Desirable Characteristics of National Pain
Strategies:
Recommendations by the International
Association for the Study of Pain
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Executive Summary
The International Association for the Study of Pain (IASP) supports
the development of policies that ensure implementation of advances in
both the science and delivery of health care for people in pain. It is
concerned that, considering the burden of pain, transfer of knowledge is
not happening at an appropriate pace. IASP has therefore developed
guidance for members, government and nongovernmental organizations
working in both developed and developing nations who seek to improve
pain care. IASP recommends strategies that address barriers to progress
based on an analysis of submissions from 19 member countries and on
feedback from IASP chapters. The process was overseen by a working party
drawn from both developed and developing nations. The document should be
read in conjunction with the Declaration of Montréal asserting that access
to pain management is a fundamental human right.
Key recommendations are:
- Access to pain education for health professionals and the general
population
- Coordination of the care system to ensure timely access to the right
support
- A quality improvement program to address access and standards of
care
- A reasonable proportion of direct and dedicated funding for pain
research
Critical factors for success are:
- Gathering of evidence on the burden of pain to the nation
- Gathering of information on access to care
- Development of government policy on pain services
- Formation of a broad coalition of stakeholders
- A clear plan with timescales to achieve strategic actions
Working Party:
Michael Cousins, Chair (Australia)
Harald Breivik (Norway)
Mary Cardosa (Malaysia)
Jim Cleary (USA)
Beverly Collett (UK)
Liliana De Lima (USA)
Rollin M. Gallagher (USA)
Maija Häänpää (Finland)
Amira Karkin-Tais (Bosnia and Herzegovina)
Kathy Kreiter, ex officio (USA)
Philipp M. Lippe (USA)
Diederik Lohman (USA)
Henry Lu (Philippines)
Mary Lynch (Canada)
John Ney (USA)
Germán Ochoa (Colombia)
Cathy Price (UK)
M. R. Rajagopal (India)
Olaitan Soyannwo (Nigeria)
Background
The International Association for the Study of Pain was established
in 1973 in response to the recognition that pain should be better
managed. In the time since IASP's inception, remarkable advances have
occurred in terms of understanding the epidemiology, causes, and
treatment of both short-term and persistent pain. Pain has many facets,
including its causes, chronicity, location, and qualities.
Concern that scientific advances are not being matched by better
treatment has prompted a series of declarations and actions by national
and international bodies advocating better pain control (Appendix 1).
These calls to action are based on three suppositions:
- Pain, no matter what type, is inadequately treated due to a variety
of cultural, attitudinal, educational, political, religious, economic,
and logistical barriers.
- Inadequately treated pain has major physiological, psychological,
economic, and social consequences for patients, their families, and
society.
- All developed and many developing countries are capable of
significant improvement in the treatment of pain.
The International Association for the Study of Pain (IASP) supports
the view that every nation should have policies on the management of
pain that describe the burden of pain, its impact, and what should be
done in terms of policy interventions to reduce these problems. This
paper sets out recommendations for the core elements of any national
pain strategy. It accompanies the Declaration of Montréal, which asserts
the human rights of those in pain. It is intended that this guidance
should act as an impetus to clinicians, educators, administrators, and
governmental or professional organizations involved in the establishment
and maintenance of standards for pain services to take steps to prevent
the continued suffering of millions of people and avoid any waste of
resources. Patients, their families and others affected by the
undertreatment of pain must be welcomed into this process as active
participants.
Scientific Advances
Major breakthroughs in our understanding of pain have occurred as a
result of advances in the neurobiological, epidemiological, and
psychological factors that give rise to high levels of pain. Imaging
studies have shown that persistent pain is associated with significant
functional, structural, and chemical changes in the brain [28,32]. The
exact implications of these data are as yet unknown, but distinct
changes have been observed. Patients who have chronic pain disorders
with known causes (e.g., osteoarthritis or nerve damage) or unknown
causes (e.g., nonspecific low back pain) may have altered cerebral pain
processing and loss of gray matter, leading to impaired function
[1,27,35,42].
Epidemiological advances in chronic pain include better
characterization of the population and longitudinal surveys. The
prevalence and impact of chronic pain appear remarkably similar, no
matter where in the world they are measured
[4,8,10,14,17,20,25,29,30].
Key common findings include:
- One in five people of all ages have moderate to severe chronic
pain.
- One-third of individuals of working age who have chronic pain have
lost the ability to perform wage-earning or other work.
Worldwide, if we continue to fail at effective pain management, we
will continue to pay a staggering and unnecessary price [12].
