Friday, July 1, 2011

Chronic Pain in America is a National Disgrace

IOM Report Chronic pain affects more than a third of all citizens, it is widely undertreated or mistreated, patients are stigmatized, physicians are inadequately educated, and it costs more than half a trillion dollars each year in medical expenses and lost productivity alone. Those are just a few of the startling findings of a newly released report from the U.S. Institute of Medicine (IOM), which also proposes a multifaceted blueprint for action. The big question is, will something really be done about this public health crisis… and soon?

The 2010 Patient Protection and Affordable Care Act required the U.S. Department of Health and Human Services (HHS) to enlist the IOM in examining pain as a public health problem. The lengthy report, released on June 30, 2011 — Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research — calls for a cultural transformation of attitudes toward pain and its prevention and management. The entire consensus report is available [here].

Among the many noteworthy findings of the 19-member committee assembled by the IOM are the following…

  • Chronic pain affects an estimated 116 million American adults — more than the total affected by heart disease, cancer, and diabetes combined. This is a much higher number than previously reported [see UPDATE here] and, at that, it may be understated, since it does not include children or people living in institutional settings (eg, nursing homes, prisons). And, as ‘baby boomers’ age, it is expected that the incidence rate of chronic pain will continue to increase.

  • Pain costs the nation up to $635 billion each year in medical treatments and lost productivity. This, too, is most likely underestimated, since the costs of pain among institutionalized or non-civilian (eg, military) populations were not included. Nor were indirect costs — eg, lost employment, lost tax revenue, costs for replacement workers, etc. — and costs incurred caregivers (eg, family members who miss work while caring for a loved one in pain).

  • Chronic pain negatively affects socioeconomic status. Whether preventing sufferers from working or interfering with completion of education or training, chronic pain contributes to lower educational and income status, with disproportionate numbers of afflicted persons living below the poverty level.

  • The report notes that primary care professionals, who manage the bulk of patients with chronic pain, are undertrained and under-staffed for such purposes. Meanwhile, there is a severe scarcity of pain-care specialists and pain facilities to adequately treat patients in need. The IOM report notes that there are only about 3,500 physicians board certified in pain care — equal to 33,000 people with chronic pain for every specialist — and fewer than 200 accredited pain care facilities in all of America. Four out of five patients with severe chronic pain have never been referred to a specialist practitioner or clinic for their conditions.

  • The IOM panel writes extensively on what they call the “Opioid Conundrum.” While acknowledging that the long-term effects and effectiveness of opioid therapy are uncertain, they also point out that “Federal and state drug abuse prevention laws, regulations, and enforcement practices have been considered impediments to effective pain management….” Among other barriers, they say “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.”

    The report observes that, “Ironically, while many people with pain have difficulty obtaining opioid medications, nonmedical users appear to obtain them far too easily.” However, the panel also states in italics for emphasis that “the majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others.”

The IOM committee offers a blueprint for action in transforming prevention, care, education, and research, with the goal of providing relief for people with pain in America. They say that more data and research are needed, and that the nation must adopt a population-level pain prevention and management strategy. At the same time, however, the committee acknowledges that federal dollars for programs and research are “in short supply and likely to decrease.” Still, they state, “Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.”

COMMENTARY: The IOM Report is extensively researched, elegantly written, and thought-provoking. Clearly, there is a crisis of chronic pain in America and its long-standing neglect is a scandalous disgrace. The committee recognizes that there are many barriers to pain care, including regulatory, legal, institutional, financial, and geographical — all of them factors that not only limit access to effective pain care but contribute to disparities among select groups, most notably but not exclusively the financially and/or socially disadvantaged.

The committee calls for government agencies, healthcare providers, and public and private funders of health care to adopt a comprehensive, strategic approach to reduce or eliminate the barriers to pain care. However, while this may be rhetorically inspiring, putting such ideology into everyday practice at grass-roots levels is another matter.

It is particularly disconcerting in the report to find a rehash of the usual “doom and gloom” statistics pertaining to the alleged rates of misuse, abuse, diversion, overdose, and mortality associated with opioid analgesics. Many of the data come from surveys and reports that are outdated, inaccurate, and/or biased — a remarkably low quality of evidence — and it was hoped the committee would take a more critical look at the research or at least question its veracity. Apparently, they had neither the time nor inclination to do that; although, their overall perspective on opioids does achieve a measure of balance and they acknowledge certain inequities.

What is most striking in the IOM report is the tremendous toll in human suffering and financial burden inflicted by pain in America. With a third of the population affected directly, and many more when one includes families of persons with pain, this could easily serve as a major campaign platform for eager politicians. A lot of votes could be at stake; so, perhaps someone will take up the cause.