Education, Education, Education. Educate more physicians on proper diagnosis and proper pain management. Educate the person living with pain and their family on addiction versus physical dependency and proper storage of medication. Educate the public and press about the realities of pain medication and people living with pain.
—A person with chronic pain1
Earlier chapters of this report reveal a disturbing discrepancy. On the one hand, pain is extremely widespread in American society, exacts a huge toll in suffering and disability, and imposes extraordinary costs on the health care system and the nation’s economy (Chapter 2). On the other hand, all too often treatment is delayed, disorganized, inaccessible, or ineffective (Chapter 3). Much of this gap between need and performance results from inadequate diffusion of knowledge about pain. Many members of the public, people with pain themselves, and many health professionals are not adequately prepared to take preventive action, recognize warning signs, initiate timely and appropriate treatment, or seek specialty consultation when necessary with respect to pain. The avoidable negative consequences are that more people than necessary experience pain, acute pain often is not optimally treated and progresses unnecessarily to chronic pain,
1 Quotation from response to committee survey.
chronic pain is not systematically addressed, and the health and quality of life of large numbers of people are severely impaired.
Improving care for people with acute or chronic pain requires broad improvements in education, especially with regard to
- the multiple causes and effects of pain,
- the range of treatments available to help people obtain relief, and
- the need to consider chronic pain as a biopsychosocial disorder.
Education efforts should be directed to people with pain, the general public, and health professionals. Each of these audiences has distinct needs for greater knowledge, and each presents its own education challenges. In addition, education programs need to be high quality and evidence based, and in their planning draw on such sources as the successful examples highlighted in this chapter, inasmuch as the history of both patient and public education efforts is littered with failed, ineffective, and poorly implemented programs.
I had to relearn how to live.
—Gwenn Herman, Pain Connection-Chronic Pain Outreach Center, Inc.2
People with acute or chronic pain often are unaware of their treatment options or may hold inaccurate or value-laden beliefs about pain that obstruct the path to treatment and relief (Chapter 3). They deserve information that can help them understand and address their condition.
The optimal timing, content, and goals of patient education will vary depending upon the type of pain (acute or chronic), the availability and effectiveness of treatment, and the educational and literacy levels of the patient. Consider the case of acute pain. Although there are only limited opportunities to provide effective pain education to patients who experience unanticipated pain as a result of an injury or medical emergency, acute pain is an appropriate target of patient education. For example, the fear of pain or the experience of poorly controlled pain with outpatient procedures can affect a person’s willingness to undergo needed medical or dental treatment. Education about the likelihood of pain, including its possible magnitude, is therefore important to informed decision making, includ-
2 Quotation from testimony to the committee, November 2010.
ing decisions about options for preventing or managing pain. There is ample opportunity to educate people who will undergo elective surgery or outpatient procedures about the likelihood and magnitude of acute pain they may experience and to inform them about the availability of methods to prevent or relieve this pain. Postoperative patients surveyed about their information needs placed a high value on information about pain and pain management plans following surgery and discharge (Kastanias, 2009).
With respect to chronic pain, the committee believes education for patients should encompass such topics as those listed in Table 4-1. While the table addresses strictly patient education, families, too, should be seen as an appropriate target for educational efforts. Education for people with chronic pain should not be a onetime effort; as pain progresses, as treatments have greater or dwindling effects, as new treatments become available, the educational process should continue. One advantage of education is that it can enable people with pain to handle many pain-related problems themselves, without having to rely on medical care.
People with chronic pain have substantial unmet educational needs. For example, while three-fourths of people with chronic pain who visited an emergency department reported a desire for information about pain treatment options or referrals to pain specialists, only half reported receiving such information (Todd et al., 2010). There is evidence that appropriate education can improve satisfaction with care and outcomes of people with pain (Merelle et al., 2008).
Sometimes, especially in cases of severe persistent pain, a person may have to learn that certain limitations and discomforts appear to be permanent. Someone facing the prospect of lifelong discomfort, disability management, and self-care challenges will require emotional support along with accurate information. The prospect of a permanent reduction in health status and quality of life is not unique to persistent pain. It also confronts people who have other chronic diseases (such as diabetes, asthma, end-stage renal disease, multiple sclerosis, and some cancer and heart disease conditions), and the rich experience of patient education about these other diseases can be mined to improve strategies and expand the supply of materials for patient education about pain. Patient education programs and materials, like treatment choices (Chapter 3), need to be age-appropriate, geared to the person’s and family’s level of comprehension and general health literacy, culturally and linguistically competent, and supported by timely opportunities to ask questions and receive authoritative and useful answers. Families and other personal caregivers deserve information about how to obtain stress relief—including, in the case of people who are terminally ill, respite care—because they, too, are part of the patient’s milieu and need to be able to remain in peak form. Given the importance of patient education on pain, it would be useful to have educational modules—available through different media, such as Internet links (which could also benefit clinicians), pamphlets, and audio connections translated into various languages or geared to different health literacy levels or age groups—that could be selected for individual patients.
TABLE 4-1 Patient Education: Essential Topics
|Essential Patient Education Topic||Reason Why the Topic Is Essential|
|Steps people can take on their own—such as relaxation strategies, exercises, or weight loss—to prevent or obtain relief, help prevent acute pain from progressing to chronic pain, and help prevent chronic pain conditions from worsening||To prevent pain from progressing (that is, secondary prevention), to provide quick relief, to empower people to manage their own care as appropriate, and to avoid unnecessary health care expenditures|
|Differences between pain that is protective (adaptive) and pain that is not protective (maladaptive)||To advise people why pain that is not protective should be treated|
|Reasons why the need for relief is important, especially the possibility that poorly managed acute pain will progress to chronic pain||To persuade people to obtain early treatment when necessary|
|When and how emergency or urgent care should be obtained||To encourage seeking immediate intervention, which sometimes can prevent pain from severely worsening|
|Treatment-related pain (such as postoperative pain) and major categories of available pain therapies, along with the main advantages and disadvantages of each (such as potential benefits and risks of opioids)||To enable patients to be informed consumers|
|Different types of health professionals who may be able to help, and how they may help||To provide information about a full range of available services, to promote individual choice|
|Treatments health insurers may or may not reimburse or may reimburse only partially||To equip people to make choices that are cost-effective for them and prepare them for reimbursement problems|
|Ways in which family, employer, colleagues, friends, school, and other contacts can help prevent the pain from progressing or becoming prolonged||To empower patients to marshal support from those who are willing and able to help them|
|How pain is measured, including the difference between numeric (“subjective,” or intensity) scales and functional (“objective,” or disability) assessments||To enable patients to place their pain in a context health professionals will recognize and serve as an informed member of their own health care team|
|The fact that pain involves a complex mind–body interaction, rather than being strictly physical (biological) or strictly emotional (psychological)||To provide patients with an understanding of the need to address both dimensions of their pain and with appropriate, rather than unrealistically high, expectations|
|The right to pain care, including access to medications that are medically necessary and properly used||To alert patients to the possible need to advocate on their own behalf|
|Self-management techniques (surveyed in Chapter 3)||To furnish patients with enough information to obtain some relief on their own and contribute meaningfully to their own care|
Because severe pain affects so many aspects of a person’s life, people with pain and their families can feel overwhelmed. Education can help them devise ways of improving those circumstances that can be improved and coping with more lasting restrictions. Various types of education programs evaluated or in use by voluntary health organizations have benefited people with pain, including
- information on ways to control and cope with pain (American Chronic Pain Association, 2011; American Pain Foundation, 2011; PainKnowledge.org, 2011);
- psychosocial supports for people with pain and their personal caregivers, with a strong patient education component (Porter et al., 2010); and
- encouragement in the use of self-management strategies (Oliver et al., 2001; Moseley, 2003; Trautmann and Kröner-Herwig, 2010).
As noted in Chapter 1, a person’s beliefs about pain correlate with pain treatment outcomes. For example, one study found that people with cancer tend to receive inadequate analgesics and have greater pain if they harbor beliefs such as that cancer pain is inevitable, that side effects of analgesic drugs are unmanageable, that “good patients” do not complain about pain, and that pain distracts physicians from treating the cancer (Gunnarsdottir et al., 2002). Correcting such beliefs and misperceptions should be an important educational goal.
Education programs also can reduce symptoms and improve functioning. A program consisting of four educational sessions for people with cancer showed “significant immediate and sustained effects … on pain and fatigue barriers” among patients who received the intervention, compared with a usual care control group, as well as increased knowledge and measurable improvements in quality of life (Borneman et al., 2011, p. 197). Among people with low back pain, one-on-one education with a physiotherapist led to improved physical functioning, as measured by both straight-leg raise and forward bending. The researchers attributed approximately 77 percent of the leg-raise improvement and 60 percent of the bending improvement to a change in cognition, especially the belief that pain means tissue damage, and to reduced catastrophizing (Moseley, 2004).
Psychosocial education appears to be especially useful. In a German study involving “back schools” for rehabilitation in patients with low back pain, those who received education in the biopsychosocial model showed greater knowledge about their illness and better self-management than those who received more traditional education (Meng et al., 2011). A study of U.S. soldiers completing their training showed that a psychosocial education program improved their knowledge about the effects of low back pain—a malady frequently faced by soldiers—and their ability to cope with it (George et al., 2009).
Patient education assists people with pain and their families, as well as specific high-risk groups, such as soldiers in the example discussed above or people
diagnosed with cancer. The next section addresses public education, which can help in the prevention and treatment of pain in the general population.
We need respectability brought to these conditions.
—Terrie Cowley, The TMJ Association, Ltd., An advocate for people with chronic pain3
Why educate the general public about pain? The committee identified five reasons why public education about pain could be highly beneficial:
- People who have received such education can take steps to avoid pain, such as practicing proper stretching and lifting techniques, and can engage in timely and useful self-management when pain strikes.
- Educated people can give appropriate advice and assistance to family members, friends, and colleagues of people with pain, especially by advising them to refrain from telling injured individuals to simply “bear with it” or “suck it up.”
- In interactions with health care providers, educated people can advocate for and accept appropriate treatment of acute and chronic pain they or family members experience.
- An educated public can act at the community level to minimize hazards that contribute to pain-producing injuries among students (such as in sports programs) and in the general community (such as unshoveled walkways or sidewalks in disrepair).
- Educated citizens can advocate for improved pain prevention and control policy measures, such as reasonable sports helmet requirements, lawful access to medically necessary opioid medications, and health insurer reimbursement of interdisciplinary pain care.
