Changing How Pain is Assessed and Treated
Sean Mackey, MD, PhD, Chief of the Division of Pain Management
Pain exacts an astoundingly high price from society in economic loss and diminished lives. More than 100 million Americans suffer from chronic pain, at a cost of up to $635 billion annually in medical treatment and lost productivity, according to Relieving Pain in America, the recent report of an Institute of Medicine (IOM) committee that Dr. Phil Pizzo co-chaired and of which I was a member. The IOM report also found that when pain becomes chronic, it is no longer merely a symptom but a disease in itself, one that fundamentally alters the entire nervous system with significant psychological and cognitive correlates. Sadly, as a nation, we are failing to respond adequately to this pressing and widespread public health problem.
What are we doing at Stanford to address this tremendous societal problem? One of the IOM committee's underlying principles is the need for interdisciplinary approaches to assess and treat chronic pain. At the Stanford Pain Management Center, we have a strong philosophy and model of comprehensive, coordinated, interdisciplinary care for patients with sub-acute, chronic and cancer pain. Within our Center, our pain-medicine-trained physicians encompass a spectrum of specialties, including anesthesiology, neurology, PM&R, addiction medicine, internal medicine and acupuncture. They work side-by-side with pain-trained psychologists, physical therapists, nurses and nutritionists to provide state-of-the-art medicines and interventional pain treatment techniques; psychological and behavioral counseling; lifestyle counseling, such as diet and weight control; and functional restoration therapies, such as physical and occupational therapy.
Our desire to locate and coordinate all of these services in one comprehensive treatment center grew out of our observations of pain centers at almost every other academic medical center. Most of these centers comprised multiple silos of excellence, with bright doctors from the various specialties providing their own pain care without collaborating with or even talking to each other. This arrangement often led to less-than-optimal assessment and care. We have worked to avoid the fragmentation of these services and, fortunately, Stanford is a magical place that fosters such interdisciplinary collaborations. In addition, I believe that our comprehensive interdisciplinary model has led us to win two Centers of Excellence awards from the American Pain Society—one of only two programs that has won this award twice.
We have also developed specialized pain programs that work collaboratively within our Center. Examples include: the GI Pain Program with GI medicine, the Headache Program with neurology, the Orofacial Pain Program with ENT and the upcoming Pelvic Pain Program with urology. Each of these programs leverages our existing platform of medical, psychological and rehabilitative resources to address the biologic, psychological and social factors that impact pain.
How do we know that we are actually providing exceptional care? This question addresses one of the primary findings of the IOM report, that we need more consistent pain data. We are working to lead the way in addressing this need by collaborating with the Stanford Center for Clinical Informatics to develop an open-source, open-platform pain and health registry. Using NIH PROMIS (http://www.nihpromis.org) surveys, we track every patient who enters the Stanford Pain Management Center, assessing their physical, mental and social health, in addition to obtaining detailed information about their pain. We use these data to guide treatment decisions, educate patients and trainees and track treatment outcomes. Our ultimate goal is to provide this system to other pain centers, which will enable us to aggregate large-scale treatment data to perform cost-effectiveness research. This platform can clearly be extended to other medical disciplines as well.
Although we are making significant progress, much work remains to be done. There are still significant barriers to the delivery of pain care, especially for populations that are disproportionately affected by and under treated for pain. We need to work more effectively to promote and enable self-management of pain and to better support collaboration between pain specialists and primary care clinicians. With 100 million Americans afflicted with chronic pain, there are simply not enough pain medicine specialists to go around. We need to institute collaborative efforts to provide educational opportunities for primary care practitioners and other providers to improve their knowledge and skills in pain assessment and treatment, and to know when to refer to patients to a pain center.
The first underlying principle of the IOM Relieving Pain in America report states that effective pain management is a moral imperative, a professional responsibility and the duty of people in the healing professions. Working together at Stanford, we can enact the cultural transformation in pain care, education and research needed to improve the quality of life for those suffering from pain and to reduce pain's impact on society.
By Sean Mackey, MD, PhD, featured guest contributor