Treatment Advances
Advances in interdisciplinary care have led to improved understanding
of how to better manage pain, yet studies have consistently demonstrated
the undertreatment of pain. This problem includes inadequate treatment
of cancer, postoperative, post-trauma, and chronic pain. A review of
published literature has identified that nearly half of people with
cancer pain are undertreated [9,15], with similar rates of
undertreatment in postoperative pain, even in developed countries
[18,39]. Access to timely and appropriate treatment for chronic pain is
an international problem [21]. Poor access to care can lead to
deterioration in health [21,22,23,36], risking aggravation of the pain
condition and further decreases in quality of life, resulting in more
expensive interventions being necessary.
Guidelines on cost-effective interventions for the management of pain
have been published. Summarizing the literature [6,16,19,26,37,43], we
now know that medical interventions aimed at the purported underlying
cause of pain may prove to be costly. For those with chronic pain,
active self-management strategies are “associated with lower levels of
pain-related disability and health care” use (5). Training is often
needed in this area for both health care professionals and people in
pain, because knowledge is frequently not applied.
The International Association for the Study of Pain has sought to
understand why there is a failure in knowledge transfer.
International Strategy Development
IASP invited member chapters to submit any examples of programs in
which there had been an attempt to identify and address underlying
reasons behind the failure in knowledge transfer.
Nineteen countries submitted health policies on pain for review by a
working party. Chapter presidents were surveyed as to their opinion on
barriers to effective pain management. Seven countries were found to
have a comprehensive strategy to address the management of pain; the
remainder had strategies focusing mainly on opioid control. These are
contained within Appendices 1 and 2. These findings were reviewed by a
working party drawn from 15 nations; barriers and potential solutions
were proposed by the group. All chapter presidents together with health
policy makers were invited to the international pain summit hosted by
IASP.
Throughout this process IASP, highlighted common professional,
public, and system barriers to implementation of better pain care:
- Pain measurement is neglected.
- Professionals caring for people in pain often lack the knowledge and
skills to manage pain. As a result, attitudes are more often shaped by a
variety of beliefs based upon experience and culture than by knowledge.
National surveys in Canada and the United Kingdom have identified that
veterinary schools have been able to integrate knowledge about pain into
their curricula, while medical schools have lagged behind [13,38].
- Resource allocation within the health care system may be overly
directed toward trying to treat the underlying cause rather than the
pain per se. Financial payment that promotes activity rather than
self-care is an example.
- Coordination between health and social care systems is poor. There
may be a lack of resources and of clear models of care to ensure
coordination of pain management between the various primary and
secondary care and health care services and social services [26].
- Research funding: pain research is grossly underfunded, considering
the burden of illness [7,24].
- Supply of medicines: there is a relative undersupply of low-cost,
effective medications in resource-limited settings and developing
countries.
- Population-based surveys on pain are rarely done outside specific
research programs. Thus, there is a lack of public health focus on pain
as a priority [14].
Based on the consultation and analysis performed, IASP recommends
that any strategy should consider four broad areas:
- Pain Education
- Patient Access and Care Coordination
- Monitoring and Quality Improvement
- Pain Research
These areas can be broken down to specific policy development
areas:
A. Education for Both Health Care Professionals and the
Public in:
- Basic science of pain
- Assessment of the needs of a person in pain
- Best practice in the management of pain
B. Models of Care:
- Biopsychosocial
- Multidisciplinary in focus
- Timely
- Have an emphasis on self-care
- Have provision for special populations e.g., learning difficulties,
dementia
- Involve family and caregivers
C: Quality Standards to Include:
- Access times
- Feedback from the patient
- Measurement of quality of life
- Measurement of the economic burden of pain
D: Research to Cover:
- Epidemiology
- Implementation science, especially in the area of knowledge
transfer.
Further details are in Appendix 3.
IASP also found that some key actions seem to enable development of
health care policy and strategy. IASP therefore recommends:
A. Gathering of Evidence on the Burden of Pain to the
Nation
Given that persistent pain is often initially associated with other
disease processes, pain is often inadequately recorded both in clinical
records and in the administrative coding that is often used as a source
for epidemiological studies.
In Australia, the economic burden of disease was estimated through
the calculation of Disability Adjusted Life Years from epidemiological
data on chronic pain [2].
Nations should carry out a basic health survey that asks questions
specifically about pain, its management, and its impact. The data can
serve as a useful baseline from which to measure the impact of any
interventions introduced [17]. This information can then inform a plan
to deliver change [14].
B. Gathering of Information on Access to Care
The recent IASP task force on waiting times has allowed a clear
consensus to develop on standards for appropriate waiting times. The
National Pain Audit in the United Kingdom is currently measuring this
with English and Welsh government sponsorship.