Data with which to measure the extent and accuracy of public knowledge about the science and treatment of pain are limited. A 2002 national telephone survey of 1,000 adults found that “most Americans have little understanding of pain and its treatment” (Partners for Understanding Pain, 2002, p. 2). Specifically, survey respondents tended to overestimate physicians’ training in pain; underestimate the extent to which pain affects people under age 65; and believe that
3 Quotation from testimony to the committee, November 2010.
most people complain about pain only to obtain drugs, avoid work, or garner attention. Similarly, a landmark 1997 survey of the public sponsored by the Mayday Fund found that many Americans had only limited knowledge about pain and its treatment, believing, for example, that pain medications are dangerous and should be avoided if possible (Bostrom, 1997).
Although the 1997 and 2002 surveys uncovered persistent deficits in public understanding about pain, they are insufficient to serve as a platform for a major public education effort today. The results are a decade or more old and are focused largely on opioid-related issues that continue to evolve. Additional research into public knowledge about pain would enable public health advocates to
- assess the overall need for public education,
- identify groups most in need of education and the most cost-effective ways of reaching them,
- determine appropriate content domains, and
- craft messages or lessons.
Some existing campaigns, described in Box 4-1, illustrate how public education on pain might take place. Some public health education campaigns outside the pain field illustrate the potential for producing change in pain-related behavior.
Public Education Campaigns on Low Back Pain
Low back pain costs Australia more than AU$9 billion a year (which amounts to approximately US$350400 per resident) (Walker et al., 2003). Partly to reduce rapidly rising workers’ compensation costs for back pain, the state of Victoria WorkCover Authority in the late 1990s conducted what is considered the first back pain public education campaign, Back Pain: Don’t Take It Lying Down.
The 3year, $10 million multimedia effort, centered on primetime television advertisements, helped convince people with pain not to fear remaining physically active (Buchbinder et al., 2001a). Pre and postcampaign evaluations showed that after the campaign, more people disagreed with certain inaccurate statements contained in the Back Beliefs Questionnaire (BBQ), such as that back trouble requires rest; that back trouble will eventually stop one from working; that there is no real treatment for back pain; and that once one has had back trouble, there is always a weakness. The desired beliefs were maintained for at least 3 years after the campaign ended and were held more widely in Victoria than in neighboring New South
Wales (Buchbinder and Jolley, 2004). General practitioners’ beliefs also improved, and claims for back injuries fell by 15 percent (Buchbinder et al., 2001b).
The Victoria campaign messages were disseminated through television, radio, billboards, posters, seminars, workplace visits, and news articles. The messages included the following:
- Back pain is not a serious problem.
- People with back pain should continue their usual activities and exercise, without resting for long periods or leaving work unnecessarily.
- People with back pain should maintain a positive attitude.
- Xrays are not useful, and surgery may not help.
- Employees should remain at work.
Underlying the Victoria campaign were specific, informed convictions about disease prevention. Campaign organizers focused on improving beliefs in a majority of the population that had been somewhat undecided (“had intermediate beliefs”) instead of trying to improve “the poorest beliefs” held by only a few people. They also thought that influencing attitudes communitywide could produce sustained behavioral change and that even expensive mass media campaigns would ultimately be more cost-effective than one-on-one education (Buchbinder, 2008).
Influenced by the Australian experience, National Health Service authorities in Scotland also conducted a media campaign on back pain, involving 1,777 radio announcements that reached three in five of the country’s adults. The effort further included leaflets, as well as information packets distributed to health professionals and employers. The campaign produced a positive effect on public and professional attitudes, as most people became aware of the benefits of staying active for those with back pain. However, the Scottish campaign, which was far smaller in scale than its Australian counterpart, did not reduce disability claims or worker absenteeism (Waddell et al., 2007).
Norway and Canada
Back pain campaigns modeled on the Australian and Scottish efforts have taken place in parts of Norway and in the province of Alberta, Canada. The Norwegian effort was relatively small and, like the Scottish campaign, improved beliefs but not workers’ compensation claims (Werner et al., 2008). The Alberta effort also was small, involving mostly radio announcements, and produced little effect on beliefs and no appreciable change in work behavior or health care utilization (Gross et al., 2010). As the evaluators of the Alberta campaign emphasized, mass media campaigns must be large in order to influence behavior significantly.
Tobacco use in the United States has fallen dramatically, for example, partly as a result of systematic public education. Between 1991 and 2009, use levels among high school students declined by 34 percent for “ever smoked cigarettes,” by 29 percent for current cigarette use, and by 43 percent for current frequent cigarette use (Office on Smoking and Health, 2010). Among adults, smoking rates declined by 24 percent between 1992-1993 and 2006-2007 (Giovino et al., 2009). Local combinations of a well-designed public education campaign, community and school-based programs, strong enforcement efforts, and smoking cessation programs have reduced smoking among youth by as much as 40 percent (Campaign for Tobacco-free Kids, 2011). Mass media tobacco control campaigns are associated with both declines in youth uptake of smoking and adult smoking cessation (Wakefield et al., 2010).
The back pain campaigns described in Box 4-1 and tobacco control campaigns represent one type of public education—social marketing—which uses simple messages, advertising techniques, and other marketing approaches to persuade large numbers of people to change behavior or support changes in public policy (Kotler and Lee, 2008). Other public education strategies include more neutral informational and awareness-building efforts. Like social marketing, these efforts seek people out proactively. In the pain context, such efforts could alert people to the range of available treatments and categories of health professionals who treat pain, to available educational resources, or to the fact that pain is both a physical and a psychosocial condition. These strategies also might also focus on reducing risk factors for pain. For example, they could remind people with frequent headaches to avoid using analgesics daily or near-daily to minimize the development of medication-overuse headache (Loder, 2006).
Many educational tools are useful in reaching the public:
- website content, listservs, and social media;
- fact sheets distributed to target audiences, such as opinion leaders or community meeting attendees;
- leaflets, to raise awareness and be retained as personal references;
- informational reports and studies;
- pamphlets distributed at schools, workplaces, churches, public meetings, and other venues;
- signs at health facilities and in health professionals’ offices;
- media outreach;
- coalition building among stakeholders;
- surveys of public or professional attitudes used to garner media attention;
- wellness classes at health facilities, gyms, senior centers, and adult education programs, for example;
- instructional videos; and
- attempts to influence purveyors of popular culture, such as television and movie scriptwriters.
An advantage of comprehensive educational efforts is that content can be far more complex than simple messages delivered via the mass media. Also, most of these approaches can be tailored to specific audiences, segmented by health status, risk group, demographic characteristics, language skills, or preferred educational media. Some educational initiatives could target nonhealth professionals who receive people’s initial reports of pain, such as employers, teachers, and clergy (Chapter 3), or third-party payers and others who influence the course of pain care. An additional advantage of public education overall is that it can draw people into public decision-making processes, for example, by encouraging them to ask their employer to make sure that their health insurance plan sufficiently covers pain management or advocate that their local public schools have an injury prevention policy, especially in sports programs.
Illustrating the capacity of public education about health issues, the American Cancer Society (ACS) has been effective in its long-term efforts to promote cancer screening and early detection. ACS began as a public education organization in an era when cancer was rarely talked about openly, and used film and other media to engender emotion and gain support for cancer research and care (Cantor, 2007). The organization maintains a nationwide 24-hour help line and offers information about local resources, clinical trials, awareness building, smoking cessation, and specific cancers (ACS, 2011). Additionally, ACS actively advocates for public policies to increase cancer prevention, care, and research and participates in prohealth coalitions (ACS et al., 2008).
Over a shorter time frame, end-of-life educational efforts have been similarly instrumental in such areas as making more Americans aware of the importance of advance directives (Ulrich, 1999; Patient Self-Determination Act, Public Law 101-508, Secs. 4206 and 4751 of Omnibus Budget Reconciliation Act of 1990). Prominent among these end-of-life educational efforts was the Last Acts campaign, a coalition-based enterprise that engaged in multiple public and professional education initiatives (Karani and Meier, 2003). For example, one Last Acts product was a national report card indicating how well each state was protecting end-of-life decisions and ensuring high-quality care for people with terminal illnesses (Robert Wood Johnson Foundation, 2003).
Public education is undertaken by many other nonprofit organizations dedicated to combating a single disease or constellation of health conditions. Typically, their efforts mix patient (and family) and public education. Alzheimer’s disease, for example, is targeted by multiple groups that have both public and patient education as part of their mission:
- The Alzheimer’s Association maintains a website with access to such materials as a chartbook and a list of ten warning signs of the disease (Alzheimer’s Association, 2011).
- The American Geriatrics Society’s Foundation for Health in Aging administers a Patient Education Forum with online answers to such questions as: “What effect can Alzheimer’s disease have on a caregiver?” and “How important is early detection and diagnosis of Alzheimer’s disease?” (American Geriatrics Society, 2011).
- A California Alzheimer’s disease task force adopted a statewide plan to reduce stigma, ensure that information clearinghouses have reliable information, increase access to public information, and promote public education (California Health and Human Services Agency and California Council of the Alzheimer’s Association, 2011).
- The National Institute on Aging maintains an Alzheimer’s Disease Education and Referral Center.
Educational efforts by these and many other organizations have helped make the country more aware of Alzheimer’s disease and have assisted individuals and their families in finding information and support.
Currently, public education about pain is not conducted in a large-scale, systematic, coordinated, and strategic way as in the tobacco, cancer, end-of-life, and Alzheimer’s disease examples. Some organizations, such as the American Pain Foundation and the Mayday Fund, certainly promote public awareness. Several patient-oriented groups focused on single pain conditions or issues—such as the National Fibromyalgia Association, Women with Pain Coalition, and American Chronic Pain Association—take strong advocacy positions. The issue of access to opioid medications has sparked numerous public advocacy efforts over the past two decades. But neither the federal government nor a coalition of pain organizations that could assemble more resources has designed and undertaken a campaign to increase public awareness of such topics as the pervasiveness of pain and the need to treat it, the multiple causes and effects of pain, the fact that pain involves a complex mind–body interaction, and the range of available and useful treatments. Without such an effort, it appears unlikely that public awareness of these issues will increase substantially in the near future or that the cultural transformation envisioned by this committee (Chapter 1) can be achieved.
On the federal level, informing the public about pain has not received sustained priority attention from the Centers for Disease Control and Prevention (CDC), the Office of the Surgeon General, the Agency for Healthcare Research and Quality (AHRQ), or the National Institutes of Health (NIH), although CDC, AHRQ, and NIH all have displayed an appreciation for the importance of pain. CDC, for example, has publicly released a fact sheet on pain (CDC, 2006); AHRQ conducted an early study on back pain and publicized the results (Chapter 3); and
Public education is a normal public health activity; indeed, “inform, educate, and empower people about public health issues” is one of the Ten Essential Public Health Services that every public health agency is expected to provide (CDC, 2011). Public education enhances the effects of each of the concentric circles of major influence on disease control: policy, community-wide environmental control measures, community awareness support and action, work and school support, clinical expertise, family involvement, and patient self-management (Clark and Partridge, 2002).
