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Committee on Advancing Pain Research, Care, and Education
Board on Health Sciences Policy
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the
National Research Council, whose members are drawn from the councils of the National Academy
of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of
the committee responsible for the report were chosen for their special competences and with regard
for appropriate balance.
This study was supported by Contract No. N01-OD-4-2139, Task Order No. 234 between the National
Academy of Sciences and U.S. Department of Health and Human Services, National Institutes of
Health. Any opinions, findings, conclusions, or recommendations expressed in this publication are
those of the author(s) and do not necessarily reflect the view of the organizations or agencies that
provided support for this project.
International Standard Book Number-13: 978-0-309-21484-1 (hardcover)
International Standard Book Number-10: 0-309-21484-X (hardcover)
International Standard Book Number-13: 978-0-309-25627-8 (paperback)
International Standard Book Number-10: 0-309-25627-5 (paperback)
Additional copies of this report are available from the National Academies Press, 500 Fifth Street,
N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington
metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and
religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute
of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies
Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon
the authority of the charter granted to it by the Congress in 1863, the Academy has a man -
date that requires it to advise the federal government on scientific and technical matters.
Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engineers.
It is autonomous in its administration and in the selection of its members, sharing with
the National Academy of Sciences the responsibility for advising the federal government.
The National Academy of Engineering also sponsors engineering programs aimed at
meeting national needs, encourages education and research, and recognizes the superior
achievements of engineers. Dr. Charles M. Vest is president of the National Academy of
Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences
to secure the services of eminent members of appropriate professions in the examina -
tion of policy matters pertaining to the health of the public. The Institute acts under the
responsibility given to the National Academy of Sciences by its congressional charter to
be an adviser to the federal government and, upon its own initiative, to identify issues of
medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute
of Medicine.
The National Research Council was organized by the National Academy of Sciences in
1916 to associate the broad community of science and technology with the Academy’s
purposes of furthering knowledge and advising the federal government. Functioning in
accordance with general policies determined by the Academy, the Council has become the
principal operating agency of both the National Academy of Sciences and the National
Academy of Engineering in providing services to the government, the public, and the
scientific and engineering communities. The Council is administered jointly by both
Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest
are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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COMMITTEE ON ADVANCING PAIN
RESEARCH, CARE, AND EDUCATION
PHILIP A. PIZZO (Chair), Dean, Carl and Elizabeth Naumann Professor
of Pediatrics and of Microbiology and Immunology, Stanford University
School of Medicine, Stanford, CA
NOREEN M. CLARK (Vice Chair), Myron E. Wegman Distinguished
University Professor; Director, Center for Managing Chronic Disease,
University of Michigan, Ann Arbor, MI
OLIVIA CARTER-POKRAS, Associate Professor, Department of
Epidemiology and Biostatistics, University of Maryland College Park
School of Public Health, College Park, MD
MYRA CHRISTOPHER, President and CEO, Kathleen M. Foley Chair in
Pain and Palliative Care, Center for Practical Bioethics, Kansas City, MO
JOHN T. FARRAR, Associate Professor of Epidemiology; Director, Master of
Science in Clinical Epidemiology, Center for Clinical Epidemiology and
Biostatistics, University of Pennsylvania, Philadelphia, PA
KENNETH A. FOLLETT, Professor and Chief of Neurosurgery, Division of
Neurosurgery, University of Nebraska Medical Center, Omaha, NE
MARGARET M. HEITKEMPER, Elizabeth Sterling Soule Chair; Professor
and Chairperson, Department of Biobehavioral Nursing and Health
