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Acute Pain Medicine in the United States: a Status Report

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Acute Pain Medicine in the United States: a Status Report Pain Medicine 2015; 16: 1806–1826 Wiley Periodicals, Inc. ACUTE & PERIOPERATIVE PAIN SECTION Original Research Article Acute Pain Medicine in the United States: A Status Report Patrick Tighe, MD, MS,* Reprint requests to: Patrick Tighe, MD, MS, University †,‡ Chester C. Buckenmaier III, MD, of Florida, P.O. Box 100254, 1600 SW Archer Road, Andre P. Boezaart, MD, PhD,§ ¶,**,††,‡‡ §§ Gainesville, FL 32610-0254, USA. Tel: 352-273-7844; Daniel B. Carr, MD, Laura L. Clark, MD, Andrew A. Herring, MD,¶¶ Michael Kent, MD,*** Fax: 352–392-7029; E-mail: [email protected]. Sean Mackey, MD, PhD,††† Edward R. Mariano, MD, MAS,‡‡‡,§§§ Disclosures: Support for the 3-year Acute Pain Initia- ¶¶¶,**** Rosemary C. Polomano, PhD, RN, tive of the American Academy of Pain Medicine came and Gary M. Reisfield, MD††††,‡‡‡‡ from the American Academy of Pain Medicine Foun- dation, which received an unrestricted gift from Mal- *Department of Anesthesiology, University of Florida Col- linckrodt Pharmaceuticals. The findings and scientific lege of Medicine, Gainesville, Florida; †Defense and conclusions in this report are those of the authors and Veterans Center for Integrative Pain Management, do not reflect the position of any funding source or its Rockville, Maryland; ‡Department of Military & Emer- representatives, who were not present during panel gency Medicine, USUHS, Bethesda, Maryland; discussions related to these findings and who had no §Department of Anesthesiology and Orthopaedic Sur- input into the design, analysis, interpretation of gery, University of Florida College of Medicine, Gain- ¶ results, or preparation of this article and any and all esville, Florida; and Departments of Anesthesiology; **Medicine; ††Public Health and Community Medicine, products of this venture. Boston, Massachusetts; and ‡‡Program on Pain Research Education & Policy, Tufts University School of Funding sources: Patrick Tighe was supported by the Medicine, Boston, Massachusetts; §§Department of NIH/NIGMS K23 GM 102697 award. Chester C. Buck- Anesthesiology and Perioperative Medicine, University enmaier III has no relevant financial relationships to of Louisville School of Medicine, Louisville, Kentucky; declare. Andre P. Boezaart receives royalty payments ¶¶Department of Emergency Medicine, University of Cali- from TeleFlex Medical. Daniel B. Carr has no relevant fornia, San Francisco, California; ***Department of Anes- financial relationships to declare. Laura L. Clark has thesiology, Walter Reed National Military Medical received honoraria and travel expenses and has ††† Center, Bethesda, Maryland; Division of Pain Medi- served on the speaker bureaus for Covidien Ltd., cine, Department of Anesthesiology, Perioperative and Mylan Inc., Mallinckrodt Pharmaceuticals, and Pacira Pain Medicine, Stanford University School of Medicine, Pharmaceuticals, Inc., and as a consultant for Pacira. ‡‡‡ Stanford, California; Anesthesiology and Periopera- Andrew A. Herring has no relevant financial relation- tive Care Service, Veterans Affairs Palo Alto Health ships to declare. Michael Kent has no relevant finan- Care System, Palo Alto, California; §§§Department of cial relationships to declare. Sean Mackey was Anesthesiology, Perioperative and Pain Medicine, supported by the NIH K24 DA029262 award and has Stanford University School of Medicine, Stanford, Cali- no other relevant financial relationships to declare. fornia; ¶¶¶Department of Biobehavioral Health Scien- Edward R. Mariano’s institution has received unre- ces, University of Pennsylvania School of Nursing; and ****Department of Anesthesiology and Critical stricted educational program funding from I-Flow/Kim- Care (Secondary), University of Pennsylvania Perel- berly-Clark Corporation and B. Braun Medical Inc. man School of Medicine, Philadelphia, Pennsylvania; Rosemary C. Polomano is on the speaker bureau and Departments of †††Psychiatry and ‡‡‡‡Anesthesiology, is a consultant for Mallinckrodt Pharmaceuticals. Gary University of Florida College of Medicine, Gainesville, Reisfield has no relevant financial relationships to Florida, USA declare. 