Relieving Pain in America A Blueprint for Transforming Prevention, Care, Education, and Research (2011) / Chapter Skim
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2 Pain as a Public Health Challenge
2 Pain as a Public Health Challenge
Pages 55-112
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From page 55... ...
-- 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.
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From page 56... ...
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.
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From page 57... ...
. 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.
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From page 58... ...
The remainder of this chapter 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.
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From page 59... ...
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)
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From page 60... ...
• 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.
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From page 61... ...
. Patterns in the prevalence of these pain conditions based on the NHIS questions may not reflect differences in levels of activity limitation, quality of life, or access to appropriate pain care.
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From page 62... ...
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.
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From page 63... ...
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.
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From page 64... ...
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.
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From page 65... ...
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)
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From page 66... ...
Nonetheless, research BOX 2-3 Health Literacy Beyond shortcomings in conventional literacy and English-language ability is the problem of limited health literacy, which is widespread and not confined to any one group or level of educational attainment, but compounded for individuals who have difficulties with English. At an Institute of Medicine workshop on medication use and health literacy, a participant underscored the problem of limited English proficiency in the populations served by many safety net providers (IOM, 2010)
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From page 67... ...
. Some researchers believe the clinical differences found in many studies are attributable at least in part to greater pain sensitivity and lower pain tolerance among African Americans.
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From page 68... ...
. A study that used a pain management index to evaluate pain control found that blacks were less likely than whites to obtain prescriptions for adequate pain relief, based on reported pain severity and the strength of analgesics provided.
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From page 69... ...
report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. These examples illustrate the pervasiveness of undertreatment of African Americans across settings, even in circumstances that appear "counterintuitive" (Barr, 2008)
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From page 70... ...
Similar to differences within the Asian American population discussed be low, there are important variations in rates of pain-related conditions among Hispanic subgroups. A secondary analysis of pain prevalence using age-adjusted NHANES data to estimate the prevalence of current, nonminor pain showed that Mexican Americans, who constitute the largest Hispanic group in the United States, are less likely to report chronic limb pain, back pain, or face/teeth pain than either blacks (non-Hispanic)
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From page 71... ...
that may shape the way pain is experienced and expressed to others. Finally, Hispanics, like African Americans, experience disparities in pain care.
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From page 72... ...
American Indians and Alaska Natives American Indians and Alaska Natives have repeatedly been found to have markedly higher rates of reported pain overall and for specific sites (e.g., severe headache or migraine, low back pain, neck pain, joint pain) (CDC and NCHS, 2010; Jimenez et al., 2011)
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From page 73... ...
Income and Education Higher pain rates among U.S. racial and ethnic minority groups can be traced in part to strong income and educational gradients in pain prevalence, with less pain being reported as a person's educational and income levels rise.
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From page 74... ...
(%) Groups Severe headache or migraine 22.0 19.5 16.3 12.5 1.76 Low back pain 35.4 32.7 28.4 23.9 1.48 Neck pain 20.8 17.0 14.7 13.1 1.59 Knee pain 23.2 22.0 20.4 16.8 1.38 Shoulder pain 12.3 10.2 9.2 7.5 1.64 Finger pain 9.5 9.4 7.9 6.4 1.48 Hip pain 9.5 7.8 7.2 5.9 1.61 SOURCE: CDC and NCHS, 2010.
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From page 75... ...
In this study, neither African American race nor Hispanic ethnicity predicted the likelihood of having disabling pain, although individuals from those groups were more likely to have the socioeconomic disadvantages that predicted pain. Sex and Gender Across nations, women consistently report a higher prevalence of chronic pain than men (Croft et al., 2010)
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From page 76... ...
(%) Ratio Severe headache or migraine 10.1 21.9 2.17 Low back pain 26.0 30.1 1.16 Neck pain 12.6 17.5 1.39 Knee pain 18.3 20.5 1.12 Shoulder pain 9.2 8.7 0.95 Finger pain 5.9 9.2 1.56 Hip pain 5.3 8.7 1.64 SOURCE: CDC and NCHS, 2010.
