Chronic pain is a significant public health problem that must be viewed as a distinct chronic illness, according to a report released on Nov. 4 by a multidisciplinary panel of pain experts.

“Chronic pain is a chronic illness with the same level of import as any other common, challenging, extensive chronic illness faced by the American public, [such as] diabetes and cancer,” Dr. Russell K. Portenoy, a cochair of the panel, said during a teleconference.

The 15-page report, “A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform,” is based on recommendations from a meeting of pain experts who assembled in Washington, D.C., in June 2009.

The report, which is available for free download at www.maydaypainreport.org, outlines the impact of chronic pain in America and highlights the current challenges of effective care delivery, including a call to improve clinician training in diagnosing and treating the illness, particularly in primary care. It also includes recommendations for the medical community, government agencies, and the U.S. Congress to address.

More than 70 million Americans experience some form of chronic pain such as back pain, migraines, and joint pain, said Dr. Lonnie Zeltzer, the panel’s other cochair. “This leads to over $100 billion in lost productivity and direct medical costs,” said Dr. Zeltzer, who directs the pediatric pain program at Mattel Children’s Hospital at the University of California, Los Angeles. “We’re really facing an epidemic of undertreated pain. We also know that minorities, children, and women are at highest risk for undertreatment.”

She added that chronic pain is the second leading cause of medically related work absenteeism, which results in more than 50 million lost workdays each year. “The burden of chronic pain is more than that of diabetes, heart disease, and cancer combined.”

Dr. Portenoy, a neurologist who chairs the department of pain medicine and palliative care at Beth Israel Medical Center, New York, said that the release of the report is timely in light of the current attention being focused on health care reform. If health care reform occurs, “the front lines of medicine – adult and pediatric primary care – could face enormous strains from millions of new patients seeking care for their pain,” he said.

“Primary care is the first stop for patients in pain. Both the training received by the clinicians and the system of care should facilitate best practices in care. Unfortunately, this is not currently the way it is. The fact is, patients aren’t getting competent and cost-effective care that they need in chronic pain, because neither the health care system overall nor the education and training of doctors support best practices across the board.”

Dr. Zeltzer added that many physicians “don’t have adequate training to know what to do” for a patient with chronic pain. “There are very few hours of time ... in medical school devoted to understanding pain and [its] treatment, and there is not enough [time spent] across other clinical professions,” she said.

One of the report’s nine recommendations – which Dr. Portenoy referred to as a “to-do list” – urges state medical and osteopathic boards, deans of medical and other health professional schools, state licensing boards, and residency training program directors in specialties that provide primary care to “make sure that every trainee and health practitioner in the health professions has the skills to assess and treat pain effectively, including chronic pain. Licensing examinations should include assessment of clinical knowledge related to appropriate pain care.”

Another recommendation calls for coordinated information technology systems “to track pain disorders, treatments, and outcomes as a mechanism to improve pain care. Quality indicators and performance measures should be developed and applied, and the public should gain access to information on the performance of hospitals, doctors, and other health care providers.”

The report also proposes that the U.S. Department of Health and Human Services form an independent commission to reform how care for chronic pain is reimbursed. “At present, Medicare and Medicaid maintain fee-for-service systems that incentivize procedures and inadequately compensate professionals for the time required to assess, counsel and educate, and coordinate the care of chronic illnesses like persistent pain,” the report states.

“This commission should explore outcome-based payments for a team approach for selected cases, revision of the disparity between nonprocedural and procedural pain treatments, and parity for psychological services. Ongoing complex chronic pain management should be treated, when possible, with an interdisciplinary, rehabilitation-oriented team approach with reimbursement for the team, rather than fee for service for specific individuals within the team.”

The report and recommendations have been endorsed by several health care organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the Joint Commission, the American Nurses Association, the American College of Emergency Physicians, and the American Academy of Neurology.

The panel included anesthesiologists, neurologists, pediatricians, primary care physicians, emergency medicine physicians, nurses, pharmacists, psychologists, and patient advocates. The panel was convened by the New York City–based Mayday Fund, a private philanthropic organization focused on alleviating the incidence, degree, and consequences of physical pain.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

据11月4日多学科疼痛专家组发布的一项报告，慢性疼痛是一个重大的公共卫生议题，应被视为一种特殊的慢性疾病。

 

专家组联席主席Russell K. Portenoy博士在一次电话会议上说：“慢性疼痛是一种慢性疾病，与美国公众熟知的其他任何常见的、疑难的、多发性慢性疾病（例如糖尿病与癌症）具有同等重要性。”

