Sunday, November 1, 2009

AAPMedicine Offers Plan for Better Pain Care

According to a new Pain Medicine Position Paper from the American Academy of Pain Medicine (AAPMedicine), pain care in America is severely inadequate and costly. Leaders from the organization are now recommending a new, "population-based" stepped approach to delivering care with the goal of alleviating pain so patients can get on with their lives. However, it could be many years, possibly decades, before the quality of pain care delivery reaches acceptable levels in the U.S.

Each year $100 billion is spent on care for the 75 million persons in the U.S. with acute or chronic pain; yet, businesses still lose $60 billion annually from lost productivity due to ineffective and suboptimal pain care delivery, mainly for chronic pain conditions. AAPMedicine President, Rollin M. Gallagher, MD MPH, says the population-based approach in their new plan includes four steps designed to deliver timely access to levels of care that are needed to prevent chronic pain from beginning, or when pain persists, minimizing morbidity through effective care:
  • Step One: Prevention of disease or injury with the use of evidence-based self-care, such as diet, exercise, ergonomics (alteration of work activities), or cessation of smoking and other drug abuse to reduce the risk of injury or disease.

  • Step Two: If self-care is not working, the patient will then visit their primary care physicians for evaluation and management using evidence-based algorithms.

  • Step Three: If disabling pain persists, the patient will be referred to a pain medicine specialist [called “algiatrist”] who will collaborate with a team of providers, including, nurse case managers, psychologists, and physical therapists.

  • Step Four: If the patient remains in disabling pain [called “maldynia” at this point], he/she will be referred to a pain medicine specialist within a subspecialty of care.
The AAPMedicine concedes that there currently is no unified organizational model of pain medicine in America, which has led to ineffective and fragmented pain care with poor outcomes and higher costs than necessary. This fragmentation threatens patient safety and causes the passing of a patient from doctor to doctor for a diagnosis and pain treatment, even though those physicians may have had minimal or even no specific training in chronic pain management. The Academy believes one of the solutions to this complex problem is the establishment of pain medicine as a recognized primary medical specialty [“algiatry”]. This recognition would allow pain medicine's specialized knowledge, education, training, and multidisciplinary approach to provide standardized training for all physicians, along with integrated and comprehensive pain care to millions of Americans suffering with acute, cancer, and chronic pain.

Commentary: The Academy’s Position Paper offers an excellent review of the state of pain medicine today; so, it is recommended reading for everyone in the field [PDF available here]. However, the Paper also is somewhat disturbing and it is disheartening, to say the least, that when it comes to managing a condition so ubiquitous in our society as pain the healthcare delivery system appears to be in a state of such disarray and deficiency. As things stand today, the AAPMedicine’s four-step plan outlined above breaks down at Step Three; they acknowledge that, “Currently there are not enough pain medicine specialists to treat back pain and other pain conditions, and the system for training physicians in the discipline of pain medicine remains insufficient”; and, the number of pain specialists is actually declining. The Academy's solution calls for better residency training programs in pain medicine, which will lead to better and more cost-effective pain care. They further believe that recognizing pain medicine as a primary medical specialty also would increase federal funding for pain research and improve healthcare coverage for pain care by insurance companies (which often refuse to cover many pain-relieving treatments today).

However, according to conditions described in this Position Paper, it appears that it could take years, possibly decades, before pain care achieves an acceptable level of performance in America. Furthermore, it should be understood that the so-called “Healthcare Reform Program” still being debated in the U.S. Congress is actually an “access to healthcare insurance reform program.” The outcome may well be that more Americans will have insurance coverage to receive healthcare that, in the case of pain management, is still in limited supply and inadequate. If you have opinions, add a comment.

Reference: Dubois MY, Gallagher RM, Lippe PH, eds. Pain Medicine Position Paper. Pain Med. 2009;10(6):972-1000 [Click here to view the document PDF].