THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania.

THE PAIN DECADE AND THE THE PAIN DECADE AND THE PUBLIC HEALTHPUBLIC HEALTH

THE PAIN DECADE AND THE THE PAIN DECADE AND THE PUBLIC HEALTHPUBLIC HEALTH

Rollin M. Gallagher, MD, MPH

Clinical Professor, Departments of Anesthesiology and PsychiatryUniversity of Pennsylvania School of Medicine

Director of Pain Management, Philadelphia VA Medical Center

National Pain Management Coordinating Committee, Veteran Affairs Health System

Editor in Chief, Pain Medicine

Board of Directors: American Academy of Pain Medicine and National Pain Foundation

Immediate Past President, American Board of Pain Medicine

Rollin M. Gallagher, MD, MPH

Clinical Professor, Departments of Anesthesiology and PsychiatryUniversity of Pennsylvania School of Medicine

Director of Pain Management, Philadelphia VA Medical Center

National Pain Management Coordinating Committee, Veteran Affairs Health System

Editor in Chief, Pain Medicine

Board of Directors: American Academy of Pain Medicine and National Pain Foundation

Immediate Past President, American Board of Pain Medicine

The Pain Decade and the Public HealthThe Pain Decade and the Public HealthThe Pain Decade and the Public HealthThe Pain Decade and the Public Health

•History– Conceptualization – Lippe, Saper,

Ashburn et al, 1999– Matriculation – SB 3163– Enrollment – October 28, 2000– Life span – 2001 - 2010

•History– Conceptualization – Lippe, Saper,

Ashburn et al, 1999– Matriculation – SB 3163– Enrollment – October 28, 2000– Life span – 2001 - 2010

“Pain is a more terrible lord of mankind than even death itself.”

“Pain is a more terrible lord of mankind than even death itself.”

Albert S. Schweitzer, 1931

On the Edge of the Primeval Forest.

New York: Macmillan, 1931:652

Albert S. Schweitzer, 1931

On the Edge of the Primeval Forest.

New York: Macmillan, 1931:652

Pain MedicinePain MedicineHistoryHistory

Pain MedicinePain MedicineHistoryHistory

• Epochs

– Antiquity to 19th Century

•Pain a symptom treated by purgation

•Dichotomy of pain – Descartes and Byron

– Physical pain– Mental pain

• Epochs

– Antiquity to 19th Century

•Pain a symptom treated by purgation

•Dichotomy of pain – Descartes and Byron

– Physical pain– Mental pain

Pain MedicinePain MedicineHistoryHistory

Pain MedicinePain MedicineHistoryHistory

•Epochs– Late 19th Century to 1980’s:

Age of medical science and technology• Spine surgery and back pain disability• Psychogenic pain, compensation neurosis

and behavioral medicine• John Bonica and IASP • Gate Theory of Pain (Wall and Melzack)• Hospice and the treatment of suffering

•Epochs– Late 19th Century to 1980’s:

Age of medical science and technology• Spine surgery and back pain disability• Psychogenic pain, compensation neurosis

and behavioral medicine• John Bonica and IASP • Gate Theory of Pain (Wall and Melzack)• Hospice and the treatment of suffering

Pain Medicine HistoryPain Medicine HistoryPain Medicine HistoryPain Medicine History

•Epochs– Late 20th Century to 2007

•Rise of epidemiology– Failed spine surgery syndrome– Geographic variation in surgical rates– National variation in opioid analgesia– The myth of “psychogenic pain” and

psychiatric co-morbidity– Pain diseases versus chronic pain– Multi-factorial bio-psycho-social causation

•Epochs– Late 20th Century to 2007

•Rise of epidemiology– Failed spine surgery syndrome– Geographic variation in surgical rates– National variation in opioid analgesia– The myth of “psychogenic pain” and

psychiatric co-morbidity– Pain diseases versus chronic pain– Multi-factorial bio-psycho-social causation

Neuropathic low back pain

DIAGNOSIS There Are Many Painful Diseases and Pain Diseases

DIAGNOSIS There Are Many Painful Diseases and Pain Diseases

*Complex regional pain syndrome.

