A new report on pain in the United States estimates that 119 million Americans, or one-third of the population, suffer from chronic pain, which costs the country on the order of $600 billion annually in health care bills and lost productivity. The report, from the Institute of Medicine at the National Academy of Sciences, calls pain a major public health issue in the U.S., and urges a “cultural transformation” in the nation’s approach to pain management and prevention.
The report highlights the dearth of support for pain research at the National Institutes of Health and other federal agencies, and calls for the NIH to reorganize its activities related to pain to provide more focused leadership and resources to the field.
“The primary message of the report is that there must be a significant change, namely, a transformation, in how pain is viewed,” committee member John Farrar of the University of Pennsylvania, Philadelphia, wrote in an email to PRF. “Pain is most common as a symptom related to a disease or injury, and we all experience some pain every day of our lives. However, when pain becomes chronic, it is no longer a symptom of another disease but often represents molecular or cellular changes to the nervous system, not unlike problems like Parkinson's disease or memory loss. When this happens, chronic pain becomes a disease of the nervous system that must be treated directly and specifically.” Farrar calls this idea “a paradigm shift” that will help to focus pain treatment and research.
The report includes a set of recommendations that the committee calls “a blueprint for transforming the way pain is understood, assessed, treated, and prevented.” The panel recommends sweeping changes at all levels—from patient education, physician training, and organization of research to health care insurance and reimbursement policies. At the heart of the report is a call for the Department of Health and Human Services to create, by the end of 2012, a comprehensive, population-level strategy for pain prevention, treatment, management, and research involving federal, state, and private organizations.
The study was mandated by Congress as part of the 2010 Patient Protection and Affordable Care Act, and funded by the NIH. Last fall, the committee of 17 leading clinicians and researchers was charged with producing a comprehensive view of the public health significance of pain, barriers to care, and approaches to improving treatment. The purpose of IOM reports is to provide independent, objective advice to policymakers, health professionals, the private sector, and the public.
In the course of the study, the panel received over 2,000 testimonies from patients and advocates, who lent an intensely personal dimension to the committee’s work, said chairman Phillip Pizzo of Stanford University in California. More than the staggering costs of pain, the human toll that was revealed “made it a moral imperative that we seek to do something about this,” Pizzo said when introducing the report at a June 29 press conference in Washington, DC.
Reviving Research?
To find out what the report means for researchers, the PRF spoke with committee members Charles Inturrisi of Weill Cornell Medical College in New York and Lonnie Zeltzer of the University of California, Los Angeles.
“Research is one of the primary modes to drive education, care, and treatment forward, ” Inturrisi said. But, he said, “There is a great disconnect between the magnitude of the problem of pain and the resources being put into solving it.”
Pain affects more people than heart disease, cancer, and diabetes combined, yet the NIH spends a paltry $200-400 million a year, or less than 1 percent of its total budget, on pain research. The report acknowledges the hard reality that funding is likely to decrease further in the near future.
One problem the committee pointed to is the lack of leadership of pain research at the NIH. Currently, pain research constitutes many small efforts spread thinly over many institutes and centers, and loosely coordinated by the Pain Consortium, a body of representatives from 19 divisions with interests in pain.
To create a more unified approach, the number one research recommendation was for the NIH to designate one institute to be the lead institute for pain.
“There should be a home for pain at the NIH, ” said Zeltzer. “Having that home will allow for an interdisciplinary and integrated, efficient, and effective pain research agenda. We’d like to see a higher percentage of the NIH budget going to pain.”
Or, as Inturrisi puts it, “Right now, pain belongs to everyone, so it belongs to no one. Somebody has to be the leader.”
The panel opined that the Institute for Neurological Disorders and Stroke would be a logical place for pain, but left the final choice to the NIH.
The group considered the question of whether the NIH should establish an Institute of Pain, but decided against recommending that course. Because of the current funding crunch, and the fact that the NIH is already at its maximum number of institutes and centers allowed by law, the group reasoned that such a proposal “would not produce a pain institute, or any other desired result.” Instead, the report says, the committee focused on “ways to reenergize and strengthen current activities…working with the existing organizational structure.”
