Pain, Percocet, and the Public’s Health

Chronic pain has become a public health epidemic in the United States, affecting more than 100 million people and costing up to $635 billion annually. But fundamental differences in views on pain management, and a narrow approach that relies heavily on pharmaceuticals, pervade the medical community.

Noreen Clark, director of the Center for Managing Chronic Disease at the University of Michigan, was cochair of a 2011 Institute of Medicine (IOM) committee that examined the extent of pain in America and called for a “cultural transformation” in the way chronic pain is managed.

Clark will discuss the need for coordinated national efforts to address pain and its management when she delivers the 2012 William J. Bicknell Lectureship in Public Health tomorrow at the School of Public Health. In her lecture, titled Pain, Percocets, and the Public’s Health, Clark will reiterate her call to action: that pain must be tackled as a public health issue.

The annual lecture will be followed by a panel discussion with Madeleine Biondolillo, director of the Massachusetts Department of Public Health Bureau of Health Care Safety and Quality, Barbara Herbert, chief of the St. Elizabeth’s Medical Center division of addiction medicine, and Richard Laing, a World Health Organization medical officer and a former SPH professor.

BU Today recently spoke with Clark about the public health implications of pain.

BU Today: Your IOM report found that chronic pain affects more than 100 million Americans and costs over $600 billion a year, more than is spent on cancer, heart disease, and diabetes combined. Is pain an epidemic?

Clark: I personally never expected our study to illustrate such a dramatic prevalence of pain and the costs associated with it. We undertook an exhaustive review of the research literature and heard testimony from over 2,000 people, and what we found was that the magnitude of pain in America is staggering. We found that pain could be better managed, and also that very particular groups experience more pain and worse outcomes than others—that is, minority people, women, and the elderly. So the disparities we worry about in many areas of health care are very much evident in pain.

Even with those kinds of costs, you say we’re not paying enough attention to pain.

We’re not paying the right kind of attention. When we think about relieving pain in America, we have to think about a cultural transformation. Essentially, the problem of alleviating pain requires not simply a medical conception—diagnosing a problem, giving someone a treatment, and the problem is solved. It requires an understanding of how complicated pain is. Pain is a biologic, psychological, and social problem. It can’t be dealt with as a public health problem unless it’s recognized as the complicated, multifaceted problem it is. Pain, in and of itself, can become a disease. People think of pain as always coming from a physical source, but it can become a parallel condition of its own.

A recent New York Times story cites federal data that the number of prescriptions for the strongest opioids has increased nearly fourfold over the last decade, with only limited evidence of their long-term effectiveness or risks. Are we becoming too reliant on drugs?

Those findings actually are a reflection of why we need a cultural transformation in the way we treat pain. There are some clinicians who say, ‘You have pain? We’ll give you opioids.’ Even in cases where it’s not possible to find the source of the pain, sometimes clinicians will prescribe something in the hope that this complaining patient will, well, go away.

But we know that the treatments don’t work for everybody. I do a lot of work in respiratory disease, and the drugs that are used in the standard care don’t necessarily work for everyone. I think there’s a move now in basic science and public health to recognize the variation in response—people are different. Drug trials are done on very narrow slices of the population, but pain is broad.

So the idea that the pharmaceutical approach won’t work for large groups of people makes sense. That’s why the pain issue is best understood as a complicated set of factors—and that, in the main, people are not being offered all the alternatives available, even though the pharmaceuticals have these associated complications and side issues, one being their addictive nature.

Why do different clinicians treat pain so differently? Some aggressively prescribe opioids, others do not.

The issue of opioids is very complicated and deserves a study of its own. But our findings suggest that it is more likely for clinicians to undertreat pain than to overtreat it. That’s a very important notion. Part of the problem is that many clinicians fear the censure of medical and drug authorities, and they just don’t want to get into problems of treating patients with opioids. On the other hand, there are certainly physicians who overprescribe.

There are two related points here. One of the problems we identified is that the health system often overlooks other means of treating pain—physical therapy, rehabilitation, meditation, moderate forms of exercise. They’re not reimbursed, and they are overlooked. That needs to change.

The other issue is with education about pain. Some clinicians are just not trained in treating pain. We found that in most medical schools, pain is allotted a very small window in the training program, and it’s mostly oriented to the use of pharmaceuticals. Most clinicians understand pain as associated with a condition they recognize, but pain that becomes a parallel condition to a chronic disease, or where the source is not identified, that concept is missing.

What do you mean when you talk about a call to action on pain?

Besides improvements in education and more comprehensive approaches to pain control, we need a national effort to understand pain. From a public health perspective, some countries are far ahead of us. In places like Australia, for example, the public health system mounted a national strategy to prevent and manage back pain. They are helping people to understand ways to avoid back pain, engaging employers to adopt workplace strategies to avoid back injuries, and helping clinicians learn about alternative treatments. We don’t do anything like that here.

We look at cancer as a public health problem. We look at asthma as a public health problem. We look at stroke as a public health problem. We need a national effort, involving a wide range of stakeholders, to understand pain as a public health problem.

The 2012 William J. Bicknell Lectureship in Public Health is tomorrow, Friday, September 21, from 9 a.m. to noon, on the BU Medical Campus, 670 Albany St., first floor auditorium. It is free and open to the public and followed by a complimentary luncheon. The lectureship is named in honor of the late William J. Bicknell, an SPH professor and chair emeritus of international health and a School of Medicine professor of sociomedical sciences and community medicine, who died in June.

Lisa Chedekel can be reached at chedekel@bu.edu.