Nociceptive painCaused by activity inneural pathways in

response to potentiallytissue-damaging stimuli

Neuropathic painInitiated or caused by a

primary lesion or dysfunction

in the nervous system

Postoperativepain

Mechanicallow back pain

Sickle cellcrisis

Arthritis

Peripheralneuropathy

Postherpeticneuralgia

Diabeticneuropathy

Sports/Exerciseinjuries

Central post-stroke pain

Trigeminalneuralgia

Inflammatory / Immunological Mediation

CANCER PAIN, LBP, CHRONIC FACIAL PAIN

(mixed pain states)

SENSITIZATIONCRPS*

Phantom tooth pain

Phenomenological Model of Pain Disease: Post Herpetic Neuralgia Phenomenological Model of Pain Disease: Post Herpetic Neuralgia

Exposure to VaricellaVirus

ChickenPox with Infection,with invasionof dorsal root ganglion& spinalnerves in childhood

“Shingles”

Activation of virus and disease of acute herpes zoster

PrecipitatingFactors:

Acute illness,Stress, Age,Immuno-Suppression,Cancer.

Risk factors for chronic pain:

Severity and duration of acute rash, Pain severity, Anxiety severity.

*

PredisposingCondition

Post-herpetic Neuralgia

Successful Pain Control

*

Factors reducing risk for PHN:

Early anti-viral treatment, Early amitriptylene, Good pain control.

Factors enhancing good outcome:

Access to appropriate pain treatment

Access to rehabilitation.

BPS

OUTCOMES

Initial exposure

Mismanaged chronic pain is often a personal catastrophe! ….and is

a huge public health problem.

Mismanaged chronic pain is often a personal catastrophe! ….and is

a huge public health problem.

• Quality of life– Physical functioning– Ability to perform

activities of daily living (ADLs)

– Work

• Social consequences– Marital/family relations– Intimacy/sexual activity– Social role and

friendships

• Quality of life– Physical functioning– Ability to perform

activities of daily living (ADLs)

– Work

• Social consequences– Marital/family relations– Intimacy/sexual activity– Social role and

friendships

• Psychological morbidity– Fear, anger, suffering– Sleep disturbances– Loss of self-esteem

• Medical comorbidites & consequences– Accidents– Medication effects– Immune function– Clinical depression

• Psychological morbidity– Fear, anger, suffering– Sleep disturbances– Loss of self-esteem

• Medical comorbidites & consequences– Accidents– Medication effects– Immune function– Clinical depression

• Societal consequences- Health care costs- Disability

- Lost workdays- Business failures- Higher taxes

Established effects (by research) of chronic pain

Pain causes these problems.

These problems reduce the effectiveness of pain treatment.

They must be managed to obtain good treatment outcomes

Depression and Pain ComorbidityDepression and Pain Comorbidity

ResponseRemission

Symptoms

Syndrome

Recovery

ContinuationAcute

Relapse

Gallagher & Verma, Prog Pain Res Man 2004, Adapted from Kupfer DJ. J Clin Psychiatry.; 1991;52(suppl):28-34. Dohrenwend BP, et al. Pain. 1999;83(2):183-192. Raphael et al Pain 2004

Treatment Phases

“Normalcy”

Maintenance

Relapse RecurrenceProgression

to disorder

Pain

Pain, A condition or symptom that causes or activates depression

Pain MedicinePain MedicineHistoryHistory

Pain MedicinePain MedicineHistoryHistory

•Epochs– Late 20th Century to 2007

•Rise of Neuroscience and Biotechnology

– Gate theory– Molecular biology and neurotransmitters– Psychopharmacology– Neuropharmacology – Neuromodulation– disease

•Epochs– Late 20th Century to 2007

•Rise of Neuroscience and Biotechnology

– Gate theory– Molecular biology and neurotransmitters– Psychopharmacology– Neuropharmacology – Neuromodulation– disease

Pain in our wounded warriors (2002-2007)

Pain in our wounded warriors (2002-2007)

• 686,306 OIF-OEF veterans

• 229,015 using VA services (33.4%)

• 43 % have musculoskeletal diseases (all cause pain by definition) - back pain most common

• 37% have mental health disorders

Kang et al. Paper presented at War-Related Illness and Injury Study Center, 2007.