Advocacy, especially at the state level, may be an appropriate education-related activity for organizations interested in reducing the burden of pain in society. To illustrate, the Massachusetts Pain Initiative has supported state legislation to require pain assessment and management in all health facilities, extend the expiration date of scheduled drugs to comply with federal law, require pain management and prescription drug abuse training for all prescribers, and establish a prescription monitoring program task force (Massachusetts Pain Initiative, 2011).
Just as public education programs may require the combined financial resources of several organizations, advocacy efforts typically require the combined voice of a strong coalition. Given the multiple barriers to better pain prevention and care, such a combined effort may be needed to have a significant impact at the federal level; in state capitals; and with key private organizations, such as health insurers, health professions training and accreditation authorities, health professions examination boards, large health care providers, employers, schools, and sports officials. Effective, multifaceted, and coordinated advocacy is a necessary condition for cultural transformation.
Patient and public education, the two topics addressed in the first part of this chapter, help shape the demand for pain care. The following sections turn to the supply of health professionals adequately prepared to provide pain care, beginning with physicians.
Pain management and physical rehabilitation were never addressed in my medical school curriculum nor in my family practice residency. My disability could have been avoided or lessened with timely treatment, and I could still be the provider instead of the patient.
—A physician with chronic pain4
4 Quotation from response to committee survey.
Did we have as students a single lecture on migraine, and did anyone tell us that migraine is not just a tiresome form of occasional headache which someone else rather boringly suffers from?
—William Gooddy, Foreword to Migraine, by Oliver Sacks, p. xxii.
The case for including comprehensive education about pain in medical education is powerful. People have sought out physicians for pain care for centuries. Pain treatment is an essential component of clinical practice, as recognized in state medical practice acts and by the Federation of State Medical Boards in its model Medical and Osteopathic Practice Act:
Practice of medicine means … offering or undertaking to prevent or to diagnose, correct and/or treat in any manner or by any means, methods, or devices any disease, illness, pain, wound, fracture, infirmity, defect or abnormal physical or mental condition of any person. … (Federation of State Medical Boards, 2010, p. 4).
The widespread prevalence of pain (Chapter 2) demonstrates the need for medical educators to recognize it as a common and often severe condition. Yet there are strong indications that pain receives insufficient attention in virtually all phases of medical education—the lengthy continuum that includes medical school (undergraduate medical education), residency programs (graduate medical education), and courses taken by practicing physicians (continuing medical education [CME]).
Deficiencies in preparing physicians to manage pain were documented and explored in depth during the First National Pain Medicine Summit, convened in November 2009 by the American Medical Association’s Pain and Palliative Medicine Specialty Section Council (Lippe et al., 2010). The genesis of the summit was widespread concern that current knowledge about pain management is not being well integrated into medical practice and that pain care in general is “delayed and inadequate.” Nearly 100 representatives of some 30 physician organizations participated in this exercise. The summit agenda was built around a two-stage Delphi, or group consensus development, process. The first stage produced strong criticism of current physician training in pain care:
- Training was seen as poor or “not leading to competency” at both the undergraduate and residency levels in all suggested areas of pain treatment. Rated highest was pharmacologic therapy training at the residency level, but even in that area, only 53 percent of respondents agreed that the training led to competency. None of the areas received a majority of
“yes” votes to the question of whether adequate care was being provided in that area.
- Participants identified three top barriers to adequate pain care: workforce issues that create a shortage of competent pain care providers, a lack of knowledge among physicians and/or people with pain regarding the field of pain care medicine, and a lack of public knowledge about pain issues. All three factors were seen as barriers by more than 90 percent of respondents.
- The average score for the question, “How well does the present system of credentialing and certification ensure competency?” was 2.65 (where 1 was “not at all” and 5 was “completely”).
Themes extracted from respondents’ comments in the first Delphi round were used to identify five topics that became the subject of work group discussions in the second round:
- What should all physicians know about pain medicine?
- How should pain medicine be taught?
- What are the parameters that define the field of pain medicine?
- What mechanisms do we need to establish the competency of a physician who wishes to practice pain medicine?
- What are the barriers, besides the absence of competent pain medicine physicians, that prevent people from receiving adequate care?
The summit therefore may have laid the groundwork for substantial improvements in physician education about pain. The summit work group discussing the question, “What should all physicians know about pain medicine?” concluded that most medical school education still treats pain mainly as a symptom. “Cure the disease, and cure the pain” is the assumption, which ignores the emerging recognition that persistent pain requires direct treatment (Chapter 1). The group found little consistency in teaching across medical schools, among departments in the same school, and even within departments (Gallagher, 2010). Identified as chief flaws were a lack of breadth in the presentation of the topic, a lack of integration of basic science and clinical knowledge, and a lack of clinical role models—especially specialists treating chronic pain—in most academic medical centers. The results included “negative generalizations about patients with chronic pain” and “further alienation and misunderstanding of the patient and chronic pain.” Moreover, this first work group observed that pain management is spread out over many clinical specialties, creating confusion about “who is in charge” of developing, documenting, and reporting best practices and pain care guidelines. As a result, there are “no standards for measuring the effectiveness of treating pain in clinical practice.” The work group also noted the paucity of information about treating pain in children.
The summit work group discussing the question, “How should pain medicine be taught?” echoed the first group’s findings and focused on the need to make pain training more comprehensive, “incorporating the needs of the primary care practitioner and the pain care specialist” alike (Burchiel, 2010, p. 1452).
The work group discussing the question, “What mechanisms do we need to establish the competency of a physician who wishes to practice pain medicine?” identified the need to determine competency through medical education, assessment, and documentation through all three stages of education. Meeting this need will require oversight of education by accreditation authorities and oversight of practice by licensure and certification authorities, including greater attention to CME (Follett, 2010). This work group’s discussion suggests that improvement could be realized if organizations such as the Accreditation Council for Graduate Medical Education (ACGME) and the National Board of Medical Examiners took steps to require pain training of most residents and include questions about pain on physician licensure examinations, respectively.
Finally, the competencies work group determined that “competing, overlapping, and sometimes conflicting efforts of the various organizations involved” mean there is no “single-party” ownership of the pain medicine specialty. This makes it difficult to develop a uniform process for training, certification, and demonstration of competency, a situation further complicated by the availability of pain treatment by nonphysicians “whose variable training and certification add even more disparity to the mix” of competencies of different practitioners.
The summit findings emerged against a backdrop of continually expressed concerns that most physicians are not equipped to provide high-quality pain care. One concern is that too many physicians harbor outmoded or unscientific attitudes toward pain and people with pain (see Chapter 3). For example, physicians are described as having “pain apathy” that inhibits them from engaging in active treatment (Notcutt and Gibbs, 2010). The perspective of scholars in medical anthropology or social medicine provides a theory about this lack of interest:
… in our studies over several decades, we found that “the medical gaze” soon becomes the dominant knowledge frame through medical school, that time and efficiency are highly prized, and that students and their attendings (that is, clinical educators) are most caring of patients who are willing to become part of the medical story they wish to tell and the therapeutic activities they hope to pursue. (Good et al., 2002, p. 596)
Pain may not be part of the “medical story” most physicians are interested in telling or learning about because they concentrate on other diseases and conditions.
People with pain, especially chronic pain, sometimes do find that physicians are poor listeners. In a study of physician communication with people with cancer pain, involving 17 oncologists and 84 patients, physicians were found to do most of the talking during patient visits and to interrupt most patients’ attempts
to provide information or answer questions (Berry et al., 2003). The researchers concluded: “The nature of such communication may prevent the patient from sharing significant facts and experiences relevant to cancer pain and thus compromise the quality of pain management” (Berry et al., 2003, p. 374). A previous Institute of Medicine (IOM) study recommended additional training for medical students in subjects involving communication skills to “assist physicians in building therapeutic relationships with their patients and increase the likelihood that patients will follow their advice” (IOM, 2004, p. 4).
Inadequate training in pain is strongly implicated in insufficient treatment. An expert panel convened by the Mayday Fund reported:
… current systems of care do not adequately train or support internists, family physicians and pediatricians, [who are] the other health care providers who provide primary care in meeting the challenge of treating pain as a chronic illness. Primary care providers often receive little training in the assessment and treatment of complex chronic pain conditions. They tend to work under conditions that permit little time with each individual and few options for specialist referrals. (Mayday Fund, 2009, p. 3)
The Mayday panel recommended that every health professional be taught “the skills to assess and treat pain effectively, including chronic pain” (Mayday Fund, 2009, p. 9). Presumably, those skills would include the application of cognitive-behavioral therapy, which also can be useful in treating conditions other than pain and should be appropriately reimbursed (Chapter 3).
Medical schools’ inadequate attention to comprehensive pain education has been quantified. A recent study of 117 U.S. and Canadian medical schools found that only 4 U.S. schools offer a required course on pain (Mezei and Murinson, in press). Most schools incorporate pain into another required course. The study also found that over the 4-year course of U.S. medical school education
- the total number of pain sessions taught ranged from 1 to 28, with a mean of 9 and a median of 7; and
- the total number of pain teaching hours ranged from 1 to 31, with a mean of 11 and a median of 9.
Levels about twice as high were found at Canadian medical schools. The inadequacy of attention to pain in medical schools is reflected in students’ specialty preferences. In a questionnaire administered annually to graduating medical school students, the percentage of respondents indicating pain medicine as their preferred choice of specialty stood at a flat 0.0 from 2006 through 2010 (AAMC, 2010).
What do primary care physicians themselves think of their preparation in pain management? Results of a national survey of residents completing their
training at U.S. academic health centers, including training in the primary care specialties for which pain management is an essential component (internal medicine, family medicine, and obstetrics-gynecology), found that
- half the primary care respondents felt only “somewhat prepared” to counsel patients about pain management;
- as many as 27 percent felt “somewhat unprepared” or “very unprepared”; • only 21 to 26 percent felt “very prepared”; and
- in response to questions about treating specific common pain problems, only about half of the internal medicine residents rated themselves “very prepared” to diagnose and treat low back pain or headache, compared with about two-thirds of family medicine residents and a quarter or less of obstetrics-gynecology residents (Blumenthal et al., 2001).
The Association of American Medical Colleges has surveyed all medical graduates regarding whether their instruction in various areas was inadequate, appropriate, or excessive. In 2006, a quarter of graduates rated their instruction in pain management and palliative care as inadequate. The rating improved somewhat by 2010, with only 20 percent rating instruction in this area as inadequate (AAMC, 2010).
Likewise, in a survey of 1,236 practicing physicians, more than half said they felt poorly prepared to manage end-of-life or chronic pain care (Darer et al., 2004). However, physicians (and other clinical staff) working in a rehabilitation hospital appeared somewhat more confident of their competence in most pain management skills (Loder et al., 2003). In a survey in which 111 staff members participated, large majorities (between 63 and 89 percent) said they were comfortable with such tasks as engaging in basic pain assessment, providing psychological support, using thermal modalities for pain, managing pain in the elderly, and teaching relaxation techniques.
