the problem, 59–64

the seriousness of pain, 85–90

Pain care

barriers to effective, 153–157

bias in, xi

demand for, 190

evidence-based, 10, 164

issues in, 137–152

need to individualize, 8, 100, 161–162, 236

Pain catastrophizing, 43, 88, 94, 278

Pain centers, 9, 98, 116, 123–124, 159–160, 220

Pain Connection-Chronic Pain Outreach Center, Inc., 180

Pain Consortium, 7, 11–12, 103, 190, 240, 242–244, 251–252, 269–270

Pain diagnoses, 262–263

total direct costs of medical care for, 312–313

uncertainty of, 4, 46

Pain diaries, 238

Pain Genetics Lab, 36

Pain in childhood, causes and persistence of, 37

Pain management, xi, 263–264. See also Self-management of pain

Pain Management Directive, 158

Pain management index, 68

Pain prevention, 95–98, 233

blueprint for transforming, 14–17, 269–275

examples of population-based initiatives, 97

importance of, 3–4, 22, 45 potential savings from improvements in, 100

role of public health in, 95–98

“Pain pumps,” 131

Pain-related disability, 29, 117

among adults with pain, extent of, 86

Pain Relief Ladder, 143

Pain Research, Informatics, Medical Comorbidities, and Education Center, 242

Pain Research Coordinating Committee, 240

Pain Research Program, 242

Pain Research Working Group, 242

Pain resource nurse (PRN) programs, 204

Pain specialists, 8–10, 116

training and credentialing of physicians as, 198–201

Pain Summit, 219

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Pain tolerance, lower among African Americans, 67

PainCAS, 234

Palliative care, 85. See also Hospice patients “Passport to Comfort,” 118

Patient-Centered Outcomes Research Institute, 247

Patient education, 180–184

essential topics for, 182

Patient Education Forum, 189

Patient-level barriers, to improved pain care, 46–47

Patient Protection and Affordable Care Act, 20, 47, 248

Patient-Provider Agreements, 142

Patient Report Medical Outcomes Reporting System (PROMIS), 237, 242

Patients. See also Access to opioid analgesics with chronic pain, 19, 24, 26, 32, 59, 85, 113, 142, 158, 179, 238, 293