Systems, University of Washington, Seattle, WA
CHARLES INTURRISI, Professor of Pharmacology, Weill Cornell Medical
College, Pharmacology, New York, NY
FRANCIS KEEFE, Professor, Department of Psychiatry and Behavioral
Sciences; Director, Duke Pain Prevention and Treatment Research
Program, Professor of Psychology and Neuroscience, Durham, NC
ROBERT D. KERNS, National Program Director for Pain Management,
VA Central Office; Director, Pain Research, Informatics, Medical
Comorbidities, and Education (PRIME) Center, VA Connecticut; Professor
of Psychiatry, Neurology and Psychology, Yale University PRIME Center,
VA Connecticut Healthcare System, West Haven, CT
JANICE S. LEE, Associate Professor, Department of Oral and Maxillofacial
Surgery, School of Dentistry, University of California, San Francisco, CA
ELIZABETH LODER, Chief, Division of Headache and Pain, Department
of Neurology, Brigham and Women’s and Faulkner Hospitals, Associate
Professor of Neurology, Harvard Medical School, Boston, MA
SEAN MACKEY, Associate Professor, Departments of Anesthesia,
Neuroscience and Neurology; Chief for the Division of Pain Management,
Stanford University School of Medicine, Palo Alto, CA
v
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RICK MARINELLI, Naturopathic Physician and Acupuncturist Clinic
Director, Natural Medicine Clinic, Portland Vein Clinic; Diplomate,
American Academy of Pain Management; Commissioner, Oregon Pain
Management Commission, Portland, OR
RICHARD PAYNE, Professor of Medicine and Divinity, Esther Colliflower
Director, Duke Institute on Care at the End of Life, Duke University
Divinity School, Durham, NC
MELANIE THERNSTROM, Contributing Writer, The New York Times
Magazine, Vancouver, WA
DENNIS C. TURK, John and Emma Bonica Professor of Anesthesiology
and Pain Research; Director, Center for Pain Research on Impact,
Measurement, & Effectiveness (C-PRIME), Department of Anesthesiology
and Pain Medicine, University of Washington, Seattle, WA
URSULA WESSELMANN, Edward A. Ernst Endowed Professor of
Anesthesiology, Professor of Neurology, University of Alabama at
Birmingham, Department of Anesthesiology, Division of Pain Medicine,
Birmingham, AL
LONNIE ZELTZER, Director, Pediatric Pain Program, Mattel Children’s
Hospital at UCLA; Professor of Pediatrics, Anesthesiology, Psychiatry
and Biobehavioral Sciences, David Geffen School of Medicine at the
University of California, Los Angeles, CA
Study Staff
ADRIENNE STITH BUTLER, Senior Program Officer
JING XI, Research Associate
THELMA L. COX, Senior Program Assistant
VICTORIA WEISFELD, Consultant Writer
NEIL WEISFELD, Consultant Writer
RONA BRIERE, Consultant Editor
Board Staff
ANDREW M. POPE, Director, Board on Health Sciences Policy
DONNA RANDALL, Assistant, Board on Health Sciences Policy
VICTORIA BOWMAN, Financial Associate
vi
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Reviewers
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures
approved by the National Research Council’s Report Review Committee. The
purpose of this independent review is to provide candid and critical comments
that will assist the institution in making its published report as sound as possible
and to ensure that the report meets institutional standards for objectivity, evi -
dence, and responsiveness to the study charge. The review comments and draft
manuscript remain confidential to protect the integrity of the deliberative process.
We wish to thank the following individuals for their review of this report:
Allan Basbaum, University of California, San Francisco
Karen J. Berkley, Florida State University
David L. Brown, Cleveland Clinic
Roger Chou, Oregon Health & Science University
Charles S. Cleeland, M.D. Anderson Cancer Center
Lisa A. Cooper, Johns Hopkins Medical Institutions
Penney Cowan, American Chronic Pain Association
Betty Ferrell, City of Hope
Kathleen Foley, Memorial Sloan-Kettering Cancer Center
Kenneth R. Goldschneider, Cincinnati Children’s Hospital Medical Center
Carlton Haywood, Jr., The Johns Hopkins School of Medicine
William Maixner, University of North Carolina at Chapel Hill
Frank Porreca, University of Arizona
Jeannette Rogowski, University of Medicine and Dentistry of New Jersey
Joseph C. Salamone, Rochal Industries, LLP
vii
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viii REVIEWERS
Joshua M. Sharfstein, Maryland Department of Health & Mental Hygiene
William S. Stokes, National Institute of Environmental Health Sciences
Diane Wilkie, University of Chicago
Kevin C. Wilson, Private practice, Hillsboro, Oregon
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions or
recommendations nor did they see the final draft of the report before its release.
