A Painful America

The numbers are staggering. One hundred and sixteen million Americans experience pain that can last from weeks to years. Costs of treatment and lost wages total between $560 and $635 billion each year. Yet treatment does not always relieve a patient's suffering.

In a Perspective published today in the New England Journal of Medicine, researchers outline how significant the problem of pain is in the U.S. and suggest approaches for more effective therapy. The piece recaps last year's Institute of Medicine Report, Relieving Pain in America.

The writers say that undertreated acute and chronic pain is a "significant overlooked problem." Dr. Phil Pizzo, Dean of Stanford's Medical School, is co-author of today's Perspective and led the IOM committee that reviewed the issue last year. In an interview, he described that both patients and doctors have differing approaches to pain and how to manage it. Some patients feel they need to tough it out. Others need someone to listen and work with them. Doctors may be either caring or judgmental about a patient's pain.

Pizzo argues for a "cultural transformation, the need for us to enter in a caring dialogue with an open mind and receptivity and willingness to listen to the individual, spend time understanding and engaging in everything from self-help to directed help."

A key component of the cultural transformation is education, he says. It's startling, but medical schools don't actually teach their students much about treating pain. Today's Perspective reports that half of all primary care doctors feel only "somewhat prepared" to help their patients with pain and about one-fourth of doctors feel "somewhat" or "very unprepared."

But the solution, Pizzo says, is not more specialists. Currently, there are about 4,000 pain specialists and they are mostly located in metropolitan areas. "We'll never have enough pain specialists to really handle the magnitude of the problem across the United Sates and therefore we really need to work with state and regional communities, with schools and hospitals, to better educate the community of physicians on the front lines of care."

Christine Miaskowski is an Associate Dean at the UCSF School of Nursing who specializes in research in unrelieved pain. She was not involved in today's report. "The field has evolved from thinking of pain as a symptom," she said, "to thinking of pain, particularly chronic pain, that needs to be managed as a medical condition. Just like we manage heart disease and we manage diabetes, we have to manage chronic pain."

She said the report does an "impressive" job in combining calls for both clinician education and public education. Barriers persist in the patient's mind to seeking adequate treatment for pain. Miaskowski described elderly patients who avoid treatment because they think pain is a normal part of aging or because they fear it will cost too much money to do a full work up to determine the cause of the pain.

When writing the original report last year, the Institute of Medicine instructed the panel of researchers not to delve deeply into the question of opioid pain relievers and the climbing rates of abuse and deaths by overdose. Both Pizzo and Miaskowski argued for the appropriate management of these drugs, so that patients with either acute or chronic pain do not suffer.