Some efforts are under way to improve pain education and training in medical schools in creative ways. For example, at the Johns Hopkins University School of Medicine, a new 4-day program in pain medicine for first-year students integrates core curriculum knowledge with emotional and reflective development (Murinson et al., 2011). Pain specialists provide instructional support, and the course emphasizes building “emotional skills.” Student performance on a variety of outcome measures has been encouraging.
In CME—the end of the medical education continuum for practicing physicians—attention to pain also has increased somewhat. In 2001, California enacted legislation requiring all physicians other than radiologists and pathologists to take 12 CME units in pain management or end-of-life care; this mandatory CME provision is implemented by the state’s Board of Medical Examiners through regulation (California Business and Professions Code, 2011,
Sec. 2190.5). This is a one-time-only requirement, however, and so does not compel clinicians to stay abreast of developments in the field throughout their careers.
Another possible shortcoming of mandatory CME is that the relationship between CME and desired changes in practice patterns is somewhat limited. In a recent review of 105 studies, only 60 percent showed that CME produces changes in physician practice patterns (although the authors found this to be a persuasive reason to promote CME) (Davis et al., 2009). A targeted approach to CME in pain management would require it only of physicians who prescribe high levels of opioids.
One frontier of CME (and quality improvement) appears to offer promise for physicians seeking to improve their competence in pain management. Academic detailing, in which medical school professors or other nonindustry experts offer tailored instruction to clinicians, was offered by a drug and therapeutics information service to primary care physicians in Fayette County, Kentucky (May et al., 2009). Instruction, in the form of personal visits, was offered in two subjects: diabetes management and pain management. Nearly three in five physicians chose to accept visits dealing with pain management.
Education and Training of Primary Care Physicians
Not all physicians require the same amount of pain-related knowledge and skills. Because so few physicians specialize in pain management, the main source of medical care for most people with common chronic pain problems is a primary care practitioner (Chapter 3), which makes the need for medical education about pain especially important in primary care training. Yet primary care physicians do not believe that they are well prepared to manage pain:
- In a survey of 500 primary care physicians at 12 academic medical centers, only 34 percent reported feeling comfortable treating people with chronic noncancer pain (O’Rorke et al., 2007).
- A survey of 111 primary care practitioners (including physicians, medical residents, nurse practitioners, and physician assistants) at community clinics found that most felt inadequately prepared to treat pain and had low satisfaction with providing pain care, even though nearly 40 percent of adult appointments involved people with chronic pain complaints (Upshur et al., 2006).
- A survey of 279 residents in internal medicine and 326 residents in family medicine showed that only about half of those in internal medicine considered themselves adequately prepared to diagnose and treat headache or low back pain, while 62 percent of those in family medicine felt adequately prepared to treat headache and 71 percent low back pain. Greater patient exposure and contact improved residents’ confidence in managing these pain conditions (Wiest et al., 2002).
Wiest and colleagues (2002) concluded that reorganization of graduate medical training programs to increase patient contact might improve residents’ readiness to care for common pain conditions. However, physicians’ beliefs about their ability to manage pain do not always match their actual competence, and physicians may not recognize deficits in their pain care knowledge:
[There is] no correlation between physicians’ confidence in their knowledge and abilities to manage pain and their ability to make good treatment decisions. Educators and policy-makers need to develop effective tools for self-assessment and creative ways of using these tools to helping [sic] physicians understand and remediate their knowledge and skill deficits. (Gallagher, 2003, p. 3)
A drive toward competency-based education, as supported by one of the 2009 pain summit work groups described above, is being promoted within internal medicine (Weinberger et al., 2006; Meyers et al., 2007). (General internists are one of the main categories of primary care physicians.) Recognizing pain management as part of the core competency of internal medicine could substantially improve the ability of a large group of physicians to manage pain.
Even if formal residency training programs are not altered to incorporate pain and pain management, Internet-based updates and tips might increase residents’ awareness of developments in pain care (Sullivan et al., 2010; Claxton et al., 2011). Another way to improve primary care physicians’ ability to manage pain would be to expand interdisciplinary education in pain so that more pain care can be delivered competently and efficiently by a primary care team instead of having to be handled by an individual physician (see Chapter 3). Given the nationwide shortage of primary care physicians, teams may deliver most primary care in the future. Further, according to Cooper (2009, p. 125), “the notion that future patients may experience regular 30-minute visits with a primary care physician is not credible.” To illustrate, teams consisting of a physician, nurse, medical assistant, and patient care representative have successfully managed hypertension in 88 percent of patients (Feder, 2011), and the American Academy of Family Physicians is ambitiously supporting the development of medical homes that use teams to provide chronic care (Nutting et al., 2011). The development of accountable care organizations could further accelerate the trend toward team care (DeVore and Champion, 2011).5
Still, some skepticism about the potential to transform pain care through primary care teams probably is well founded. The United States has a long history of failed attempts to promote interdisciplinary teamwork (Grumbach and
5 A completely different model is that used in the United Kingdom under its system of “specialization in general practice” (Jones, 2006). Preliminary findings in a headache service suggested that, for patients with comparable severity of illness, outcomes from care by generalists with special training in headache management were similar to those from care by a traditional neurology service, while patient satisfaction was higher and costs were lower (Ridsdale, 2008).
Bodenheimer, 2004). Poor communication skills and technologies, a lack of appreciation of the capabilities of different disciplines, entrenched interprofessional conflicts, and inexperience in collaborating collegially across professional divides make team practice difficult. In general, professional silos allow few opportunities for meaningful interaction and joint problem solving (IOM, 2001b). The route to success in team care probably begins with interdisciplinary training so that members of different professions become comfortable with collaboration (Schuetz et al., 2010).
Training and Credentialing of Physician Pain Specialists
At present, pain medicine is recognized by the American Board of Medical Specialties (ABMS) not as a distinct physician specialty but as a subspecialty fellowship training program that can be offered by residency programs in anesthesiology, physical medicine and rehabilitation, and psychiatry and neurology. Although these pain fellowship programs could admit physicians trained in other specialties, they rarely do.
The American Board of Anesthesiology first issued pain subspecialty certificates in 1993, and the other two specialty boards followed in 2000. After completing an accredited pain fellowship, candidates are allowed to sit for an examination; if they pass, they receive board certification in pain medicine. The certification examination for all three boards is administered by the American Board of Anesthesiology (ABMS, 2010).
Between 2000 and 2009, a total of 3,488 physicians obtained board certification in pain medicine (Chapter 3). This amounts to 4 percent of all physicians obtaining certification in some field during that decade. Many who did obtain certification in pain medicine are believed to have allowed their certification to lapse because of retirement, difficulties in obtaining desired reimbursement for specialty pain care, or other factors.
The American Board of Pain Medicine (ABPM) also certifies physicians in the field of pain medicine. ABPM is not a member of ABMS, but state medical boards in California and Florida deem it to be equivalent to ABMS for purposes of recognizing a physician as board certified in pain medicine—entitled, therefore, to advertise as a board-certified specialist and to seek insurance reimbursement at specialist rates. Whereas ABMS pain certification is subsidiary to the three fields of anesthesiology, physical medicine and rehabilitation, and psychiatry and neurology, ABPM certification is held out as a free-standing, or “primary,” specialization.
Approximately 2,150 physicians have been certified in pain medicine by ABPM since 1991. Some pain specialists hold both ABMS and ABPM certificates. Thus, in light of lapsed certificates, the actual number of certified, currently practicing pain specialists may be in the range of 3,000 to 4,000.
These small numbers, set against the large number of Americans with pain conditions, clearly demonstrate that referral to a pain specialist is not easily accomplished.
Simultaneously with the effort to establish pain fellowship training in the 1990s and early 2000s, interest was growing in palliative care, and certification somewhat similar to the pain medicine certification is provided in that field. Although broadly concerned with symptom relief in terminal, progressive illnesses, palliative care necessarily involves a substantial degree of pain treatment. Both fields address pain and other symptom control; physician–patient communication; fatigue; and psychosocial issues, such as depression and social problems (IOM, 2001a, p. 60). An IOM report published in the 1990s (IOM, 1997, pp. 287-288) contributed to the development of the palliative care field. Recommendations from that report included the following:
- Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to care well for people who are dying.
- Palliative care should become, if not a medical specialty, at least a defined area of expertise, education, and research.
ABMS approved hospice and palliative care subspecialties in 2006 and began awarding certificates in 2008 for ten medical specialties: anesthesiology, emergency medicine, family medicine, internal medicine, obstetrics and gynecology, pediatrics, physical medicine and rehabilitation, psychiatry and neurology, radiology, and surgery.
In addition, since 2006 the United Council for Neurologic Subspecialties (UCNS) has offered subspecialty certification in headache medicine to qualified candidates who pass an examination. UCNS is sponsored by five parent organizations, including the American Academy of Neurology and the American Neurological Association. UCNS also accredits headache medicine fellowship programs. Beginning in 2012, only physicians who have completed an accredited headache medicine fellowship will be allowed to sit for the UCNS headache medicine certification examination. As of 2010, 294 physicians had passed this examination, and there were 12 accredited headache medicine fellowship programs (United Council for Neurologic Subspecialties, 2011). The very existence of the UCNS certification effort may reflect the lack of sufficient attention to pain care in the overall scope of graduate medical education.
In 2008, three leading academic centers, perhaps perceiving a leadership vacuum, convened a conference to discuss ways to improve pain education for physicians. Participants recommended, in part:
- finding ways to expose more neurology residents to people with chronic pain;
- recruiting the most gifted teachers and promoting use of the best teaching methods in pain education;
- identifying academic champions of pain research, whom students and residents could seek out; and
- outlining a curriculum for medical students, primary care physicians, neurologists, and pain specialists that identifies specific information necessary to help each medical professional accurately diagnose and appropriately treat or refer people with pain (Drexler, 2008).
A bright side of the picture consists of the presence of 93 pain fellowship programs—1-year programs typically sponsored by, and located at, an academic medical center (ACGME, 2011). Generally, physicians who have completed a residency in a pain-related specialty are eligible to apply for one of these fellowships. Fellowship programs are accredited by ACGME, based on rigorous standards (ACGME, 2007). But specialization in pain medicine is now such a long path, involving core residency training followed by a pain fellowship, that potentially interested physicians may be deterred from entering the field.
