Intended for healthcare professionals


US needs new strategy to help 116 million patients in chronic pain

BMJ 2011; 343 doi: (Published 01 July 2011) Cite this as: BMJ 2011;343:d4206
  1. Bob Roehr
  1. 1Washington, DC

A new report from the US Institute of Medicine calls for “a cultural transformation” in the way chronic pain is viewed, treated, and researched. The report says that it is a public health challenge needing an overarching strategy and prompt, sustained action.

At least one in three US adults, an estimated 116 million people, suffer from chronic pain—more than the sum total of the number of people with heart disease, cancer, or diabetes. The annual economic burden is as much as $635bn (£400bn; €440bn) in medical treatment and lost productivity, shows an analysis conducted for the report.

But the figures may be underestimated, because of poor data collection and the omission of children, military personnel, and institutionalised people such as those in nursing homes.

Chronic pain “can become a disease in its own right” by rewiring nerve and brain circuits so that pain continues even after the original insult has abated, said Phillip Pizzo, dean of the Stanford University School of Medicine and chairman of the committee behind the report.

The report calls for action in four areas by the end of 2012 and the implementation of changes in an additional dozen areas by 2015. The US Department of Health and Human Services should improve its coordination of activities across government agencies to better assess how types of pain and their treatment vary along lines of sex, race, age, and socioeconomic factors, it says.

Barriers to the effective delivery of existing interventions should be reduced. That begins with the education and training of doctors, particularly primary care doctors, who deal with most of the care of people with chronic conditions. Only five of the nation’s 133 medical schools currently have a mandatory course on pain, and just 17 offer such courses as an elective.

Insurance payers should be open to covering non-medical interventions of proved effectiveness, such as physical therapy for lower back pain. Such interventions can provide equal or greater relief than questionable interventions such as surgery, says the report, and often at lower cost.

The committee received an unusually large number of public comments during its hearings in three cities. Melanie Thernstrom, a journalist who served on the committee as a patients’ advocate, said, “It is extraordinary how many patients describe themselves as collateral in the war against drugs.”

Patients recounted how pressure from law enforcement officers concerned about the potential for misuse of prescription drugs resulted in doctors stopping prescribing opioids that relieved their pain. Patients often had to take time off from work and travel long distances to a pain specialist to obtain a single month’s supply of drugs.

Sean Mackey, a neurologist and pain specialist at Stanford University School of Medicine and a committee member, said, “What we desperately need are new classes of medications to really attack pain at every point along where the injury and signals are processed.”

The report calls for the National Institutes of Health to improve coordination and integration of basic and translational pain research among its institutes. Dr Mackey said that this requires the breaking down of “silos” of expertise and greater collaboration across disciplines and between government agencies, academia, and the industry.


Cite this as: BMJ 2011;343:d4206