cultural attitudes of, 156–157

phenotyping, 223

roles for, 3, 22

written public testimony on experiences seeking treatment for pain, 294

Patrick and Catherine Weldon Donaghue Medical Research Foundation, 246

Ped-IMMPACT, 231

Pediatric ED, analgesia in, 78

Peripheral sensitization, 33

Persian Gulf war, 82

Persistence of pain, 34–44

the brain’s role, 38–40

and causes, 34–44

cognitive context, 42–44

the complexity of chronic pain, 34–36

emotional context, 40–42

genetic influences, 36–37

nerve pathways, 38

pain in childhood, 37

Pharmacist, 129

Pharmacokinetic data, 233

Phenotyping, 223

Physical and occupational therapy

education in, 207–208

not covered by insurance, 296

rehabilitative, 133–134

Physical conditioning programs, 133

Physical health, impact of pain on, 31–32

Physician-patient communication, 68, 126, 137, 152

Physicians

with chronic pain, 190

education of, 190–201

listening skills of, 193–194

“medical story” each is telling, 193

promoting physicians’ understanding of medication abuse and misuse, 201

training and credentialing of physician pain specialists, 198–201

training of primary care physicians, 196–198

visits to, 19–20

who treat chronic pain, 32

Placebos, 228

note on the use of for treating people with pain, 136–137

Population-based prevention initiatives

campaign to reduce back pain disability, 74, 97

examples of, 97

need for, 6–7

Prescription Drug Take-Back programs, 97

suicide prevention, 97

Posttraumatic stress disorder (PTSD), 81

PPP Program, 247

Practice-based evidence (PBE), 235

difficulty of developing new analgesics, 224–225

moving from research to, 224–228

need for interdisciplinary approaches, 227–228

shortfalls in applying psychosocial approaches in practice, 226–227

Prescriptions, 201. See also Electronic prescription monitoring system

getting filled, 157

of opioids, written public testimony on difficulties surrounding, 297–298

President’s Commission on Care for America’s Returning Wounded Warriors, 81

Prevalence of pain, 9, 61–64

key shortcomings of data on, 60

rising, 5

trends in the United States, 64

Prevention of pain. See Pain prevention

Primary care physicians, 9, 116–117

education challenges of, 154–155, 163, 196–198

first step for many patients, 8, 116, 150

protocols to guide, 155–156

shortage of, 148, 197

Principles. See Underlying principles

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Problem-solving ability

deficits in, 88

of teams, 198

Productivity, effects of pain on, 86–87

Project STEP, 246

Projects for public–private partnerships, potential, 248–250

Provider attitudes and training, a barrier to effective pain care, 153–156

Psychiatric disorders, 265

Psychological stressors, 37

as factors in pain, 25

Psychological therapies, for treating people with pain, 114, 132–133, 227

Psychological traits, assessment of, 237–238

Psychology, education in, 204–206

Psychosocial approaches

assessment of dimensions of pain, 236–237

assessment of psychological traits and states related to pain adjustment, 237–238

ongoing assessment and monitoring of pain and pain-related states, 238

opportunities in, 127, 133, 223

research in, 220, 236–238

shortfalls in applying in practice, 226–227

PsycINFO, 282

Public education, 184–190

Public education campaigns on low back pain, 185–186

Australia, 97, 185–186

Canada, 186

Norway, 186

Scotland, 186

Public health-based approach. See also Pain as a public health challenge

costs and savings from a public health approach, 100

other public health considerations, 99

potential roles for, 95–100

public health defined, 55

role in prevention, 95–98

support for multimodal efforts, 98–99

value of, 3

Public meetings, 282–291. See also Written public testimony

Public–private partnerships (PPPs), 243, 245–250

current, 245–248

lowering costs for, 100

potential projects for, 248–250

Public understanding of pain, 63

Q

Quality improvement (QI) model, 160, 196

Quality of life, effects of pain on, xi, 87–88, 139

Quotations from pain sufferers, 19, 24, 26, 32, 59, 85, 113, 142, 158, 179, 190, 238, 293–300

R

Racial and ethnic factors, 66–73, 89–90

African American, 67–70

American Indians and Alaska Natives, 72–73

Asian Americans, 71–72

Hispanics, 70–71

Randomized controlled trials (RCTs), 228–230

failures of, 229–230

Recommendations and findings, 4–13, 100

audiences for, 23, 57

Reengineering the Clinical Research Enterprise, 241

Referred pain, 35, 279

Registries, 234–236

Regulatory barriers, to effective pain care, 157

“Regulatory science,” defined, 224

Regulatory Science Initiative, 224

Rehabilitation Institute of Washington, 161

Rehabilitative therapy, for treating people with pain, 114, 133–134

Reimbursement policies

inadequate, 10, 156, 226

need to revise, 10, 121, 164

written public testimony on, 298–299

Reinecke, Peter, 239

Reinjury, fear of, 42

Relaxation techniques, 132

Religious judgment, 46

Report, organization of, 49

Reporting of pain, 150–152

Research

blueprint for transforming, 14–17, 269–275

potential savings from improvements in, 100

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Research challenges, 56, 217–258

Annex 5-1: Mechanisms, models, measurement, and management in pain research funding opportunity announcement, 259–267

biobehavioral pain, 261

building the research workforce, 238–239

diagnosis and assessment of pain, 262–263

epidemiology of pain, 264–265

expanding basic knowledge, 220–223

findings and recommendations, 250–254

fostering public–private partnerships, 245–250

genetics of pain, 260

health disparities, 265–266

improving and diversifying research methods, 228–238

models of pain, 262

molecular and cellular mechanisms of pain, 259–260

moving from research to practice, 224–228

need for longitudinal, 13

obtaining federal research funding, 244–245

organizational alternatives, 241–243

organizing research efforts, 239–243

pain management, 263–264

research objectives, 259

a road not taken, 239–241

translational pain research, 266–267

Research methods

comparative effectiveness research, observational studies, and psychological research, 232–234