Most physicians who are board certified in pain medicine are anesthesiologists by prior training. In part, this reflects the early attention of the anesthesiology field to pain—attention that began with that specialty’s origins, when William Morton first publicly demonstrated the effects of ether in Boston in 1846. By virtue of its historical and current ties to pain management, the specialty of anesthesiology tends, more than other specialties, to attract physicians interested in pain care. In addition, most pain fellowship training programs are anesthesiology based, so the majority of physicians interested in pain management will take advanced training in such programs. The result can be a loss of the diversity that can be advantageous for the systemwide practice of multidisciplinary pain care as practitioners from disparate medical backgrounds (e.g., neurology and physiatry) learn similar approaches to pain care. In 2007, the ACGME committee that oversees pain fellowship training redefined the training requirements to emphasize the importance of multidisciplinary care with the integration of training from the fields of neurology, psychiatry/psychology, physiatry, and anesthesiology. For a variety of reasons, however, such as reimbursement patterns or patient preferences for invasive, procedural techniques, even graduates of programs that provide multidisciplinary training may develop clinical practices that focus disproportionately on interventional (procedural) approaches to pain care (Chapter 3). If so, patients may have little opportunity to choose among treatment options to obtain the treatment most appropriate for them.
While anesthesiology has a key position in the delivery of pain care, other specialties have strong reasons to engage in pain medicine. One reason is the potentially broad range of applications of pain medicine’s rapidly evolving knowl-
edge base. For example, analysts conducting a literature review regarding the relationship between pain and psychiatry found that “psychiatric disorders are commonly associated with alterations in pain processing” and that “chronic pain may impair emotional and neurocognitive functioning” (Elman et al., 2011, p. 12). The analysts concluded that pain training among psychiatrists would enable “deeper and more sophisticated insight” into both pain syndromes and psychiatric conditions, regardless of patients’ pain status. The same could be true of other specialties as well.
Promoting Physicians’ Understanding of Medication Abuse and Misuse
Physicians’ understanding of opioid-related issues, especially diversion of drugs for illicit purposes, is an important concern, discussed in Chapter 3. What is particularly relevant here is the existence of knowledge deficits among physicians on important topics related to opioids (e.g., Fineberg et al., 2006).
For example, prescriptions written by physicians can inadvertently enter the nonmedical, illegal market. Accordingly, physicians should assess the risk that medications they prescribe in the care of their patients could find their way into unauthorized use and counsel their patients about this possibility. Further, professional confusion and the recent rise in opioid diversion and abuse contribute to a backlash against the medical use of opioids. This backlash leads, in turn, to restrictive public policies and enforcement approaches, reduced access to opioid medications, and individual and family apprehensions about using these drugs.
Development of a standardized curriculum in pain management and opioid prescribing across disciplines has been suggested by the Nurse Practitioner Healthcare Foundation (Arnstein and St. Marie, 2010, p. 4). A foundation white paper states: “One of the main adverse consequences of the rise in prescription opioid use is the potential criminalization of pain sufferers who use opioids and the [health care professionals] who prescribe these agents to treat pain.” The white paper recommends providing outcome-oriented continuing education and making pain education available to all members of health care teams, including those who are not health professionals.
Every patient is an individual pharmacological experiment; one size does not fit all.
—A nurse in a pain management clinic6
6 Quotation from response to committee survey.
The experience of pain is an overwhelming, whole-person experience with devastating effects on the experiencing person, the family witness, and the nurse.
—Nurse educator Betty Ferrell (2005)
Nurses provide bedside care to people with pain in hospitals and nursing homes, in patients’ homes, at schools and workplaces, in physicians’ offices, in public health and patient education programs, and as advanced practice nurses (a category that includes nurse practitioners, clinical nurse specialists, certified nurse midwives, and nurse anesthetists). Nursing leaders emphasize their profession’s focus on the “whole patient,” a helpful perspective when one is considering the complex interplay of factors involved in caring for people with acute and chronic pain. Nurses are educated to take into account that the “human response to a health problem may be much more fluid and variable” than suggested by the medical diagnosis and a greater key to recovery than a single medical treatment (ANA, 2011, p. 1). Moreover, nurses are trained to be attentive to the needs of families, who play a vital role in the care of people with chronic pain.
More specifically, nurses with baccalaureate degrees are charged with responsibility for providing care that incorporates many components of high-quality pain care. A recent report of the American Association of Colleges of Nursing states:
Baccalaureate-prepared nurses provide patient-centered care that identifies, respects, and addresses patients’ differences, values, preferences, and expressed needs (IOM, 2003). Patient-centered care also involves the coordination of continuous care, listening to, communicating with, and educating patients and caregivers regarding health, wellness, and disease management and prevention. The generalist nurse provides the human link between the healthcare system and the patient by translating the plan of care to the patient. A broad-based skill set is required to fill this human interface role. (American Association of Colleges of Nursing, 2008, p. 8, citing IOM, 2003)
To the extent that such psychosocially oriented care is delivered to people with chronic pain early in their course of treatment, it may have a particularly salutary effect in preventing serious problems—such as the progression from acute to chronic pain—later on. The report also outlines expectations for students’ clinical experiences within baccalaureate programs. These clinical experiences should be “focused on developing and refining the knowledge and skills necessary to manage care as part of an inter-professional team” and should take place “across the range of practice settings” (American Association of Colleges of Nursing, 2008, pp. 4, 34).
Pain management now is considered an essential responsibility for nurses, and nursing organizations acknowledge the need for “prompt, safe, and effective pain management.” The nursing profession views pain as a complex and multidimensional experience (Lewis et al., 2011) that responds subjectively to both physical and psychological stressors (LeMone et al., 2011). In a joint position statement, the American College of Emergency Physicians, American Pain Society, Emergency Nurses Association, and American Society for Pain Management Nursing enunciated 14 core principles regarding pain management (American College of Emergency Physicians et al., 2010). Two of these principles refer to educational issues:
- Clinician education and resources [should] support optimal pain management.
- Research and education are encouraged to support widespread dissemination of evidence-based analgesic practices.
Elsewhere among these principles, the need to rely on evidence-based practices is reinforced. Despite these well-articulated goals for nursing education, however, shortfalls persist. A survey of 111 nurse practitioners and physician assistants working in community clinics, surveyed about the adequacy of their training for pain management, rated it 0.5 on a scale of 0 to 4 (Upshur et al., 2006).
Numerous actions demonstrate the nursing profession’s commitment to high-quality pain care. In 2006, the house of delegates of the American Nurses Association passed an “Improving Pain Management” resolution (Trossman, 2006). And in 2005, the American Nurses Credentialing Center began administering a certification examination in pain management for generalist nurses (ANA, 2005).
Recognition of the need to sensitize and educate nursing students about pain management has been based on evidence and expert opinion. College students surveyed were found to have “many misconceptions” about pain management that must be addressed before education specific to pain management is attempted (McCaffery and Ferrell, 1996), although efforts to overcome personal biases and opinions are not universally successful. For example, nurses’ personal opinions about patients’ pain levels have been shown to affect their clinical behavior (McCaffery et al., 2000).
One important construct, interprofessional education, is intended to increase the effectiveness of the care received from both physicians and nurses. An example of an initiative intended to foster improved interdisciplinary teamwork is that of the Centers of Excellence in Primary Care Education program of the Department of Veterans Affairs, which recently awarded grants to five of the department’s medical centers and collaborating organizations (Department of Veterans Affairs, 2011). The funded centers will “develop and test innovative approaches to prepare physician residents and students, advanced practice nurse and undergraduate nursing students, and associated health trainees for primary care practice in the
21st Century.” The projects are designed to promote shared decision making; interprofessional collaboration; quality improvement; and longitudinal relationships among students, patients, and teachers. These projects may well contribute to enhancing pain care, a central focus of veterans’ services (Chapter 3).
In other, nonfederal settings, state laws that restrict the scope of practice of nurse practitioners and other advanced practice nurses may impede the delivery of primary care (IOM, 2010). Given that responsibility for most pain care falls heavily on primary care practitioners, and too few primary care physicians exist to shoulder that burden, nurse practitioners are likely to play an increasingly important role.
One innovation in nursing pain education consists of pain resource nurse (PRN) programs. Initially developed at the City of Hope National Medical Center, PRN programs are intended to create a cadre of well-trained nurse coaches and mentors to promote nurses’ use of best-practice pain strategies. PRN training includes in-person coursework, regular follow-up in-service training, newsletters, ongoing peer support, and other forms of education. This approach has been found to produce significant improvements in nurses’ knowledge and attitudes about pain care, as well as improved patient satisfaction with pain control and a reduction in the prevalence of pain (Paice et al., 2006). However, some participants in PRN programs have expressed frustration with “the slow pace of change and improvement, the lack of visible signs of their success, and the ongoing nature of the work” (McCleary et al., 2004, p. 34). Institutional support is considered key to the success of the PRN initiative.
If dentists couldn’t offer “pain-free” dentistry, no one would go to them!
—A dental educator7
Many health professions are involved in pain care. Although a comprehensive survey of the pain-related educational preparation of all health professions is beyond the scope of this report, the committee identified a few particularly noteworthy efforts.
Psychologists, in particular, have addressed the need for professional education about pain management. An ad hoc subcommittee of the multidisciplinary
7 Quotation from committee member.
International Association for the Study of Pain (IASP) developed a core curriculum for educating psychology students about pain (IASP, 1997, p. 1), which still appears progressive 14 years later. The subcommittee declared:
All pain has a psychological component and psychological factors are important at all stages of pain (whether the problem is acute, recurrent or chronic) and have a major role in the prevention of unnecessary pain-associated dysfunction in a wide range of settings from primary prevention to terminal care.
IASP’s detailed curriculum encompasses
- nociceptive mechanisms,
- experimental and clinical pain measurement,
- the psychological impact of different types of pain,
- psychological and behavioral assessment of the individual with pain,
- the psychosocial impact of pain,
- pain syndromes particularly influenced by sex and gender,
- life-span issues,
- health care seeking,
- the economic and occupational impact of pain-associated disability,
- psychological and psychiatric treatment,
- pharmacological and invasive pain management procedures,
- interdisciplinary treatment programs,
- prevention and early intervention,
- treatment outcome and evaluation, and
- ethical standards and guidelines.
The Health Psychology Network, an online educational source for psychologists, includes chronic pain as one of eight areas in which it offers information about evidence-based treatments (Health Psychology Network, 2011). Similarly, the American Psychological Association’s website targets pain as one of seven types of disorders or health problems that need additional attention from policy makers (American Psychological Association, 2011).
As is true with other health professions, it would be useful to encourage more psychologists to provide pain care and to conduct pain-relevant research. As the profession of psychology has matured in the past half century, specialization, and even subspecialization, among practicing psychologists have increased. Most psychologists who claim a specific expertise in pain management have pursued specialty training in clinical health psychology (France et al., 2008), which is dedicated to developing scientific knowledge at the interface between behavior and health and to delivering high-quality services based on that knowledge. Education and training programs in clinical health psychology emphasize approaches and experiences that are entirely consistent with some of the core
principles of pain management emphasized in this report, including adherence to the biopsychosocial model, integration of science and practice, interdisciplinary methods, and explicit attention to culture and diversity.
