Relieving Pain in America A Blueprint for Transforming Prevention, Care, Education, and Research (2011) / Chapter Skim
Currently Skimming:
1 Introduction
1 Introduction
Pages 19-54
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 19... ...
-- A patient with chronic pain2 Approximately 100 million U.S. adults -- more than the number affected by heart disease, diabetes, and cancer combined -- suffer from common chronic pain conditions (Tsang et al., 2008; see also Appendix C)
|
From page 20... ...
To conduct this study, the IOM assembled a 19-member committee, which began meeting in November 2010. Reflecting the complexity of the problem at hand, the committee included experts in pain research, pain management, pharmacology, clinical specialties (pediatrics, oncology, infectious disease, neurology, neurosurgery, anesthesiology, pain medicine, dentistry, psychology, and comple mentary medicine)
|
From page 21... ...
• dentify demographic groups and special populations, including older adults, I individuals with co-morbidities, and cognitive impairment, that may be dis parately undertreated for pain, and discuss related research needs, barriers particularly associated with these demographic groups, and opportunities to reduce such barriers. • dentify and discuss what scientific tools and technologies are available, what I strategies can be employed to enhance training of pain researchers, and what interdisciplinary research approaches will be necessary in the short and long term to advance basic, translational, and clinical pain research and improve the assessment, diagnosis, treatment, and management of pain.
|
From page 22... ...
In general, the committee considered the complexities of individual pain conditions and the diseases that cause pain -- which vary widely in their presentation, treatment, effects, and outcomes -- to be beyond the scope of this study. Nor did the study address the important issue of psychological or existential pain that exacerbates many experiences of pain.
|
From page 23... ...
, health care organizations, health professions associations, pain researchers, individuals living with pain and their families, the public, and private health funding organizations in addressing the problem of pain. The ultimate goal of this study is to contribute to improved outcomes for individuals who experience pain and their families.
|
From page 24... ...
Pain is a complex phenomenon. The unique way each individual perceives pain and its severity, how it evolves, and the effectiveness of treatment depend on a constellation of biological, psychological, and social factors, such as the following: Biological -- the extent of an illness or injury and whether the person • has other illnesses, is under stress, or has specific genes or predisposing factors that affect pain tolerance or thresholds; 3 Quotation from committee survey.
|
From page 25... ...
This useful definition has been influential in replacing earlier views that pain is strictly a physical, or biological, problem because it takes into account that emotional and psychosocial reactions to pain are clinically significant. Most chronic diseases involve multiple physical, cognitive, and emotional factors.
|
From page 26... ...
On the right side are the pathways for acute pain, one branch of which moves a person to the left side of the figure, which illustrates the erratic course of chronic pain. The figure shows that pain may be treated and controlled at a number of points in a person's experience, but also that it may persist, loop back on itself, engender related complications, and prompt an ongoing search for relief.
|
From page 27... ...
NOTE: People can move between and among these groupings and can be in more than one group simultaneously. Similar colors represent 27 similar endpoints (e.g., for those within or outside the health system, or for those with chronic or acute pain)
|
From page 28... ...
Furthermore, people who experience acute pain may go on to develop chronic, intractable pain. BOX 1-4 Pain by the Numbers • 00 million -- approximate number of U.S.
|
From page 29... ...
The likelihood of experiencing a transition from acute to chronic pain is likewise influenced by various factors, especially the adequacy of acute pain relief. The factors that influence the development of chronic pain can be assessed using a life-cycle approach (see Table 1-1)
|
From page 30... ...
Low socioeconomic status Emotional, conduct, and peer problems Hyperactivity Serious illness or injury, hospitalization Separation from mother Acute or recurrent pain experience Changes of puberty, gender roles Education level, learning (behavioral reactions to pain) Injuries Obesity Low levels of fitness Vivid recall of childhood trauma Lack of social support, accumulated stress ("allostatic load")
|
From page 31... ...
For example, knowing that there are immutable factors (such as gender differences) in the susceptibility to chronic pain syndromes should lead to earlier intervention when acute pain occurs and greater efforts to avoid or reduce the influence of other risk factors.
|
From page 32... ...
. The consequences of acute pain add to the preceding list the following: reduced quality of life, impaired physical function, high eco nomic costs (principally hospital readmissions)
|
From page 33... ...
• An injury, if the pain persists after the original injury heals -- for example, "phantom limb" or "phantom tooth" pain, in which a person continues to feel pain in an amputated limb or missing tooth. • Medical treatment, for example, after surgery, when the typical im mediate acute pain, if unresolved, evolves into chronic pain or if nerve damage occurs during a procedure.
|
From page 34... ...
