Alleviating suffering 101--pain relief in the United States.

n engl j med 366;3 nejm.org january 19, 2012 197 $635 billion per year, according to Relieving Pain in America,1 the recent report of an Institute of Medicine (IOM) committee that we cochaired. And these figures don’t include pain in children or people in long-term care facilities, the military, or prison. The annual U.S. expenditures related to pain (including direct medical costs and lost wages) are higher than those for cancer, heart disease, and diabetes combined. They include nearly $100 billion annually from state and federal budgets. Yet the treatment covered by these expenditures doesn’t fully alleviate Americans’ pain. Indeed, our committee reviewed the scientific and clinical evidence, held public workshops, received testimony from more than 2000 Americans, commissioned a review on pain’s economic burden, and concluded that relieving acute and chronic pain is a significant overlooked problem in the United States. Major impediments to relief include patients’ limited access to clinicians who are knowledgeable about acute and chronic pain — owing in part to the prevalence of outmoded or unscientific knowledge and attitudes about pain. Fundamental differences in views about pain and its management pervade the medical profession. Some physicians overprescribe medications including opioids, while others refuse to prescribe them at all for fear of violating local or state regulations. More than 65% of nursing home residents report having inadequately treated pain, which suggests that the impact of ineffective pain management could increase dramatically as the population ages. Decisions about medical care are also influenced by insurance coverage that may be preferential for injections, infusions, procedures, and surgery over the physical therapy, rehabilitation, or other more comprehensive approaches to pain control that may benefit patients more. Physicians’ referral of patients to other health care professionals, including nurses, chiropractors, and practitioners of complementary medicine, and patients’ willingness to seek such care, can be influenced by bias, unclear data, and the availability of care. Sadly, many people with chronic pain see physicians as “poor listeners.” Differences in expectations and outcomes related to genetic makeup, age, race, and sex, as well as social and cultural mores, influence people’s approach to pain relief. Many people with chronic pain simply don’t know where to go for help, and when they do seek help, they may become frustrated, disappointed, or angry beAlleviating Suffering 101 — Pain Relief in the United States