Education and training in the specialty of clinical health psychology, and by extension pain psychology, follow a graded and sequential series of learning experiences beginning with doctoral training programs in clinical or counseling psychology, followed by internship training and specialty training at the postdoctoral level (Kerns et al., 2009). On an entirely volunteer basis, some psychologists pursue specialty board certification in clinical health psychology following a more intensive process of continuing education and training beyond the doctoral degree. However, only recently has the American Psychological Association begun to accredit specialty training in clinical health psychology at the postdoctoral level. Even so, pain psychology remains a subspecialty within the broader field of clinical health psychology, and there are no explicit criteria for credentialing psychologists with specific expertise in pain management.
Despite an apparently robust market for psychologists with this expertise, the field has been slow to expand its capacity for education and training of psychologists with competencies in pain management. One of the key challenges is that doctoral training programs in clinical and counseling psychology may not have faculty with this interest and expertise, thus limiting students’ exposure to the field, including clinical practicum experiences and participation in research laboratories or clinical research settings. The few students who do develop this interest and expertise are likely to pursue internship and postdoctoral training in the subspecialty area in academic medical environments that support this training. In the past 10 years, for example, the Department of Veterans Affairs has continued to expand its predoctoral and postdoctoral psychology training programs, and with this expansion and an increased emphasis on system improvements in pain management for veterans (see Chapter 3), a growing number of training opportunities for psychologists interested in pain management have emerged. A small and growing number of subspecialty training opportunities in pain psychology, focused on pain-relevant rehabilitation and health services research, also have begun to emerge.
The Commission on Dental Accreditation (CODA) states that dental school “graduates must be competent in providing oral health care within the scope of general dentistry, as defined by the school, for the child, adolescent, adult, and geriatric patient … including anesthesia, and pain and anxiety control. …” (CODA Standard 2-25e, 2007). Pain management and control, particularly for acute and postoperative pain, remain a core curriculum component that, historically, has affected the relationship between dental procedures and pain.
As a specialty, dentistry has long recognized the fear of the dental experi-
ence. Dental education programs have therefore taken steps to decrease the pain associated with dental care through several approaches, aided by the advent of new anesthetics (local anesthesia, intravenous [IV] sedatives, and inhalation agents such as nitrous oxide). In addition the American Dental Association (ADA) and several other dental organizations have held comprehensive workshops on pain control. And through the active work of dental educators and the dental community, Guidelines for Teaching the Comprehensive Control of Pain and Sedation to Dentists and Dental Students provides training guidelines for predoctoral dental programs, postdoctoral (residency) programs, and continuing dental education (ADA, 2007). These efforts have allowed dentistry to evolve from a specialty restricted to extracting problematic teeth; to one that restores and maintains a person’s natural teeth; to one that promotes prevention of caries and periodontal disease and the recognition that dental care can have an effect on a person’s overall health.
As an example of postgraduate (residency) training that includes specific competencies in pain management and anxiety control, oral and maxillofacial surgery residencies typically include 4 months of training as an anesthesiology resident. Residents must demonstrate competence in outpatient ambulatory surgeries utilizing IV sedation techniques and pain control. Acute pain control is managed aggressively and has improved the overall experience of the patient.
Unfortunately, the development of chronic pain of the temporomandibular joint (TMJ) or the orofacial region is poorly understood, and that type of pain is poorly controlled. Management approaches vary among practitioners and may highlight a variable etiology. However, there is growing evidence that the negative affective, cognitive, and psychosocial state of chronic pain is universal, whether it be non-neuropathic/nociceptive pain (TMJ chronic pain) or neuropathic pain (trigeminal neuralgia), which suggests that cognitive-behavioral therapy may help (Gustin et al., 2011).
Although predoctoral programs and continuing education in chronic orofacial pain are limited, the ADA recently established accreditation standards for postgraduate training in orofacial pain. A particular emphasis in this advanced training program is the incorporation of interprofessional care.
Physical and Occupational Therapy
Rehabilitation therapies are an important part of pain care (Chapter 3). Historically, however, physical therapists were not well prepared to help manage pain. In a survey of 119 physical therapists who belonged to the American Physical Therapy Association’s Section on Orthopaedics, all but 4 percent said they preferred not to work with patients likely to have chronic pain, 72 percent said their entry-level education in pain management was very inadequate or less than adequate to handle orthopedic patients, and pain knowledge scores were found to be low (Wolff et al., 1991). In a faculty survey of slightly more than
100 accredited physical therapy education programs in North America, the modal amount of time spent on pain in the curriculum was 4 hours; most respondents nevertheless believed pain was adequately covered, except for pain in the elderly and children and cognitive-behavioral therapy (Scudds et al., 2001). Similarly, in a survey of 201 seniors in occupational therapy programs, the mean score on a 10-item test about pain was 61 percent (Rochmann, 1998). And in an Australian-based study of 35 recent occupational therapy graduates, the combined score on a test including 69 questions about pain knowledge and attitudes was only 53 percent (Strong et al., 1999).
Another health profession that has focused on pain is pharmacy. To improve the use of analgesics to achieve “good therapeutic outcomes for patients,” some pharmacists and physicians have created drug therapy management teams, or even collaborative practice models (Brushwood, 2001). A few states authorize collaborative practice in which physicians consult pharmacists about the use of opioid medications, and both practitioners share accountability.
Complementary and Alternative Medicine (CAM)
Because complementary and alternative therapies are widely used in pain care (see Chapter 3), the education of CAM practitioners is an important component of health professions education about pain and pain management, although systematic reviews of this training are scant. In general, education and training of CAM practitioners are less formal than is the case for physicians, nurses, and other conventional health professionals, in part because of the lack of accreditation standards for CAM education programs, the existence of many small proprietary training programs, and a chaotic set of state licensure regulations for CAM practitioners (Kreitzer et al., 2009). Thus, for example, substantial variation has been found in pain education among chiropractors and acupuncturists (Breuer et al., 2010).
Few educational programs in state-licensed CAM fields involved in pain care—chiropractic, acupuncture, naturopathic medicine, traditional Chinese medicine, and massage therapy—appear to focus specifically on pain and pain management. However, several interdisciplinary undergraduate and graduate degree or certificate programs have emerged that allow for a focus on pain in CAM practice. For example, a collaborative program sponsored by Tufts University School of Medicine and the New England School of Acupuncture provides an opportunity for master’s students in acupuncture to enroll in a multidisciplinary pain management program at Tufts (White House Commission on Complementary and Alternative Medicine Policy, 2002). Several organizations representing CAM practitioners and others who offer pain treatment (e.g., the American
Holistic Medical Association, American Association of Orthopaedic Medicine, and American Association of Naturopathic Physicians) are able to contribute to the education of relevant stakeholders.
Curricula for all health professions are full, and advocates of many important causes compete for a greater share of students’ and clinicians’ valuable educational time. Yet despite the large role that care of patients with pain will play in their daily practice, many health professionals, especially physicians, appear underprepared for and uncomfortable with carrying out this aspect of their work. These professionals need and deserve greater knowledge and skills so they can contribute to the necessary cultural transformation in the perception and treatment of people with pain.
Finding 4-1. Education is a central part of the necessary cultural transformation of the approach to pain. The committee finds that the federal government is in a position to contribute to substantial improvements in patient and professional education about pain.
Recommendation 4-1. Expand and redesign education programs to transform the understanding of pain. Federal agencies and other relevant stakeholders should expand education programs to transform patient and public understanding of pain. In concert with Recommendation 2-2, federal agencies, in partnership with health professions associations, payers, pain advocacy and awareness organizations, and other relevant stakeholders, should develop education programs for patients, the public, and health care providers that are designed to promote a transformation in their expectations, beliefs, and understanding about pain, its consequences, its management, and its prevention. Programs should
- be endorsed by expert pain health professions organizations;
- strive to increase awareness of the significance of pain, its prevention, the need to address acute and chronic pain in timely and effective ways, the biological and psychosocial aspects of pain, and the need for comprehensive assessment of pain, as well as to instill a balanced understanding of available treatments;
- incorporate materials such as fact sheets and information that can be made widely available, including on the Internet; and
- be specifically and appropriately targeted to patients, the public, and providers to ensure understanding of the concepts being imparted.
Recommendation 4-2. Improve curriculum and education for health care professionals. The Centers for Medicare and Medicaid Services, the Health Resources and Services Administration, accrediting organizations, and undergraduate and graduate health professions training programs should improve pain education curricula for health care professionals.
- Accrediting organizations, such as the Liaison Committee on Medical Education and American Psychological Association Committee on Accreditation, should establish specifically identifiable standardized curriculum requirements for pain education.
- The Centers for Medicare and Medicaid Services should provide financial support for advanced training in pain management.
- The Bureau of Health Professions should provide financial support for training grants for the education of practitioners in pain assessment and management.
- Undergraduate and graduate health professions training in programs whose graduates will participate in pain care should include pain education.
- Relevant accrediting organizations (such as residency review committees and the Accreditation Council for Graduate Medical Education) should establish specifically identifiable and standardized curriculum requirements for pain education in graduate training programs, such as primary care programs.
- Training should include education in interprofessional settings.
- Assessment of pain knowledge should be included in examinations for licensure (e.g., the U.S. Medical Licensing Examination), certification (the American Board of Medical Specialties), and recertification.
- Health care professionals should engage in ongoing pain education through postgraduate continuing education programs.
Recommendation 4-3. Increase the number of health professionals with advanced expertise in pain care. Educational programs for medical, dental, nursing, mental health, physical therapy, pharmacy, and other health professionals who will participate in the delivery of pain care should have increased capacity to train providers who can offer advanced pain care.
AAMC (Association of American Medical Colleges). 2010. 2010 GQ medical school graduation questionnaire: All schools summary report—final. Washington, DC: Association of American Medical Colleges.
ABMS (American Board of Medical Specialties). 2010. AMBS maintenance of certification: Ten years strong & growing. 2010 ABMS certificate statistics. Chicago, IL: ABMS.
ACGME (Accreditation Council for Graduate Medical Education). 2007. ACGME program requirements for graduate medical education in pain medicine. http://www.acgme.org/acWebsite/downloads/RRC_progReq/sh_multiPainPR707.pdf (accessed March 26, 2011).
ACGME. 2011. Reports—programs by specialty. http://www.acgme.org/adspublic/reports/program_specialty_list.asp (accessed April 13, 2011).
ACS (American Cancer Society). 2011. ACS National Cancer Information Center. http://www.cancer.org/aboutus/howwehelpyou/helpingyougetwell/cancer-information-services (accessed June 8, 2011).