• 686,306 OIF-OEF veterans

• 229,015 using VA services (33.4%)

• 43 % have musculoskeletal diseases (all cause pain by definition) - back pain most common

• 37% have mental health disorders

Kang et al. Paper presented at War-Related Illness and Injury Study Center, 2007.

The Polytrauma ChallengeThe Polytrauma Challenge• 65% of OEF/OIF combat injuries are caused

by improvised explosive devices (IEDs), landmines, shrapnel, and other blast phenomena.

– multiple visible injuries (tissue wounds)

– hidden injuries [bone and soft tissue damage, including nerves]

– 60% with symptoms of traumatic brain injury (TBI) : hearing, vision, cognition, emotional control

– Over 95% have chronic pain

• 65% of OEF/OIF combat injuries are caused by improvised explosive devices (IEDs), landmines, shrapnel, and other blast phenomena.

– multiple visible injuries (tissue wounds)

– hidden injuries [bone and soft tissue damage, including nerves]

– 60% with symptoms of traumatic brain injury (TBI) : hearing, vision, cognition, emotional control

– Over 95% have chronic pain

C fiber

Abeta fiber

Nerve injury

PhenotypicalChanges

Spinal cord Damage

Neuro-plasticity

Central sensitization

Alteration of modulatory

systems

Ectopic discharge

Ectopic discharge

Adapted from Woolf & Mannion, Lancet 1999Attal & Bouhassira, Acta Neurol Scand 1999

ANS activation <<< Stress <<< Pain <<< BRAIN PROCESSING

+++

Limb trauma

567 severe single extremity trauma patients at 7 years

• Predictors of poor outcome before injury include:• Alcohol abuse 1 month before injury • Older age, lower education, low self efficacy (Gallagher Pain 1989)

• Predictors of poor outcome at 3 months post-injury:• Acute pain intensity, anxiety, depression and sleep disturbance

Does early intervention make a difference?

Castillo et al. Pain 124 (2006): 321-329

Opioid protective effectOpioid protective effect

• Patients treated with opioids for pain at three months post-discharge were protected against chronic pain..

• despite the fact that these patients had higher pain intensity levels and were thus at higher risk for chronic pain

• lending support to the theory that…

..early aggressive pain treatment may protect patients from central sensitization and chronic pain.”

• Patients treated with opioids for pain at three months post-discharge were protected against chronic pain..

• despite the fact that these patients had higher pain intensity levels and were thus at higher risk for chronic pain

• lending support to the theory that…

..early aggressive pain treatment may protect patients from central sensitization and chronic pain.”

Early, Continuous, and Restorative Pain Management in Injured Soldiers:

The Challenge Ahead

Early, Continuous, and Restorative Pain Management in Injured Soldiers:

The Challenge Ahead

Rollin M. Gallagher, MD, MPH Rosemary Polomano, PhD, RN

Pain Medicine 2006;7(4):284-286

John Farrar, MD, PhD David Oslin, MD

Wensheng Guo, PhD

Chester Buckenmaier, MDGeselle McKnight, CRNP

Alexander Stojadinovic, MD

Rollin M. Gallagher, MD, MPH Rosemary Polomano, PhD, RN

Pain Medicine 2006;7(4):284-286

John Farrar, MD, PhD David Oslin, MD

Wensheng Guo, PhD

Chester Buckenmaier, MDGeselle McKnight, CRNP

Alexander Stojadinovic, MD

THE END: CPRS Pain Cycle THE END: CPRS Pain Cycle Pathology:-Muscle atrophy, weakness;-Bone demineralization;-Depression

Less activeKinesophobiaDecreased motivationIncreased isolationRole loss

Disability

Pathophysiology of Maintenance:-Radiculopathy-Neuroma traction-Myofascial sensitization-Brain pathology (loss, reorganization)