C. Development of Government Policy on Pain
Services
Goals for improvement, as laid out above, are agreed by a wide range of
stakeholders including central government and prioritized appropriately.
It is noted that the impetus for this effort in two nations has occurred
through the holding of the United States and Australian Pain Summits,
respectively.
D. Formation of a Broad Coalition of Stakeholders
Examples of this are the UK Chronic Pain Policy Coalition, Pain
Australia, and the European Federation of IASP Chapters (EFIC).
E. Realistic Timelines are Established for Achieving
Incremental Change
The impact of such change should be measured in terms of both process
and outcome. Population outcome data together with process measurements
need to be established and agreed upon.
IASP hopes that this document will be used to enable more rapid
implementation of scientific evidence than is currently happening. A
further review of the situation is planned to assess the impact of
IASP's recommendations.
Appendix 1: Summary Chart. Examples of National Pain Care
Strategies, Relevant Statements and Proposals, and Enacted Government
Regulations/Laws
View Summary Chart
>
Appendix 2: Survey Results: National Pain Management Assessment
Survey
View Survey Results
>
Purpose
To obtain information on an international scale regarding the state of
pain medicine at the primary care and specialist level, and regarding
obstacles to improvement in pain management through policy initiatives
and government interventions.
Methods
A link to an online questionnaire was sent to 85 International
Association for the Study of Pain (IASP) chapter presidents, each
representing the pain medicine faculty for a particular country. The
questionnaire consisted of 29 largely multiple choice questions in three
areas: (1) Pain treatment by primary care providers, (2) pain treatment
by specialists, and (3) the role of the government in regulating and
oversight of pain management. Several open-ended questions were also
asked. The respondents were encouraged to answer all questions to the
best of their knowledge, although they were allowed to skip individual
questions.
Results
By 12 August, 2011, 29 of 85 responses (response rate of 34%)
representing 28 different countries, had been collected. The majority of
respondents were from developing nations, although nations with
developed health care systems, such as Canada, Australia, and the UK
were also represented. The response rate per multiple-choice question
ranged from 62% to 76%. The response rates below were based on
respondents who actually answered the relevant question in the
survey.
- With regard to primary care, the majority of respondents noted that
their nation's populace had access to primary care providers (PCPs)
(67.3% of question respondents). Most PCPs were medical doctors (65% of
respondents), although nurses also played a significant role (>25% of
primary care in respective nations) for 1/4 of respondents. Forty-four
percent of respondents indicated that less than half of PCPs in their
nation did not have residency training, and 48% of respondents noted
that less than 5% of PCPs had supervised clinical rotations in a
pain-related medical specialty. Indeed, lack of supervised clinical
training in pain for primary care was cited as one of the top three
national challenges in pain management by 42% of respondents. However,
pain diagnosis and management was felt to be a significant portion
(>1/4) of their practice for 45% of respondents. Sixty percent of
respondents noted some barrier to PCP prescription of opiates, 45% noted
some restriction on the prescription of expensive adjunctive pain
medications (anticonvulsants and antidepressants) by PCPs, and 70%
indicated some limitation on PCPs performing pain-related procedures,
such as joint injections. More than 70% of respondents indicated that
PCPs in their nation were able to refer patients to an allied health
provider (a physical therapist, counselor, nurse, or pharmacist) to help
manage pain disorders.
- For pain specialist care: In assessing challenges to improving pain
management on a national level, lack of pain specialists was cited by
100% of respondents. Ninety percent of respondents indicated that pain
specialists represented 5% or less of the health care providers in their
nation, with 47% of respondents indicating that 5% or less of pain
specialists were MDs. Insufficient formal supervised clinical training
for pain specialists was noted by 37% of those surveyed. For 69% of
respondents, only 1/4 or less of the total practice of pain specialists
was related to the diagnosis or treatment of pain. Nearly 40% of
respondents indicated that at least 1/4 of pain specialist time was
spent managing chronic pain with oral medications, while only 17%
indicated that pain specialists in their nation spent more than 1/4 of
their time performing procedures. A significant portion of respondents
(21%) indicated that more than 1/4 of pain specialists' practice was
spent educating non-specialists. Among different types of pain
(cancer-related, neuropathic, post-procedure, or other chronic pain),
chronic non-neuropathic/noncancer pain was the type most commonly seen
(39% of respondents indicating >1/4 of pain specialist practice).
Respondents indicate that patients were more likely to be referred to a
pain specialist by a PCP or other medical specialist than to be
self-referred.