ACS, Framework Convention Alliance, and Campaign for Tobacco-free Kids. 2008. How do you sell death. http://www.cancer.org/acs/groups/content/@internationalaffairs/documents/document/acspc-024669.pdf (accessed March 22, 2011).
ADA (American Dental Association). 2007. Guidelines for teaching the comprehensive control of pain and sedation to dentists and dental students. http://www.ada.org/sections/professionalResources/pdfs/anxiety_guidelines.pdf (accessed June 3, 2011).
Alzheimer’s Association. 2011. 10 Signs of Alzheimer’s. http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp (accessed September 13, 2011).
American Association of Colleges of Nursing. 2008. The essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing.
American Chronic Pain Association. 2011. ACPA consumer guide to pain medications and treatments 2011. Rocklin, CA: American Chronic Pain Association. http://www.theacpa.org/uploads/ACPA_Consumer_Guide_2011%20final.pdf (accessed March 18, 2011).
American College of Emergency Physicians, American Pain Society, Emergency Nurses Association, and American Society for Pain Management Nursing. 2010. Optimizing the treatment of pain in patients with acute presentations. http://www.ampainsoc.org/advocacy/downloads/APS10_Optimizing%20PositionPaper.pdf (accessed January 27, 2011).
American Geriatrics Society. 2011. Foundation for health in aging. http://www.healthinaging.org/public_education/pef/alzheimers_caregiver.php (accessed March 22, 2011).
American Pain Foundation. 2011. Pain conditions. http://www.painfoundation.org/learn/pain-conditions/ (accessed March 20, 2011).
American Psychological Association. 2011. Health-care reform. http://www.apa.org/health-reform/pain.html (accessed March 27, 2011).
ANA (American Nurses Association). 2005. ANCC announces new certification for pain management nurses. http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2005/pr09208536.aspx (accessed January 27, 2011).
ANA. 2011. What is nursing? http://www.nursingworld.org/EspeciallyForYou/StudentNurses/WhatisNursing.aspx (accessed January 28, 2011).
Arnstein, P., and B. St. Marie. 2010. Managing chronic pain with opioids: A call for change. http://www.nphealthcarefoundation.org/programs/ (accessed January 15, 2011).
Berry, D. L., D. J. Wilkie, C. R. Thomas, Jr., and P. Fortner. 2003. Clinicians communicating with patients experiencing cancer pain. Cancer Investigation 21(3):374-381.
Blumenthal, D., M. Gokhale, E. G. Campbell, and J. S. Weissman. 2001. Preparedness for clinical practice: Reports of graduating residents at academic health centers. Journal of the American Medical Association 286(9):1027-1034.
Borneman, T., M. Koczywas, V. Sun, B. F. Piper, C. Smith-Idell, B. Laroya, G. Uman, and B. Ferrell. 2011. Effectiveness of a clinical intervention to eliminate barriers to pain and fatigue management in oncology. Journal of Palliative Medicine 14(2):197-215.
Bostrom, M. 1997. Summary of the Mayday Fund Survey: Public attitudes about pain and analgesics. Journal of Pain Symptom Management 13(3):166-168.
Breuer, B., R. Cruciani, R. K. Portenoy. 2010. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey. Southern Medical Journal 103(8):738-747.
Brushwood, D. B. 2001. From confrontation to collaboration: Collegial accountability and the expanding role of pharmacists in the management of chronic pain. Journal of Law, Medicine, & Ethics 29(2001):69-93.
Buchbinder, R. 2008. Self-management education en masse: Effectiveness of the back pain: Don’t take it lying down mass media campaign. Medical Journal of Australia 189(10):S29-S32.
Buchbinder, R., and D. Jolley. 2004. Population based intervention to change back pain beliefs: Three year follow up population survey. British Medical Journal 328(7435):321.
Buchbinder, R., D. Jolley, and M. Wyatt. 2001a. 2001 Volvo award winner in clinical studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine 26(23):2535-2542.
Buchbinder, R., D. Jolley, and M. Wyatt. 2001b. Population based intervention to change back pain beliefs and disability: Three part evaluation. British Medical Journal 322(7301):1516-1520.
Burchiel, K. 2010. How should pain medicine be taught? Workgroup report. The first national pain medicine summit—final summary report. Pain Medicine 11:1452-1453.
California Health and Human Services Agency and California Council of the Alzheimer’s Association. 2011. California’s State Plan for Alzheimer’s Disease: An Action Plan for 2011-2021. http://www.caalz.org/PDF_files/CA%20State%20Plan.pdf (accessed June 2, 2011).
Campaign for Tobacco-free Kids. 2011. Public education campaigns reduce tobacco use. http://www.tobaccofreekids.org/research/factsheets/pdf/0051.pdf (accessed March 21, 2011).
Cantor, D. 2007. Uncertain enthusiasm: The American Cancer Society, public education, and the problems of the movie. Bulletin of the History of Medicine 81:39-69.
CDC (Centers for Disease Control and Prevention). 2006. New report finds pain affects millions of Americans. http://www.cdc.gov/nchs/pressroom/06facts/hus06.htm (accessed March 24, 2011).
CDC. 2011. National public health performance standards program. http://www.cdc.gov/nphpsp/essentialServices.html (accessed March 22, 2011).
Clark, N. M., and M. R. Partridge. 2002. Strengthening asthma education to enhance disease control. Chest 121(5):1661-1669.
Claxton, R., S. Marks, R. Buranosky, D. Rosielle, and R. M. Arnold. 2011. The educational impact of weekly e-mailed fast facts and concepts. Journal of Palliative Medicine 14(4):475-481.
Cooper, R. A. 2009. Workforce reorientation. Integrative medicine and the health of the public: A summary of the February 2009 summit. Washington, DC: The National Academies Press. Pp. 124-125.
Darer, J. D., W. Hwang, H. H. Pham, E. B. Bass, and G. Anderson. 2004. More training needed in chronic care: A survey of U.S. physicians. Academic Medicine 79(6):541-548.
Davis, D., R. Galbraith, and American College of Chest Physicians, Health and Science Policy Committee. 2009. Continuing medical education effect on practice performance: Effectiveness of continuing medical education. American College of Chest Physicians evidence-based educational guidelines. Chest 135(3S):42S-48S.
Department of Veterans Affairs. 2011. VA centers of excellence in primary care education.http://www.va.gov/oaa/rfp_coe.asp (accessed January 30, 2011).
DeVore, S., and R. W. Champion. 2011. Driving population health through accountable care organizations. Health Affairs 30(1):41-50.
Drexler, M. 2008. New approaches to neurological pain: Planning for the future. http://www.painandhealth.org/didyouknow.html (accessed January 27, 2011).
Elman, I., J.-K. Zubieta, and D. Borsook. 2011. The missing P in psychiatric training. Archives of General Psychiatry 68(1):12-20.
Feder, J. L. 2011. At Martin’s Point in Maine, primary care teams for chronic disease patients. Health Affairs 30(3):394-396.
Federation of State Medical Boards. 2010. A guide to the Essentials of a Modern Medical and Osteopathic Practice Act. Euless, TX: Federation of State Medical Boards. www.fsmb.org/pdf/GRPOL_essentials.pdf (accessed June 3, 2011).
Ferrell, B. 2005. Ethical perspectives on pain and suffering. Pain Management Nursing 6(3):83-90.
Fineberg, I. C., N. S. Wenger, and K. Brown-Saltzman. 2006. Unrestricted opiate administration for pain and suffering at the end of life: Knowledge and attitudes as barriers to care. Journal of Palliative Medicine 9:873-883.
Follett, K. 2010. What mechanisms do we need to establish the competency of a physician who wishes to practice pain medicine? Workgroup report. The first national pain medicine summit—final summary report. Pain Medicine 11(10):1455-1457.
France, C. R., K. S. Masters, C. D. Belar, R. D. Kerns, E. A. Klonoff, K. T. Larkin, T. W. Smith, S. Suchday, and B. E. Thorn. 2008. Application of the competency model to clinical health psychology. Professional Psychology: Research and Practice 39(6):573-580.
Gallagher, R. 2003. Physician variability in pain management: Are the JCAHO standards enough? Pain Medicine 4(1):1-3.
Gallagher, R. 2010. What should all physicians know about pain medicine? Workgroup report. The first national pain medicine summit—final summary report. Pain Medicine 11:1450-1452.
George, S. Z., D. S. Teyhen, S. S. Wu, A. C. Wright, J. L. Dugan, G. Yang, M. E. Robinson, and J. D. Childs. 2009. Psychosocial education improves low back pain beliefs: Results from a cluster randomized trial (NCT00373009) in a primary prevention setting. European Spine Journal 18(7):1050-1058.
Giovino, G. A., F. J. Chaloupka, A. M. Hartman, K. G. Joyce, J. Chriqui, C. T. Orleans, K. Wende, C. Tworek, D. Barker, J. T. Gibson, J. Yang, J. Hinkel, K. M. Cummings, A. Hyland, B. Fix, M. Paloma, and M. Larkin. 2009. Cigarette smoking prevalence and policies in the 50 states: An era of change—The Robert Wood Johnson Foundation ImpacTeen Tobacco Chart Book. Buffalo, NY: University at Buffalo, State University of New York.
Good, M.-J. D., C. James, B. J. Good, and A. E. Becker. 2002. The culture of medicine and racial, ethnic, and class disparities in healthcare. Russell Sage Foundation Working Paper, No. 199. New York: Russell Sage Foundation.
Gooddy, W. 1992. Foreword. In Migraine (revised and expanded), author O. Sacks. New York: Vintage Books.
Gross, D. P., A. S. Russell, R. Ferrari, M. C. Battié, D. Schopflocher, R. Hu, G. Waddell, and R. Buchbinder. 2010. Evaluation of a Canadian back pain mass media campaign. Spine 35(8):906-913.
Grumbach, K., and T. Bodenheimer. 2004. Can health care teams improve primary care practice? Journal of the American Medical Association 291:1246-1251.
Gunnarsdottir, S., H. S. Donovan, R. C. Serlin, C. Voge, and S. Ward. 2002. Patient-related barriers to pain management: The Barriers Questionnaire II (BQ-II). Pain 99:385-396.
Gustin, S. M., S. L. Wilcox, C. C. Peck, G. M. Murray, and L. A. Henderson. 2011. Similarity of suffering: Equivalence of psychological and psychosocial factors in neuropathic and non-neuropathic orofacial pain patients. Pain 152(4):825-832.
Health Psychology Network. 2011. Chronic pain. http://www.healthpsychology.net/Chronic%20Pain. htm (accessed March 27, 2011).
IASP (International Association for the Study of Pain). 1997. Curriculum on pain for students in psychology. Seattle, WA: IASP.
IOM (Institute of Medicine). 1997. Approaching death: Improving care at the end of life. Washington, DC: National Academy Press.