Psychopathologyof maintenance:-Encoded anxiety dysregulation - PTSD-Emotional allodynia-Mood disorder

NeurogenicInflammation:- Glial activation- Pro-inflammatory cytokines- blood-nerve barrier dysruption

Acute injuryand pain

PeripheralSensitization:Na+ channelsLower threshold

Central sensitization

PNS

NA channels Lidocaine Patch 5%CarbamazepineOxycarbazineTricyclicsTopiramate

Spinal cord

BRAINModulation byNorepinephrineSerotoninEndogenous opiates

Tricyclics, SSRIs, SNRIs (Venlafaxine, Duloxetine),Tramadol, Opiates

Voltage gated Ca channels (L & PQ presynaptic): Gabapentin, Pregabalin

Mechanism Targets For Neuropathic Pain Pharmacotherapy

2 agonistsTizanidineClonidine

(Adapted from Beydoun 2001)

Anti-inflammatoryNSAID, Cox 2

NMDA antagonists: Ketamine, Dextromethorphan

Pain MedicinePain MedicineHistoryHistoryPain MedicinePain MedicineHistoryHistory

• Epochs– Late 20th Century to 2007

• Emergence of the specialty of Pain Medicine

• Evolving organizational models of care– Sequential care model– Multidisciplinary pain center model– Managed care model– Pain medicine and primary care community

rehabilitation model

• Epochs– Late 20th Century to 2007

• Emergence of the specialty of Pain Medicine

• Evolving organizational models of care– Sequential care model– Multidisciplinary pain center model– Managed care model– Pain medicine and primary care community

rehabilitation model

The tertiary, sequential care modelThe tertiary, sequential care model

INJURY/SYMPTOMEmergencyServices Primary

CareSpecialty Office #1

Specialty Office #2

Specialty Office #3

TREATMENTFAILURES

Specialty Office #4

ALTERNATIVE TREATMENTS

TIME1

11

3

4

5

4

(6)

22

3

3

4 (5)

Gallagher RM. Med Clin N Am 83(5): 555-585, 1999.

CHASING THE SYMPTOM THROUGH A REDUCTIONISTIC,

BIOMEDICAL MODEL

The multi-disciplinary, biobehavioralpain center modelINJURY/SYMPTOM

EmergencyServices Primary

CareSpecialty Offices, Alternative CareTreatment

FailureTreatment

Success

MultidisciplinaryPain Center: MD, PT, OT, Behav Med, Voc Rehab

1

2 2

3

4

5

time

1 1

The managed primary care modelThe managed primary care model

INJURY/SYMPTOM

PrimaryCare Office

EmergencyServices

Specialty OfficesTreatment

Failures

time

JOB LOSSINSURANCE LOSS

11

2

(3)

3 (4)

5

6

2

Gallagher RM. Med Clin N Am 83(5): 555-585, 1999.

DOES NOT WORK FOR PATIENTS OR POPULATIONS

JUST SAY NO!!

Cost vs. QualityCost vs. Quality

RReessoouurrccee

Quality of care (outcomes)Quality of care (outcomes)

Excess careExcess care

Best practiceBest practice

(From W. Brose, MD)

The pain medicine and primary care community rehabilitation model

The pain medicine and primary care community rehabilitation model

A “systems” model for pain management that is based on three core principles:

1) empowerment by education of and support for primary care provider, patient and community

2) outcomes focus: evidence based, quality improvement approach

3) shared responsibility for outcomes amongst, patient, providers, health care system, and payers

4) Easy access for early intervention

5) Evidence-based rational polypharmacy imbedded in goal-oriented, stepped, selectively multi-modal

treatment (e.g., PT, behavioral, social) **

** Gallagher RM. Rational polypharmacy in integrated pain treatment. Am J Phys Med & Reh 2005(S);84(3):S64-76

Pain medicine and primary care community rehabilitation model

Pain medicine and primary care community rehabilitation model

INJURY/SYMPTOM

EmergencyServices

PrimaryCare: ClinicalAlgorithms

Recurrent or persistent pain impairing functionIntegrated

Pain MedicineEval & Services:Med. trials, PT, Blocks, Behavioral mgmt.