Examples of such chronic pain conditions are irritable bowel syndrome, fibromyalgia, vulvodynia, chronic headaches, and temporo mandibular disorders. For some disorders, research points to impaired central pain sensitivity and responses in these conditions, but their com plex mechanisms have not yet been unraveled (Kindler et al., 2011)
|
From page 35... ...
Over time, pain has become understood as a complex condition involving numerous areas of the brain; multiple two-way communication pathways in the central nervous system (from the site of pain to the brain and back again) ; and emotional, cognitive, and environmental elements -- a complete, interconnected apparatus.
|
From page 36... ...
. Efforts such as those at the Pain Genetics Lab of McGill University are focused on describing how genetic makeup can explain individual differences in pain sensitivity, response to analgesia, and susceptibility to chronic pain conditions, as well as how genes and environmental factors interact in producing these effects.
|
From page 37... ...
are generally learned in childhood, and these learned responses are important in understanding how adults cope with persistent pain. For example, a study of children with recurrent abdominal pain suggests that those who learn unhealthy responses to chronic pain, reflected in somatic and emotional distress, are more likely to become adults with chronic pain (Walker et al., 1995; Macfarlane, 2010)
|
From page 38... ...
The neuromatrix theory enables new thinking about chronic pain syndromes, such as fibromyalgia, that do not have an obvious cause but are associated with changes in the central nervous system. These changes are possible because the brain and nerves are not a fixed system but neuroplastic -- that is, capable of adapting (in this case, in a negative way)
|
From page 39... ...
Several abnormal resting state brain networks have been identified
|
From page 40... ...
Combined use of these methods has shown promise in the evaluation of other brain-related illnesses, and each adds a unique angle to the investigation of brain structure and function. Basic research employing neuroimaging has shown which areas of the brain respond to specific nociceptive stimuli in people with acute pain sensitivity and with neuropathic pain.
|
From page 41... ...
It is hardly surprising that people experience significant emotional distress when they have persistent pain and related symptoms that impair their ability to function and impede their overall quality of life, often for years. People with many chronic diseases experience comparable emotional consequences.
|
From page 42... ...
Likewise, it may be important to provide a greater measure of pain assessment and treatment to patients in psychiatric hospitals, substance abuse treatment centers, and other mental health settings as a routine practice. That is, an interdisciplinary approach to diagnosis and management is important, even if coordinated by a single health care provider.
|
From page 43... ...
Negative interpretations may contribute, as one example, to the finding that cancer patients who believed their post–physical therapy pain was due to their cancer reported greater pain intensity than those who attributed this pain to some other cause (Smith et al., 1998)
|
From page 44... ...
-- -- Von Roenn et al., 1993 Barriers to improved pain care exist at multiple levels: at the system level, where changes are needed in reimbursement policy and research emphasis, for example; at the clinician level, where improvements are needed in clinical educa
|
From page 45... ...
Overcoming the barriers to improved pain care will, in the committee's view, require a cultural transformation. This transformation will lead to a greater awareness of the impact of pain on individuals and society, wider support of efforts to understand and prevent pain, a greater commitment to assessing and treating pain effectively, and enhanced recognition of the highly individual ways in which people experience pain and respond to treatment.
|
From page 46... ...
. Yet while a substantial amount of acute and chronic pain can be re lieved with proper treatment by a single clinician or the appropriate mix of trained professionals, providers encounter a number of barriers to appropriate pain care: • Well-validated evidence-based guidelines on assessment and treatment have yet to be developed for some pain conditions, or existing guidelines are not followed.
|
From page 47... ...
To remediate the mismatch between knowledge of pain care and its application will require a cultural transformation in the way clinicians and the public view pain and its treatment. Currently, the attitude is often denial and avoidance.
|
From page 48... ...
-- While pain sometimes can serve as a warning sign that protects individuals from further harm, chronic pain is harmful and im pairs productivity and quality of life. -- When acute pain persists and becomes chronic, it may in some cases become a disease in its own right, resulting in dysfunction in the central nervous system and requiring a comprehensive treatment approach.
|
From page 49... ...
This chapter describes the magnitude of pain's impact on Americans, including the population as a whole and, where data are available, high-risk subgroups. Chapter 3 provides an overview of treatments; describes the major treatment modalities; addresses several issues in pain care practice, including aspects of opioid use; elaborates on selected barriers to effective pain care; and presents pain care models.
|
From page 50... ...
2009b. Altered resting state in diabetic neuropathic pain.
|
From page 51... ...
2004. Psychological aspects of persistent pain: Current state of the science.
|
From page 52... ...
1993. Labor pain as a model of acute pain.
|
From page 53... ...
2010. Causes and consequences of inadequate management of acute pain.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.