Health Care for Chronic Pain: Overuse, Underuse, and Treatment NeedsCommentary on Chronic Pain and Health Services Utilization—Is There Overuse of Diagnostic Tests and Inequalities in Nonpharmacologic Methods Utilization?

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In 2011, the Institute of Medicine (IOM) reported that over 100 million Americans are affected by chronic pain, costing the nation up to $635 billion each year in health care and lost productivity costs.1 This thoughtful and timely report concluded that, “Healthcare providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted.” The IOM report also observed that, “Health care organizations should take the lead in developing innovative approaches and materials to coach and empower patients in self-management.” Certainly, self-management is of fundamental importance for a condition affecting 4 persons of 10.The IOM estimate of 100 million Americans affected by chronic pain has since been cited by others who have implied that this represents the number of people needing medical treatment for chronic pain. For example, a member of the IOM panel used this estimate when arguing that “there is a moral imperative to treat pain.”2Although 100 million is an eye-catching number, this number was derived by the IOM from prevalence rate estimates for the United States from the World Mental Health Surveys in which respondents from diverse developed and developing countries were asked whether they had chronic back or neck pain, frequent or severe headaches, arthritis or joint pain, or some other chronic pain condition in the prior 12 months.3 The intent of the World Mental Health Survey analyses was to compare the prevalence of common chronic pain conditions in different countries, not to estimate the percentage of the population who might need medical treatment for chronic pain. In the World Mental Health Surveys report, moderate to severe chronic pain was not differentiated from mild chronic pain.Is there a moral imperative for health care professionals to treat all persons with chronic pain irrespective of its severity or of the potential benefits from therapeutic interventions? I think not. Although safe, evidence-based, and compassionate care of all persons seeking treatment for chronic pain is an ethical duty, a moral imperative for treatment is based on the potential for treatment benefits to exceed harms and costs. Human suffering alone does not confer a moral imperative for medical intervention. When loosely applied to a wide range of human maladies, irrespective of the benefits and safety of treatment options, the assumption that human suffering per se defines a moral imperative for medical intervention may contribute to unnecessary treatment accounting for 10%–30% of US health care costs, or $250–$800 billion annually, and to an estimated 30,000 deaths per year from unnecessary medical interventions among Medicare beneficiaries.4,5In this issue, a survey of the adult population of Portugal provides a refined understanding of the significance of chronic pain in the population at large, and how it is cared for. The overall estimate of chronic pain prevalence (37%) is similar to that used by the IOM report on chronic pain, and to chronic pain prevalence estimates observed in other countries worldwide.3 However, this report clarified the overall estimate of chronic pain prevalence by differentiating the 11% of the adult population with moderate to severe chronic pain from the 26% with less severe chronic pain. In other words, roughly two thirds of those with chronic pain in this study had relatively mild chronic pain conditions for which self-management is likely to be the safest and most cost-effective alternative.A striking result of their research is the lack of pronounced differences in use of specific health care services comparing those with moderate to severe chronic pain with those with mild chronic pain.

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