Sub-specialtyEval. & mgmt.

Treatment Failure

Multidisc-iplinary

Pain Center

1

2

3

(4)5

6

6

7

CommunitySupport &Services (PT, OT, Voc,behavioral, pharmacy)

Gallagher RM. Med Clin N Am 83(5): 555-585, 1999.

.

3

Nociceptivepain

Neuropathicpain

Pain condition +

depressionSecondary sleep

disturbance

Secondary depression Primary D.

NSAIDs,Cox-IIs,opioids,

lidocaine p.? doxepin cr.?

Persists afteradequateanalgesia

Persists afteradequateanalgesia

Evaluate risks

Evaluate risks

Antihistamine,zolpidem,

etc.

Trazodone

Low-doseTCA

Lidocaine patch;gabapentin & other

AED (Ca+ & Na+ channels); alpha 2 agonists

(tizanidine, clonidine);opioids

Titrate TCAs (Na+ channels and SNRI) :

desipramine, nortriptyline,

SSRI trial

Evaluate risksSNRIs: venlafaxine,

duloxetine

Algorithm for Medication Selection in Chronic Pain With and Without Comorbid Depression

Algorithm for Medication Selection in Chronic Pain With and Without Comorbid Depression

Adapted from Gallagher RM, Verma S. Semin Clin Neurosurgery. 2004.This information concerns uses that have not been approved by the US FDA.

Evaluate risks

The Opioid Renewal Clinic: A structured approach to managing opioids for pain in primary care

Wiedemer N, et al Pain Medicine 2007Bair M, Pain Medicine 2007

Aberrant Behavior Categories over one year

The Opioid Renewal Clinic: A structured approach to managing opioids for pain in primary care

Wiedemer N, et al Pain Medicine 2007Bair M, Pain Medicine 2007

Aberrant Behavior Categories over one year

Referred for Addiction Treatment

13%

Aberrant Behavior Resolved

33%Self Discharged32%

Possible Diversion4%

Still Monitoring w/ Aberrancy

18%

Referred for Aberrant Behavior

n=170

Referred for Addiction Treatment

13%

Aberrant Behavior Resolved

33%Self Discharged32%

Possible Diversion4%

Still Monitoring w/ Aberrancy

18%

Referred for Aberrant Behavior

n=170

OUR CONUNDRUMOUR CONUNDRUMGrowing societal awareness of:

1. the prevalence of inadequately treated chronic pain 2. its impact on society3. the need for access to effective pain treatment

vs

Growing societal awareness of: 1. The rapidly increasing rate of use of opioid prescriptions2. The increasing rate of prescription drug abuse3. The increasing rate of prescription drug abuse deaths

Growing societal awareness of: 1. the prevalence of inadequately treated chronic pain 2. its impact on society3. the need for access to effective pain treatment

vs

Growing societal awareness of: 1. The rapidly increasing rate of use of opioid prescriptions2. The increasing rate of prescription drug abuse3. The increasing rate of prescription drug abuse deaths

Balanced Pain Policy Initiative Center for Practical Bioethics

Kansas City, MO

Balanced Pain Policy Initiative Center for Practical Bioethics

Kansas City, MO

• American Academy of Pain Medicine• American Pain Society• American Society of Addiction Medicine• DEA• FSMB• National Association of Attorneys General• Wisconsin Pain Policy Center• Wisconsin Department of Regulation &

Licensing

• American Academy of Pain Medicine• American Pain Society• American Society of Addiction Medicine• DEA• FSMB• National Association of Attorneys General• Wisconsin Pain Policy Center• Wisconsin Department of Regulation &

Licensing

Physicians Charged with Opioid Analgesic Prescribing Offenses

Physicians Charged with Opioid Analgesic Prescribing Offenses

Goldenbaum, Donald M., Ph.D.; Christopher, Myra; Gallagher, Rollin M., M.D., M.P.H.; Fishman, Scott, M.D; Payne, Richard, M.D.; Joranson, David, MSSW;

Edmondson, Drew, J.D.; McKee, Judith, J.D.; Thexton, Arthur, J.D., M.A.

