Pain as a Top-Down Phenomenon: a Bibliography

by Daniel B. Carr, MD, FABPM, FFPMANZCA (Hon.), Director, Pain Research, Education and Policy (PREP) Program, Tufts University School of Medicine

Since its inception in 1999, a single concept has unified PREP’s curriculum and connected its community. This theme is that the study of pain is best accomplished if it is seen as a top-down (i.e., population-based) public health phenomenon as noted in the 2011 IOM Report on Pain.  We are fortunate that PREP has always been situated within the Department of Public Health and Community Medicine and grateful that its Chairs and Deans — Harris Berman and Aviva Must — have shared this view and continually encouraged PREP’s growth.

Advances in pain research and education, particularly as informed by the emerging field of social neuroscience, have made PREP’s vision more and more timely.  Reflecting the broader pain community’s growing awareness of PREP’s distinctive voice, this year I’ve had the privilege of delivering keynote addresses at congresses of the American Pain Society, the Special Interest Group on Pain Education of the International Association for the Study of Pain, and the American Society of Pain Educators’ PAINWeek. The specifics of each talk differed somewhat but all conveyed PREP’s underlying theme.

In response to requests from attendees at these lectures, I have assembled an interim bibliography to allow anyone interested to become better informed about some of the sources that the PREP program draws upon. Reflecting PREP’s interprofessional, eclectic outlook, many are from the humanities and social sciences, complemented by the biomedical literature.  For example, according to the narrator in the novel by Greer, “I do not know what joins the parts of an atom, but it seems what binds one human to another is pain”.

Those who wish to immerse themselves in our curriculum will enroll in a course or one of our certificate or degree programs. Click here to find out more about taking a course.  Following the great success this summer of PREP 233 (End of Life and Palliative Care, directed by Pam Ressler) in a blended onsite-online format, our foundational course PREP 230 is the next of our courses to be offered in this format.  This fall, PREP 230 will begin on September 28.  To reflect exciting advances in the field of pain, we have changed this course’s title from “Neuroanatomy, Neurophysiology and Neuropharmacology of Pain” to “Neuroscience of Pain: from Society to Synapse”.  Click here to learn more about this course.  As in earlier years it will be directed by Steve Scrivani, who has consistently earned high praise for his meticulous running of this course. Besides his own lectures, over the years Steve has assembled a core group of dedicated, expert faculty to provide students with an unparalleled learning experience.

Click here to access bibliography.

Add comment September 5th, 2012

Patients are Dissatisfied with Chronic Pain Management

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?

Add comment December 8th, 2011

Pain Education is a Public Health Imperative: Reflections on Pain Awareness Month and the Institute of Medicine Pain Report

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

References

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

Add comment September 1st, 2011

Wounded Warriors: Pain Management in the Military

by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP candidate, PREP-AIRED blog moderator and administrator, Tufts University School of Medicine 

Please join the Pain Research Education and Policy Program’s (PREP) faculty, students and alumni for the 2011 Sackler Lecture on Thursday, April 21 at 4 PM in the Tufts Medical Center’s Wolff Auditorium.   The PREP program is honored to host  Dr. Rollin (Mac) Gallagher, MD, MPH  for this year’s lecture.  Dr. Gallagher, a prominent expert in the field of pain management, will address the complex pain issues confronting the military  in today’s wars and how the VA Health System is managing these from acute injury through rehabilitation.  His lecture is entitled: “The Veterans Administration Department of Defense Systems Redesign: Pain Management for Wounded Warriors from Injury to Recovery”. 

Dr. Gallagher currently serves as Director of Pain Management, Philadelphia Veteran Affairs Medical Center.  He is also Clinical Professor of Psychiatry, Anesthesiology and Critical Care and Director for Pain Policy Research and Primary Care, Penn Pain Medicine Center, University of Pennsylvania School of Medicine.  He is Editor-in-Chief of Pain Medicine, the official journal of the American Academy of Pain Medicine, that he has also served as president. He currently serves on the National Pain Management Strategy Coordinating Committee for the Department of Veterans Affairs.

