The medical industry has dropped the ball big time for pain management.
Training in pain management is not a top priority
September 11, 2016 - Lifestyle - Tagged: Greater Waterbury, Health, Saint Mary's Hospital
BY TRACEY O’SHAUGHNESSY
REPUBLICAN-AMERICAN
In 2011, The Institute of Medicine reported that more than one-third of Americans, or 100 million patients, are affected by chronic pain, or pain that lasts more than 12 weeks. More people are affected by chronic pain than by heart disease, diabetes and cancer combined, at a cost of more than $600 billion a year in medical treatments and lost productivity, according to the National Center for Biotechnology Information.
Part of the problem, doctors and chronic pain advocates agree, is the lack of knowledge and education about pain. “Training in pain management has been very poor,” said Dr. Mark L. Kraus, an internist with Saint Mary’s Hospital in Waterbury. “That means doctors are not trained well to deal with pain. Doctors are trained to heal patients, to make sure they are not suffering and not in pain.” By some estimates, doctors receive only 12 hours of education on pain in a six-year medical program. Veterinarians receive five times that. Cindy Steinberg, chair of the Policy Council of the Massachusetts Pain Initiative, reports that fewer than 1 percent of physicians in the U.S. specialize in pain management.
“We weren’t taught anything,” said Dr. William C. Becker, an assistant professor at the Yale University School of Medicine. “We were dissuaded in getting involved in it because it was a hopeless cause. We couldn’t fix it.”
Nor can medicine measure pain. Unlike many other health conditions, pain is subjective and its severity can vary from patient to patient. However, researchers know that certain groups – women, non-Hispanics and seniors – are more likely to report pain. One study found that 17.6 percent of Americans are in “severe” pain.
The study also found that adults who were considered to be in the most “severe pain” groups had the worst health in general – and used more health care. Women are also more likely to be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. Although most Americans believe those with ongoing pain are 65 are older, 80 percent of those with chronic pain are between the ages of 24 and 64, according to The Arthritis Foundation. However, researchers have found that women may become dependent on prescription pain relievers more quickly than men.
Nevertheless, the biology of pain is poorly understood, poorly studied and poorly researched. Moreover, in the cases of severe pain, doctors have few long-term remedies that are non-narcotic.
“Few medical schools have included formal training in pain and pain management in their curriculum in the past and doctors have not felt well prepared to deal with their patients’ pain,” said Dr. Daniel Carr, vice chairman of research and medical director for the chronic pain management program at Tufts-New England Medical Center. “Pain has been like the elephant in the middle of the room; no one knows exactly what to do about it, so we act as if it isn’t there.”
Still, Becker, who researches pain management at Yale, does not believe more pain specialists will solve the problem. “Yes, there are not nearly enough ‘pain specialists,'” he said. “But really pain specialists are not suited to managing chronic pain. Historically, they have been more interested in highly reimbursed procedures that aren’t really what improve outcomes in patients with chronic pains.” He pointed to epidural steroid injections for the back, which, he said, have not been demonstrated as effective for long-term relief. “We need more generalists who are fluent in the treatment of chronic pain,” he said.
Steinberg became disabled and was seriously injured more than 15 years ago after a file cabinet fell on her, leaving her with a band of severe neuropathic pain across her thoracic area. She said she, too, tried alternatives to opioids, including epidural steroid injections and nerve blocks. “I just couldn’t believe that someone could live in incredible pain and that there was no solution to it,” she said. “I equate pain treatment to doctors being blindfolded and just throwing darts at a target that they can’t really see.”
In part, that is because of the lack of research and treatment options for pain. Less than 2 percent of the National Institutes of Health’s research budget goes to pain research, said David Woodmansee, associate director of state and local campaigns for American Cancer Society Cancer Action Network. “Our federal government has not invested a lot of mechanisms into pain,” he said. “Now that we are at an epidemic level, people are starting to realize that we now need to invest on the front end to understand the mechanism of how pain works in the human body_ Pain is the leading contributor to health care costs in our country. We’d be doing ourselves a win-win if we could get some research into so many to start discovering ways that we could stop people from having to access the health care situation because of pain.”
Increasingly, pain is seen not as a symptom, but a disease in itself. That’s because with chronic pain, the nervous system essentially rewires itself, Becker said. “Your body and brain become hyper-sensitized and the tracks along which pain travels become hyper-sensitive.” After a year or more, he said, “you are looking at a rewiring situation. Past the point of tissue healing and it’s a neural problem in and of itself.” That means opioids – even at higher doses – are unlikely to help.
“The pain now becomes its own autonomous disease,” he said. “The nervous system is creating a self-sustaining pain cycle.”
For doctors, he said, “it’s sort of like, ‘well, I don’t know if this is helping my patient or not but at least if I keep them on a low dose at least I’m not doing him any harm’.”
At that point, other medication that treats neuropathic pain, like Cymbalta or gabapentin, might be more effective.
“Everybody wants the magic pill,” Kraus said. “Pain is not going to be cured. We can make it tolerable and return people to functionality. Some people are luckier than others where the pain is abated. It’s very important to make them understand that the benefits of pain management are function and quality of life. Cognitive behavioral therapy and motivational enhanced therapy also help. …
We have to educate all aspects of society, including commercial insurance, that an investment in proper treatment is going to save them a lot of money and improper treatment is going to cost them a lot of money.”
What is Chronic Pain?
Chronic pain is often defined as any pain lasting more than 12 weeks. Whereas acute pain is a normal sensation that alerts us to possible injury, chronic pain is very different. Chronic pain persists-often for months or even longer.
Chronic pain may arise from an initial injury, such as a back sprain, or there may be an ongoing cause, such as illness. However, there may also be no clear cause. Other health problems, such as fatigue, sleep disturbance, decreased appetite, and mood changes, often accompany chronic pain. Chronic pain may limit a person’s movements, which can reduce flexibility, strength, and stamina. This difficulty in carrying out important and enjoyable activities can lead to disability and despair.
– Source: National Institutes of Health