The designated institute should have pain as a major component of its mission and take over the leadership of the Pain Consortium, which should get more financial support and more responsibility. Because most institutes are funded directly by Congress, getting pain settled in one could help increase support for pain research. “We need somebody who is going to go to Congress and present a budget that has a line item for pain,” Inturrisi explained.
Having a lead institute for pain might help with another vexing problem that the committee indentified: grant review. “The review process is suboptimal,” said Inturrisi. Projects on pain get distributed over many study sections, and there is a perceived lack of expertise on those committees. That means the best science is not always funded. “It’s impossible to get enough pain experts on the committees when they are so scattered,” he said. The committee sets improving the review process as one important task for the Pain Consortium.
Pain research is not just the purview of the NIH. “Other federal funding agencies should be stepping up to the plate in moving pain research forward,” said Zeltzer. To help that, the leading institute would also be home for the new Interagency Pain Research Coordinating Committee. The latter was part of the same health care legislation that mandated the IOM report, and is a super-consortium of the NIH with other HHS and federal agencies that do pain research including the Centers for Disease Control, the FDA, and others.
Other recommendations include improving the process for developing new pain therapies, rather than recycled versions of old ones, and increasing support for interdisciplinary research across agencies, disciplines, and professions. Public and private funders should increase conduct of longitudinal research (including comparative effectiveness research and novel trial designs), the committee says. In all these efforts, public-private partnerships will be important. Finally, they find the lack of scientists working in pain a “significant barrier to advances,” and emphasize the need to increase the training of pain researchers.
The Sticking Point
“The report clearly states that a substantial investment of research funding specifically focused on pain and pain therapies will be necessary to make the substantial improvements we all hope to see in the near future,” Farrar wrote to PRF. “We hope that this will improve the ability of researchers of all types to obtain funding for their important efforts.”
But where will that money come from? With the release of the new cost figures commissioned for the IOM report, that has become a $600 billion question.
You can read the full text of the report “Relieving Pain In America: A Blueprint for Transforming Prevention, Care Education and Research.” Have you taken a look? Please share your thoughts: What do you believe are the most important issues the IOM committee raises (or doesn’t)?
Comments
Karen Berkley, Florida State University
The report's urgent call for a transformation in the way pain, particularly chronic pain, is understood--a call to action for stimulating a full cultural change at all levels scientific, clinical, media, political, and lay public--is long past due. The report provides substantive support for its conclusion that chronic pain is an enormous public health challenge and that a cultural shift in recognition of this challenge is needed to advance knowledge and improve health and reduce healthcare costs (in the long run). The report's urgent calls (recommendations) for both research and educational efforts at all levels from basic to clinical to psychological to sociocultural to healthcare delivery and managment are well justified. If heeded, many of the report's suggestions have enormous potential for reducing suffering along with health care costs.
John Liebeskind, PhD, a pain researcher and member of the National Academy of Sciences, who was elected president of the International Association for the Study of Pain, but sadly died too young (in 1997, age 62) before he could serve it that capacity, once famously said, "Pain kills!" What he meant, of course, is chronic pain. This report just released, if heeded, therefore has the potential to increase life (and its quality).
Allan Basbaum, University of California
The IOM report does a good job of defining the problem of pain, and the call for more education of patients and their families about pain will be of tremendous benefit. The report emphasizes the need for a forceful response to the profoundly negative impact that chronic pain has on society.
An important question is whether the alternatives to a pain institute, notably the Pain Consortium, has the ability to generate the funding mechanisms that will continue to support pain research at the level endorsed by the IOM report.
Because there are few coordinated patient groups who advocate for increased funding of pain research (pain is usually seen as a symptom of another disease that needs to be funded), it is not obvious how to promote greater research funding for pain research.
John Quintner, Fremantle Hospital
It seems to me that the
It seems to me that the assertion "chronic pain becomes a disease of the nervous system" rests more upon matters of belief and social consensus than upon a stable epistemology. In fact this proposed taxonomy is informed by an inherently unstable epistemology. We must at all costs avoid the trap of confusing speculation with proven knowledge.