If you cannot join us in person for Dr. Gallagher’s lecture, we will have a link to his recorded lecture posted here next week.

Add comment April 19th, 2011

The Pain Chronicles

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

1 comment April 11th, 2011

Top 4 Reasons to Return to Tufts

by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP candidate, PREP-AIRED moderator and administrator, Tufts University School of Medicine

The Pain Research, Education and Policy Program(PREP) is the first and only multidisciplinary university-based pain curriculum program in the nation.  There are numerous reasons to become part of the PREP program: small class sizes, diverse student backgrounds, and expert faculty are a few of the unique qualities of the program.  What also sets the PREP program apart is the continued connection with PREP alumni, who are are welcomed and encouraged to remain an integral part of the PREP program.  

Here are 4 top reasons for PREP Alumni to return to Tufts:

#4 Meet world renowned speakers and authors:

Please join us to hear two prominent pain experts lecturing in April.  Melanie Thernstrom will be speaking about her acclaimed book, The Pain Chronicles on April 12, 2011 at 4pm in the Wolff Auditorium at Tufts Medical Center. 

Dr. Rollin (Mac) Gallagher of the University of Pennsylvania and the VA Administration will describe recent efforts to alleviate pain and suffering beginning in the battlefield and extending through rehabilitation.  He will be speaking in the Wolff Auditorium at Tufts Medical Center at 4pm.  The date of his lecture is April 21, 2011.

#3 Network with New Alumni 

Come and hear our graduating MS student capstone presentations on Monday, May 2 from 3:30pm to 5:00pm in Conference Room 1, M&V Building.   We would love your support and networking with our hard-working graduates. 

#2 Enroll in a Tufts course and save 75% 

Did you know that all alumni from the Public Health and Professional Degree programs are able to enroll in a maximum of three courses in PHPD (one per year) at a 75% savings???  Yes, you can take that elective that you always wanted to and spend only 25% on that course!  Contact Lauren Budd, Assistant Registrar at lauren.budd@tufts.edu  for more information.

#1 Expand your world by connecting with PREP’s social media sites

In addition to PREP-AIRED, the PREP program’s widely read blog, the PREP program now has its own Facebook page.  Join the community of current students, policy makers, leaders in the pain conversation and alumni by “liking” our page.  Here is the link: http://www.facebook.com/#!/pages/PREP-Pain-Research-Education-and-Policy-Graduate-Program-Tufts/198047410219415

What are your top reasons for returning to Tufts?

Add comment April 6th, 2011

PREP Capstone Presentations

by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED blog administrator and moderator

Congratulations to two MS-PREP candidates who recently presented their capstone projects to a group of faculty, alumni and students of the Tufts University School of Medicine’s Pain Research, Education and Policy Programs and the New England School of Acupuncture

Kai-Yin Hsu investigated the clinical use of the MYMOP form and outcome of acupuncture treatment from a U.S. traditional Chinese Medicine teaching clinic.

Pratchi Morajkar conducted a systematic review of Dexmedetomidine and its implications for non-narcotic-based analgosedation in cardiac surgery.

Prachi Morajkar, Dr. Libby Bradshaw, PREP academic director, Kai-Yin Hsu

Both presentations reflect the diverse interests and broad scope of the Tufts University Pain Research, Education and Policy Programs.

Kai-Yin Hsu presenting her PREP capstone project

2 comments January 13th, 2011

The Pain Research, Education, and Policy Programs at Tufts University Welcome Wendy Williams

By Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED blog moderator

You may see a new face if you are on the Tufts University School of Medicine campus in Boston these days.  Wendy Williams, BSN, M.Ed, is in a new role with the Pain Research, Education and Policy Programs at Tufts University School of Medicine, focusing on program development and administration. I recently had the opportunity to sit down with Wendy to ask her a few questions about herself and her visions for the PREP programs.  

Welcome Wendy…Can you tell us a bit about yourself?