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From page 77... ...
. Most data on the prevalence of pain in pediatric populations focus on just one or two disease subpopulations, limiting information on pain prevalence among children in general (Goldstein and Sakae, 2010)
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From page 78... ...
Research has documented numerous examples of situations in which children may not receive appropriate pain care: • In the regular ED -- In one academic medical center studied, very few children undergoing a laceration repair received antianxiety medication or procedural sedation, which often are indicated (Brodzinski et al., 2010)
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From page 79... ...
. However, both experimental and clinical studies have shown that elderly people are more vulnerable to severe or persistent pain and that the inability to tolerate severe pain increases with age.
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From page 80... ...
. A study of more than 13,000 people with cancer aged 65 and older discharged from the hospital to nursing homes found that, among the 4,000 who were in daily pain, those aged 85 and older were more than 1.5 times as likely to receive no analgesia than those aged 65-74; only 13 percent of those aged 85 and older received opioid medications, compared with 38 percent of those aged 65-74 (Bernabei et al., 1998)
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From page 81... ...
In the first year after their last deployment, a comparison of male and female veterans found that the females were less likely to report pain, but those who did so were more likely to report moderate to severe pain and less likely to report persistent pain (Haskell et al., 2009)
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From page 82... ...
. Combining the percentages for mental disorders and Alzheimer's disease suggests that a third of nursing home residents have a serious condition that might interfere with self-reports of pain.
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From page 83... ...
. The results indicated that nationally, nearly 15 percent of residents still in a nursing home at the time of the second assessment were in persistent pain, and more than 41 percent of those who had been in pain at the first assessment were in severe pain 60 to 180 days later.
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From page 84... ...
With respect to pain care, analysis of 26 international studies showed that across nations, nearly half of cancer patients' pain was undertreated. Higherincome countries such as the United States performed better than other countries, a finding attributed to better clinician education, stronger pain treatment pro grams, and insurance coverage of medications.
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From page 85... ...
-- A person with chronic pain9 Understandably, pain prevalence estimates decrease as the severity of pain and its effects increases. Studies across countries suggest that approximately 9 Quotation from response to committee survey.
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From page 86... ...
(%) Severe headache or migraine 31.0 33.5 Low back pain 51.6 55.0 Neck pain 30.2 34.4 Knee pain 37.3 38.6 Shoulder pain 17.7 21.4 Finger pain 14.3 16.3 Hip pain 15.0 18.4 aDefined as having difficulties in one or more of the following areas: movement, emotional, seeing, hearing, or cognition.
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From page 87... ...
. The economic analysis conducted for this study found that people with severe pain missed an average of 5.0-5.9 more days of work per year than people with no pain.
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From page 88... ...
. In this study population, 29 percent of the subjects had chronic pain, back or neck pain, frequent or severe headaches, or other nonarthritis pain.
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From page 89... ...
. Past research has found that African Americans with low back injuries, compared with whites with such injuries, report higher rates of problems with physical functioning and with carrying out family/home responsibilities, social and occupational activities, self-care, and basic life-supporting activities
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From page 90... ...
, 447 African American (nonHispanic) , and 434 Hispanic adults in the United States found that the prevalence of "frequent or persistent pain" for 3 months or longer during the previous year was roughly similar across the three groups.
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From page 91... ...
-- A nurse11 Costs to the Nation The rising cost of health care is the greatest challenge facing the nation's health care system and the public programs that pay for health services. Estimat ing the total national toll of pain on the U.S.
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From page 92... ...
cost of pain given in Appendix C is higher than published estimates of the annual costs of heart disease, cancer, and diabetes; however, because different methods were used to derive these estimates, they are not strictly comparable. The analysis found that moderate pain, severe pain, joint pain, arthritis, and functional disability were all strongly associated with an increased probability of higher health expenditures.
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From page 93... ...
