by Pamela Katz Ressler, MS-PREP, RN, HN-BC, adjunct faculty Pain Research, Education and Policy Program, Tufts University School of Medicine and PREP-Aired blog moderator
As has been discussed previously in this blog, the under-treatment of chronic or persistent pain places an enormous burden on individuals, the health care system, the economy and our society. In June 2011, the Institute of Medicine reported that there are an estimated 116 million individuals in the United states who report chronic pain, at an economic cost of $635 billion per year. According to a recent article by Matthew Brady in the magazine of the site, Angie’s List, (which reviews numerous categories of service and health care providers;) “health care providers in the pain management category garner negative reviews at twice the average of other Angie’s List categories” Additionally, Angie’s List members reported that their “health care provider didn’t take their problem with pain seriously”.
While reports of patient dissatisfaction with chronic pain management are disturbing, they are understandable when one recognizes the paucity of training most clinicians receive in chronic pain management. According to the Association of American Medical Colleges less than 1 in 4 of the 133 accredited medical schools in the country teach students about chronic pain management and most students receive less than 11 hours of pain management training in their entire 4 years of medical school.
Addressing the systemic lack of comprehensive pain education is a key mission of the Tufts University School of Medicine’s Pain Research, Education and Policy Program (PREP). The founding director of the PREP program, Dr. Dan Carr, states that the high level of dissatisfaction and complaints among patients seeking effective chronic pain management may reflect the traditional training of clinicians to focus only on objective measures and procedures to alleviate pain, without regard to the social and psychological aspects of persistent pain. “There is an enormous social component to pain,” states Dr. Carr. “Patients will be more satisfied if they feel they have been cared for. That has more to do with their satisfaction with pain control than the actual intensity of their pain.”
While there are no easy answers to chronic pain management; patients, clinicians, educators and health care stakeholders all agree that our current approach to pain management is inadequate and needs to be addressed as we prepare to meet the increasing health needs of an aging baby-boomer population.
What are your thoughts on how we can create a more comprehensive model of chronic pain management?
December 8th, 2011
by Daniel B. Carr, MD, FABPM, FFPMANZCA (Hon.), Co-Founder and Director of the Pain Research, Education and Policy Program (PREP) at the Tufts University School of Medicine
Each year, September is “Pain Awareness Month” – a time of intense activity for PREP faculty and the entire pain community It is also when PREP’s academic year begins. One key insight connects diverse Pain Awareness activities and PREP’s own vision and mission: PAIN IS A PUBLIC HEALTH ISSUE, AND PAIN EDUCATION IS A PUBLIC HEALTH IMPERATIVE. Now is a perfect time to step back and place some context around this idea at the heart of not only PREP’s curriculum, but also our entire approach to interprofessional education.
The report issued by the Institute of Medicine earlier this summer – “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research” (ref 1) — is the latest in a series of white papers on pain by governmental and professional groups dating back well over two decades. These include the first US federal clinical practice guideline (ref 2) on any topic, numerous international guidelines (ref 3), and white papers from authoritative sources such as the Mayday Fund (ref 4), the American Academy of Pain Medicine (ref 5), and even the World Health Organization (ref 6). Together, they present steadily accumulating evidence that acute, chronic and cancer-related pain are widely prevalent and exact a major economic and human burden in developed nations and even more so in resource-poor countries. Other common themes include lost opportunities for early intervention to control or prevent the transition from acute to chronic pain, the negative outcomes of undertreated pain, the importance of optimal pain control for patient-centered care, disparities in pain assessment and treatment experienced by minorities and other under-represented groups such as women or those at the extremes of age, and the need “to adopt a population-level prevention and management strategy” (ref 1) for pain. Related to all these is the growing perspective that pain control is a fundamental human right (ref 7) as articulated by Human Rights Watch (ref 8 ) and recently affirmed in the 2010 Declaration of Montreal by delegates to the International Pain Summit (ref 9).
Since its inception in 1999, the Tufts program on pain research, education and policy has been housed in its Department of Public Health and Community Medicine. Although the pain community has long held a consensus that pain is a biopsychosocial phenomenon, most prestigious journal articles and a majority of research funding have emphasized the “bio” end of that word. Thus, the classical Loeser model of pain originates in subcellular nociceptive machinery, then broadens to encompass the experiences of pain and suffering, followed by pain behavior. The Loeser model is an intrinsically individual one.