1806 Acute Pain Medicine in the United States Abstract address their wants [3], needs, and rights [4]. These trends have relevance to the area of acute pain medi- Background. Consensus indicates that a compre- cine (APM). hensive, multimodal, holistic approach is founda- tional to the practice of acute pain medicine (APM), The practice of APM involves the practice of medicine but lack of uniform, evidence-based clinical path- at multiple levels of inpatient healthcare, rehabilitation, ways leads to undesirable variability throughout and recovery of the patient at home. Specialists in APM U. S. healthcare systems. Acute pain studies are diagnose variants of and conditions related to acute pain, offer medical, interventional, and complementary inconsistently synthesized to guide educational and integrative medicine therapies, and provide for pri- programs. Advanced practice techniques involving mary and secondary prevention of acute pain where regional anesthesia assume the presence of a feasible, all via direct patient-physician relationships. physician-led, multidisciplinary acute pain service, which is often unavailable or inconsistently applied. The historical foundations of modern scientific pain This heterogeneity of educational and organiza- research relied largely upon observations in acute pain tional standards may result in unnecessary patient [5]; however, in recent decades much of the focus of pain and escalation of healthcare costs. pain medicine has been on chronic and cancer pain [6]. This emphasis owes much to John Bonica, whose work Methods. A multidisciplinary panel was nomi- treating World War II veterans with chronic pain and nated through the APM Shared Interest Group of psychological comorbidity convinced him of the value of the American Academy of Pain Medicine. The a multidisciplinary approach. Exceptions are the first panel met in Chicago, IL, in July 2014, to identify U.S. federal clinical practice guidelines, published in gaps and set priorities in APM research and 1992, which focused on the topic of acute pain [7], and education. the first guidelines in acute pain from the American Society of Anesthesiologists (ASA) in 1995 [8]. Even so, Results. The panel identified three areas of critical the intellectual center of much 21st century pain need: 1) an open-source acute pain data registry research and practice has shifted away from acute pain, and clinical support tool to inform clinical decision concurrent with greater attention to chronic pain proc- making and resource allocation and to enhance esses such as sensitization and psychological comor- research efforts; 2) a strong professional APM iden- bidity. Indeed, no chapter in the historical memoir tity as an accredited subspecialty; and 3) educa- published by the International Association for the Study tional goals targeted toward third-party payers, of Pain (IASP), which surveyed scientific and clinical pro- hospital administrators, and other key stakeholders gress during that organization’s first 30 years, was to convey the importance of APM. devoted to acute pain [9]. Conclusion. This report is the first step in a 3-year The practice of APM is once again gaining attention as megatrends converge [10,11]. First, as the U.S. health- initiative aimed at creating conditions and incen- care system strives to provide cost-effective, high-qual- tives for the optimal provision of APM services to ity care while also improving access, any means to facilitate and enhance the quality of patient recov- reduce complications, facilitate recovery, and shorten ery after surgery, illness, or trauma. The ultimate stays after surgery, trauma, or illness are being eval- goal is to reduce the conversion of acute pain to the uated. Acute pain control subsequent to the approxi- debilitating disease of chronic pain. mately 70 million U.S. surgical procedures each year is “low-hanging fruit” for cost savings, and many countries Key Words. Acute Pain; Delivery of Healthcare; publish guidelines or evidence syntheses addressing Medical Informatics; Anesthesiology; Research; postsurgical pain control [12–14]. Acute pain control is Education also an essential component of current clinical pathways and enhanced recovery protocols after surgery [15,16]. Second, ever-improving multimodal regimens have Introduction: Acute Pain (Re-) Enters the Limelight brought everyday acute pain control to a level of effec- tiveness previously seen only in intensive research pro- The insight that the experience of pain is not simply a tocols [15]. Unfortunately, unimodal reliance on systemic sensation but an experience more akin to hunger or opioids for aggressive pain control is fraught with seri- nausea was a seminal event that inaugurated modern ous and sometimes fatal side effects [17,18], mandating pain research [1,2]. Unraveling this observation gave rise the need for progress in delivering effective opioid- to the research discipline of psychophysics research sparing analgesia. Third, clinicians and neuroscientists and coincided with, in Beecher’s words, “a common alike recognize that the transition from acute to chronic tide of interest at that time in the pain problem [1].” Sim- pain may begin within minutes of injury, making the dis- ilarly, the current upsurge of professional and regulatory tinction between the two an artificial one [19–23]. interest in pain control can be seen as an offshoot of Population-based data suggest that better
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