Author Affiliations: • Center for Practical Bioethics (Goldenbaum and

Christopher)• AAPM: Philadelphia V.A. Medical Center/University of

Pennsylvania (Gallagher)• AAPM: U. California, Davis (Fishman)• Duke University Divinity School (Payne)• U. Wisconsin (Joranson)• Attorney General, State of Oklahoma (Edmondson)• National Association of Attorneys General (McKee)• Wisconsin Department of Regulation & Licensing

(Thexton).

PRINCIPLES OF TREATMENT:Summary

PRINCIPLES OF TREATMENT:Summary

Primary prevention: • avoid injuries and diseases

Secondary prevention: • When injuries or diseases occur, prevent or

minimize nociception or neural activation of pain pathways, improve coping and adaptation, and restore and maintain function

• Risk management

Tertiary prevention• manage perpetuating factors, control pain and

restore function and quality of life

Primary prevention: • avoid injuries and diseases

Secondary prevention: • When injuries or diseases occur, prevent or

minimize nociception or neural activation of pain pathways, improve coping and adaptation, and restore and maintain function

• Risk management

Tertiary prevention• manage perpetuating factors, control pain and

restore function and quality of life

Decade of Pain Control and ResearchDecade of Pain Control and ResearchDecade of Pain Control and ResearchDecade of Pain Control and Research

• Goals: To Promote Pain Medicine– Research– Education– Clinical Practice– Advocacy & Policy Development

•How are we doing after 6 years?•A snapshot

• Goals: To Promote Pain Medicine– Research– Education– Clinical Practice– Advocacy & Policy Development

•How are we doing after 6 years?•A snapshot

Growth in the Number of Published Articles on Pain over the Past 30 years. (Source: June 10, 2003, Pub Med search

with keyword pain)

Growth in the Number of Published Articles on Pain over the Past 30 years. (Source: June 10, 2003, Pub Med search

with keyword pain)

Articles Published, by Decade, Retrieved Using PubMed with Keyword "Pain"

30,138

60,421

105,828

0

20,000

40,000

60,000

80,000

100,000

120,000

1970-1979 1980-1989 1990-1999

Decade

Nu

mb

er o

f A

rtic

les Keyword: Pain

Articles Published, by Decade, Retrieved Using PubMed with Keyword "Pain"

30,138

60,421

105,828

0

20,000

40,000

60,000

80,000

100,000

120,000

1970-1979 1980-1989 1990-1999

Decade

Nu

mb

er o

f A

rtic

les Keyword: Pain

Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004

Growth in the Number of Published Articles on Nociception over the Past 30 years. (Source: June 10, 2003, Plumbed search with

keyword nociception)

Growth in the Number of Published Articles on Nociception over the Past 30 years. (Source: June 10, 2003, Plumbed search with

keyword nociception)

Articles Published, by Decade, Using PubMed with Keyword "Nociception"

1,391

532

45

0

200

400

600

800

1000

1200

1400

1600

1970-1979 1980-1989 1990-1999

Decade

Nu

mb

er o

f A

rtic

les

Keyword: Nociception

Articles Published, by Decade, Using PubMed with Keyword "Nociception"

1,391

532

45

0

200

400

600

800

1000

1200

1400

1600

1970-1979 1980-1989 1990-1999

Decade

Nu

mb

er o

f A

rtic

les

Keyword: Nociception

Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004

Growth in the Number of Published Articles related to pain over the past 3.5 years.

(Source: August 2, 2004, Plumbed search with keywords: pain, neuropathic, nociception)

Growth in the Number of Published Articles related to pain over the past 3.5 years.

(Source: August 2, 2004, Plumbed search with keywords: pain, neuropathic, nociception)

No. Published Articles-------------------------------------------

Search 1995-99 2000-04 Term (5 years) (3.5 years) % increase

Pain 59,749 72,018 > 21%

Neuropathic 1,527 2,481 > 62%

Nociception 831 1,220 > 47%

Journal proliferationJournal proliferation

• Concomitantly rapid rise in numbers of journals devoted to pain– 2 new academic journals started in 2000 indexed recently by the

National Library of Medicine for MEDLINE, Index Medicus and Pub Med.