IOM. 2001a. Improving palliative care for cancer. Washington, DC: National Academy Press.
IOM. 2001b. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
IOM. 2003. The future of the public’s health in the 21st century. Washington, DC: The National Academies Press.
IOM. 2004. Improving medical education: Enhancing the behavioral and social science content of medical school curricula. Washington, DC: The National Academies Press.
IOM. 2010. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Jones, R., 2006. General practitioners with special interests: Evolution and evaluation. Journal of Health Services Research and Policy 11:106-109.
Karani, R., and D. E. Meier. 2003. Results from the Last Acts Campaign: How can we improve? Supportive Oncology 1(1):69-72.
Kastanias, P., 2009. What do adult surgical patients really want to know about pain and pain management? Pain Management Nursing 10(1):22-31.
Kerns, R. D., S. Barry, L. M. E. Frantsve, and J. C. Linton. 2009. Life-long competency development in clinical health psychology. Training and Education in Professional Psychology 3(4):212-217.
Kotler, P. R., and N. R. Lee. 2008. Social marketing: Influencing behaviors for good, 3rd ed. Thousand Oaks, CA: Sage Publications.
Kreitzer, M. J., B. Kligler, and W. C. Meeker. 2009. Health professions education and integrative health care. Unpublished paper commissioned for the IOM Summit on Integrative Health Care and the Health of the Public. Washington, DC: IOM.
LeMone, P., K. M. Burke, G. Bauldoff, and J. Bostick. 2011. Clinical handbook for medical-surgical nursing: Critical thinking in patient care. Upper Saddle River, NJ: Prentice Hall.
Lewis, S. L., M. Heitkemper, S. R. Dirksen, P. G. O’Brien, and L. Bucher. 2011. Medical-surgical nursing: Assessment and management of critical problems, 7th ed. Maryland Heights, MO: Mosby.
Lippe, P. M., C. Brock, J. David, R. Crossno, and S. Gitlow. 2010. The first national pain medicine summit—final summary report. Pain Medicine 11:1447-1468.
Loder, E. 2006. The public health paradox of migraine. Headache Care 3(1):21-29.
Loder, E., A. Witkower, P. McAlary, M. Huhta, and J. Matarrazzo. 2003. Rehabilitation hospital staff knowledge and attitudes regarding pain. American Journal of Physical Medicine and Rehabilitation 82(1):65-68.
Massachusetts Pain Initiative. 2011. Legislative issues and access to care council. http://masspaininitiative.org/index.cfm?p=p.12&title=Councils#Legis (accessed March 22, 2011).
May, F., D. Simpson, L. Hart, D. Rowett, and D. Perrier. 2009. Experience with academic detailing services for quality improvement in primary care practice. Quality and Safety in Health Care 18:225-231.
Mayday Fund. 2009. A call to revolutionize chronic pain care in America: An opportunity in health care reform. Report of the Special Committee on Pain and the Practice of Medicine. New York: Mayday Fund.
McCaffery, M., and B. R. Ferrell. 1996. Correcting misconceptions about pain assessment and use of opioid analgesics: Educational strategies aimed at public concerns. Nursing Outlook 44(4):184-190.
McCaffery, M., B. R. Ferrell, and C. Pasero. 2000. Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Management Nursing 1(3):79-87.
McCleary, L., J. A. Ellis, and B. Rowley. 2004. Evaluation of the pain resource nurse role: A resource for improving pediatric pain management. Pain Management Nursing 5(1):29-36.
Meng, K., B. Seekatz, H. Roband, U. Worringen, H. Vogel, and H. Faller. 2011. Intermediate and long-term effects of a standardized back school for inpatient orthopedic rehabilitation on illness knowledge and self-management behaviors: A randomized controlled trial. Clinical Journal of Pain 27(3):248-257.
Merelle, S. Y. M., M. J. Sorbi, L. J. Van Doornen, and J. Passchier 2008. Lay trainers with migraine for a home-based behavioral training: A 6-month follow-up study. Headache 48(9):1311-1325.
Meyers, F. J., S. E. Weinberger, J. P. Fitzgibbons, J. Glassroth, F. D. Duffy, C. P. Clayton, and the Alliance for Academic Internal Medicine Education Redesign Task Force. 2007. Redesigning residency training in internal medicine: The consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Academic Medicine 82(12):1211-1219.
Mezei, L., and B. B. Murinson. In press. Assessment of pain education in North American medical schools. Journal of Pain.
Moseley, G. L. 2003. Joining forces—combining cognition-targeted motor control training with group or individual pain physiology education: A successful treatment for chronic low back pain. Journal of Manual and Manipulative Therapy 11(2):88-94.
Moseley, G. L. 2004. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain 8(1):39-45.
Murinson, B. B., E. Nenortas, R. S. Mayer, L. Mezei, S. Kozachik, S. Nesbit, J. A. Haythornthwaite, and J. N. Campbell. 2011. A new program in pain medicine for medical students: Integrating core curriculum knowledge with emotional and reflective development. Pain Medicine 12(2):186-195.
Notcutt, W., and G. Gibbs. 2010. Inadequate pain management: Myth, stigma, and professional fear. Postgraduate Medical Journal 86:453-458.
Nutting, P. A., B. F. Crabtree, W. L. Miller, K. C. Stange, E. Stewart, and C. Jaén. 2011. Transforming physician practices to patient-centered medical homes: Lessons from the national demonstration project. Health Affairs 30(3):439-445.
Office on Smoking and Health. 2010. Cigarette use among high school students—United States, 1991-2009. Morbidity and Mortality Weekly Report 59(26):797-801.
Oliver, J. W., R. L. Kravitz, S. H. Kaplan, and F. J. Meyers. 2001. Individualized patient education and coaching to improve pain control among cancer outpatients. Journal of Clinical Oncology 19(7):2206-2212.
O’Rorke, J. E., I. Chen, I. Genao, M. Panda, and S. Cykert. 2007. Physicians’ comfort in caring for patients with chronic nonmalignant pain. American Journal of Medical Sciences 333(2):93-100.
Paice, J. A., C. Barnard, J. Creamer, and K. Omerod. 2006. Creating organizational change through the Pain Resource Nurse program. Joint Commission Journal on Quality and Patient Safety 32(1):24-31. PainKnowledge.org. 2011. Important news about PainKnowledge.orgPainKnowledge.org. http://www.painknowledge.org/ (accessed June 2, 2011).
Partners for Understanding Pain. 2002. Survey shows myths, misunderstandings about pain common among Americans. http://www.theacpa.org/uploads/documents/Partners%20for%20Understanding%20Pain%20Electronic%20Press%20Kit1.pdf (accessed March 21, 2011).
Porter, L. S., F. J. Keefe, J. Garst, D. H. Baucom, C. M. McBride, D. C. McKee, L. Sutton, K. Carson, V. Knowles, M. Rumble, and C. Scipio. 2010. Caregiver-assisted coping skills training for lung cancer: Results of a randomized clinical trial. Journal of Pain and Symptom Management 41:1-13.
Ridsdale, L. 2008. A new GP with special interest headache service: Observational study. British Journal of General Practice 58:478-483.
Robert Wood Johnson Foundation. 2003. Means to a better end: A report on dying in America today. Princeton, NJ: Robert Wood Johnson Foundation.
Rochmann, D. L. 1998. Students’ knowledge of pain: A survey of four schools. Occupational Therapy International 5(2):140-154.
Scudds, R. J., R. A. Scudds, and M. J. Simmonds. 2001. Pain in the physical therapy (PT) curriculum: A faculty survey. Physiotherapy Theory and Practice 17(4):239-256.
Schuetz, B., E. Mann, and W. Everett. 2010. Educating health professionals collaboratively for team-based primary care. Health Affairs 29(8):1476-1480.
Strong, J., L. Tooth, and A. Unruh. 1999. Knowledge about pain among newly graduated occupational therapists: Relevance for curriculum development. Canadian Journal of Occupational Therapy 66(5):221-228.
Sullivan, M. D., B. Gaster, J. Russo, L. Bowlby, N. Rocco, N. Sinex, J. Livovich, H. Jasti, and R. Arnold. 2010. Randomized trial of web-based training about opioid therapy for chronic pain. Clinical Journal of Pain 26(6):512-517.
Todd, A. K., P. Cowan, N. Kelly, and P. Homel. 2010. Chronic or recurrent pain in the emergency department: National telephone survey of patient experience. Western Journal of Emergency Medicine 11(5):408-415.
Trautmann, E., and B. Kröner-Herwig. 2010. A randomized controlled trial of Internet-based self-help training for recurrent headache in childhood and adolescence. Behaviour Research and Therapy 48(1):28-37.
Trossman, S. 2006. Improving pain management: Call to action. American Nurse Today, December, pp. 29-30.
Ulrich, L. P. 1999. The Patient Self-Determination Act: Meeting the challenges in patient care. Washington, DC: Georgetown University Press.
United Council for Neurologic Subspecialties. 2011. About UCNS. http://www.ucns.org/go/home (accessed March 24, 2011).
Upshur, C. C., R. S. Luckmann, and J. A. Savageau. 2006. Primary care provider concerns about management of chronic pain in community clinic populations. Journal of General Internal Medicine 21(6):652-655.
Waddell, G., M. O’Connor, S. Boorman, and B. Torsney. 2007. Working backs Scotland: A public and professional health education campaign for back pain. Spine 32(19):2139-2143.
Wakefield, M. A., B. Loken, and R. C. Hornik. 2010. Use of mass media campaigns to change health behaviour. Lancet 376(9748):1261-1271.
Walker, B. F., R. Muller, and W. D. Grant. 2003. Low back pain in Australian adults: The economic burden. Asia-Pacific Journal of Public Health 15(2):79-87.
Weinberger, S. E., L. G. Smith, and V. E. Collier. 2006. Redesigning training for internal medicine. Annals of Internal Medicine 144(12):927-932.
Werner, E. L., C. Ihlebaek, E. Laerum, M. E. A. Wormgoor, and A. Indahl. 2008. Low back pain media campaign: No effect on sickness behavior. Patient Education and Counseling 71(12):198-203.
White House Commission on Complementary and Alternative Medicine Policy. 2002. Final report. http://www.whccamp.hhs.gov/pdfs/fr2002_document.pdf (accessed June 3, 2011).
Wiest, F. C., T. G. Ferris, M. Gokhale, E. G. Campbell, J. S. Weissman, and D. Blumenthal. 2002. Preparedness of internal medicine residents and family practice residents for treating common conditions. Journal of the American Medical Association 288(20):2609-2614.
Wolff, M. S., T. H. Michel, D. E. Krebs, and N. T. Watts. 1991. Chronic pain—Assessment of orthopedic physical therapists’ knowledge and attitudes. Physical Therapy 71(3):207-214.