Improving pain care

The article lists the main recommendations made by the Institute of Medicine on pain management. Effectively, it describes the current practice as bad and …

For some time, there’s been concern that the average US doctor is failing his or her patients. This is due to a number of problems, but the most important is that almost every doctor is trapped in a for-profit system. This puts pressure on the individual to meet performance targets regardless of the actual quality of care delivered. In many cases, this means creating billable work to do on each patient while actually spending as little time with each patient as possible. So if the patient complains of pain, the shortest time is spent in writing out and handing over a prescription for a painkiller. If the complaints continue, the prescription is changed to a higher dose and then a stronger drug. As a country, we take more painkillers per head of population than any other country in the world and we have one of the highest rates of dependence.

The Institute of Medicine (IOM) has just released a report into pain management. It estimates that about 115 million adults currently suffer chronic pain, i.e. pain lasting more than six months. This costs the US about $600 billion in medical expenses and lost productivity. Obviously, this excludes children, those who are institutionalized, and those who are treated through the military healthcare service. Not to put too fine a point on it, this is a sizable chunk of change and the IOM is calling for a culture change in the medical profession to treat pain more seriously. From the other side of the fence, there’s also a problem with many patients abusing the drugs they receive. Once they are dependent, their pain never goes away. It can only increase in severity.

The IOM notes there are no coordinated research projects into pain or how to manage it. When you consider how much pain costs the country, this is an extraordinary failure. The formal recommendations are for work to develop better drugs and to refine the diagnostic approaches for pain management. At present, the assessment of pain is very subjective, relying on the patient to grade the pain on a scale. There are also regulatory problems in testing drugs, particularly in the older population. This is ironic. Older people are more likely to have painful conditions yet the research options are limited. These rules should be rewritten. Next, the IOM suggests a major change to the way doctors are trained. There are more than 130 medical schools yet only five have mandatory courses on pain management. This means only a small percentage of US doctors have any positive knowledge about pain management.

Finally, the IOM suggests the rules in Medicare, Medicaid and private health insurance be rewritten to pay a proper rate for interdisciplinary consultations on pain. Only if specialists from different fields combine their skills and knowledge can the best diagnosis of the causes of the pain be made. Only if the causes are properly understood can the best treatment options be selected. This is already being described as a landmark report and the hope is that it will change the culture of the medical profession. In the meantime, those in moderate to severe pain will no doubt continue to receive their prescriptions for Tramadol. No matter what federal reports may say, Tramadol does remain the trusted drug for pain management.