I just arrived at Tufts from spending 8 years at Northeastern University in the School of Nursing working to ensure high quality clinical nursing education placements for both the undergrad/pre-licensure students and the advanced practice students seeking both clinical and non-clinical nursing master’s degrees.   My own clinical nursing background centers around oncology and HIV/AIDS.    I spent wonderful years at both Dana Farber Cancer Institute, during the time they had inpatient units, and at Harvard Community Health Plan/Harvard Vanguard with other highly skilled nurses on the HIV/AIDS Resource Team.I married a great guy back in 1996 who had a couple of sweet little boys who are now terrific college age young men, studying here in Boston.  My husband, Jeff, and I live in Framingham with our 3-legged cat, Punky, and hairless dog, Diddy.

What interests you about the PREP programs?

The concern for under-treated pain and pain management are steady threads that ran throughout my own clinical practice.  Ensuring adequate pain management is a strong cornerstone of quality nursing care and practice, so the PREP programs of study are very attractive to me and tie together much of what I value.  The chance to work collaboratively with the three program leaders (who are also physicians), Dr. Dan Carr and Dr. Richard Glickman-Simon and Dr. Ylisabyth Bradshaw, is an opportunity I want to leverage.I have long sought ways to be a force behind strengthening linkages between medicine and nursing and other health care disciplines to encourage both multidisciplinary and interdisciplinary approaches to health care.  The PREP programs present an ideal setting to have broad-based conversations around the area of pain issues.  Also, my own master’s degree is in education, specializing in adult and organizational learning, so .  the opportunity to develop a program of study and optimize learning for students globally is a really strong draw for me to be here at Tufts working with the PREP programs.

What do you see as the strengths and challenges of the PREP program?

A real strength of the PREP programs is its unique position in masters level education  that delves deeply into the many physical/clinical, social and scientific aspects of pain.  There is not a population of people, worldwide, that is not impacted by pain issues.  Also, the fact that the PREP programs are not solely clinically based creates a rich learning environment for many types of students… clinicians seeking to be subject matter experts in pain issues learn side by side with non-clinicians who may be seeing the PREP programs as a way to become well-informed advocates for pain issues.  After about a month in this role, I see two challenges to the PREP programs that I would like to positively impact.  One challenge is getting more and more people in the greater Boston area to know about this great set of programs and to become students in the program.  I happen to know one graduate of the program, Hallie Greenberg, a nurse from the Brigham & Women’s Hospital, and know that there are so many others that would be really inspired to become proficient in this area.  The other challenge is understanding and communicating to others clear linkages between getting one of the certificates and/or the master’s degree and a specific career enhancement.  There seems to be a certain pioneering element to encouraging students to go for the certificates or the degree as a natural next step in career growth.

What are your hopes and vision for the PREP program?

I hope that PREP grows steadily, both in numbers and in innovative educational initiatives, and sustainably with input from all communities of interest: students and alumni and staff and our steering committee and faculty and leaders in pain issues globally.  I would love to speak with students and alumni and gain their insights on how we can best lead the way in pain research, education and policy.  I welcome calls, 617 636-0815, emails wendy.williams@tufts.edu, or simply stop by my office in the M&V building, Room 142A. I’d love to meet you.

Add comment November 15th, 2010

International Job Opportunity in Pain Research

by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP student, PREP-AIRED blog moderator
MS-PREP alumna, Anne Colyn, sent along the following job posting for a Pain Research Co-ordinator in the United Kingdom. It sounds very applicable and may be of interest to MS-PREP graduates. The job is located at the University of Bath in the United Kingdom and has an application deadline of April 9, 2010, so don’t delay in checking it out! Click on the link below for more information:
http://www.bath.ac.uk/jobs/Vacancy.aspx?ref=JK23

Add comment April 5th, 2010

Hard Choice for a Comfortable Death: Sedation

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by Anne Colyn, MAc, MS-PREP
Critical article on end-of-life care featured in the New York Times on December 26, 2009. Being that this was part of my studies in the PREP program at Tufts University School of Medicine, I find this a decent introduction on the core issue in palliative care. It raises some crucial points of thought in terms of ethical and moral standards. Worth the read, if only to ponder one’s own preferences
Click here to read the New York Times article entitled: Hard Choice for a Comfortable Death: Sedation

2 comments December 27th, 2009

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