The review of this report was overseen by Caswell A. Evans and Elaine L.
Larson. Appointed by the National Research Council and Institute of Medicine,
they were responsible for making certain that an independent examination of this
report was carried out in accordance with institutional procedures and that all
review comments were carefully considered. Responsibility for the final content
of this report rests entirely with the authoring committee and the institution.
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Preface
Protection from and relief of pain and suffering are a fundamental feature of
the human contract we make as parents, partners, children, family, friends, and
community members, as well as a cardinal underpinning of the art and science
of healing. Pain is part of the human condition; at some point, for short or long
periods of time, we all experience pain and suffer its consequences. While pain
can serve as a warning to protect us from further harm, it also can contribute to
severe and even relentless suffering, surpassing its underlying cause to become a
disease in its own domains and dimensions. We all may share common account -
ings of pain, but in reality, our experiences with pain are deeply personal, filtered
through the lens of our unique biology, the society and community in which we
were born and live, the personalities and styles of coping we have developed, and
the manner in which our life journey has been enjoined with health and disease.
The personal experience of pain is often difficult to describe, and the words we
choose to describe pain rarely capture its personal impact, whether it is sudden and
limited or persists over time. Severe or chronic pain can overtake our lives, having
an impact on us as individuals as well as on our family, friends, and community.
Through the ages, pain and suffering have been the substrates for great works
of fiction, but the reality of the experience, especially when persistent, has little
redeeming or romantic quality. The personal story of pain can be transformative
or can blunt the human values of joy, happiness, and even human connectedness.
As a physician and a public health professional, we have experienced pain
in different ways, but we also share a common bond of experience with those
we have cared for professionally or personally. Those experiences shaped the
way we approached the request of the Institute of Medicine (IOM) to co-chair a
committee to assess the impact of pain in America. Our experiences extend from
ix
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x PREFACE
the care of individuals to evaluation of health and disease in populations, and we
were joined by an outstanding group of individuals with deep knowledge of the
biological, psychosocial, ethical, legal, clinical, and deeply personal aspects of
pain and suffering. Over an intense 5-month period, we shared facts and figures,
perceptions and realities, knowledge and assumptions, and listened carefully to
each other and to the dozens of individuals and groups who provided testimony at
our public meetings, as well as the thousands who shared their stories, hopes, dis-
appointment, and anger in their written comments and testimonials. Throughout
this process, we received extraordinary support from the IOM—especially from
Adrienne Stith-Butler and Thelma Cox. We also benefited from the writing skills
of Victoria and Neal Weisfeld. We have been enriched by all these experiences
and encounters and have tried to respond to the pleas of many for recognition,
understanding, and help. While we came to this study with our own expectations,
we have recognized as a consequence of our shared efforts that the magnitude
of the pain suffered by individuals and the associated costs constitute a crisis for
America, both human and economic. We recognize further that approaching pain
at both the individual and the broader population levels will require a transforma-
tion in how Americans think and act individually and collectively regarding pain
and suffering. We believe this transformation represents a moral and national
imperative.
Our conclusions are consonant with our individual life journeys. One of us
spent decades as a pediatric oncologist and clinical scientist focused on chil -
dren with catastrophic diseases. Pain and suffering were natural extensions of
these disease processes and evoked sympathy and compassion from health care
providers, families, and communities. But those experiences also made clear
that while pain can often be controlled, it frequently cannot be eliminated, and
when that is the case, it becomes more dominant for the individual than her or
his underlying disease.
