Managing Chronic Pain
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OVERVIEW
In 1931, the French medical missionary Dr. Albert Schweitzer wrote “Pain is a more terrible lord of mankind than even death itself.”
Chronic pain is a silent epidemic. An estimated 50 million people suffer from chronic pain resulting from disease, a disorder or injury.1 It disables more people than cancer or heart disease.2 It affects a person’s ability to work, participate in family and social activities, and do the things that make life satisfying. It is debilitating and demoralizing. Many chronic pain patients looking for a way to escape their pain consider suicide. It is such a pervasive problem that in October 2000, President Clinton signed into law a bill passed by Congress in which the ten calendar years beginning on January 1, 2001 were officially designated the “Decade of Pain.” It was hoped that this action would create greater public awareness, which in turn would strengthen the opportunity to gain funding for research.
Despite available pain relief technology, approximately 40% of chronic pain sufferers cannot find adequate relief3. In a 1999 article titled “Chronic Pain in America: Roadblocks to Relief,” the president of the American Pain Society stated that, “Many Americans with chronic pain are suffering too much for too long and need more aggressive treatment.”4
The magnitude of the chronic pain problem manifests not only in the staggering number of patients seeking medical attention for their relentless pain, but in the cost of chronic pain to the public health system. If you consider direct medical expenses, lost income, lost productivity, compensation payments, and legal charges, this annual cost is estimated to be approximately $90 billion dollars.5
The burden of chronic pain, both on those who suffer from it and those who treat it, has triggered an explosion of research aimed at uncovering the roadblocks to optimal pain care. If appropriate use of pain medication can restore a person’s enjoyment of life, why are so many people still battling pain? Study results point to a number of barriers, ranging from lack of knowledge to attitudinal barriers to fears of regulatory sanction and opioid addiction. A key learning from this research is that discriminatory practices impact the chronic pain population as a whole, and that the risk of under treatment is even higher among children, the elderly, women, and racial/ethnic groups.
Paralleling the efforts to understand the scope and causes of chronic pain under treatment are new pressures from government, medical specialty groups, pain advocacy organizations and society in general to place a higher priority on quality pain care. Ethical and practice issues surrounding pain management are now being shaped by state and national agendas, and new clinical practice guidelines have been published by professional organizations. These and other future guidelines will establish a standard of care against which a physician’s actions can be measured.
As was seen in the case of Bergman vs. Chin6, where jurors found an internist guilty of elder abuse for under treating an 85-year-old patient’s pain during his final days, there is growing intolerance of inadequate pain management. It is exactly this climate of intolerance that raises the knowledge and skills bar for all practitioners treating patients with pain.
The purpose of this monograph is to build awareness of key chronic pain issues and to direct physicians to relevant guidelines and resources for improved diagnosis and treatment. While the pathophysiology of different chronic pain conditions and recommended pharmacologic agents are broadly discussed, the greater focus is on information and processes for developing productive caregiver-patient relationships and improving the chances for successful outcomes.