- (Fig 1. Loeser Model used with permission of Professor John Loeser)
Our program’s framing of pain employs a sociobiological perspective, in keeping with our having been co-founded by a PhD sociologist, Kathy Lasch. Those individuals better able to detect and remember threats to their survival have better odds of propagating their DNA within the collective gene pool. Indeed, within Darwin’s (and more recently, Dawkins’s) “selfish gene” framework, individuals are mere vessels through which genes propagate themselves (ref 10). Whether or not we agree with this view, it sets the stage for interesting discussion by shifting our reference frame to a distinctly supraindividual model of pain. According to PREP’s social model, the experience of pain is still at the core, but to understand it requires research that goes beyond the individual. In human society, research is lost if not translated into education – particularly one that embraces the intersubjective, social and emotional nature of the pain experience. We at PREP are committed to interprofessional education of pain leaders as the most effective way to effect social change – a commitment that led to our program’s specific acknowledgment in the IOM report in its chapter 4, on education. Among recent PREP graduates and applicants we are beginning to see a few exceptional persons who have chosen to spend their careers as policymakers in the important field of pain. I am delighted to see this, because the continuous translation of the benefits of research and education requires ongoing support through enlightened, population-based health policies.
- Fig 2. PREP model
1: Institute of Medicine Report (2011) http://books.nap.edu/openbook.php?record_id=13172
2: AHCPR clinical practice guideline: acute pain (1992) http://www.ncbi.nlm.nih.gov/books/NBK16501/
3: Carr, DB .”The Development of National Guidelines for Pain Control: Synopsis and Commentary”, European Journal of Pain (2001), 5 (Suppl. A) p. 91-98.
4: “A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform”, Mayday Fund (2009) http://www.maydaypainreport.org/docs/A%20Call%20to%20Revolutionize%20Chronic%20Pain%20Care%20in%20America%2003.04.10.pdf
5: Dubois, MY, Gallagher, RM, Lippe, PM. “Pain Medicine Position Paper”, Pain Medicine, vol. 10, issue 6, p. 972-1000, Sept 2009. http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2009.00696.x/full
6: World Health Organization press release (Oct 11, 2004) http://www.who.int/mediacentre/news/releases/2004/pr70/en/index.html
7: Brennan, F, Carr, DB, Cousins, M. “Pain Management: A Fundamental Human Right”, Anesthesia & Analgesia, vol. 105, no. 1, p. 205-221, July 2007. http://www.anesthesia-analgesia.org/content/105/1/205.full.pdf+html
8: Human Rights Watch 2009 report http://www.hrw.org/reports/2009/03/02/please-do-not-make-us-suffer-any-more-0
9: Declaration of Montreal 2010 from International Pain Summit http://www.iasp-pain.org/Content/NavigationMenu/Advocacy/DeclarationofMontr233al/default.htm
10: Carr, DB; “What Does Pain Hurt?”, IASP — Pain Clinical Updates, vol. XVIII, issue 3, p. 1-6, July 2009 http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=HOME&TEMPLATE=/CM/ContentDisplay.cfm&SECTION=HOME&CONTENTID=9599
September 1st, 2011
by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP candidate, PREP-AIRED moderator and administrator, Tufts University School of Medicine
One in 10 people in the United States identifies themselves as having chronic pain. Over $90 billion is spent annually in the United States on the associated costs of chronic pain, including disability, medical costs, and loss in productivity. The global impact of chronic pain is immense. Yet treatment of chronic pain remains as elusive to our modern medical treatment methods as it did to the ancient Greeks. In The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering, author Melanie Thernstrom masterfully weaves her personal pain narrative into a rich tapestry of the science, history, culture and ethical underpinnings of the study of pain. The PREP program’s director, Dr. Daniel Carr, lends a pivotal voice in Ms. Ternstrom’s understanding of the challenges of pain medicine, along with other pain medicine luminaries such as Dr. Scott Fishman and Dr. Clifford Woolf. What makes The Pain Chronicles so compelling are the multiple layers of inquiry that unfold throughout the book, often challenging the reader to ask more questions than find answers on the nature of pain and suffering. Ms. Thernstrom’s use of the patient voice from the perspectives of authors such as Elaine Scarry (The Body in Pain) and Arthur Frank (At the Will of the Body) help to illustrate the complex interaction between pain perception and suffering. The Pain Chronicles allows a deeper understanding of the disease of pain, and should be “required reading” for both patients and health practitioners for whom chronic pain plays a role in their lives.
The Tufts Pain Education and Policy Program, with assistance from the Tufts University Public Health and Professional Degree Student Activity Fund, is pleased to be hosting author Melanie Thernstrom on Tuesday, April 12 at 4:00 PM in the Wolff Auditorium at Tufts Medical Center. The event is free and open to the public. Signed copies of The Pain Chronicles will be available. Please join us!
