ARTICLE IN BRIEF
An IOM report called for increased spending for research as well as steps to improve physician education and training in the management and treatment of chronic pain. The panel calls for the development of a comprehensive plan for improving chronic pain care by the end of 2012.
A report by the Institute of Medicine (IOM) commissioned by the NIH has proposed a game plan for improving and heightening awareness of chronic pain — including a timetable for swift changes for consolidating and coordinating research and data collection by federal health agencies as well as taking steps to raise awareness of the problem.
The IOM report, which was featured at the American Public Health Association's annual meeting in Washington, DC, on Nov. 2, said chronic pain should be “a national priority” given its scope and related costs; it affects one out of every three Americans and costs the country upwards of $600 billion each year.
The report called for increased spending for research as well as steps to improve physician education and training. More controversially, the IOM panel recommended that the NIH shift responsibility for pain research to a single institute rather than having each institute study pain as it pertains to different medical disorders, and develop a comprehensive plan for improving chronic pain care by the end of 2012.
“Reliable data are lacking on the full scope of the problem, especially among those currently under-diagnosed and under-treated, including racial and ethnic minorities; people with lower levels of income and education; women, children, and older people; military veterans; surgery and cancer patients; and people at the end of life; among others,” according to the report. To improve this, it said federal and state agencies, as well as private organizations, should accelerate collection of data on pain incidence, preva-lence, and treatments.
“Many of us see this as a crisis in health care that needs to be addressed,” commented IOM committee member Robert D. Kerns, PhD, professor of psychiatry, neurology and psychology at Yale School of Medicine, and national program director for pain management at the Veterans Health Administration VA Connecticut Healthcare System in New Haven, CT.
“I don't think we would have made any recommendations that we felt were unfeasible, but this will take continued input from, and action by, all stakeholders, including advocacy groups, in order to promote the changes,” he told Neurology Today in a telephone interview.
And because neurologists play a central role in how chronic pain is treated, cooperation with other related specialties is an integral component in improving patient care, he said.
“We understand that pain is a broad concept and covers a range of bio-psycho-social factors, which is why we recommend a multidimensional, multimodality, and interdisciplinary approach to treatment and management. In this, neurologists play a very important part, especially as educators. They will be training the next generation of students who will see these patients.”
Neurology is also one of only four specialties at the residency level for which advanced fellowships are available for training in pain management, he said.
“I feel that the future is bright for chronic pain research. The report's reception by NIH seems quite favorable, and even though the report's recommendation that a single institute be charged with carrying the agenda forward is somewhat provocative,
I feel confident that there will be more discussions.”
Anne Louise Oaklander MD, PhD, associate professor of neurology at Harvard Medical Schools and Massachusetts General Hospital in Boston, said the wider issue is why many neurologists are not as involved in treating patients with unexplained chronic pain.
“Right now, lack of neurological input is part of the problem,” she told Neurology Today in a telephone interview. “Many patients with unexplained ‘mystery’ pain have an underlying rheumatological or neurological cause that needs to be diagnosed and treated. If the origin of their pain is unclear most will receive only symptomatic treatment, typically with pain medications. But these don't work that well. For instance, small-fiber polyneuropathy, often caused by treatable diseases including diabetes, should be considered in patients with unexplained widespread chronic pain. Neurologists, for the most part, are missing in action.”
The reasons are unclear, but a host of clinical and social issues are involved, said Dr. Oaklander, who serves on the editorial advisory board for Neurology Today.
Part of their hesitancy might be concerns about having to prescribe opioids, even though non-opioid medications are also effective, including tricyclic antidepressants and gabapentin-type drugs that help neuropathic pain. Moreover, she said neurologists, like other physicians, “have an underlying suspicion” that unexplained chronic pain may be caused by psychiatric issues.In her experience, this is no more common than in other areas of neurology, such as epilepsy.
Today other types of specialists treat most chronic pain patients — even those with clear neurological causes such as post-herpetic neuralgia or nerve problems, she noted.
“They have stepped into the breach, but current techniques for treating acute and perioperative pain, especially nerve blocks and high-dose opioids, are not necessarily best for chronic pain and non-neurologists may struggle with difficult diagnoses.”
Most patients with complex regional pain syndrome, for instance, have underlying nerve injury, but few of these patients ever see a nerve specialist or have electrodiagnostic testing, she told Neurology Today. “Unexplained chronic pain is one of the cardinal symptoms of diseases of the nervous system and should be treated as such,” she said.
“There is a real challenge moving forward on how chronic pain is treated,” added IOM committee member John T. Farrar, MD, PhD, associate professor of epide-miology and neurology at the University of Pennsylvania in Philadelphia.
“We need a change in the current paradigm on how the health care system approaches chronic pain, especially neuropathic pain, while at the same time educating the public and physicians. Given the extent of the problem, there is a also disproportionately small amount of research,” he told Neurology Today in a telephone interview.
Part of the problem is how to help patients gain better access to multiple components of health care that might help.
Another challenge will be finding new treatments, he continued. “Even though there have been some advances in neuroactive agents, from amitriptyline to gabapentin, pregabalin, and duloxetine, we still do not have drugs that will work well for many patients and their doctors. There is a tremendous need for basic, translational, and clinical research, which presents a tremendous opportunity for neurologists and neuroscientists.”
THE IOM report recommended that the Department of Health and Human Services develop a comprehensive plan with specific goals, actions, and timeframes. Among strategies they proposed to be implemented before the end of 2012:
- create a comprehensive population health-level strategy for pain prevention treatment, management and research;
- develop strategies for reducing barriers to pain care;
- support collaboration between pain specialists and primary care clinicians, including referral to pain centers, when appropriate
- designate a lead institute at the NIH to move pain research forward
Moreover, the panel recommended that the National Center for Health Statistics, Agency for Healthcare Research and Quality (AHRQ), other federal and state agencies, and private organizations should accelerate the collection of data on pain incidence, prevalence, and treatments. Data should be collected at regular intervals using standardized questions, protocols for surveys, and electronic medical records to identify the following information:
- subpopulations at risk;
- characteristics of acute and chronic pain;
- profound health consequences of pain, including death, disease, and disability; and related trends over time.
For more on the report, visit http://bit.ly/k5qXoc.