Cover Story

No one knows for sure just how many Americans suffer chronic pain from conditions such as arthritis, migraines and back problems. The American Pain Foundation puts the number as high as 50 million people.

What experts do know is that there are significant barriers to managing these patients' pain adequately. These "roadblocks to relief," as the American Pain Society calls them, range from lack of reimbursement for pain treatment to physicians' inexperience to patients' own attitudes about pain and painkillers.

But recently there have been signs that these roadblocks may be coming down. And psychologists are helping to make that happen.

Barriers to care

In a culture whose attitude toward pain is summed up in such clich├ęs as "No pain, no gain" and "Grin and bear it," patients may be reluctant to complain about pain for fear of being deemed "bad" patients. Others fear that pain may signal a life-threatening condition like cancer or worry about the tests and procedures used to assess and treat pain.

Physicians' own attitudes can exacerbate patients' reluctance, says Judith A. Turner, PhD, the Hughes M. and Katherine G. Blake Professor of Health Psychology at the University of Washington in Seattle.

"Most providers aren't comfortable seeing patients with chronic pain, because they can try all their tricks but the person still comes back," says Turner. "Many patients say they feel abandoned when their doctors give up on them and say, 'This must be all in your head,' or 'I don't know what else to do,' and just throw up their hands."

That kind of attitude isn't surprising given the fact that most physicians and other health-care professionals receive no training in pain management, says Bob Gant, PhD, who has "inherited" countless patients left dangling after failed back surgeries. Medical school curricula contain almost nothing about pain management, he says.

"Physicians do what they're trained to do," says Gant, president of the Glen Lakes Clinic in Dallas and a liaison between the American Academy of Pain Management and APA's Board of Professional Affairs. "If they're orthopedists, they're interested in fixing joints. If they're surgeons, they're interested in surgery. And so on. They're not trained to offer ongoing management of chronic pain. Folks are being left to suffer because their caretakers don't know enough about these issues."

The stigma associated with morphine and other powerful painkillers presents another barrier, says Robert N. Jamison, PhD, an associate professor of anesthesia and psychiatry at Harvard Medical School and program director of the Pain Management Center at Brigham and Women's Hospital in Boston.

Although some patients cite potential addiction as a reason for rejecting painkillers, Jamison says such fears are ungrounded. His research has found that opioids decrease pain and improve mood without causing addiction or withdrawal problems.

"People with chronic pain tend to use opioids differently than people who use them to get euphoric," says Jamison, author of "Learning to Master Your Chronic Pain" (Professional Resource Press, 1996). "The medication doesn't make them high; it just lessens their pain."

Physicians themselves may be nervous about prescribing opioids--with good reason. Both overprescribing and underprescribing pain medication can land physicians in court, explains Jamison. State and federal regulations can exert a chilling effect on physicians' prescribing habits; in states with triplicate prescribing laws, for example, copies of every opioid prescription go to the government. Recent reports about abuse of the painkiller OxyContin have only exacerbated the problem.

Reimbursement issues can also prevent patients from getting adequate pain relief, says Dennis C. Turk, PhD, the co-editor of "The Handbook of Pain Assessment, Second Edition" (Guilford Press, 2001) and the John and Emma Bonica Professor of Anesthesiology and Pain Research at the University of Washington. For one thing, the lengthy claims process--and the conservative approach insurers encourage--can cause patients to miss what Turk calls the "window of opportunity" for preventing permanent disability.

And although recent years have seen the introduction of new medications and innovative technologies, such as implantable morphine pumps, insurers' enthusiasm about possible cures is waning. While these interventions can reduce patients' pain, says Turk, there's no evidence that patients return to normal functioning as a result.

"Altruistically, it's nice to reduce pain, but if you're the one paying the bills you want the outcomes that are important to you," he explains. "If patients say their pain is better but they don't go back to work or they continue to use the same amount of health care, the people who are paying the bills are not all that excited."

Special risks

Certain groups of patients face even higher risks of unrelieved pain. Rural patients may not have access to physicians trained in pain management, for instance. Older people may view pain as an inevitable part of aging; some may have strokes or other conditions that prevent them from describing problems.

At the other end of the age spectrum, children may also have difficulty communicating pain. As recently as the 1970s, many physicians didn't believe infants could feel pain. While that belief has mostly died out, many children still don't get adequate treatment.

"If you're lucky enough to be in a tertiary care center with a pediatric chronic pain clinic, you're probably getting pretty good service," says Patrick J. McGrath, PhD, the editor and publisher of the Pediatric Pain Letter and a professor of psychology, psychiatry and pediatrics at Dalhousie University in Halifax, Nova Scotia. "But that type of service is not widespread."

Minorities also face special risks, according to Charles S. Cleeland, PhD, director of the Pain Research Group at M.D. Anderson Cancer Center and the McCullough Professor of Cancer Research at the University of Texas in Houston.

Minority cancer patients are at two to three times the risk of inadequate pain management, Cleeland has found. Factors responsible for this disparity may include cultural differences between providers and patients and the length of time spent with physicians.

"If you have metastatic cancer and get 10 minutes for a follow-up visit, you have to decide how much time to devote to pain and how much to the cancer," says Cleeland. "While that's true of everybody, those kinds of issues are probably exaggerated in minority patients."

Hopeful signs

There are signs that the barriers to pain management may become a thing of the past, however.

The Joint Commission on Accreditation of Healthcare Organizations recently implemented new standards requiring hospitals and nursing homes to assess and control patients' pain. The American Academy of Pediatrics and American Pain Society released a joint policy statement calling on physicians to do more to control children's pain. And Congress has declared this to be the Decade of Pain Control and Research. The Veterans Health Administration (VHA) is one organization that has already committed itself to better pain management. Launched in 1999, the VHA National Pain Management Strategy represents an effort to develop a systematic approach to treating pain.

"There were some incredible inconsistencies in the way our system was delivering care," explains coordinating committee member Robert D. Kerns, PhD, chief of psychology service at the Department of Veterans Affairs (VA) Connecticut Healthcare System in West Haven.

The strategy's first goal was to make sure that health-care providers assess pain at every clinical encounter, transforming pain into a vital sign just as important as temperature or blood pressure. When monitoring began in early 2000, says Kerns, only about 50 percent of randomly selected medical records contained at least one documented pain score. Today that figure has jumped to about 95 percent. Subsequent goals include new pain management protocols, education for all clinical staff and expanded research on pain management.

"The VA is in the forefront," says Kerns, an associate professor of psychiatry, neurology and psychology at Yale. "In the world of American pain, the eyes and ears are open and paying attention to the VA."

Rebecca A. Clay is a writer in Washington, D.C.