Albert Schweitzer – whose portrait hangs outside Dean Must’s office -- observed that “Pain is a more terrible lord than even death itself.” Traditionally considered as an individual’s problem, pain and pain management are now increasingly recognized as requiring a societal focus.
Pain was envisioned as a public health problem in a 1999 editorial in Medical Clinics of North America. Titled “Primary Care and Pain Medicine,” this essay’s subtitle was “A community solution to the public health problem of chronic pain.” Authored by Rollin Gallagher, now head of the Veterans Health Administration’s pain programs, it proposed a model of chronic pain that integrated environment, host, and causative agents in the progression from injury to disability and called for community-based rehabilitation of the patient with chronic pain.
That same year, medical sociologist Kathy Lasch, PhD, and Daniel Carr, a biomedically trained physician, received approval to launch a new program on pain research, education and policy (PREP) at the School of Medicine. Initially, we often found ourselves explaining to colleagues and prospective students why we weren’t part of a “hard science” department such as anatomy or pharmacology. We did not then fully grasp the implications of the population-based perspective on health, defined by the World Health Organization (WHO) as not simply the absence of disease but rather “a state of physical, mental, and social well-being” that emphasized prevention and considered social determinants of health.
In 2011, the prestigious Institute of Medicine (IOM) issued a “blueprint for transforming pain prevention, care, education, and research” highlighting pain as a public health challenge: “We believe pain arises in the nervous system but represents a complex and evolving interplay of biological, behavioral, environmental, and societal factors that go beyond…the molecular and genetic to the cellular, neural network, and systems levels.” Subsequently, a panel of clinical and public health experts, patient advocates and federal employees was convened by the National Institutes of Health (NIH) to draft a National Pain Strategy (NPS) to implement the IOM recommendations. The panel addressed the entire spectrum of pain-related needs: professional education and training, public education and communication, service delivery and reimbursement, prevention and care, disparities, and population research.
Pain researchers and clinicians are now realizing that many of their efforts overlap traditional areas of public health: epidemiology, biostatistics, preventive medicine, health policy, and health services. Issues termed “public health” typically affect large numbers of people and exact a substantial societal burden, are amenable to prevention, and have a social justice dimension. The WHO’s writings on the social determinants of health are especially relevant to pain. They define exclusion as a “dynamic, multi-dimensional process driven by unequal power relationships interacting across four main dimensions – economic, political, social, and cultural – and at different levels.” Echoing papers by Kenneth Craig, PhD, editor-in-chief of Pain Research and Management, the journal of the Canadian Pain Society, and his co-authors that view pain as a population-based, top-down phenomenon, one WHO monograph opens with an African aphorism: “A person is a person because of other people.” These WHO reports resonate with the marginalization and stigmatization of patients with pain, extending into inequities of access to pain assessment and treatment based upon race, ethnicity, and socioeconomic status.
The overlap of pain medicine and public health extends to unintended negative consequences of interventions that target a single component of a complex, population-based problem (e.g., increased cigarette smoking following introduction of “better” filters). In the pain domain, liberalized prescribing of opioids intended to reduce pain and suffering has been paralleled by an epidemic of prescription opioid diversion, misuse, and damage to society of crisis proportions – including tens of thousands of deaths and an upsurge in neonatal opioid abstinence syndrome. Libby Bradshaw and Carr are now active in state and national efforts to better prepare medical students to manage pain and addiction, and increase the availability of abuse-deterrent opioid formulations and the opioid antagonist, naloxone.
The public’s health requires population research, public education and empowerment, prevention and care, and overcoming disparities in accessing treatment. To our knowledge, the PREP Program’s broad pain curriculum is the first and still only one that balances the traditional approach to pain as originating in synapses and ion channels, with a perspective on pain as a “top-down,” population-based process.
Daniel B Carr, MD, Director, Pain Research, Education and Policy Program
Libby Bradshaw, DO, MS, Academic Director, Pain Research Education and Policy Program
Portions of the above text are derived from the American Academy of Pain Medicine’s “Presidential Message” by Dr. Carr, now in press in Pain Medicine.