 

这份15页主题为“美国慢性疼痛保健的革命性号召：医疗改革中的一次机遇” 的报告基于来自2009年6月在华盛顿特区召开的一次疼痛专家会议的建议。

 

这份报告可在www.maydaypainreport.org网站上免费下载，它概述了慢性疼痛在美国人群中的影响，强调了当前有效治疗慢性疼痛中所面临的挑战，包括提高对临床医师在疾病诊断和治疗方面的培训，尤其是在初级医疗中。这份报告也包括了向医疗机构、政府部门及美国国会提出建议等内容。

 

该专家组的另一位联席主席Lonnie Zeltzer博士说，目前大约有7,000多万美国人遭受各种慢性疼痛的折磨，例如背痛、偏头痛、关节痛。“这导致达1,000多亿美元的经济损失和直接医疗费用。”Zeltzer博士是洛杉矶加利福尼亚大学Matteler儿童医院儿科疼痛项目的负责人。她说：“实际上我们面对着一种未得到有效治疗的流行性疾病。我们也了解到少数民族、儿童及妇女正处于治疗不足的高度风险中。”她补充说，慢性疼痛是引起医学相关旷工的第二大原因，每年可导致5,000多万工作日的损失。“慢性疼痛的负担超过了糖尿病、心脏病及癌症的总和。”

 

Portenoy博士是一名神经学专家，现为纽约Beth以色列医学中心疼痛药物与姑息治疗科主任。他说：“这份报告的发布及时地将人们的关注点转向了当前的医疗制度改革。如果医疗制度改革成功，处于医学的前线——成人与儿科初级医疗——将面临来自数以千万计新患者寻求其疼痛治疗的压力。”

 

“初级医疗是遭受疼痛折磨患者的第一站。医生所受到的培训与医疗体系都应该确保患者获得最佳治疗，然而遗憾的是当前事实并非如此。事实上，患者在慢性疼痛方面并不能获得其所需的充分的、性价比较高的治疗，因为无论医疗体系整体还是医生的教育和培训都不能保证患者获得最佳的全方位治疗。”

 

Zeltzer博士补充道，许多医生“没有得到充分培训，并不知道对慢性疼痛患者该做什么。”她说：“已经没有多少时间允许我们去医学院校灌输疼痛及其治疗的知识，也没有足够的时间去进行临床跨学科学习。”

 

该报告9项建议中的1项，即Portenoy博士所指的“行动列表”敦促各州医学与骨科委员会、医学和其他卫生专业学院的院长、各州医疗注册委员会和住院医师培训项目负责人在各专科方面提供初级保健知识，以“确保每位受训者和医疗执业者在相关专业上具有评估和有效治疗疼痛(包括慢性疼痛)的技能。注册医师考试也应包括对相应专科中疼痛处理的临床知识评估。”

 

另有一项建议号召与信息技术(IT)系统协作，以“追踪疼痛疾病、治疗及转归的研究进展，将其作为改善疼痛保健的一种机制。应开发并应用质量指标与工作指标，公众也应获得有关医院、医生及其他医务人员业绩的信息”。

 

该报告还建议美国卫生与公众服务部(DHHS)成立一个独立的委员会，以改革现行的慢性疼痛医疗保险偿付机制。报告中陈述：“目前，医疗保险和医疗救助仍为事后赔付机制，这种机制程序繁琐，而且在时间上因需要评估、咨询与培训以及与其他慢性疾病如持续性疼痛进行比较而使患者往往不能获得足够赔付。”

 

“这一委员会应该探索一种针对特定病例的基于转归的一体化赔付方法，修订疼痛的程序性治疗与非程序性治疗之间的差异，这与精神性疾病治疗类似。应尽可能地对慢性疼痛患者采用多学科、康复导向的一体化治疗措施，而且这些治疗措施的费用应得到赔付，而不是那种特定个体特定治疗方案的赔付原则。”

 

这份报告及其建议经多个医疗卫生组织签署，包括美国家庭医师学会(AAFP)、美国儿科学会(AAP)、美国医疗机构评审联合委员会、美国护士协会(ANA)、美国急诊医师学会(ACEP)及美国神经学会(AAN)。

 

该专家组由麻醉医师、神经学医师、儿科医师、初级医疗医师、急诊医学医师、护士、药剂师、心理学家及患者代表组成。该专家组由纽约市Mayday基金会召集，该基金会是一个私募慈善组织，旨在降低身体疼痛的发生率，减轻疼痛程度，并改善预后。

 

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