Published in Nations Health. 2014;44(7)
Author: Lindsey Wahowiak
A new report documenting pain and its treatment in America shows that only 15 states are doing well in helping Americans in pain. With most states failing to adequately address the issue, pain remains a huge public health issue.
“Achieving Balance in State Pain Policy: A Progress Report Card” was published by the Pain and Policy Studies Group at the University of Wisconsin School of Medicine and Public Health and Carbone Cancer Center in July. The report gives 15 states an “A” rating in their treatment of pain. But at less than a quarter of the population, that leaves millions more suffering.
In 2011, an Institute of Medicine report found that at least 100 million Americans live with chronic pain, from people who have to regularly take over-the-counter pain relievers to those who are bedridden from pain.
Myra Christopher said she believes that is a low estimate, however. Christopher, the former CEO and current Kathleen M. Foley chair for Pain and Palliative Care at the Center for Practical Bioethics, served on the IOM report committee. She noted that the report did not cover children, veterans or people living in nursing homes — populations that have a history of chronic pain issues.
Pain is more than a symptom, the IOM report said. It is a complex issue that can change the nervous system and become its own distinct, chronic disease. Certain groups disproportionately suffer from chronic pain. One in three cancer patients will suffer from cancer pain, according to the American Chronic Pain Association. A survey of cancer patients by the European Association of Palliative Care found that of those patients with pain, a third said the pain was so bad they wanted to die.
The elderly, too, face disproportionate amounts of pain. A study published in the fall 2010 issue of The Ochsner Journal found that between 25 and 40 percent of people ages 65 and older suffer from daily pain. The likelihood that these patients received pain medication decreased with age, the study found. The IOM report also noted that people with cognitive impairments, such as Alzheimer’s, may be unable to report their own pain.
Veterans, too, suffer from chronic pain. A June study in the Journal of the American Medical Association Internal Medicine found that of 2,500 soldiers recently returned from deployment, 44 percent had chronic pain, and 15 percent regularly used opioids to cope, more than the general population.
With such a vast and disparate patient population, there is no simple solution.
“It’s a very complicated issue,” Christopher told The Nation’s Health. “Western medicine is very much focused on the visible, the objective. Pain is very individual; it’s very subjective. It can be genetic, it can be cultural, and there can be various reasons for that.
“We so often want to find simple solutions to complex problems, and it doesn’t work,” she said.
There are also issues with quantifying pain. The typical “1-to-10” scale can be problematic, Christopher said, because it is subjective. A four to one person might not be a four to another, for example. And pain can come in a variety of forms: Burning pain might be different than a throbbing pain, and each could be treated differently.
Pain can be debilitating beyond the physical: a 2010 study from the Veterans Affairs Serious Mental Illness Treatment Research and Evaluation Center in Ann Arbor, Michigan, found a correlation between chronic pain and a higher suicide rate.
Christopher said health care providers’ education is one issue in treating pain.
“Our clinicians, physicians and nurses are not trained to treat pain,” she said. “The median number a physician receives (in treating pain) is eight hours. A veterinarian gets 87 hours.”
Prescription painkillers can be an obvious treatment choice. Powerful opioids have the ability to relieve even intense and chronic pain. But they are not the be-all, end-all for pain treatment. According to the IOM report, some doctors may be reluctant to prescribe due to the potential the drugs have for addiction, and indeed, they may have a point: The Centers for Disease Control and Prevention reported that 46 Americans die each day from an overdose of prescription painkillers.
But under-prescription can lead to unrelieved pain, leaving providers and patients in a Catch-22.
“Pharmaceuticals certainly have their place, but they can’t be the only option,” said Elizabeth Sommers, PhD, MPH, LAc, chair of APHA’s Integrative, Complementary and Traditional Health Practices Section. “Once someone starts living chronically with pain, there are repercussions in the mind and spirit. The best options are…more comprehensive. How can we really address the cause of pain?”
U.S. soldiers take part in physical therapy at Brooke Army Medical Center in San Antonio, Texas, in 2012. Veterans are one of the groups in the U.S. who suffer from chronic pain.
For people who live with chronic pain, treatment is not always about eliminating pain altogether. Patients want to be able to go about their daily lives with relative ease. For them, quality of life is the most important thing.
Penney Cowan, founder of the American Chronic Pain Association, said patients must advocate for their own well-being. Cowan, who herself has lived with chronic pain, says she knows the frustration patients feel when it comes to treating pain.
“Our expectation is, if medicine can give you a new heart or lungs…why can’t it take away my pain?” Cowan told The Nation’s Health. “But you can live with it. You have to teach (patients) how to live with it.”
Qualitative pain treatment means looking beyond painkillers. Lifestyle and self-care strategies need to be included in a pain treatment plan, Sommers said. Some people may benefit from massage. Others might try low-impact exercise, such as yoga or tai chi. Better sleep can help improve some people’s pain. Counseling, surgery, physical therapy — any of these, or a combination, could be what it takes to help a patient, but there is no one silver bullet.
“The analogy we use is a car,” Cowan explained. “The car has four flat tires. We say ‘Give me that one simple thing and I’m on my way.’ But you’re only putting air in one of those tires. And once you have air in all four tires, it’s your responsibility to keep the car running.”
Some states are treating pain well. Alabama and Idaho improved their pain policies in 2013, joining Georgia, Iowa, Kansas, Maine, Massachusetts, Michigan, Montana, Oregon, Rhode Island, Vermont, Virginia, Washington and Wisconsin and as “A” grade states in the Pain and Policy Studies Group report. A grade of “A” indicates states adopted policies to encourage appropriate pain management, palliative care or end-of-life care, and state legislatures or regulatory agencies repealed restrictive or ambiguous policy language.
Researchers are taking steps to better understand and treat pain, and clinicians are working to create a balance between medical availability and drug control, as was called for in the report. In May, the National Institutes of Health launched the Interagency Pain Research Portfolio, a database that tracks pain research and training in the federal government. Its overseeing body, the Interagency Pain Research Coordinating Committee, is developing a National Pain Strategy for better management across the country.