Here is a link to Melanie Thernstrom’s lecture on April 12: http://www.tufts.edu/med/education/phpd/msprep/prepforum.html
April 11th, 2011
By Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student, PREP-AIRED blog moderator and administrator
Thank you to Dr. Daniel Carr, founder of the Tufts University School of Medicine’s Pain Research Education and Policy Programs (PREP) for alerting us to a collection of articles in a recent edition of Nature Medicine which review progress and challenges in pain research from the bench to the bedside. Take a look at some of the interesting issues being addressed with a focus on pain research and treatment.
Click here to view the table of contents
December 10th, 2010
by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED blog moderator
Untreated or under-treated pain causes needless suffering and negatively affects the quality of life. That is why the management of pain remains a critical area of health care and why the concept is addressed throughout the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements.
We congratulate the Tufts University School of Medicine’s Pain Research, Education and Policy Programs co-founder, Daniel Carr, MD, FABPM for providing the forward to the newly published second edition of Approaches to Pain Management: An Essential Guide for Clinical Leaders
Approaches to Pain Management: An Essential Guide for Clinical Leaders, published by the Joint Commission Resources, provides an overview of pain assessment and management, identifies what the standards require regarding the treatment of patients with pain, and offers guidance on making pain management an integral part of care services. Dr. Carr, an internationally recognized expert in pain management, provides both perspective and vision on the complex nature of pain.
The majority of the book is devoted to the best practices of health care institutions that have adopted focused pain programs. This updated guide also incorporates a global view of pain management, additional organizational best practices—including some from non-U.S. institutions. Other features include the following:
- Summaries of every Joint Commission and Joint Commission International pain assessment and management requirement across all health care settings
- Strategies for identifying and using evidence-based medicine resources for pain management
- Expanded case study chapters from clinical leaders describing how their organizations developed and implemented their pain management activities
- Techniques and ideas for understanding and meeting pain-related standards
- Guidance on committing an organization to pain management improvements
For more information about the newly released edition of Approaches to Pain Management: An Essential Guide for Clinical Leaders, click here
November 29th, 2010
by Daniel Carr, M.D., FABPM, Founding Director of the Pain Research, Education and Policy Program, Tufts University School of Medicine, and Pamela Katz Ressler, RN, BSN, HNC, MS-PREP student and PREP-AIRED blog moderator
Every academic field has a handful of texts that are classic, definitive reference works. For pain medicine and regional anesthesia the textbook first prepared by Michael Cousins and Philip Bridenbaugh in 1988, Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine, has enjoyed worldwide success as one of the most, if not the most, comprehensive and authoritative monographs on these topics. Professor Cousins has pioneered in the development of pain research and treatment in Australia, and is a Past President of the International Association for the Study of Pain. During his tenure as IASP President he formed a Task Force on Pain Curricula whose recommendations have influenced pain education around the world — including Tufts’ PREP program. Dr Bridenbaugh is Past President of the American Society of Anesthesiologists and also the American Society of Regional Anesthesia.
About five years ago Professors Cousins and Bridenbaugh approached Dr Dan Carr, Founding Director of the PREP program, and Professor Terese Horlocker of the Mayo Clinic to join them as co-editors for the fourth edition of this text. Dr Carr is happy to report that the text has now been published! Compared to the prior edition, the number of chapters has expanded from 34 to 51, and the total number of authors from 52 representing 9 countries to 90 (including 68 new ones) representing 15 countries. Of note for those with an interest in acupuncture, it is the first text on regional anesthesia to include a chapter on the effects of needle insertion per se, by two Western physicians who studied acupuncture with Professor Han in Beijing. The book also includes chapters on placebo, psychological aspects of pain, and pain mechanisms.
The very first user review on Amazon’s website states “This edition has been almost rewritten and [a] larger portion is dedicated to pain management and basic pain mechanisms.
August 18th, 2009
by Daniel Carr, M.D, FABPM, Founding Director PREP program Tufts University School of Medicine and Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP student and PREP-AIRED blog moderator
As the healthcare system has become more patient-centered, one sees increasing reference to patient rights to aspects of care, such as pain care. What does it mean for something — in particular, pain management
– to be a “human right”?
Do entitlements evolve into rights, or are rights something that have always existed but whose formal recognition may be slow to come? How is the human right to pain management operationalized within national legislative, judicial and regulatory systems, and healthcare policy? Dr Dan Carr, Founding Director of the PREP program, explores whether there is a fundamental human right to pain management in a comprehensive review available at
http://www.anesthesia-analgesia.com/cgi/reprint/105/1/205. Co-authored with two distinguished international authorities, this article was published in the official journal of the International Anesthesia Research Society along with an unprecedented four editorials including a very affirming one from the World Health Organization. Those with a deeper interest in this important topic may wish to read the white paper prepared by Human Rights Watch, available at http://www.hrw.org/sites/default/files/reports/health0309web_1.pdf .
What are your thoughts about pain managment as a fundamental human right? Please share your thoughts and comments.
July 29th, 2009