Saturday, February 7, 2015

Chronic Pain -- The Invisible Public Health Crises

Chronic Pain -- The Invisible Public Health Crises

A Call for Moral Leadership

“I am an invisible man. No I am not a spook like those who haunted Edgar Allen Poe: Nor am I one of your Hollywood movie ectoplasms. I am a man of substance, of flesh and bone, fiber and liquids- and I might even be said to possess a mind. I am invisible, simply because people refuse to see me.”
- Ralph Ellison

Ralph Ellison’s famous novel, The Invisible Man, starts with this passage, which also reminds me of the problem of chronic pain. The Institute of Medicine (IOM) report, Relieving Pain in America, documented the more than 100 million Americans (almost 1 in 3 and surely someone whom you know and love) suffers from chronic pain, at an economic cost of $6 billion and an incalculable psychological cost. We named pain as a “disease” because of its profound effects on the brain and its interference with multiple domains of the quality of life of sufferers. The committee identified chronic pain as a public health problem, given the sheer numbers affected, and the opportunities to intervene to prevent acute pain from becoming chronic pain. However, the report is now almost four years old, and it is fair to say has not really moved the needle in doing what we implored in the IOM report—“changing the way in which pain is judged, managed and perceived.” Why is that?

Because pain is subjective -- and therefore difficult to measure by the usual medical tests -- it is often doubted. As someone once said, my pain is real, your pain is in doubt. Also, we live in profound cultural ambivalence about pain. Cultural icons such as  Julius Caesar and Albert Schweitzer have been quoted as saying that pain is worse than death, but there is also an ethos of “no pain, no gain.” Medical interventions, particularly powerful opioid drugs such as morphine and oxycodone, although essential to manage acute and persistent pain, come with a cost of many side effects and may induce psychological dependence in some. Persons in pain and their doctors fear addiction, although we do not truly know the risk of addiction in persons taking opioids who have not abused recreational or illicit drugs. For these and other reasons, on an individual and societal level, we prefer to ignore the problem of chronic pain, unless confronted by it in our personal lives.

So how do we advance the moral imperative to address pain and suffering in contemporary medical practice, as required by our ethical codes and professional oaths? How do we bring the invisible suffering of so many to light and work to alleviate it? I think we commit ourselves to five big goals:

1. We advocate for more and better science to understand the underlying neuroscience of pain production and modulation. This requires advocacy at the NIH and other federal agencies to fund worthy science related to pain mechanisms and clinical trials of pain treatments.

2. We advocate for more and better drug development, including the creation of abuse deterrent opioid formulations and novel non-opioid based analgesics. This will require advocacy for effective public-private partnerships between the pharmaceutical industry, academia and federal agencies.

3. We advocate and demand better education of health care professionals to live up to their obligations to be competent and to attend to pain and suffering in their patients. We also advocate for better public education so that persons suffering with chronic pain understand that this is a disease, and not subject to quick fixes.

4. We advocate and demand better policy solutions to provide sustainable and patient-centric interdisciplinary pain treatment programs that truly address patient and provider needs. 

5. Finally, we need effective collaboration on a shared policy agenda between pain specialists and substance abuse specialists to advocate for comprehensive, rehabilitation-focused care for chronic pain, and greater access to substance abuse treatment for those persons who have a dual diagnosis of chronic pain and addiction.    

These are my thoughts. What do you think?

Richard Payne, MD
John B. Francis Chair, Bioethics
Center for Practical Bioethics

Esther Colliflower Professor of Medicine and Divinty
Duke University

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Anonymous Lynn Webster said...

"A Moral Imperative", "The invisible Public Health Crises", "A Human Right" all describe the need for a social movement to bring dignity to those living in pain. We must focus our collective energies humanity to where humanity doesn't exist.

Thank you Dr. Payne

Monday, February 09, 2015  
Blogger drprose2002 said...

I agree with you wholeheartedly and thank you for your post. There is so much still left unattended when it comes to chronic pain. There is so many emotions patients have and go through while waiting and getting a diagnosis. There is confusion, sadness, shame, anger, and then there is family. I was diagnosed with RSD. Was bed ridden for 8 months waiting for it and when I got it, no one really knew anything about it. I was left to myself to find a path that would work for me. I
come from a tuff family that said to pick myself up by the boot straps and tuff it out. Absolutely no empathy at all. And when I filed for disability, they shamed me as if I was lazy and didn't want to work anymore. I had just spent two years in night school while running my business fulltime to land a job after I sold my business. They have no clue what I have lost. My new job that I adored. The excellent pay and less time working to spend with my children. I just want to shake them and tell them to wake up and stop all the judging. I've lost so much because of this illness. This is just a touch of what we go through. Then there is the subject of doctors and treatment. I'll save that for another time. I'll just say education is the key to helping and there is lack there of. If there is anything I can do to help, I do it. But know I'm at the point of not being able to do much physicially. To much pain and no effective treatment for RSD.

Thursday, February 12, 2015  

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