The title of this column comes from a quote often attributed to the great baseball player Yogi Berra. It is used to acknowledge that something that is supposed to be new is in fact very familiar. As I read the Institute of Medicine’s (IOM) new report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,1 I experienced a feeling of déjà vu.
Although the report is more than 300 pages, there is little in it that could not have been written 25 years ago, if not longer. This article provides a brief overview of the IOM’s findings and its recommendations.
The report notes that pain is a significant public health problem that affects more than 100 million Americans, costs our society at least $560 to $659 billion annually, and can be severely detrimental to the lives of sufferers. It acknowledges that large numbers of Americans receive inadequate pain prevention, assessment, and treatment, most notably because of poor pain-management education of health care professionals, especially physicians. Our system of financial compensation for health care, unrealistic patient expectations, and a lack of valid and objective pain-assessment measures are also factors. Finally, the report makes recommendations for remedying these problems but notes that these will require “a cultural transformation.”1(pS-4)
The financial burden associated with pain is the result of inflation and the rising cost of health care as well as of newer brain imaging techniques that have value in research but as yet have provided little benefit with regard to clinical care. Although we have new medications for chronic pain, very few of these are markedly different from earlier medications.
In fact, in comparing the current report with a previous IOM report that focused on pain and disability, it is impossible not to note how similar the findings and recommendations are.2 For example, the earlier report stated, “Practitioners are not adequately trained to manage patients with pain, despite increased attention to this area in recent years.”2(p283) This statement closely resembles what is said in the current report.
When one considers the vast number of advances that have been made in many areas of medicine during the past quarter century, we must ask why we have continued to fail so miserably in properly addressing pain. There are many theories, but I believe the following are the most valid.
The first has to do with the continuing inadequate education most US physicians receive about pain. There are 3 major reasons for this lack in medical education. Pain—especially chronic pain—does not fit neatly into any single medical specialty. Most illnesses clearly fall under the purview of 1 or 2 specialties, but pain is a problem encountered in all specialties.
In the United States, anesthesiology is the specialty associated with pain management. However, during rotations in anesthesiology, most medical students receive little information about pain and that which they receive usually focuses on perioperative pain rather than chronic pain. Although students see many patients with pain on other rotations, it is unlikely that they learn much about evaluating and treating pain, and the information they do receive may be inaccurate. Therefore, each specialty believes that pain management is being taught somewhere else in medical school.
The misconception that pain-management education is provided elsewhere persists in postgraduate training programs. There have been suggestions to make pain medicine a separate primary specialty, but the report appropriately acknowledges that this is probably unrealistic in the foreseeable future.
Another factor that accounts for inadequate training is that most physicians, including those on medical school faculties, have themselves received limited education on pain. Pain is perceived as a secondary issue that will end once the underlying medical cause is resolved rather than as a primary problem that needs to be addressed separately.
The report identifies a second major problem that interferes with proper pain management: compensation for pain management. The report calls for more interdisciplinary programs—something that virtually all guidelines on chronic pain management have recommended. We are, however, going in the opposite direction, and such programs are becoming rarer. The report also notes that while insurance carriers often pay for invasive techniques, such as surgery and injections, even if there is limited evidence that they work, compensation for psychosocial therapies or preventive interventions is less likely.
The third problem is that pain is a subjective complaint. Physicians increasingly rely on technology to make a diagnosis. Moreover, there is a tendency to try to correlate pain with physical abnormalities, although multiple studies have shown that this is often not possible. Pain is a complex, multidimensional problem. Numerous factors are involved and can vary from person to person and even from day to day for the same person. In light of this, it is questionable whether there will ever be the valid and objective measures of pain that the report calls for.
Do I expect this new report to significantly improve the care of patients with pain? I wish I could be more optimistic. But having read many guidelines that have made similar recommendations and having been involved in the development of some myself, I am doubtful. Those of us involved in pain medicine have long been aware of the problems identified in the current report and of the corrective measures that are needed. It will require “a cultural transformation” to implement these measures. Unfortunately, I see no reason to believe that such a transformation is likely to occur in the foreseeable future—much less by the end of 2015 as recommended by the report.