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

Institute of Medicine Releases Report on the State of Pain Care in the United States

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

On June 29, 2011, the Institute of Medicine (IOM) released a report addressing the issue of pain in the United States and called for “a cultural transformation in the way pain is viewed and treated” (IOM report p. 3).   The 313-page report entitled: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, examines the enormity of the burden of pain from many measures.  Chronic pain affects at least 116 million U.S. adults and the financial cost of pain to society, measured in 2010 dollars, is estimated to range between $560 and $635 billion annually.  In comparing these staggering numbers to other chronic diseases, the cost of pain is greater than the cost of heart disease, cancer and diabetes combined. 

The authors of the IOM report base their recommendations for change and transformation of pain on nine underlying principles:

  • A moral imperitive
  • Chronic pain can be a disease in itself
  • Value of comprehensive treatment
  • Need for interdisciplinary approaches
  • Importance of prevention
  • Wider use of existing knowledge
  • Conundrum of opioids
  • Roles of patients and clinicians
  • Value of a public health and community-based approach

The IOM report highlights the importance of education in the multidisciplinary nature of pain issues and includes it as a key action item in the proposed blueprint for transformation of pain in our society.  On the topic of professional education IOM report recommends:

  • Expansion and redesign of education programs to transform the understanding of pain
  • Improving the curriculum and education for health care professionals around the issue of pain
  • Increasing the number of health professionals with advanced expertise in pain care

We, at the Tufts Pain Research Education and Policy program (PREP), applaud the IOM for increasing awareness of the enormous burden of pain in our society by issuing the report: “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research“.   We are also extremely proud that the Tufts PREP program has been providing the type of  comprehensive pain curriculum proposed by the IOM report for over a decade, since 1999, and remains the first and only multidisciplinary postgraduate  program of its kind in the United States.

Your comments and thoughts on the IOM report are welcome;  please click here to read a full, unabridged online version of “Relieving Pain in America: A blueprint for Transforming Prevention, Care, Education and Research”.

Add comment July 5th, 2011

Quality of Life

 

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

As we mentioned in our last blog post, 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 spotlighting the global burden of inadequate pain treatment in the project:  LIFE Before Death.

This week’s short film is entitled: Quality of Life and focuses on the dramatic benefits of palliative care services offered to patients and families facing end of life issues.

We welcome your comments on the overall LIFE Before Death project or the specific short films, which we will continually highlight on the Tufts University Pain Research, Education and Policy Program’s PREP-Aired blog throughout the year.

Add comment June 17th, 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

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

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

A New Year…What Advances in Pain Management Will We See in 2011?

by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED Blog Administrator and Moderator

As we enter a new year, pain is still the #1 reason individuals seek out medical care (American Pain Foundation data).  Those who are involved in research, as well as direct caregivers of patients, know that pain is complex and needs to be addressed by a multi-modal and interdisciplinary approach.  Let’s take stock of where we are and where we hope to go in 2011.  We invite you to comment, discuss and brainstorm ways that we can more effectively manage pain on this site  Let’s envision a day when pain is no longer the #1 reason individuals seek medical care.

Happy New Year…may your year be filled with opportunities and possbilities.

Add comment January 3rd, 2011

New Release: Approaches to Pain Management with foreward by Daniel Carr, MD, FABPM

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 

 

Add comment November 29th, 2010

MS-PREP August 2010 Capstone Presentations

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

 

August 11, 2010 marked the culmination of intensive research and planning for two candidates for Master’s degrees in the Pain Research, Education and Policy Program at the Tufts University School of Medicine with the presentation of their capstone projects.

Margaretta Elizabeth (Beth) Sangree, a student in the joint program with the New England School of Acupuncture (NESA), presented her capstone project entitled

PREP%20August%202010.jpg

Pictured L-R: Ylisabyth (Libby) Bradshaw, DO, MS, Associate Director of the Pain Research, Education and Policy Program; Margaretta Elizabeth (Beth) Sangree, MS-PREP candidate, Richard Glickman-Simon, MD, Director of the Pain Research, Education and Policy Program; and Sherry Brink, RN, BSN, MS-PREP candidate

“Measures of the Patient-Provider Relationship in Acupuncture Treatments”. Beth highlighted several studies that support the importance of relationship-centered care in effective pain treatment. Future directions will include quanitfiable, replicable, randominzed control studies to continue to document the effect of patient-provider relationship on treatment effectiveness.

Sherry Brink, RN, BSN, presented her capstone project on “Post-Op Pain Management in the Pediatric Patient” with emphasis on bringing best practices of post-op pain managment to underserved, international patient populations. Sherry recounted her experience bringing comprehensive pain management methods to a small rural hospital in the Andes mountains of Peru and her development and integration of a bilingual nursing education module on pain management currently being used by the staff in Peru. Sherry hopes to use her MS-PREP degree to further her international medical mission work by continuing to educate nurses worldwide in effective, compassionate pain management methods.

Congratulations to these two exceptional MS-PREP degree candidates!

Add comment August 23rd, 2010

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