improving and diversifying, 228–238

initiatives to address limitations of clinical trials, 230–232

observational studies, databases, and registries, 234–236

psychosocial research, 236–238

randomized controlled trials: the gold standard, 229–230

Research results, 303, 309–313

incremental costs of health care, 309–311

indirect costs of health care, 311–312

total direct cost for medical care for pain diagnoses, 312–313

Research Teams of the Future, 241

Research workforce

building, 238–239

increasing training of, 13

Restoration techniques, 134

Richard, Patrick, 301–337

Risk, 26–31

Risk Evaluation and Mitigation Strategy (REMS), approach to opioids, 142–143

Roadmap for Medical Research, 237, 241

New Pathways to Discovery, 241

Reengineering the Clinical Research Enterprise, 241

Research Teams of the Future, 241

Royal College of General Practitioners, 219

S

Sacks, Oliver, 191

Sample, of the economic costs of pain, 304–305

Saunders, Cecily, 139–141

Savings from a public health approach, 100

Scientific Management Review Board (SMRB), 240

Scope of the problem of pain, 59–64

data sources and limitations, 59–61

overall prevalence, 61–64

Scotland, public education campaign on low back pain, 186

Self-care, facilitation of, 4

Self-efficacy, 44, 279

Self-management of pain, 8, 44, 114, 116–117

promoting and enabling, 162, 227

Self-reporting of pain, 236

Sensitivity, declining in the elderly, 79

Sensitization, 33, 36, 279

Seriousness of pain, 85–90

differences in the seriousness of pain by race/ethnicity and sex, 89–90

effects on activities of daily living, 86

effects on productivity, 86–87

effects on quality of life, 87–88

effects on the risk of suicide, 88–89

Serotonin, 40

Sex

differences in the seriousness of pain by, 89–90

disparities in prevalence and care by, 75–77

Shingles, 79

Shoulder replacement surgeries, 132

Sickle-cell disease, pain associated with, 122, 295

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

Sleep disorders, 88

Social factors in pain, 25

Socioeconomic status, chronic pain inversely related to, 74–75

Sources

of acute pain, common, 29

of chronic pain, common, 29

of data, methods and, 281–291

Spinal manipulation, 135

St. Jude’s Children’s Research Hospital, 160

Statistics on pain, 28

Stem cells, 222

Steps in care, 115–124

Stereotyping, 78

Stigma against pain, 4, 46

Stoicism, “deeply-rooted value and belief in,” 71

Structural neuroimaging, to investigate pain, 39

Structured psychiatric interview methods, 237

Subgroups. See Undertreated groups

Subjectivity, of the experience of pain, 25, 223

Substance Abuse and Mental Health Services Administration (SAMHSA), 99, 145–146

Substance P antagonists, 300

Suffering, protection from and relief of, ix

Suicide, effects of pain on the risk of, 88–89

Surgeon General, Office of, 56, 189

Surgery, for treating people with pain, 68, 114, 131–132

Surgical patients, 63

disparities in prevalence and care for, 83–84

Survey overview, 294

System-level barriers, to improved pain care, 45

T

Teams, using interdisciplinary approaches, 121–124

Telephone survey, American Productivity Audit, 86

Temporomandibular joint (TMJ) disorders, 75, 207

Terminal illnesses. See End of life Tissue healing, pain persisting after, 35

TMJ Association, Ltd., 184, 217, 224

Tobacco use, campaigns to reduce, 187

Tockarshewsky, Tina, 59

Tolerance. See Pain tolerance

Training of primary care physicians, 196–198

inadequate, 194

“leading to competency,” 191–192

provider attitudes and, 153–156

Transcutaneous electrical nerve stimulation (TENS), 134

Transforming education, x–xi

blueprint for, 14–17, 269–275

Transient receptor potential (TRP) ion channels, 222

Transition, from acute to chronic pain, 29–31

Translational pain, research in, 266–267

Treatment. See also Overtreating people with pain

access to pain care, 127–128

value of comprehensive, 3, 22

written public testimony on lack of timely, 296

Treatment modalities for pain, 129–137

choice of a treatment approach, 124–127

complementary and alternative medicine, 134–136

measuring effectiveness of, 192, 227

medications, 129–131

note on the use of placebos, 136–137

overview, 115

psychological therapies, 132–133

