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

August PREP Capstone Presentations

by Pamela Katz Ressler, MS, RN, HN-BC, adjunct faculty, Pain Research, Education and Policy Program, Tufts University School of Medicine and PREP-Aired blog administrator and moderator
On August 11, three Pain Research, Education and Policy graduating students presented their capstone research projects to faculty, staff, alumni of both Tufts University School of Medicine and the New England School of Acupuncture. The projects highlighted the unique nature of the Pain Research, Education and Policy Program; each focusing on addressing the complex nature of pain through very different means. The presenters displayed their individual passions in working to decrease the enormous global burden of pain: from the development of a strategic survey on pain management needs and goals for a global health organization; to creation of a brochure targeting veterans and returning military personnel on the benefits of acupuncture; and to initiating a book proposal on pain theory curriculum for licensed massage therapists.
Congratulations, Ian, George and Holly. Best wishes for continued success in making a difference in the treatment of pain.
Ian Koebner: Towards a Strategic Plan on Pain Management for Partners in Health: Stakeholder Interviews Preceptor: Giuseppe Raviola, MD
George Koromilas: Veteran Reach-Out Preceptor: Beth Sommers, MPH, LicAc; Pathways to Wellness
Holly Roche, BS, LMT: Finding Insight, Exploring pain education for LMTs Preceptor: Steven Scrivani, DDS, DMSc

Add comment August 16th, 2011

Life Before Death

by Pamela Katz Ressler, MS-PREP, RN, HN-BC, PREP-Aired blog moderator and administrator, Program in Pain Research, Education and Policy (PREP) at Tufts University School of Medicine

The global burden of pain is immense.  Pain is universal; including all constructs of ethnicity, nationality, culture, race, socioeconomic status, age and gender.  Although pain is ubiquitous, it is woefully under-treated globally.  The International Association of  the Study of Pain , along with other prominent pain organizations such as The Mayday Fund, the Institute for Palliative Medicine at San Diego Hospice, the Union for International Cancer Control, have joined with the Lien Foundation by co-sponsoring a series of 50 short documentary films, released for viewing each week beginning in May 2011, highlighting the international epidemic of the under-treatment of pain.  The project, Life Before Death, will culminate with the release of a feature film in late 2011, followed by a one-hour TV documentary. 

We welcome your comments on the overall Life Before Death project or the specific short films, which we will highlight on the Tufts University Pain Research, Education and Policy Program’s PREP-Aired blog each week.  Let’s start a dialog, that will be heard round the world, affirming the right of all people to have access to effective pain treatment.

Click here to watch the first short film of the Life Before Death project: Conspiracy of Silence

Add comment June 7th, 2011

Nurse Leads Effort in Pain Care Management Program for Emergency Department

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

When Bat Masterson, RN, a former Navy nurse, was hired as the emergency department case manager at Kootenai Medical Center, a 246 bed acute care hospital in Coeur d’Alene, Idaho, he recognized that an effective, collaborative, multidisciplinary pain management plan was needed.  He saw that repetitive emergency department visits for pain issues were often the norm for patients without primary care health care providers and there was  limited follow-up for effective pain management for these patients.  Additionally, staff were often burdened by responding to drug-seeking or doctor-shopping individuals who visited the emergency department repeatedly to attempt to obtain narcotic prescriptions.  In 2006, Mr. Masterson and a multidisciplinary team of health care professionals developed the Pain Care Management Program that embraced a coordinated care model and electronic communication tools to monitor and support pain patients who visited the emergency department.  Four goals of emergency department pain care were identified by the team and served as guiding principles in the development of strategies and interventions of the Pain Care Management Program of Kootenai Medical Center.

  • Manage patients with chronic pain or pain related complaints through coordination of care with the patient’s primary physician and the Emergency Department.
  • Support the treatment goals of the primary physician without encumbering the Emergency Department.
  • Use non-narcotic pain relief, whenever possible, and as a standard of care for the treatment of headaches.
  • Provide the best care for the patient for the condition they have that day

The results of the Pain Care Management Program have been impressive:

  • A 77% reduction in emergency department visits for pain care management.
  • An increase from 42% to 89% of individuals in the pain care study with primary care providers
  • Improved patient and nursing satisfaction scores

Congratulations to Bat Masterson, RN and the emergency department pain care management team at Kootenai Medical Center for an innovative and collaborative model of pain care.

Click here to read a PainEDU.org interview with Mr. Masterson

Add comment May 16th, 2011

PREP Capstone Presentations on May 2

by Wendy Williams, BSN, M.Ed, Associate Director PREP Program, Tufts University School of Medicine

The PREP Community here at Tufts is pleased to announce our most recent capstone presentations.  Come to the Tufts Health Sciences Campus, 136 Harrison Ave,  Boston, M&V conference room 1, on Monday, May 2 at 3:30pm to both hear from two of our nurse graduates and to enjoy a reception following. 

Carol Krieger, RN, BSN, LicAc, MAOM: Development of a research proposal for the effectiveness of acupuncture as a treatment of central and neuropathic pain syndromes from polytrauma – spinal cord injury, traumatic brain injury, and phantom limb pain

Pamela Katz Ressler, RN, BSN, HN-BC: Communicating the Experience of Chronic Illness through Blogging

Please join us as we all learn on how the study of pain in this graduate program of ours is improving the world of pain… one student at a time!

PREP Capstones_May 2011 Presentations

Add comment April 25th, 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

Chronic Pain: Focus of Time Magazine and Sackler Lecture

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

Chronic pain is elusive, often impossible to visualize or describe, and a continuing challenge for patients and health care providers alike.  The National Center for Health Statistics estimates that 76.5 million Americans suffer from chronic pain, an all encompassing term which includes pain that persists for months or years, often with no visible evidence of underlying injury.  A recent Time Magazine Health Special featured an informative series of articles on the issue of chronic pain with new insights from the bench and the bedside, as well as patient stories reflecting on the challenges of living with pain. 

Leading voices in pain management are quoted extensively in the Times Magazine health special focusing on chronic pain, one of whom is Dr. Rollin M. Gallagher, editor of Pain Medicine and the American Academy of Pain Medicine’s Past President.  The Tufts University Pain Research, Education and Policy Program is honored that Dr. Gallagher will be presenting the annual Sackler Lecture at Tufts Medical Center on April 21. Dr. Gallagher will be addressing the complex pain management issues of today’s combat veterans.  

For more information about the 2011 Sackler Lecture, please click here.

Add comment March 27th, 2011

Health Professionals Making a Difference in Pain Care

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

The American Pain Foundation has produced a number of helpful online videos for patients, families and health care professionals highlighting the complex nature of pain, especially chronic pain.  It is essential that pain care be a multidisciplinary process with the patient an active participant in care.  You may want to check out the American Pain Foundation’s selection of online videos on their YouTube site.  Take a look at “Health Professionals Making a Difference in Pain Care” to listen to  health professionals and pain patients share their message.

Add comment March 17th, 2011

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