Chronic pain as a public health problem

Some estimates suggest that 120 million Americans suffer from chronic pain. However, the issue is how to improve access to state of the art pain treatment. It is becoming clearer that treatments that are effective in acute pain, such as opioids, are far less effective in treating chronic pain. Chronic pain is fundamentally different than acute pain since chronic pain involves the remodeling of the brain and CNS. Acute pain is adaptive; chronic pain is usually maladaptive, and serves little physiologic purpose, yet its prevalence is so high.

In the last few years, it has become clear how little we know about public health approaches to chronic pain. Even the epidemiology and risk factors of chronic pain have received little attention–perhaps 10 or 15 people globally have published the major research in pain epidemiology. It is repeated again and again, now, that there is no proof that the use of opioids in chronic pain is appropriate. They may help some people adapt to chronic pain. The ultimate test is whether these individuals are more able to go about activities of daily living, and lives that *they* consider to be happy and productive.

Multiple disciplinary pain research teams have found in the last 50 years that graded exercise is very helpful in most chronic pain states–exercise that is appropriate for the particular individual. This includes both aerobic/cardio exercise, and appropriate muscle training, such as core muscle strengthening exercises. More recently, it has been shown that the use of imagery, relaxation techniques, and mindfulness meditation help to down regulate pain. Movement, exercise, imagery, and mindful breathing all have their places.

In addition, for many types of pain, antiepileptic medication such as gabapentin (Neurontin) and pregabalin (Lyrica, in the US) can help. Even earlier, it became clear that tricyclic antidepressants are helpful. More recently, some of the newer antidepressants, such as venlafaxine (Effexor) and duloxetine (Cymbalta) may be helpful.

Medical intervention aside, might more walkable cities help in the treatment and even prevention of pain? Research has shown that walkable neighborhoods are associated with lower rates of obesity, and possibly lower rates of obesity-related disease, such as diabetes, and cardiovascular disease. Might these walkable neighborhoods–areas with sidewalks, good lighting, and parks, to name a few characteristics–help to prevent and treat chronic pain? A testable hypothesis is that such neighborhoods are associated with lower chronic pain prevalence, after adjusting for confounders and effect modifiers.

The fact that there is no central pain registry, and that it is nearly impossible to get geographically specific data from some of the national health survey data, such as the National Health Interview Survey, hinders pain research. Basically, it is necessary to collect primary data to address these questions, which poses logistical and financial difficulties.

The fact that chronic pain is viewed as a symptom rather than as a set of pathological conditions in themselves may hinder research. This is because most research is disease oriented rather than symptom oriented. For example, most departments of epidemiology have cancer epidemiologists, cardiovascular epidemiologists, neuroepidemiologists, and, going back to the origins of the field, infectious disease epidemiologists. Though there have been several books published on the epidemiology of pain, I know of no epidemiology departments that have pain epidemiologists (maybe I am the only one).

This poses a more fundamental question: is chronic pain a symptom or a disease? A disease in itself that hinders function and happiness. Pain researchers have begun to view chronic pain as a disease. I prefer to consider it as a phenomenon: it just *is*, but chronic pain hinders happiness and harms public health.

If one third of a population (such as in the US) reports that they have chronic pain, we are dealing with one of the most prevalent public health problems. It is time to increase funding for and research on chronic pain. It is time to address chronic pain as perhaps the most prevalent public health issues. And, once there is more understanding and more appreciation of chronic pain, it will be time to address it definitively from a public policy perspective.

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About epihealth

Professor of Epidemiology and Medical Geography, University of Washington, Seattle and Adjunct Prof, Depts of Medicine (Div of Infectious Diseases), Family Medicine, Health Services, and Global Health. President, Health Improvement and Promotion Alliance-Ghana www.hip-ghana.org Expertise in infectious diseases, epidemiology and clinical epidemiology, epi. of pain, community health, travel medicine, tuberculosis, disease control.
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