regional anesthetic interventions, 131

rehabilitative/physical therapy, 133–134

steps in care, 115–124

surgery, 131–132

written public testimony on the need for new, 300

TRICARE, 5, 93

Truman, Harry S, 269

Tufts University School of Medicine, 208

Typology of pain, 32–34

U

U.K. Department of Health, Chronic Pain Policy Coalition, 219

U.N. Single Convention on Narcotic Drugs, 143

Underlying principles, 3, 20–23

chronic pain as a disease in itself, 3, 22

the conundrum of opioids, 3, 22

importance of prevention, 3, 22

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
×

a moral imperative, 3, 22

need for interdisciplinary approaches, 3, 22

roles for patients and clinicians, 3, 22

value of a public health and community-based approach, 3

value of comprehensive treatment, 3, 22

wider use of existing knowledge, 3, 22

Undertreated groups, 55, 68

written public testimony on, 294

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 69

United Council for Neurologic Subspecialties (UCNS), 199

University of New Mexico Project ECHO Pain Clinic, 161

Unknown causes of pain, 34

Urban Indian Health Program (UIHP), 72

U.S. Bureau of the Census, 303

U.S. Medical Licensing Examination, 210

V

Variables, in the economic costs of pain, 305–307

Veterans. See also Department of Defense; Department of Veterans Affairs disparities in prevalence and care for military, 80–82

Veterinary science, 223

Vicodin, 146

Vietnam war, 82

Von Roenn, J. H., et al., 44

Vulnerable populations, 5, 55, 65, 76, 99

Vulvodynia, 75, 137

W

Wages. See Hourly wage reductions

Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain and function scale, 231, 237

White House comprehensive action plan on prescription drug abuse, 142

Women with Pain Coalition, 189

Work disability, 20

days missed because of selected pain conditions, 325, 334

hours lost due to selected pain conditions, 335

Workers’ Compensation, 5, 69, 93, 296

Workers’ Compensation database, 304

World Health Organization (WHO), 47

Constitution, 47

Pain Relief Ladder, 143

World War II, 82

WorldCat, 282

Written public testimony, 293–300

conclusion, 300

difficulties surrounding prescription of opioids, 297–298

economic burden, 296

the impact of pain, 295

lack of timely treatment, 296

need for new treatments, 300

Q1: on barriers to pain care, 294

Q2: on improving pain care, 294

Q3: on undertreated groups, 294

Q4: on experiences seeking treatment for pain, 294

Q5: on experiences providing pain treatment, 294

Q6: additional comments, 294

reimbursement policies, 298–299

summary of, 293–300

Suggested Citation:"Index." Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. doi: 10.17226/13172.
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Chronic pain costs the nation up to $635 billion each year in medical treatment and lost productivity. The 2010 Patient Protection and Affordable Care Act required the Department of Health and Human Services (HHS) to enlist the Institute of Medicine (IOM) in examining pain as a public health problem.

In this report, the IOM offers a blueprint for action in transforming prevention, care, education, and research, with the goal of providing relief for people with pain in America. To reach the vast multitude of people with various types of pain, the nation must adopt a population-level prevention and management strategy. The IOM recommends that HHS develop a comprehensive plan with specific goals, actions, and timeframes. Better data are needed to help shape efforts, especially on the groups of people currently underdiagnosed and undertreated, and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. Because pain varies from patient to patient, healthcare providers should increasingly aim at tailoring pain care to each person's experience, and self-management of pain should be promoted. In addition, because there are major gaps in knowledge about pain across health care and society alike, the IOM recommends that federal agencies and other stakeholders redesign education programs to bridge these gaps. Pain is a major driver 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. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.

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