In the January 19th Perspective Section of The New England Journal of Medicine, an article appeared entitled “Alleviating Suffering 101 – Pain Relief in the United States”.
The article discusses the recent report by the Institute for Medicine committee detailing the astounding impact that chronic pain has on our society. The financial costs of this epidemic are roughly $600 billion per year and affect more than 110 million Americans with pain that persists for weeks to years. It is remarkable that the annual US expenditures related to pain, including direct medical costs and lost wages, are higher than those for cancer, heart disease and diabetes combined.
As co-founder of the global health organization, the Institute for OneWorld Health, we built clinics and hospitals in Bihar India and experienced the power that bureaucracy has on health care. It took five licenses for a medical doctor to be allowed to prescribe pain medication. In smaller cities and on the village level, painful conditions were routinely endured because doctors warned patients that they would become addicted to pain medications.
Why is this relevant to us in the Western world? How is the power of our bureaucracy affecting our pain care?
The pain system in the United States needs to be fixed. Despite access to all forms of pain medications, two-thirds of our nursing home patients currently report inadequate pain control. Pain patients don’t know where to go and are not educated about pain and its consequences, so that they may be enabled to play a more active role in the management of their pain.
We have two main drivers of our current system:
Inadequate education: One quarter of primary care physicians feel “somewhat or very unprepared” to handle pain. In 2009, 30 physicians’ organizations concluded that training in pain management was poor and did not lead to competency. Most medical schools still don’t have a single course on pain management. The New England Journal of Medicine article states, “Such training deficiencies pervade virtually every medical specialty but are most surprising in fields such as oncology, since pain management should be an important part of cancer care.”
Given that chronic pain is so pervasive, it is not realistic or desirable to relegate pain management to specialists alone (there are fewer than 4,000 pain specialists in the United States, largely limited to large metropolitan areas). So, why isn’t there a more ideal solution possible, where primary care physicians would coordinate pain management? That would only be possible with significant improvements to education and training. But, is that the only barrier? Why is there such a large market gap between the shortage of pain specialists and the huge patient demand for pain care? The answer lies in our payment system.
2) Inadequate time to spend with pain patients due to lack of proper reimbursement. Chronic pain patients require more time to adequately deliver care more effectively— adequate time to educate patients, counsel them and their families, provide appropriate follow-up and referrals. Our payment system doesn’t support it. Insurance companies continue to pay for MRI scans to identify the source of pain, but not adequately reimburse for doctor visits of sufficient duration to provide comprehensive treatment. The same constraints apply to nurses, physical therapists, psychologists and all caregivers who want to provide effective care to patients with chronic pain.
The Institute of Medicine report specifically recommended expanding and redesigning education programs to transform the understanding of pain, improving education for clinicians and increasing the number of health professionals with advanced expertise in pain care. But, without a cultural change where suffering from pain is a condition worth incentivizing our medical practitioners to focus on, we will remain unable to cope with the epidemic of pain in the United States.
I have come full circle now. During my experiences in India, I witnessed cultural biases, bureaucratic challenges and the consequences of limited access to healthcare resources. In contrast, here in the US, we have access to amazing and sophisticated resources but lack an adequate “business plan” for pain management. We have neither the incentives for physicians to educate themselves to become experts in pain management, nor the reimbursement models to enable them to deliver comprehensive pain care during longer patient visits.
At Anatara Medicine, we believe that the best proactive approach to pain management is prevention. When a patient has acute or chronic pain, we apply a convergence approach using seven disciplines from around the world, one not only gets the best of modern medicine but access to other pain modalities such as acupuncture and herbal medicine. We also take time to educate all of our patients, since we deeply believe in the concept of proactive medicine and its potential impact on your long-term health.