- Government role in pain management: Eighty-four percent of
respondents indicated that the government was responsible for health
care for all of its citizens. A government entity specifically tasked
with pain management was noted by only 11% of respondents, while 26%
indicated that their government had published referral guidelines to
pain specialists, and there was no government involvement in pain
specialist training and certification according to 68% of respondents.
Ninety-five percent of survey respondents indicated at least moderate
difficulty in contacting government legislators, administrators, and
political figures regarding health care and pain management. Of 18
possible challenges for national pain management strategies, lack of
government prioritization of pain management was cited by 58% of
respondents.
Conclusions
Our survey of IASP chapter presidents provides a description of some of
the major problems facing pain management on a global scale. The
shortage of pain specialists, insufficient training for specialists and
primary care providers in pain management, and the minimal role of
national governments were each noted as prominent challenges in
reforming pain management in their respective nations. Although our
results should not be interpreted as definitive, they point to the need
for greater education of health care providers and involvement of
government in pain practice.
< Hide Survey
Results
Appendix 3: Detailed Desirable Characteristics of National Pain
Strategies
View Detailed Table
>
| Characteristics |
Examples |
Responsible
Parties |
|---|
| Pain Education |
| Undergraduate |
At an early stage in
training to equip trainees with both the knowledge and skills to address
all types of pain. The IASP core curriculum sets out standards for
education in pain. |
Centers of learning,
regulatory bodies |
| Postgraduate |
All clinicians required
to have ongoing education in the relief of pain; clinicians trained to a
specialist level in pain medicine. |
Centers of learning,
regulatory bodies |
| Public
awareness |
To understand pain and
its management, empower consumers, and reduce the stigma of having
ongoing pain, access to information on pain should be available to the
general public. |
Providers of health
care, patient organizations, and health educator programs |
| Patient Access and Care
Coordination |
| Care in differing
settings |
Rapid access to expert
pain care. All hospitals should have staff with expert training in pain
assessment and management to call upon. All primary care practitioners
should be able to perform a basic assessment of need with regard to pain
that includes determination of relief of pain and suffering. |
Health care policy
makers, providers and commissioners of health care |
| Medicines |
The World Health
Organization's list of essential medicines should be available in
preparations suitable for all ages. Support from the pharmaceutical
industry will be needed to achieve this goal. |
Government regulatory
agencies, drug enforcement agencies, and key clinical staff |
| Informed
choice |
Coordination of the
system so that access to the right help is available as early as
possible with a fully informed choice on options. |
|
| Care pathways |
Care pathways agreed on
by consensus are a useful way to achieve this goal. |
Providers and
commissioners of health care |
| Expert care |
Establish pain care
networks to ensure excellent relationships between providers. Where
secondary care exists, there should be a vertical system for escalation
of referrals of difficult problems from primary, through secondary, to
tertiary care centers. |
Commissioners and
providers of health care |
| Interdisciplinary
approach |
A biopsychosocial
approach to assessment and management that involves a team of health
care professionals working closely together within a non-hierarchical
framework. |
Providers of health
care |
| Family and
caregiver involvement |
Families and caregivers
should be actively included in the management of a person in pain. |
|
| Self-care |
Adoption of approaches
and systems that support self-care. Any pain management program must
engage the community both in advocacy and in use of trained volunteers
in the care program. Development of patient-led support networks. |
|
| Special
populations |
Special populations
include the very young and very old, victims of torture and natural
calamities, those with learning difficulties, those with mental health
and addiction disorders, ethnic minorities, and impaired persons. Their
needs should be recognized and provided for. |
Providers and
commissioners of health care |
| Monitoring-Quality
Improvement |
| Time to care |
Standards for access
times and activity planning that allow sufficient time to assess and
care for people in pain. |
|
| Quality of
service |
Improvements in patient
experience should be routinely sought, including reduction in waiting
times for care. |
|
| Quality of
life |
Improvements in
individual patients' quality of life (pain relief if possible and
improvement in function) using both generic and disease-specific
measures. |
|
| Economic
burden |
Monitoring should
include work loss and school absence due to pain, prescription costs,
urgent care, and use of other services. |
|
| Outcomes |
Outcomes from care
should be routinely measured including patient safety, patient
experience, and clinical effectiveness, drawing upon IMMPACT's
recommendations. |
|
| Pain Research |
| Epidemiologic |
A national health
survey to determine population needs for pain care and monitor progress
both in the general population and within institutions. |
Public health services,
health economists |
| Science |
Prioritization of pain
for funding opportunities that target gaps in pain treatment,
implementation science, knowledge transfer, education, and policy
development. |
Federal health research
funding bodies |
< Hide
Table
References
 View a PDF of all references.
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