Wednesday, June 29, 2011
QD: News Every Day--Pain's toll warrants new treatment approaches
Pain affects at least 116 million adult Americans annually and costs the nation between $560 billion and $635 billion annually, says a new report from the Institute of Medicine (IoM). Much of this pain is preventable or could be better managed, added the committee that wrote the report.
The breakdown of pain's impact includes the costs of health care ($261-$300 billion) and lost productivity ($297-$336 billion) attributable to pain, according to a press release. These figures do not include lost tax revenues. Medicare bears one-fourth of U.S. medical expenditures for pain, totaling at least $65.3 billion, or 14% of all Medicare costs in 2008. Medicare, Medicaid, the Department of Veterans Affairs, TRICARE, workers' compensation, and other federal and state programs paid out $99 billion in 2008 for pain.
Pain is a chronic disease unto itself, and there is a moral imperative to treating it with a comprehensive, interdisciplinary approach that includes the patient. Chronic pain has a distinct pathology that triggers changes throughout the nervous system that often worsen over time. "It has significant psychological and cognitive correlates and can constitute a serious, separate disease entity," the report reads.
The majority of care and management should take place through primary care providers and patient self-management, with specialty care reserved for more complex cases. Health care organizations should take the lead in developing innovative approaches and materials for patient self-management.
The report acknowledges that opioids crate problems of drug diversion and abuse, even as questions remain about their long-term usefulness. But, "[W]hen opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, post-operative, and procedural pain, as well as for patients near the end of life who desire more pain relief."
Pain often produces psychological effects, such as anxiety, depression, and anger. While interdisciplinary approaches are the most promising, there are too many barriers to that approach, including reimbursement for clinicians.
As a result, costly procedures often are performed when other actions should be considered, such as prevention, counseling, and facilitation of self-care. Insurers and government health care programs are not designed to efficiently pay for an interdisciplinary approach of integrated patient management. The report calls on Medicare, Medicaid, workers' compensation programs, and private health plans to find ways to cover interdisciplinary pain care.
In addition, adequate pain treatment and follow-up is hampered by uncertain diagnosis and societal stigma, especially when patients do not respond to treatment.
"Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it," the report reads.
Education should include a "substantial" amount of training. For example, a recent study found that only five of the nation's 133 medical schools have required courses on pain and just 17 offer elective courses. Licensing and certification exams should include assessment of pain-related knowledge and capabilities. Programs that train specialists or offer training in advanced pain care need to be expanded.
The committee called for coordinated, national effort with results expected as soon as the end of 2012 including:
--Create a comprehensive population-level strategy for pain prevention, treatment, management and research;
--Develop strategies for reducing barriers to pain care;
--Support collaboration between pain specialists and primary care clinicians, including referral to pain centers when appropriate; and
--Designate a lead institute at the National Institutes of Health responsible for research.
Others efforts should be in place by 2015, including providing educational opportunities in pain assessment and treatment in primary care. ACP Internist reported on prescription opiate abuse and outlined ways internists can intervene, as well as available resources to help them with this patient group.
Labels: Medicaid, medical education, medicare, opioids, pain management, QD, reimbursement
posted by Ryan DuBosar at
11:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
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his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.
Controversies in Hospital
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Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
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studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
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Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
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Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
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FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
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John H. Schumann, MD, FACP, provides transparency on the workings
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
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the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
interest in basic and clinical science and education, with
interests in noninvasive monitoring and diagnostic testing using
novel bedside imaging modalities, diagnostic reasoning, medical
informatics, new medical education modalities, pre-code/code
management, palliative care, patient-physician communication,
quality improvement, and quantitative biomedical imaging.
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William Hersh, MD, FACP, Professor and Chair, Department of Medical
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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
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Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
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KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
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MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
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relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
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Elaine Schattner, MD, FACP, shares her ideas on education, ethics
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Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
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blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
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David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections of a Grady
Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.
Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.
Other blogs of note:
American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical
Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS Blog
The Public Library of Science's open access materials include a
blog.
White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.
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