- Pain Medicine indexed 2003; Imp F. 2.477Increased to six issues yearly in 2005Increased to eight issues in 2007Increase to twelve issues in 2009

- Journal of Pain indexed in 2004

– Neuromodulation, likely to follow.

– Growth of review pain journals (Pain Practice, Pain Physician, J Opioid)

– Multiple special supplements to other specialty society journals (Family Practice, Neurology, Psychiatry, JAMA, Internal Medicine, Neurosurgery)

– Multiple sponsored articles and “throw away” journals

• Concomitantly rapid rise in numbers of journals devoted to pain– 2 new academic journals started in 2000 indexed recently by the

National Library of Medicine for MEDLINE, Index Medicus and Pub Med.

- Pain Medicine indexed 2003; Imp F. 2.477Increased to six issues yearly in 2005Increased to eight issues in 2007Increase to twelve issues in 2009

- Journal of Pain indexed in 2004

– Neuromodulation, likely to follow.

– Growth of review pain journals (Pain Practice, Pain Physician, J Opioid)

– Multiple special supplements to other specialty society journals (Family Practice, Neurology, Psychiatry, JAMA, Internal Medicine, Neurosurgery)

– Multiple sponsored articles and “throw away” journals

NIH Research InitiativesNIH Research Initiatives

• Pain is much more prominent in RFAs from several institutes.Challenge: Capps-Rogers 2007: HR 2994 “The National Pain Care Policy Act 2007”

• National Cancer Institute: Challenge:

Will pain and palliative care become a pre-requisite in evaluating CA clinical trials?

• Pain is much more prominent in RFAs from several institutes.Challenge: Capps-Rogers 2007: HR 2994 “The National Pain Care Policy Act 2007”

• National Cancer Institute: Challenge:

Will pain and palliative care become a pre-requisite in evaluating CA clinical trials?

VA-military InitiativesVA-military Initiatives

Senator Akaka (D-HI) introduces bill to enhance VA and military pain care and research

– Promoting Improvements in Treatment of Veterans Suffering from Chronic and Acute Pain

– Provide research funding for studies of pain in military and in VA

– October 15, 2007

Senator Akaka (D-HI) introduces bill to enhance VA and military pain care and research

– Promoting Improvements in Treatment of Veterans Suffering from Chronic and Acute Pain

– Provide research funding for studies of pain in military and in VA

– October 15, 2007

COMMUNITY HEALTH SYSTEM

VETERANS HEALTH SYSTEM

COMMUNITY SUPPORT SYSTEM

MILITARY HOSPITAL, USA

MILITARY BASE CLINIC, USA

Transition to Community Care:

Pain Medicine and Mental

Health Services

SOCIETAL INTERESTSOCIETAL INTEREST

• Non-profit advocacy organizations:

– American Chronic Pain Association

– National Pain Foundation: • www.nationalpainfoundation.org

– American Pain Foundation:• www.painfoundation.org

• Non-profit advocacy organizations:

– American Chronic Pain Association

– National Pain Foundation: • www.nationalpainfoundation.org

– American Pain Foundation:• www.painfoundation.org

The future?The future?

• Pain Medicine as a Specialty– Standardize training– Create qualified teachers of all doctors

• Medical schools• Residencies• Pain Fellowships

– Promote important research

• Societal Awareness for Advocacy and Policy Change

• Organization of health care– Performance-based medicine– Pain Medicine and Primary Care Community Rehabilitation

Model– Integrated medical record– Risk management

• Pain Medicine as a Specialty– Standardize training– Create qualified teachers of all doctors

• Medical schools• Residencies• Pain Fellowships

– Promote important research

• Societal Awareness for Advocacy and Policy Change

• Organization of health care– Performance-based medicine– Pain Medicine and Primary Care Community Rehabilitation

Model– Integrated medical record– Risk management