It also became clear that when pain could be ascribed to an underlying dis -
ease, such as cancer, it was accepted as real and treated with concern. The valida -
tion of disease made the pain socially acceptable, not shunned by the health care
system or by families and communities. However, when as a pediatric oncologist
one of us also experienced chronic pain in a family member whose underlying
disease was less well defined, the cultural perception of and response to the pain
by the health care community was dramatically different. Reactions ranged from
care and compassion to judgmental opinions that lacked compassion and some-
times devolved into blaming or personalization of responsibility. The lack of a
defined disease made the symptoms of pain and suffering less acceptable and
more ascribed to overreaction, emotional instability, or worse. Because the pain
could not be seen or measured “objectively” or interpreted within the context of
the known, it was more likely to be dismissed, diminished, or avoided. The irony
is that this pain and suffering, just like that of the patient with a known disease,
could be life dominant—a disease in its own right.
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xi
PREFACE
As a behavioral scientist, one of us has worked for years with individuals,
families, and communities that are trying to manage chronic disease effectively.
This personal journey has made clear that for people who must deal with a heart
condition, a digestive disease, a rheumatic condition, or a similar problem, pain
can be a persistent companion. It can exacerbate depression, produce fatigue,
hamper functioning, and diminish quality of life. It can create stress and extract
high psychic and material costs in families. It also can lead to the development of
unexpected personal strengths and an astonishing capacity to prevail. However,
pain is a fearsome way to develop such qualities. Control of pain, and of the
disease that often accompanies it, depends on the ability of individuals to garner
information and assistance, of family members to give productive help, of clini -
cians to explore many options, and of communities to create systems to support
families and clinicians. Most people living with pain, however, are not cosseted
in this way, and we are woefully lacking in understanding how to offer them
with the help they need or, when we do understand, in the capacity to provide it.
This is not to say that the medical community is uncaring and unwilling to
help people with pain. But health care providers are subject to bias, limitations
in knowledge, and differences in the systems in which they work. They are eager
for new solutions and new insights, particularly with respect to chronic pain
when a defined cause is lacking. Unfortunately, many health care providers lack
a comprehensive perspective on pain and not infrequently interpret the suffering
of others through their own personal lens. Misjudgment or failure to understand
the nature and depths of pain can be associated with serious consequences—more
pain and more suffering—for individuals and our society.
Our committee recognizes the need for a transformed understanding of pain.
We believe pain arises in the nervous system but represents a complex and evolv-
ing interplay of biological, behavioral, environmental, and societal factors that
go beyond simple explanation. Knowledge of pain needs to be enriched from the
molecular and genetic to the cellular, neural network, and systems levels. It is
necessary to understand how the settings and surroundings in which pain occurs
and is experienced have an impact on its biology. The committee recognizes the
need for new tools and metrics with which to define, diagnose, and monitor pain
and its consequences, as well as for new approaches to treatment and preven-
tion that are likely to result from novel and more interdisciplinary approaches to
research. We see a need for better ways to develop, evaluate, and make available
new approaches to pain management more rapidly and expeditiously. We also
see the importance of approaching the individual within the broader domain of
cultural diversity and of recognizing the subpopulations that are most affected
by chronic pain and develop strategies to address their needs. We believe it is
necessary to understand better the link between acute and chronic pain and find
ways to break that link. We recognize the need to develop ever more informed
health care professionals, working individually and in teams, in rural and urban
settings, to address pain in the communities they serve. We believe it is neces -
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xii PREFACE
sary to understand better the true impact of pain on the workforce, our families,
and the broader population and seek ways to lessen that impact. Meeting these
challenges will require a cultural transformation in the way pain is perceived and
managed on both the personal and societal levels.
The committee worked diligently to develop this report in an objective man -
ner based on evidence. In doing so, we became acutely aware of the limitations
of existing knowledge and the data on which it is based. We learned from our
deliberations that there is crisis in the impact of and response to pain in America.
Individually and collectively, we have a moral imperative to address this crisis. It
is our hope that this report will help stimulate a concerted response to this crisis.