A person with severe pain generates health ex penditures $3,210 higher than those for a person with moderate pain. The precise reasons for these large cost differences are unclear; to the extent that they reflect differential utilization of health services due to pain, however, the potential cost savings if pain were prevented or treated more effectively are enormous.
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From page 94... ...
Heightened stress may affect the children, who do not understand why their parent is withdrawn, irritable, and no longer the willing playmate of the past. One study showed that parents of children being treated in a pediatric rheu matology clinic were highly likely to have chronic pain conditions themselves and that higher levels of parental pain and related disability were reflected in higher levels of pain in the children.
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From page 95... ...
It further has shown that pain is exceedingly costly in terms of both direct health care costs and the indirect costs associated with disability, lost employ ment, and reduced income. The beginning of the chapter presented eight rationales for regarding pain as a public health issue.
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From page 96... ...
In many instances, pain prevalence could be reduced as a consequence of normal public health initiatives aimed at preventing chronic disease, injuries, and violence and promoting healthy weight, dental care, and so on -- factors associated with ameliorating health problems. A prevention approach to pain, for example, would consider conditions in the work environment that contribute to back and other musculoskeletal injuries or promotion of the use of safety helmets and goggles to reduce sports injuries.
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From page 97... ...
. Although such programs do not directly affect pain prevalence, the rising rates of opioid use may lead to policy and enforcement practices that make these medications less available to people who need them.
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From page 98... ...
. Developing or disseminating guidelines on pain care, creating partnerships with pro fessional societies and advocacy groups, developing quality standards around pain management, and requiring pain care content in graduate medical education and continuing education programs all can be used to improve the clinical care of people with pain and prevent the related disability and other negative consequences of inadequate care.
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From page 99... ...
One such role would involve CDC, the Substance Abuse and Mental Health Services Administration, the FDA, and federal and state law enforcement agencies in reconciling the competing goals of effective pain management and avoidance of the harmful effects of opioids. This issue should be addressed within the public health structure; involve all interested parties; and be communicated clearly to health care providers, people with pain, and the public.
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From page 100... ...
Pain reduces quality of life, affects specific population groups disparately, costs society at least $560-635 billion annually (an amount equal to about $2,000 for everyone living in the United States) , and can be appropriately addressed through population health-level interventions.
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From page 101... ...
The National Center for Health Statistics, the Agency for Healthcare Research and Quality, other federal and state agencies, and private organi zations should improve and accelerate the collection and reporting of data on pain. Data should be collected in the following domains: • t he incidence and prevalence of pain; • i nterference with activities of daily living and work, as well as dis ability, related to pain; • u tilization of clinical and social services as a result of pain; • c osts of pain and pain care, including indirect costs of lost employ ment and public- and private-sector costs for disability payments; and • t he effectiveness of treatment in reducing pain and pain-related disability, determined through research on the comparative effec tiveness of alternative treatments (including in different patient populations)
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From page 102... ...
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.
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From page 103... ...
Canberra, Australia: MBF Foundation in collaboration with the University of Sydney Pain Management Research Institute. AHRQ (Agency for Healthcare Research and Quality)
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From page 104... ...
2007. Cognitive impairment and pain management: Review of issues and challenges.
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From page 105... ...
2011. Development of a composite pain measure for persons with advanced dementia: Exploratory analyses in self-reporting nursing home residents.
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From page 106... ...
2010. The adequacy of chronic pain management prior to present ing at a tertiary care pain center: The role of patient socio-demographic characteristics.
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From page 107... ...
2009. The National Nursing Home Survey: 2004 overview.
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From page 108... ...
Long-bone fracture pain management in the emergency department. Journal of Emergency Nursing 37.
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From page 109... ...
2008. Disparities in pain management between cognitively intact and cognitively impaired nursing home resi dents.
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From page 110... ...
2001. Persistent pain in nursing home residents.
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From page 111... ...
2008. Presentation by Donald Warne, Health Policy Research Director, InterTribal Council of Arizona, Inc., at Cultivating and Community of Care, a conference hosted by the American Academy of Pain Management and Meharry Medical College.
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