Robert Daoust, algosphere.org
"A cultural shift", "a new
"A cultural shift", "a new paradigm", "a transformation in how pain is viewed"... Sigh... The problem, in my opinion, is that the IASP definition of pain refers to a complex (sensory, unpleasant, emotional) experience, while the phenomenon of pain per se is just a kind of sensation (pain is not painful, said Patrick Wall and many others).
There was no theory of suffering (i.e. unpleasantness) when Harold Merskey and others came up with their theoretical defintion of pain, and everyone then wished to keep, of course, the unpleasant aspect of pain in the forefront. As a result, pain was defined as a kind of suffering (i.e. an unpleasant experience), which it is normally, but not always. Nowadays, neurobiologists are attempting the impossible task of translating their research into clinical practice, whilst they should rather begin by clarifying the conceptual discombobulation of pain and suffering (i.e. unpleasantness) with which they are working.
In other words, what I am saying is that if we want a better science of pain, we need to develop a brand-new science of unpleasantness or suffering (as defined in wikipedia).
John Quintner, Fremantle Hospital
Surely a complex experience
Surely a complex experience can properly be regarded as a phenomenon.
I agree with your comment on the impossibility of the task being undertaken by neurobiologists working in the area of pain of translating their research into clinical practice.
However, will they not encounter the same problem when developing a "brand-new science of unpleasantness or suffering"? How do you see them getting around it?
Robert Daoust, algosphere.org
Thanks for your question,
Thanks for your question, John. Here is how I see that neurobiologists could get around their problem of translation, if they are willing to embark on a trip of creation, invention, discovery.
First they might take inspiration from such researchers as Pierre Rainville and Donald Prince regarding the relative independence of two aspects of pain: sensory intensity and affective unpleasantness. But they should go further and follow Murat Aydede, perhaps our best contemporary philosopher of pain, who claims, for instance after his review of Nikola Grahek’s “Feeling Pain and Being in Pain”, that the distinctive mark of pain is its sensory aspect, with or without an accompanying unpleasantness.
Neurobiologists could easily establish, I believe, an experimental protocol demonstrating, for everyone who wishes to see or feel it, the existence of two distinct and dissociable phenomena within the experience of pain: unpleasantness and sensory pain. I guess that is possible with the clever use of morphine or hypnosis, or perhaps even with the temporary shutdown of selected brain parts via injected drugs or electromagnetic disturbance.
From there, we could get out of the inherently unstable epistemology into which we are trapped by the ambiguous term “pain”. There could be a science of sensory pain (i.e. physical pain) and a science of unpleasantness (i.e. suffering or pain in the broad sense), both based on a technical terminology that would be, from now on, unequivocal. The translation problem would be changed a lot. But, I wonder, who among us care enough to get involved in such a 'revolutionary' work of basic pain science?
John Quintner, Fremantle Hospital
Thanks Robert.
Thanks Robert.
I sincerely hope that the proposed new "science of unpleasantness" does not give rise to the terminology "good" suffering and "bad" suffering, a problematic binary classification that has recently been proposed for chronic pain (i.e. eudynia/maldynia).
David Becker, Power of Pain Foundation
The IOM report ironically
The IOM report ironically calls more of the same a blueprint for transforming pain in the U.S. As Einstein said, you can't change a problem with the same consciousness that created it and so it's no surprise to me that the IOM failed to call for substantive changes in pain care and research on pain. Note well no mention is made of better research or better treatments- just more research and more treatments. No mention is made of research on adaptive treatments, no mention is made of developing better models of research. No mention is made of improving the rights of people in pain or holding health care providers accountable for the pain care they deliver or don't deliver. This report is a red herring. The ideas for transforming pain care we've heard before in reports by state pain initiatives. The IOM has failed to jump over the shadows in pain care to create the symbols of a new day--they can rest assured that no one will ask them to break their heads open to improve pain care--after all accountable pain care and research is not what they care for.
John Quintner, Fremantle Hospital
Well said, David. Where to
Well said, David. Where to from here?
Andrew Ahn, University of Florida
It has now been fully a year
It has now been fully a year since the publication of the IOM report on "Relieving Pain in America." Has this report had the impact that its authors intended? Does Congress have to further affirm these provisions of the 2010 Patient Protection and Affordable Care Act in order to follow through on these recommendations?