Philip A. Pizzo, Chair
Noreen M. Clark, Vice Chair
Committee on Advancing Pain Research, Care, and Education
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Acknowledgments
Many individuals and organizations made important contributions to the
study committee’s process and to this report. The committee wishes to thank
these individuals, but recognizes that attempts to identify all and acknowledge
their contributions would require more space than is available in this brief section.
To begin, the committee would like to thank the sponsors of this report.
Funds for the committee’s work were provided by the U.S. Department of Health
and Human Services, National Institutes of Health. The committee thanks Amy
B. Adams, who served as project officer, for her assistance during the study
process.
The committee gratefully acknowledges the contributions of the many indi-
viduals who provided valuable input to its work. These individuals helped the
committee understand varying perspectives on pain research, care, and educa -
tion. The committee thanks those who provided important information and data
at its open workshops. Appendix A lists these individuals and their affiliations.
As part of its work, the committee received written testimony from thousands of
individuals and organizations. This testimony helped the committee understand
the experiences of persons living with pain and their family members, as well
as health care providers, and the perspectives of many stakeholder organiza-
tions. Appendix B provides a summary of this input. The committee is grateful
for the time, effort, and valuable information provided by all of these dedicated
individuals.
The committee would like to thank the authors whose commissioned paper
added to the evidence base for this study. These include Darrell J. Gaskin, Johns
Hopkins Bloomberg School of Public Health, and Patrick Richard, The George
xiii
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xiv ACKNOWLEDGMENTS
Washington University School of Public Health and Health Services. Finally,
the committee thanks individuals who assisted in its work by providing data. The
committee acknowledges Jennifer Madans, Charlotte Schoenborn, Vicki Burt, and
colleagues from the National Center for Health Statistics, and Kevin Galloway,
Army Pain Task Force.
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Contents
SUMMARY 1
Charge to the Committee and Study Approach, 2
The Need for a Cultural Transformation in the Way Pain Is Viewed and
Treated, 3
Findings and Recommendations, 4
Conclusion, 13
1 INTRODUCTION 19
Study Context and Charge to the Committee, 20
Study Approach and Underlying Principles, 20
What Is Pain?, 24
Who Is at Risk?, 26
Impact of Pain on Physical and Mental Health, 31
A Typology of Pain, 32
What Causes Pain, and Why Does It Sometime Persist?, 34
The Need for a Cultural Transformation, 44
Organization of the Report, 49
References, 49
2 PAIN AS A PUBLIC HEALTH CHALLENGE 55
Scope of the Problem, 59
Disparities in Prevalence and Care in Selected Populations, 64
The Seriousness of Pain, 85
The Costs of Pain and Its Treatment, 91
Potential Roles for Public Health, 95
xv
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xvi CONTENTS
Findings and Recommendations, 100
References, 103
3 CARE OF PEOPLE WITH PAIN 113
Treatment Overview, 115
Treatment Modalities, 129
Selected Issues in Pain Care Practice, 137
Barriers to Effective Pain Care, 153
Models of Pain Care, 158
Conclusion, 161
Findings and Recommendations, 161
References, 165
4 EDUCATION CHALLENGES 179
Patient Education, 180
Public Education, 184
Physician Education, 190
Nurse Education, 201
Other Health Professions Education, 204
Conclusion, 209
Findings and Recommendations, 209
References, 210
5 RESEARCH CHALLENGES 217
Expanding Basic Knowledge, 220
Moving from Research to Practice, 224
Improving and Diversifying Research Methods, 228
Building the Research Workforce, 238
Organizing Research Efforts, 239
Obtaining Federal Research Funding, 244
Fostering Public–Private Partnerships, 245
Findings and Recommendations, 250
References, 254
Annex 5-1, 259
6 A BLUEPRINT FOR TRANSFORMING PAIN PREVENTION,
CARE, EDUCATION, AND RESEARCH 269
Reference, 271
GLOSSARY 277
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xvii
CONTENTS
APPENDIXES
A Data Sources and Methods 281
B Summary of Written Public Testimony 293
C The Economic Costs of Pain in the United States 301
D Committee and Staff Biographies 339
INDEX 349
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